COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX00043486 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/americantextbook1900star 


AN  AMERICAN  TEXT-BOOK 


DISEASES  OF  CHILDREN. 


INCLUDING 

SPECIAL  CHAPTEKS  ON  ESSENTIAL  SURGICAL  SUBJECTS ;  ORTHOPJEDICS ; 

DISEASES  OF  THE  EYE,  EAR,  NOSE,  AND  THROAT ;  DISEASES  OF  THE 

SKIN ;   AND  ON   THE   DIET,    HYGIENE,  AND  GENERAL 

MANAGEMENT  OF  CHILDREN. 


BY   ^M:ERIO^]Sr    TEACHERS. 

EDITED  BY 

LOUIS    STARR,  M.D., 

Consulting  Psediatrist  to  the  Maternity  Hospital,  Philadelphia  ;  Late  Clinical  Professor  of 

Diseases  of  Children  in  the  Hospital  of  the  University  of  Pennsylvania ;  Member 

of  the  Association  of  American  Physicians  and  of  the  American 

Psediatric  Society ;  Fellow  of  the  College  of 

Physicians  of  Philadelphia,  etc. 

ASSISTED    BY 

THOMPSON  S.  WESTCOTT,  M.D., 

Instructor  in  Diseases  of  Children,   University  of  Pennsylvania ;  Visiting  Physician  to  the 

Methodist  Episcopal  Hospital ;  Physician  to  the  Dispensary  of  the  Children's 

Hospital ;    Fellow  of  the   College  of  Physicians  of  Philadelphia ; 

and  Member  of  the  American   Psediatric  Society. 


SECOND  EDITION,  REVISED. 


PHILADELPHIA 
W.    B.    SAUNDERS 

1900 


Copyright,  1900,  by 
W.     B.    SAUNDERS. 


KLECTEOTYPED  BY  PRESS  OF 

WBSTCOIT  A  THOMSON.  FHILASa.  W.  B.  SAUNDERS.  PHILADA. 


PREFACE  TO  THE  SECOND  EDITION. 


To  keep  up  with  the  rapid  advances  in  the  field  of  paediatrics  and  to  round 
into  a  more  perfect  treatise  the  work  so  admirably  accomplished  by  the  various 
authors,  most  of  whom  labored  entirely  independently  of  one  another,  the 
whole  subject  matter  embraced  in  the  first  edition  of  this  work  has  been  care- 
fully revised ;  new  articles  have  been  added ;  some  of  the  original  papers  have 
been  emended,  and  a  number  have  been  entirely  rewritten  and  brought  up  to 
date.  For  greater  accuracy  in  classification,  the  section  on  the  Infectious 
Diseases  has  been  rearranged  so  as  to  embrace  Tuberculosis  and  Malaria. 
The  new  articles  include  "Modified  Milk  and  Percentage  Milk  Mixtures," 
"  Lithsemia,"  and  a  section  on  Orthopaedics;  those  rewritten  are  "Typhoid 
Fever,"  "Rubella,"  "Chicken-pox,  "Tuberculous  Meningitis,"  "Hydro- 
cephalus," and  "Scurvy";  while  more  or  less  extensive  revision  has  been 
made  in  the  chapters  on  Infant  Feeding,  Measles,  Diphtheria,  and  Cretinism. 
The  volume  has  been  thus  increased  in  size  by  fully  fifty  pages  of  fresh 
material. 

The  editor  records  with  profound  regret  the  decease  of  two  of  his  most 
valued  collaborators — Dr.  Charles  Warrington  Earle,  of  Chicago,  and  Dr.  J. 
Lewis  Smith,  of  New  York — to  whose  pioneer  work  in  paediatrics  the  medical 
profession  owes  a  lasting  debt  of  gratitude. 

The  editor  gratefully  acknowledges  the  flattering  reception  accorded  the 
first  edition  of  the  work,  and  expresses  his  thanks  to  Dr.  Thompson  S.  Westcott 
for  his  most  efiicient  assistance  in  the  preparation  of  the  revision. 

LOUIS   STARR. 


347528 


PREFACE, 


In  the  preparation  of  this  volume  the  Editor's  object  has  not  been  to  add 
unnecessarily  to  the  number  of  encyclopaedias  already  existing,  but  to  present 
to  the  profession  a  working  text-book  which  shall  be  closely  limited  to,  while 
completely  covering,  the  field  of  pediatrics. 

To  make  such  a  book  useful  to  the  practitioner,  who  must  too  often  read 
as  he  runs,  and  to  the  student,  who  of  necessity  is  unable  to  devote  his  study 
hours  to  one  branch  of  medical  science,  but  must  divide  them  between  many 
general  and  special  subjects,  it  seems  essential  that  certain  conditions  should 
be  closely  adhered  to.  These  are — first,  careful  condensation,  without  omission, 
that  the  whole  subject  may  be  embraced  between  the  covers  of  one  readily 
handled  volume  ;  second,  limitation  of  the  subject-matter  to  such  practical 
points  as  Etiology,  Symptomatology,  Diagnosis,  and  Treatment  including 
Feeding,  Hygiene,  Therapeutics  and  the  Prevention  of  Disease,  while  avoid- 
ing, so  far  as  possible,  the  insertion  of  references  to  journals  or  authorities, 
of  more  interest  to  those  engaged  in  research  than  to  those  in  active  practice; 
third,  the  selection  of  a  large  stafi"  of  collaborators  from  the  most  important 
medical  centres  of  our  country,  to  secure  for  each  subject  the  care  of  the 
authority  best  fitted  to  portray  it,  to  give  the  work  broadness  and  stamp  it 
with  a  national,  rather  than  a  sectional,  imprint ;  fourth,  so  to  time  the  pub- 
lication that,  without  undue  haste,  each  article  contributed  should  have  the 
same  freshness,  and  the  book  as  a  whole  be  thoroughly  abreast  with  the  rapid 
advance  which  is  constantly  made  in  this  branch  of  our  profession ;  finally, 
the  addition  of  chapters  upon  certain  subjects  which,  though  usually  treated 
specially  and  separately,  constantly  come  under  the  notice  of  those  who  work 
with,  or  study,  the  ills  of  childhood,  such  as  diseases  of  the  eye,  the  ear, 
the  skin,  the  nose  and  throat,  and  the  anus  and  rectum ;  circumcision, 
tracheotomy,  intubation,  vesical  calculus,  venereal  disease  and  allied  subjects. 
These  conditions  we  have  endeavored  to  fulfil. 


vi  PREFACE. 

In  conclusion,  the  Editor  desires  to  thank  individually  the  collaborators  he 
has  been  so  very  fortunate  in  securing,  and  to  tender  them,  in  advance,  the 
greater  share  of  whatever  credit  may  attend  the  venture.  His  thanks  are 
also  due  to  Dr.  Thompson  S.  Westcott  for  his  most  efficient  and  interested 
assistance. 

LOUIS   STARR. 

1818    RiTTENHOUSE    SQrARE. 

Philadelphia. 


LIST   OF   CONTRIBUTORS. 


SAMUEL   S.  ADAMS,  A.M.,  M.  D., 

Professor  of  Diseases  of  Infancy  and  Childhood,  Georgetown  University,  Washing- 
ton, D.  C. 

JOHN  ASHHURST,  Jr.,  M.  D., 

Barton  Professor  of  Surgery,  and  Professor  of  Clinical  Surgery,  University  of  Penn- 
sylvania. 

A.  D.  BLACKADER,  M.  D., 

Professor  of  Pharmacology  and  Therapeutics,  and  Lecturer  on  Diseases  of  Children, 
McGill  University,  Montreal,  Canada. 

DAVID   BOVAIRD,  M.  D., 

Clinical  Assistant  to  the  Chair  of  Diseases  of  Children,  Bellevue  Hospital  Medical 
College,  New  York. 

DILLON   BROWN,  M.  D., 

Adjunct  Professor,  Department  of  Diseases  of  Children,  New  York  Polyclinic;  Visiting 
Physician  to  Episcopal  Orphan  Asylum,  New  York. 

EDWARD   M.  BUCKINOHAM,  M.  D., 

Instructor  in  Diseases  of  Children,  Harvard  University. 

CHARLES   W.  BURR,  M.  D., 

Clinical  Professor  of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia. 

WM.  E.  CASSELBERRY,  M.  D., 

Professor  of  Laryngology  and  Ehinology  in  the  Chicago  Medical  College. 

HENRY   DWIGHT   CHAPIN,  M.  D., 

Professor  of  Diseases  of  Children  in  the  New  York  Post-Graduate  Medical  School  and 
Hospital. 

W.  S.  CHRISTOPHER,  M.  D., 

Professor  of  Paediatrics,  College  of  Physicians  and  Surgeons,  Chicago. 

ARCHIBALD    CHURCH,  M.  D., 

Professor  of  Neurology,  Chicago  Polyclinic,  and  Professor  of  Mental  Diseases  and 
Clinical  Neurology  in  the  Chicago  Medical  College, 

FLOYD   M.  CRANDALL,  M.  D., 

Adjunct  Professor,  Department  of  Diseases  of  Children,  New  York  Polyclinic. 

ANDREW   F.  CURRIER,  M.  D., 

Assistant  Gynaecologist,  Skin  and  Cancer  Hospital,  New  York ;  Visiting  Gynaecologist, 
Out-door  Poor  Department,  Bellevue  Hospital,  New  York;  Consulting  Gynaecol- 
ogist, McDonough  Memorial  Hospital,  New  York. 

ROLAND    G.  CURTIN,  M.  D., 

Consulting  Physician  to  the  Push  Hospital  for  Consumptives,  St.  Timothy's,  and  Doug- 
las Hospitals,  Philadelphia. 


viii  LIST   OF    CONTRIBUTORS. 

J.  M.  D.vCUrSTA,  M.  D..  LL.D., 

Emeritus  Professor  of  I'raciice  of  Medicine  and  Clinical  Medicine,  Jefferson  Medical 
College,  Philadelphia. 

I.  N.  DANFOKTII.  A.M..  M.  I)., 

Professor  of    Principles  and   Practice  of  Medicine  and  of  Clinical   Medicine,  North- 
western  Liiiversity,  Wonian'b  Medical  School,  Chicago. 

EDWAHD    P.   DAVIS,  A.M..  M.  D., 

Professor  of  Obstetrics.  .IeHer>on  Medical  College,  Philadelphia;  Professor  of  Obstetrics 
and  Diseases  of  Infancy,  Philadelphia  Polyclinic. 

JOHN   B.  DEAVER,  M.D.. 

Assistant  Professor  of  .Applied  Anatomy  in  the  University  of  Pennsylvania;  Professor 
of  Surgery  in  the  Philadelphia  Polyclinic. 

GEORGE   E.   DE  SCIIWEINITZ,  M.  D.. 

Professor  of  Ophthalmology,  Jeflerson  Medical  Collie,  Philadelphia. 

JOHN   DORNING,  M.D., 

Instructor  in  Diseases  of  (  hildren  in  the  New  York  Post-Gradnate  Medical  School  and 
Hospital;  Attending  Physician  to  Demilt  Dispensary,  New  York. 

CHAS.  WARRINGTON   EARLE,  M.  1)., 

Late  Professor  of  Diseases  of  Children,  Woman's  Medical  College,  Chicago. 

WM.  A.  EDWARDS,  M.  D., 

San  Diego,  Cal. 

FREDERICK    FORCHHEIMER,  M.  D., 

Professor  of  Practice  of  Medicine  and  Diseases  of  Children,  Medical  College  of  Ohio. 

J.  HENRY   FRUITNIGHT,  A.M..  M.  D. 

Attending  Physician  to  St.  John's  Guild  Hospital  for  Children,  New  York. 

J.  r.  CROZER    GRIFFITH.  M.  D.. 

Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 

WM.  A.  HARDAWAY,  A.M..  M.  D.. 

Professor  of  Diseases  of  the  Skin  and  Syphilis,  Missouri  Medical  College,  St.  Louis. 

MARCUS    P.  HATFIELD,  M.  D., 

Emeritus  Professdr  of  Diseases  of  Children,  Chicago  Medical  College. 

BARTON   COOKE    HIRST.  M.  D., 

Professor  of  Obstetrics.  University  of  Pennsylvania. 

H.  ILLOWAY,  M.D., 

Professor  of  Diseases  of  Children,  Cincinnati  College  of  Medicine  and  Surgery. 

HENRY   JACKSON,  M.  D., 

Physician  to  Out-Patient  Department,  Boston  City  Hospital. 

CHAS.  G.  JENNINGS,  M.D., 

Professor  of  Practice  of  Medicine  and  Diseases  of  Children,  Detroit  College  of  Medi- 


LIST   OF    CONTRIBUTORS.  ix 

HENRY   KOPLIK,  M.  D., 

Attending  Physician,  Good  Samaritan  Dispensary,  New  York;  Adjunct  Attending 
Physician,  Mt.  Sinai  Hospital  (Children),  New  York. 

THOMAS    S.  LATIMER,  M.  D., 

Professor  of  Principles  and  Practice  of  Medicine,  College  of  Physicians  and  Surgeons, 
Baltimore. 

ALBERT   R.  LEEDS,  Ph.D., 

Professor  of  Chemistry,  Stevens  Institute  of  Technology,  Hoboken. 

J.  HENDRIE   LLOYD,  A.M.,  M.D., 

Neurologist  to  the  Philadelphia  Hospital  ;  Physician  to  the  Methodist  Episcopal  Hospi- 
tal and  to  the  Home  for  Crippled  Children,  Pliiladelphia. 

GEO.  ROE   LOCKWOOD,  M.  D., 

Professor  of  Principles  and  Practice  of  Medicine,  Woman's  Medical  College  of  New 
York  Infirmaiy. 

HENRY   M.  LYMAN,  M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine,  Kush  Medical  College,  Chicago. 

FRANCIS    T.  MILES,  M.  D., 

Professor  of  Physiology,  and  Clinical  Professor  of  Diseases  of  the  Nervous  System, 
University  of  Maryland. 

CHAS.  K.  MILLS,  M.  D., 

Professor  of  Mental  Diseases  and  of  Medical  Jurisprudence,  University  of  Pennsyl- 
vania; Professor  of  Diseases  of  the  Mind  and  Nervous  System,  Philadelphia 
Polyclinic. 

JAMES   E.  MOORE,  M.  D., 

Professor  of  Orthopedia  and  of  Clinical  Surgery,  University  of  Minnesota. 

F.  GORDON   MORRILL,  M.  D., 

Visiting  Physician  to  Children's  Hospital,  Boston. 

JOHN   H.  MUSSER,  M.  D., 

Assistant  Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 

THOMAS   R.  NEILSON,  M.  D., 

Professor  of  Genito-urinary  Surgery,  Philadelphia  Polyclinic. 

WM.  PERRY   NORTHRUP,  M.  D., 

Professor  of  Paediatrics,  Bellevue  Hospital  Medical  College,  New  York. 

WM.  OSLER,  M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University,  Bal- 
timore. 

FREDERICK   A.  PACKARD,  M.  D., 

Instructor  in  Clinical  Medicine,  University  of  Pennsylvania,  and  Visiting  Physician  to 
the  Children's  Hospital,  Philadelphia. 

WM.  PEPPER,  M.D.,  LL.D., 

Professor  of  the  Theory  and  Practice  of  Medicine  in  the  University  of  Pennsylvania. 

FREDERICK   PETERSON,  M.  D., 

Clinical  Professor  of  Mental  Diseases,  Woman's  Medical  College  of  the  New  York 
Infirmary. 


X  LIST   OF    CONTRIBUTORS. 

WM.  T.  PLANT,  M.D., 

Emeritus  Professor  of  Psediatrics,  Syracuse  University,  New  York. 

WM.  M.  POWELL,  M.D., 

Attending  Pliysician  to  the  Mercer  Memorial  Home,  Atlantic  City. 

B.  K.  RACHFORD,  M.i)., 

Professor  of  Physiology  and  Clinician  to  Children's  Clinic,  Medical  College  of  Ohio. 

B.  ALEXANDER   RANDALL,  A.  M.,  M.  D., 

Clinical  Professor  of  Diseases  of  the  Ear,  University  of  Pennsylvania. 

EDWARD   0.  SHAKESPEARE,  A.M.,  M.  D.,  Ph.D., 

Late  Pathologist  to  the  Philadelphia  Hospital ;  late  United  States  Commissioner  to  In- 
vestigate Cholera;  late  United  States  Commissioner  to  the  International  Sanitary 
Conference  of  Paris. 

FREDERICK    C.  SHATTUCK,  M.  D.. 

•Jackson  Professor  of  C  linical  Medicine  in  Harvard  University. 

J.  LEWIS    SMITH,  M.D., 

Late  Professor  of  Diseases  of  Children,  Bellevue  Hospital  Medical  College,  New  York. 

M.  ALLEN   STARR,  M.  D., 

Professor  of  Diseases  of  the  Mind  and  Nervous  System,  College  of  Physicians  and  Sur- 
geons, New  York. 

LOUIS    STARR,  M.  D., 

Consulting  Psediatrist  to  the  Maternity  Hospital,  Philadelphia  ;  Late  Clinical  Professor 
of  Diseases  of  Children,  University  of  Pennsylvania. 

CHARLES   W.  TOWNSEND,  M.D., 

Physician  to  Out-Patients  at  Massachusetts  General,  Children's,  and  Boston  Lying-in 
Hospitals. 

JAMES    TYSON,  M.  D.. 

Professor  of  Clinical  Medicine,  University  of  Pennsylvania. 

W.  S.  THAYER,  M.D., 

Associate  Professor  of  Medicine,  Johns  Hopkins  University ;  Resident  Physician  to  the 
Johns  Hopkins  Hospital,  Baltimore. 

VICTOR    C.  VAUGHAN,  M.  D., 

Professor  of  Hygiene  and  Physiological  Chemistry,  University  of  ilichigan. 

THOMPSON   S.  WESTCOTT,  M.D., 

Instructor  in  Disenses  of  Children,  L'nivei-sity  of  Pennsylvania;  Assistant  Physician  to 
the  Children's  Hospital,  Philadelphia. 

HENRY   R.  WHARTON,  A.M..  M.  D., 

Lecturer  on  Surgical  I)iseases  of  Cliildren  and  Demonstrator  of  Surgery,  L'niversity  of 
Pennsylvania  ;  Surgeon  to  the  Children's  Hospital,  Philadelphia. 

J.  WILLIAM    WHITE.  M.  D., 

Professor  of  Clinical  Surgery,  University  of  Pennsylvania. 

JAMES    C.  WILSON,  M.  D  , 

Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medicine,  Jefferson  Medical 
College,  Philadelphia. 


CONTENTS. 


INTRODUCTION. 

Page 
THE    CLINICAL    INVESTIGATION    OF    DISEASE    AND    THE    GENEKAL 

MANAGEMENT  OF  CHILDEEN.     By  Louis  Starr,  M.  D 1 

Feeding. — Bathing. — Clothing. — Sleep. 

THE    CHEMISTRY    OF    MILK    AND  OF  AETIFICIAL    FOODS    FOR    CHIL- 
DREN.    By  Albert  E.  Leeds,  Ph.  D 37 

MODIFIED  MILK  AND  PERCENTAGE  MILK-MIXTURES.     By  Thompson  S. 

Westcott,  M.  D 53 

SEA-AIR  AND  SEA-BATHING  IN  CONVALESCENCE.     By  W.   M.    Powell, 

M.D 60 


PART  I. 

INJURIES   INCIDENT   TO   BIRTH   AND   DISEASES   OF   THE    NEW-BORN. 
By  Edward  P.  Davis,  A.  M.,  M.  D 

Caput  Succedaneum. — Cephalhaematoma. — Hsematoma  of  the  Sterno-cleido-mastoid  Mus- 
cle.— Haemorrhage  in  the  New-born. — Asphyxia.— Haemorrhages  fi'om  Mucous  Sur- 
faces.— Obstetric  Paralysis  and  Injuries  to  the  Nervous  System. — Fractures  and  Dislo- 
cations of  the  Trunk  and  Extremities. — Umbilical  Haemorrhage. — Umbilical  Polypi. 
— Umbilical  Hernia. — Gastro-intestinal  Haemorrhage. — Icterus  Neonatorum. — The 
Infections  attacking  the  New-born. — General  Septic  Infection. — Erysipelas.— Acute 
Peritonitis  in  the  New-born. — Tubercular  and  Typhoid  Infections. — Inspiration 
Pneumonia. — Tetanus. — Mastitis. — Infections  of  the  Blood. — Meltena  Neonatorum. 


PART   II. 

TBE  DIATHETIC  DISEASES. 

LITH^MIA.    By  B.  K.  Eachford,  M.  D 94 

HEREDITARY  SYPHILIS.     By  Henry  Dwight  Chapin,   M.  D 103 


xii  CONTENTS. 

PART    III. 

THE   INFECTIOUS   DISEASES. 

Page 

MEASLES.     By  Louis  Starr,  M.  D 117 

SCARLET  FEVER.     By  Marcus  P.  Hatfield,  M.  D 131 

RUBELLA.     By  Wm.  T.  Plant,  M.  D 152 

CHICKEN-POX.     By  Wm.  T.  Plant,  M.  D 156 

VARIOLA    AND  VARIOLOID.     By  C.  G.  Jennings,  M.  D 163 

VACCINIA.    By  Thompson  S.  Westcott,  M.D 171 

PAROTITIS.     By  Andrew  F.  Currieh,  M.  D 177 

WHOOPING-COUGH.     By  J.  P.  Crozer  Griffith,  M.  D 182 

TYPHOID  FEVER.     By  F.  Gordon  Mokrill,  M.  D 194 

EPIDEMIC  CEREBRO-SPINAL  MENINGITIS.    By  Roland  G.  Ccrtin,  M.D.  .    .  208 

EPIDEMIC  INFLUENZA.    By  Chas.  Warrington  Earle,  M.  D 214 

ERYSIPELAS.     By  Frederick  A.  Packard,  M.  D 221 

CHOLERA.     By  E.  O.  Shakespeare,  M.  D 231 

DIPHTHERIA.     By  Dillon  Brown,  M.  D 250 

TUBERCULOSIS.    By  Wm.  Osler,  M.  D.,  M.  R.  C.  P 270 

MALARIAL  FEVER.     By  AV.  S.  Thayer.  M.  D 303 


PART   IV. 

GENERAL    DISEASES   NOT  INFECTIOUS. 

RACHITIS.     By  J.  Lewis  Smith,  M.  D 319 

RHEUMATISM.     By  J.  M.  DaCosta,  M.  D.,  LL.D 351 


PART   V. 

DISEASES    OF    THE   BLOOD. 

AN.EMIA,  SPLENIC  AN.EMIA,  LYMPHATIC   AN-EMIA,  AND   LEUKAEMIA. 

By  Frederick  A.  Packard,  M.  D 359 

HAEMOPHILIA.     By   Wm.  Perry   Northrup,  M.  D 377 

PURPURA  HiEMORRHAGICA.    By  Geo.  Roe  Lockwood,  M.D 379 

SCORBUTUS.    By  Wm.  P.  Northrup,  M.  D.,  and  David  Bovaird,  M.  D 389 


CONTENTS.  xiii 

PART   VI. 

DISEASES  OF  THE  DIGESTIVE  OBGANS. 

Page 
I.  DISEASES  OF  THE  MOUTH ;   11.  DENTITION.     By  F.  Forchheimer,  M.  D.  396 

Stomatitis  Catarrhalis. — Stomatitis  Aphthosa. — Stomatitis  Mycosa. — Stomatitis  Ulcerosa. 
— Stomatitis  Gangrenosa. — Stomatitis  Crouposa  and  Diphtheritica. — Stomatitis 
Syphilitica. — Dentition. 

DISEASES  OF  THE   PHARYNX  AND  NASO-PHARYNX.      By  W.  E.  Cassel- 

BERRY,  M.  D 415 

Acute  Pharyngitis  and  Naso-pharyngitis. — Simple  Chronic  Pharyngitis  and  Elongation 
of  Uvula. — Chronic  Folliculous  Pharyngitis. — Acute  Folliculous  Tonsillitis. — Peri- 
tonsillar Abscess  or  Suppurative  Tonsillitis. — Hypertrophy  of  the  Tonsils. 

GASTRIC  CATARRH  (ACUTE  AND  CHRONIC) ;  GASTRIC  ULCER.    By  A.  D. 

Blackader,  M.  D.  .    .    .  • 441 

MUCOUS  DISEASE  (CHRONIC  GASTRO-INTESTINAL  CATARRH).    By  W.  A. 

Edwards,  M.  D 454 

DIARRHCEAL  DISEASES.     By  Victor  C.  Vatjghan,  M.  D 463 

Acute  Intestinal  Indigestion. — Chronic  Intestinal  Indigestion. — Milk  Infection,  Acute, 
Subacute. 

INFLAMMATION     OF    COLON    AND    RECTUM     (DYSENTERY).      By  S.   S. 

Adams,  M.  D 485 

CHRONIC  CONSTIPATION.     By  J.  Henry  Fruitnight,  A.  M.,  M.  D 496 

SIMPLE   ATROPHY.     By  Louis  Starr,  M.  D 503 

DISEASES  OF  THE  C^CUM  AND  APPENDIX.     By  John  Ashhurst,  Jr.,  M.  D.  509 

INTUSSUSCEPTION.     By  John  Ashhurst,  Jr.,  M.  D 517 

INTESTINAL   PARASITES.     By  Chas.  W.  Townsend,  M.  D 524 

DISEASES  OF  THE   LIVER.     By  John  H.  Musser,  M.  D 538 

Jaundice. — Congestion  of  the  Liver. — Fatty  Liver. — Amyloid   Disease  of  the  Liver. 

— Syphilitic  Inflammation  of  the  Liver. — Suppurative  Hepatitis. — Hydatid  Disease. 

— Cirrhosis  of  the  Liver. 

PERITONITIS,  TUMORS    OF  THE    PERITONEUM    AND    OMENTUM,   AND 

ASCITES.      By  J.  Henry  Fruitnight,  A.  M.,  M.  D 563 

CONGENITAL   INTESTINAL   MALFORMATIONS,    AND   DISEASES  OF  THE 

ANUS  AND  RECTUM.     By  Henry  R.  Wharton,  M.  D 575 

Pruritus  Ani. — Syphilitic  Affections  of  the  Anus. — Vegetations  and  Warts. — Fistula  in 
Ano. — Fissure  of  the  Anus. — Stricture  of  the  Anus. — Marginal  Abscess. — Diph- 
theria of  the  Anus. — Proctitis  and  Periproctitis. — Ischio-rectal  Abscess. — Ulceration, 
Stricture,  and  Syphilis  of  the  Rectum. — Prolapsus  of  the  Rectum. — Haemorrhoids. — 
Polypus  and  Nsevus  of  the  Rectum. — Malignant  Diseases  of  the  Rectum. — Wounds 
of,  and  Foreign  Bodies  in,  the  Rectum. 


PART  VII. 


DISEASES  OF  THE  NEBVOUS  SYSTEM. 

SIMPLE  CEREBRAL   MENINGITIS.     By  Thos.  S.  Latimer,  M.  D 596 

SIMPLE  CEREBRO-SPINAL  MENINGITIS.     By  Thos.  S.  Latimer,  M.  D,  .    .    .    605 


xiv  CONTENTS. 

Page 
TUBERCULOUS  MENINGITIS.    By  James  Hendbie  Lloyd,  M.  D 610 

HYDROCEPHALUS.     Bv  James  Hendrie  Lloyd,  M.  D 624 

ABSCESS  OF  THE  BRAIN.    By  Frederick  Peterson,  M.  D 630 

TUMORS  OF  THE  BRAIN  AND  MENINGES.     By  Frederick  Peterson,  M.  D.   634 

THE    AFFECTIONS    OF    THE  NERVOUS    SYSTEM    DUE    TO    INHERITED 

SYPHILIS.    By  Chas.  W.  Burr,  M.  D 645 

INFANTILE  CEREBRAL  PALSIES.     By  Frederick  Peterson,  M.  D 649 

SPEECH  DEFECTS  AND  ANOMALIES.     By  Chas.  K.  Mills,  M.  D 658 

IDIOCY  AND  IMBECILITY.     By  Chas.  K.  Mills,  M.  D 667 

CRETINISM.    By  Chas.  K.  Mills,  M.  D 680. 

MYOTONIA,  OR  THOMSEN'S   DISEASE.    By  Chas.  K.  Mills,  M.  D 687 

ACROMEGALY.    By  Chas.  K.  Mills,  M-  D 690 

ATHETOSIS  AND  ATHETOID   AFFECTIONS.    By  Chas.  K.  Mills,  M.  D.    .    .  694 

INSANITY    IN    CHILDREN.     By  Chas.  K.  Mills,  M.  D 697 

IMPERATIVE    MOVEMENTS,    HEAD-NODDING,   ETC.      By  Chas.   K.  Mills, 

M.  D 712 

HEADACHE.     By  Chas.  K.  Mills,  M.  D 718 

HYSTERIA.     By  James  Hendrie  Lloyd,  M.  D 727 

CONVULSIONS.     By  Frederick  Peterson,  M.  D 741 

EPILEPSY.    By  James  Hendrie  Lloyd,  M.  D 747 

CHOREA.    By  M.  Allen  Starr,  M.  D.,  Ph.  D 754 

TETANY.     By  Henry  M.  Lyman,  M.  D 764 

PSEUDO-HYPERTROPHIC   MUSCULAR   PARALYSIS.      By  F.  T.  Miles,  M.  D.  768 

FACIAL  PARALYSIS,  AND  FACIAL  HEMIATROPHY.  By  Chas.  W.  Burr,  M.D.  774 

INFLAMMATORY  DISEASES  OF  THE  SPINAL    MENINGES  AND   SPINAL 

CORD.    By  Archibald  Church,  M.  D 777 

ACUTE  ANTERIOR  POLIOMYELITIS.    By  Archibald  Church,  M.  D.     ...    789 

LANDRY'S  PARALYSIS.     By  Archibald  Church,  M.  D 798 

TUMORS  OF  THE  SPINAL  CORD.     By  James,  Hendrie  Lloyd,  M.  D 801 

SYRINGOMYELIA  AND  HYDROMYELIA.      By  James  Hendrie  Lloyd,  M.  D.  809 

HEREDITARY"   ATAXIA.     By  Archibald  Church,  M.  D 815 

RAYNAUD'S  DISEASE.     By  Thompson  S.  Westcott,  M.  D 820 

PART   VIII. 

DISEASES    OF    THE   RESPIRATORY  SYSTEM. 

DISEASES  OF  THE  NOSE.     By  W.  E.  Casselberry,  M.  D 826 

Acute  Rhinitis. — Simple  Chronic  Rhinitis  and  Purulent  Rhinitis. — Hypertrophic 
Rhinitis. — Atrophic  Rhiniti.s. — Nasal  Myxomata. — Hereditary  Syphilis  of  the  Nose 
and  Throat. 

CATARRHAL   LARYNGITIS  (SPASMODIC   CROUP).     By  H.  Illoway,  M.  D.  .    844 

LARYNGISMUS  STRIDULUS.     By  H.  Illoway,  M.  D 857 

FOREIGN  BODIES  IN  LARYNX  AND  TRACHEA.    By  John  B.  Deaver,  M.D.  865 


CONTENTS.  x\ 

TEACHi:OTOMY.     By  Hexey  E.  Whaetox,  M.  D 870 

INTUBATIOX  OF  LAEYX'X.     By  Hexry  E.  Wharton,  M.  D 891 

POST-X^ATAL  ATELECTASIS.     By  S.  S.  Adams,  M.  D ;   .    .  899 

BEO^XHO-P^'E^MOXIA.     By  William  Pepper,  M.  D 904 

CEOUPOUS   PXEUMOXIA.     By  William  Pepper,  M.  D 913 

GANGEEXE  A^Tf  ABSCESS   OF    THE   LL3G.     By  Henry  Jackson,  M.  D.  .    .  919 

BEONCHITIS.    By  W.  S.  Christopher,  M.  D 994 

PLEUEISY  AND  EMPYEMA.     By  Henry  Koplie,  M.  D 935 

PULMOXAEY  EMPHYSEMA.     By  John  Doening,  M.  D 950 

BEOXCHIAL  ASTHMA.     By  John  Dorning,  M.  D 956 

FIBEOID  PHTHISIS.     By  Frederick  C.  Shattuck,  M.  D 963 


PAET   IX. 

DISEASES  OF  THE  HEART. 

CONGENITAL    AFFECTIONS    OF    THE    HEAET.      By  Barton  Cooke   Hirst, 

M.  D. 968 

OEGANIC  DISEASE   OF  THE  HEAET.    By  Floyt)  M.  Crandall,  M.  D.   .    .    .    974 
Pericarditis. — Acute  Endocarditis. — Chronic  Heart  Disease. 

FLTsXTIONAL  AFFECTIONS  OF  THE  HEAET  (THE  CAEDIAC  NEUEOSES). 

By  J.  C.  Wilson,  M.  D 986 


PART   X. 

DISEASES  OF  THE  GENITO-VBINARY SYSTE3L 
H^MATUEIA,  PYUEIA,  ENURESIS,  Etc.    By  E.  M.  Buckingham,  M.  D.     .   .    991 

DIABETES  MELLITUS,  DIABETES  INSIPIDUS,  AND  LITHIASIS.     By  James 

Tyson,  M.  D 999 

ACUTE    AND    CHEONIC    NEPHEITIS,    AND  AMYLOID    DISEASE  OF  THE 

KIDNEY.    By  I.  N.  Danforth,  M.  D 1011 

TUMOES  AND  OTHEE    ENLAEGEMENTS  OF  THE  KIDNEY.      By  Thomas 

E,  Neilson,  M.  D 1027 

Eenal  Cysts. — Hydroneplirosis. — Pyonephrosis. — Perinephritic  Abscess. — Tumors  of  the 
Kidney. 

VESICAL   CALCULUS.     By  J.  AVilliam  White,  M.  D 1038 

GONOEEHCEA   AND  YULYO- VAGINITIS.     By  J.  William  White,  M.  D.    .    .  1053 

PHIMOSIS,  ADHEEENT  PEEPUCE,  PAEAPHIMOSIS.     By  Henry  E.  Whar- 
ton, M.  D -  1057 

PART  XL 

OETHOP^DICS.    By  James  E.  Moore,  M.  D 1062 


xvi  CONTENTS. 

PART   XIL 

Page 

DISEASES  OF  THE  SKIN.     By  W.  A.  Hardaway,  M.  D 1090 

I.  Disorders  of  the  Glands:  Sebaceous  Glands:  Seborrhoea, Comedo,  Acne,  Milium. 

Sweat- Glands:  Hyperidrosis,  Miliaria. 
II.  Inflammations:  Erythema  Simplex,  Erythema  Multiforme,  Herpes  Iris,  Erythema 
Nodosum,  Relapsing  Scarlatiniform  Erythema,  Eczema,  Lichen  Planus,  Psoriasis, 
Pemphigus,  Herpes  Simplex,  Herpes  Zoster,  Impetigo  Contagiosa,  Dermatitis 
Exfoliativa  Neonatorum,  Dermatitis  Gangrenosa  Infantum  (Crocker),  Urticaria 
Pigmentosa,  Pityriasis  Rosea,  Prurigo,  Furunculus. 

III.  HEMORRHAGES:  Purpura. 

IV.  Hypertrophies:   Lentigo,   Ichthyosis,   Molluscum    Epitheliale,    Verruca,  Nfevus 

Pigmentosus,  Sclerema  Neonatorum,  Scleroderma,  Morphcea. 
V.  Atrophies:  Albinism,  Leucoderma,  Alopecia  Areata. 
VI.  New  Growths:    Kaposi's   Disease,    Nfevus  Vascularis,  Lupus  Vulgaris,  Scrofulo- 
derma, Syphiloderma. 
VII.  Parasitic  Affections:  Tinea  Favosa,  Tinea  Trichophytina,  Scabies,  Pediculosis. 


PART   XIII. 

DISEASES  OF  THE   EAR.     By  B.  Alexander  Randall,  A.  M.,  M.  D 1158 

I.  Affections  of  the  External  Ear  :  Eczematous  Inflammations,  Furuncle,  Ceru- 
men Impaction,  Foreign  Bodies,  Caries  of  the  Wall  of  the  Auditory  Canal,  Congeni- 
tal Atresia. 
II.  Affections  of  the  Middle  Ear  :  Acute  Simple  Inflammation  of  Middle  Ear, 
Acute  Suppurative  Inflammation  of  Middle  Ear,  Chronic  Suppuration  of  Middle 
Ear. 
III.  Affections  of  the  Internal  Ear. 


PART   XIV. 

DISEASES  OF  THE   EYE.     By  G.  E.  de  Schweinitz,  M.  D 1178 

I.  Diseases  of  the  Lids  :  Abscess  and  Furuncle,  Hordeolum,  Exanthematous  Erup- 
tions, Blepharitis,  Phthiriasis,  Syphilis  of  the  Eyelids,  Tumors  and  Hypertrophies, 
Tarsitis,  Blepharospasm,  Ptosis,  Lagophthalmos,  Symblepharon,  Trichiasis  and  Dis- 
tichiasis.  Entropion,  Ectropion,  Milium,  Molluscum  Contagiosum,  Sebaceous  and 
Dermoid  Cysts,  Injuries  of  the  Eyelids,  Emphysema  of  the  Eyelids. 
II.  Diseases  of  the  Conjunctiva:  Simple  Conjunctivitis,  Purulent  Conjunctivitis, 
Diphtheritic  Conjunctivitis,  Spring  Catarrh,  Follicular  Conjunctivitis,  Granular  Con- 
junctivitis, Ecchymosis  of  Conjunctiva,  Chemosis,  Tumors  and  Cysts,  Tubercle, 
Injuries,  Phlyctenular  Kerato-Conjunctivitis. 

III.  Diseases  of  the  Cornea  :  Ulcer,  Kerato-malacia,  Interstitial  Keratitis,  Injuries, 

Foreign  Bodies. 

IV.  Diseases  of  the  Iris  and  Ciliary  Body  :    Iritis,  Gumma  of  Iris,  Injuries  to 

the  Iris  and  Ciliary  Region,  Sympathetic  Irritation  and  Sympathetic  Inflammation. 
V.  Diseases  of  the  Lachrymal  Apparatus  :  Dacryoadenitis,  Dacryocystitis,  Lach- 
rymal Abscess. 
VI.  Diseases  of  the  Orbit  :  Periostitis,  Cellulitis,  New  Growths. 
VII.  Congenital  Cataract. 
VIII.  The  Refraction  of  the  Eye  in  Childhood. 
IX.  Strabismus,  or  Squint. 


A'N  AMERICAN  TEXT-BOOK 


DISEASES  OF  CHILDREN. 


mTRODUCTIOK 


THE    CLINICAL   INVESTIGATION   OF   DISEASE   AND   THE 
GENEEAL   MANAGEMENT   OF   CHILDREN. 


By  LOUIS  STARR,  M.  D., 

PHIIiADELPHIA. 


I.  THE    CLINICAL    INVESTIGATION    OF    DISEASE. 

Early  life  may  be  divided  into  two  periods — namely,  infancy  and  child- 
hood. Infancy  is  the  time  elapsing  between  birth  and  the  complete  eruption 
of  the  milk  teeth,  an  event  that  transpires  about  the  end  of  the  second  year  of 
life ;  childhood  extends  from  this  age  to  the  development  of  puberty,  about  the 
age  of  thirteen  or  fifteen  years. 

Of  the  diseases  that  may  occur  during  these  periods  a  few  are  peculiar  to 
the  time  of  life,  or  are  "  children's  diseases  "  proper ;  others,  while  identical 
in  class  with  the  ordinary  aifections  of  adult  and  mature  years,  are  variously 
modified  in  symptoms  and  course  by  conditions  inherent  to  early  age ;  but  in 
all  the  clinical  investigation  is  beset  with  difficulties  which  the  student  must 
be  prepared  to  overcome.  Thus,  the  absence  of  speech  in  the  infant  deprives 
us  of  the  important  assistance  afforded  by  correctly  described  subjective  symp- 
toms, and  renders  it  necessary  to  look  to  the  mother  or  nurse  for  the  history 
of  an  illness.  In  older  children  the  case  is  little  better,  since  with  them  words 
are  not  prompted  by  sufficient  knowledge  to  be  of  great  service.  Further,  the 
wilfulness,  dislikes,  fear,  and  agitation  of  the  child  are  impediments  which 
must  be  overcome  before  a  satisfactory  examination  can  be  made,  and  which 
will  often  tax  the  skill  and  patience  of  the  physician  to  the  utmost  in  the  over- 
coming. Another  source  of  difficulty  lies  in  the  activity  of  growth  and  devel- 
opment in  infants,  which  renders  them  liable  to  be  affected  by  slight  causes, 
and  makes  disease  sudden  in  its  attack,  short  in  its  course,  and  intense  in  its 
symptoms.  The  rapid  development  of  the  nervous  system  especially  leads  to 
confusion.  The  nerves  bind  every  portion  of  the  frame  in  a  sympathy  so  close 
that  an  affection  of  a  single  part  may  cause  marked  general  disturbance,  and 
local  symptoms  are  often  reflected,  directing  attention  to  organs  very  distant 
from  those  really  diseased.  Finally,  the  extreme  excitability  of  the  nervous 
system  of  healthy  children  often  causes  a  trifling  illness  to  assume  an  aspect  of 
the  greatest  gravity ;  while,  on  the  contrary,  the  depression  of  nervous  sensi- 

1 


2         A3fEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

bility  that  attends  chronic  wasting  diseases  so  obscures  the  symptoms  that  a 
dangerous  intercurrent  affection  may  appear  trifling  or  remain  altogether 
latent. 

On  the  other  hand,  to  offset  these  difficulties,  disease  in  the  child  is  usually 
uncomplicated,  rarely  has  its  course  and  symptoms  modified  by  tissue  lesions 
the  result  of  previous  affections,  and  never  by  vicious  habits,  such  as  the  abuse 
of  stimulants  and  narcotics,  or  by  mental  overwork  and  nerve-strain.  The 
confusing  clement  of  misstated  subjective  symptoms  is  also  absent,  while  cor- 
rect diagnosis  is  greatly  aided  by  the  facility  with  which  physical  examination 
of  the  Avhole  body  may  be  practised. 

In  conducting  the  investigation  it  is  well  to  proceed  in  three  regular  stages, 
as  follows :  1st.  Questioning  the  attendants ;  2d.  Inspecting  the  child ;  3d. 
Physical  examination. 

1.  Questioning  the  Attendants. 

When  the  patient  is  under  eight  or  ten  years  of  age,  the  only  way  of 
obtaining  a  knowledge  of  the  previous  history  and  of  what  may  occur  between 
visits  is  carefully  to  question  the  mother  or  nurse.  The  account  must  be 
patiently  elicited,  and  credited  with  due  reference  to  the  narrator's  intelligence. 
It  is  well  never  entirely  to  discredit  a  statement  without  good  reason,  for  many 
women,  though  weak  and  foolish  in  other  respects,  are  excellent  observers  when 
their  powers  are  guided  by  affection.  Besides,  being  thoroughly  acquainted 
with  their  children's  habits  and  dispositions,  they  will  often  detect  deviations 
from  health  that  the  physician  might  overlook  entirely.  This  part  of  the 
examination,  particularly  when  the  acquaintance  and  good-will  of  the  child 
have  not  previously  been  obtained,  should,  if  possible,  be  made  before  entering 
the  sick-room. 

As  there  are  certain  points  about  which  it  is  always  necessary  to  be 
informed,  the  adoption  of  a  definite  order  of  questioning  is  advisable. 

The  family  history  as  far  back  as  the  parents  should  first  be  ascertained, 
inquiry  being  chiefly  directed  to  the  detection  of  chronic  maladies  and  trans- 
missible diseases,  as  tuberculosis  and  syphilis.  If  any  deaths  have  occurred, 
their  causation  should  be  investigated ;  and  an  inquiry  into  the  occurrence,  or 
the  reverse,  of  previous  stillbirths  is  often  important.  Then  an  outline  of  the 
child's  life  from  birth  up  to  the  date  of  the  illness  in  question  must  be  obtained. 
This  should  include  the  following  items :  The  manner  of  feeding  during 
infancy — whether  at  the  breast  or  from  a  bottle,  and  if  the  latter,  the  com- 
position of  the  food  employed ;  the  date  of  commencement  and  the  regularity 
of  dentition  ;  the  general  state  of  health  in  regard  to  strength  or  weakness  and 
liability  to  illness ;  the  time  of  occurrence  and  the  nature  of  any  prominent 
attack  of  illness,  especially  of  the  eruptive  fevers ;  whether  vaccination  has 
been  performed  or  no ;  the  hygienic  surroundings — for  instance,  the  healthful- 
ness  of  the  locality  of  residence,  the  sort  of  house  and  room  occupied,  and  the 
character  of  the  clothing  and  food.  In  older  children,  if  at  school,  the  time 
devoted  to  study,  and  if  at  labor,  the  nature  and  the  hours  of  work. 

After  this  it  is  necessary  to  fix  the  time  the  attack  in  hand  began.  The 
occurrence  of  some  striking  symptom,  as  convulsions  or  violent  vomiting,  often 
establishes  this  point  beyond  a  doubt ;  but  when  there  is  any  uncertainty  the 
best  plan  is  to  question  back,  day  by  day,  until  a  time  is  reached  at  which  the 
child  was  perfectly  well,  and  to  date  the  onset  from  this  period.  The  most 
common  of  the  general  indications  of  commencing  illness  are  disturbed  sleep 
and  irritability  of  temper. 


CLINICAL   INVESTIGATION   OF  DISEASE.  3 

The  next  step  is  to  learn  the  mode  of  attack  and  the  symptoms  and  course 
of  the  disease  prior  to  the  first  visit.  The  questions  now  must  be  general, 
never  leading.  They  must  be  sufficiently  exhaustive  to  touch  upon  all  the 
functions  of  the  body,  and  when  a  trail  is  started  it  must  be  patiently  followed 
to  the  end.  Alterations  in  sleep,  bodily  strength,  surface  temperature,  appe- 
tite, digestion,  urine  elimination,  respiration,  and  so  on,  must  be  sought  for, 
and  the  account  of  such  deviations  from  the  normal  state  as  vomiting,  diarrhoea, 
or  cough  will  suggest  further  questions,  as  well  as  point  out  the  path  to  be 
followed  in  the  future  examination. 

This  portion  of  the  investigation  is  closed  by  an  inquiry  into  the  treatment 
that  may  have  been  already  adopted. 

2.  Inspecting  the  Child. 

When  the  eye  and  ear  of  the  physician  are  trained  to  their  work,  valuable 
information  can  be  obtained  by  simply  looking  at  an  ill  child  and  listening  to 
its  cry  or  spoken  words.  Even  while  the  child  is  lying  asleep  or  sitting  quietly 
in  the  nurse's  lap  many  facts  may  be  learned ;  but  this  portion  of  the  exami- 
nation is  never  complete  without  an  inspection  of  the  naked  body.  The  points 
thus  ascertained  consist  in  alterations  in  the  expression  of  the  face,  in  decubitus, 
in  the  appearances  of  the  body,  and  so  on,  and  may  be  designated  the  features 
of  disease.  The  relative  position  of  the  observer  and  patient  during  inspection 
is  of  importance.  If  possible,  the  former  should  stand  with  his  back  to,  and 
the  latter  be  so  placed  that  his  face  is  toward,  a  window  or  lamp.  The  light 
must  never  be  strong  enough  to  dazzle  when  the  countenance  is  the  object  of 
inspection,  as  this  causes  distortion  of  the  features. 

For  convenience,  the  features  of  disease  will  be  studied  under  different 
headings ;  and  since  to  appreciate  them  it  is  necessary  to  have  a  knowledge  of 
the  healthy  aspect,  both  the  normal  and  abnormal  appearances  will  be  described. 

Face. — The  face  of  a  healthy  sleeping  child  wears  an  expression  of  perfect 
repose.  The  eyelids  are  completely  closed,  the  lips  slightly  parted,  and  while 
a  faint  sound  of  regular  breathing  may  be  heard,  there  is  no  perceptible  move- 
ment of  the  nostrils.  Incomplete  closure  of  the  lids,  with  more  or  less  exposure 
of  the  whites  of  the  eyes,  is  noted  when  sleep  is  rendered  unsound  by  moderate 
pain  and  during  the  course  of  all  acute  and  chronic  diseases,  particularly  when 
they  assume  a  grave  type.  Twitching  of  the  lids  heralds  the  approach  of  a 
convulsion,  and  at  such  times,  too,  there  is  often  oscillation  of  the  eyeballs  or 
squinting.  A  marked  smile,  due  to  contraction  of  the  muscles  about  the 
mouth,  signifies  abdominal  pain  or  colic,  and  pursing  out  of  the  lips  and  chew- 
ing motions  of  the  jaw,  gastro-intestinal  irritation.  Dilatation  of  the  alse  nasi, 
with  or  without  noisy  breathing,  points  to  embarrassed  respiration,  the  result 
of  extensive  bronchial  catarrh,  pneumonia,  or  pleurisy  with  effusion. 

When  awake  and  passive  the  healthy  infant's  face  has  a  look  of  wondering 
observation  of  whatever  is  going  on  about  it.  As  age  advances  the  expression 
of  intelligence  increases,  and  every  one  is  familiar  with  the  bright,  round, 
happy  face  of  perfect  childhood,  so  indicative  of  careless  contentment  and  so 
mobile  in  response  to  emotions. 

The  picture  is  altered  by  the  onset  of  any  illness,  the  change  being  in  pro- 
portion to  the  severity  of  the  attack.  An  expression  of  anxiety  or  of  suffering 
appears,  or  the  features  become  pinched  and  lines  are  seen  about  the  eyes  and 
mouth.  Pain  most  of  all  sets  its  mark  upon  the  countenance,  and  by  noting 
the  feature  affected  it  is  often  possible  to  fix  the  seat  of  serious  disease.  Thus, 
contraction  of  the  brows  denotes  pain  in  the  head ;  sharpness  of  the  nostrils, 


4         A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

pain  in  the  chest ;  and  a  drawing  of  the  upper  lip,  pain  in  the  abdomen.  As 
a  rule,  the  upper  third  of  the  face  is  modified  in  expression  in  affections  of  the 
brain,  the  middle  third  in  diseases  of  the  chest,  and  the  lower  third  in  lesions 
of  the  abdominal  viscera.  Puffiness  of  the  eyelids  and  a  fulness  of  the  bridge 
of  the  nose  indicate  dropsy,  and  should  direct  attention  to  the  kidneys.  When 
there  is  a  tuberculous  tendency  the  face  is  often  oval,  the  features  delicate,  and 
the  expression  intelligent ;  the  hair  fine  and  silky ;  the  skin  smooth  and  trans- 
parent ;  the  temporal  veins  visible ;  the  eyelashes  long  and  curving,  the  irides 
large  and  deep-colored,  and  the  sclerotics  pearly  white  or  bluish  ;  finally,  a 
growth  of  fine  hair  is  often  noticeable  on  the  temples  and  in  front  of  the  ears. 
On  the  contrary,  the  face  may  be  round  and  heavy  ;  the  complexion  doughy ; 
the  upper  lip  swollen ;  the  nostrils  wide  and  the  alas  of  the  nose  thick  ;  the 
eyelids  swollen  and  reddened  at  their  edges ;  the  hair  coarse ;  and  the 
lymphatic  glands  of  the  neck  enlarged. 

A  marked  disfigurement  of  the  face  may  indicate  one  of  several  diseases, 
according  to  its  character.  For  example,  broadness  or  complete  flatness  of 
the  bridge  of  the  nose  is  significant  of  constitutional  syphilis.  A  large,  square 
head  and  projecting  forehead,  with  a  face  of  natural  size  or  smaller,  show  that 
the  child  has  suffered  from  rickets.  An  immense  globular  head,  overhanging 
forehead,  and  diminutive  face,  with  eyeballs  projected  downward  and  irides 
almost  concealed  by  the  lower  lids,  are  pathognomonic  signs  of  chronic 
hydrocephalus. 

Decubitus. — The  complete  repose  depicted  on  the  countenance  of  a  healthy 
sleeping  child  is  shown  also  by  the  posture  of  the  body.  The  head  lies  easy 
on  the  pillow ;  the  trunk  rests  on  the  side,  slightly  inclined  backward ;  the 
limbs  assume  various  but  always  most  graceful  attitudes,  and  no  movement  is 
observable  but  the  gentle  rise  and  fall  of  the  abdomen  in  respiration.  In  the 
waking  state  the  child,  after  early  infancy,  is  rarely  still.  The  movements  of 
the  arms,  at  first  awkward,  soon  become  full  of  purpose  as  he  reaches  to  handle 
and  examine  various  objects  about  him.  The  legs  are  idle  longer,  though 
these,  too,  soon  begin  to  be  moved  about  with  method,  feeling  the  ground  in 
preparation  for  creeping  and  walking. 

With  the  onset  of  disease  the  scene  changes.  In  acute  attacks  attended 
with  pain  sleep  is  no  longer  restful.  The  infant  is  content  only  when  rocked, 
fondled,  or  "walked"  in  the  nurse's  arms.  The  older  child  tosses  about 
uneasily  in  bed,  or  demands  a  constant  change  from  the  bed  to  the  lap. 
During  the  waking  hours  the  movements  are  purposeless,  quick,  and  impatient, 
the  position  is  constantly  shifted,  and  frequent  whining  complaints  are  made. 
As  a  contrast  to  this  condition  of  jactitation,  at  the  beginning  of  the  specific 
fevers  children  often  lie  quiet  and  drowsy  for  hours.  In  chronic  affections 
attended  with  debility  the  movements  become  slow  and  languid,  and  in  stupor 
and  coma  there  are  perfect  stillness  and  immobility. 

There  are  certain  positions  and  gestures  which  have  especial  significance. 
Sleeping  with  the  head  thrown  back  and  the  mouth  open  is  a  frequent  accom- 
paniment of  chronic  enlargement  of  the  tonsils.  A  tendency  to  "sleep  high  " — 
that  is,  with  the  head  and  shoulders  elevated  by  the  pillow — indicates  impaired 
pulmonary  or  cardiac  function.  So,  too,  does  an  upright  position  in  the  nurse's 
arms,  with  the  chest  against  her  breast  and  the  head  hanging  over  her  shoul- 
der— a  posture  assumed  by  young  children.  "  Sleeping  cool  " — namely,  rest- 
ing only  after  all  the  bed-clothing  has  been  kicked  off — is  an  early  symptom 
of  rickets.  The  position  termed  en  chien  de  fusil  is  a  symptom  of  the  advanced 
stages  of  cerebral  disease,  especially  tubercular  meningitis.  The  child  lies 
upon  one  side,  with  the  head  stretched  far  back,  the  arms  pressed  close  to  the 


CLINICAL   INVESTIGATION   OF  DISEASE.  6 

sides  and  folded  across  the  chest,  the  thighs  drawn  up  toward  the  abdomen,  the 
legs  flexed  on  the  thighs,  and  the  feet  crossed.  Restless  movements  of  the 
head  or  boring  of  the  head  into  the  pillow  also  point  to  cerebral  disease.  A 
retained  position,  as  on  the  back  or  one  side,  together  with  short,  quick  breath- 
inof,  points  to  some  inflammatory  change  in  the  respiratory  or  abdominal  organs. 
Persistent  lying  on  the  face  is  an  evidence  of  photophobia. 

Of  gestures,  the  frequent  carrying  of  the  hand  to  the  head,  ear,  or  mouth 
indicates  headache,  earache,  or  the  pain  of  dentition  respectively,  and  constant 
rubbing  of  the  nose  is  a  feature  of  gastro-intestinal  irritation. 

If  the  thumbs  be  drawn  into  the  palms  of  the  hands  and  the  fingers  tightly 
clasped  over  them,  or  if  the  toes  be  strongly  flexed  or  extended,  a  convulsion 
may  be  expected.  The  presence  of  clonic  contractions  of  the  muscles,  with 
unconsciousness,  indicates,  of  course,  a  convulsion ;  while  irregular,  badly 
co-ordinated,  jerky  movements — consciousness  being  retained — attend  chorea. 
In  infants  the  existence  of  colic  is  shown  by  repeated  extension  and  retrac- 
tion of  the  legs,  clenching  of  the  hands  into  fists,  flexion  and  extension  of 
the  forearms,  and  a  writhing  movement  of  the  trunk.  The  fact  of  one  limb 
remaining  passive  while  the  others  are  actively  moved  about  naturally  sug- 
gests motor  paralysis. 

The  Skin. — In  the  new-born  infant  the  color  of  the  skin  varies  from  a 
deep  to  a  light  shade  of  red.  After  the  lapse  of  a  week  this  redness  fades 
away,  leaving  the  surface  yellowish-white,  and  in  a  fortnight  the  skin  assumes 
its  typical  appearance.  Allowing  for  natural  variations  in  complexion,  the 
skin  of  a  healthy  child  is  beautifully  white,  transparent,  and  velvety.  The 
cheeks,  palms  of  the  hands,  and  soles  of  the  feet  have  a  delicate  pink  color, 
and  the  general  surface  is  rosy  in  a  warm  atmosphere,  marbled  with  faint  blue 
spots  or  lines  in  a  cool  one.  As  age  advances  the  coloring  becomes  more  pro- 
nounced, and  until  the  completion  of  childhood  the  complexion  is  much  fresher 
than  in  adult  life. 

Lividity  of  the  eyelids  and  lips  is  a  sign  of  imperfect  aeration  of  the  blood 
and  points  to  pulmonary  or  cardiac  disease.  Marked  blueness  of  the  whole 
face  is  a  symptom  of  morbus  cceruleus,  and  indicates  a  congenital  malforma- 
tion of  the  heart.  On  the  other  hand,  a  faint  purple  tint  of  the  eyelids  and 
around  the  mouth  shows  weak  circulation  merely,  or,  more  frequently,  deranged 
digestion.  A  decided  yellow  hue  of  the  skin  and  conjunctivae  is  seen  in  jaun- 
dice ;  an  earthy  tinge  of  the  face  in  chronic  intestinal  diseases ;  a  Avaxy  pal- 
lor in  renal  diseases ;  and  paleness  in  any  affection  attended  with  exhaustion. 
Brownish-yellow  discoloration  of  the  forehead  is  significant  of  inherited  syphi- 
lis ;  a  bright,  circumscribed  flush  on  one  or  both  cheeks,  of  inflammation  of 
the  lungs  or  pleura  or  of  gastro-intestinal  catarrh,  according  to  its  occurrence 
with  or  without  an  elevated  temperature. 

In  addition  to  the  cutaneous  lesions  of  the  eruptive  fevers,  each  having  its 
special  characteristics,  an  eruption  of  herpetic  vesicles  on  the  lips  may  be  men- 
tioned as  present  both  in  pneumonia  and  in  malarial  fevers. 

Slight  want  of  proper  aeration  of  the  blood  is  shown  by  blueness  of  the 
finger-nails ;  a  greater  degree,  by  cyanosis  of  the  whole  hand.  Deformity  of 
the  nails  is  a  symptom  of  syphilis ;  clubbing  of  the  fingei'-tips,  of  chronic  lung 
disease ;  and  redness,  swelling,  and  suppuration  about  the  nails,  of  struma. 
The  dropsy  of  scarlatinal  nephritis  causes  a  puffiness  and  cushiony  appear- 
ance of  the  dorsum  of  the  hands.  Often,  too,  in  this  condition,  the  finger-ends 
are  glossy  as  if  smeared  with  oil,  and  there  is  an  exfoliation  of  the  epidermis 
about  the  nails.  The  last  two  symptoms  frequently  serve  to  confirm  a  retro- 
spective diagnosis  of  scarlet  fever. 


6         AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Mode  of  Drinking. — By  -watching  an  infant  taking  the  breast  or  bottle 
some  knowledge  can  be  obtained  of  the  condition  both  of  the  mouth  and 
throat  and  of  the  respiratory  organs. 

If  there  be  any  soreness  of  the  mouth,  the  nipple  is  held  only  for  a 
moment,  and  then  dropped  with  a  cry  of  pain.  When  the  throat  is  affected, 
deglutition  is  performed  in  a  gulping  manner,  an  expression  of  pain  passes 
over  the  face,  and  no  more  efforts  are  made  than  required  to  satisfy  the  first 
pangs  of  hunger.  Under  similar  circumstances  older  children  drink  little  and 
refuse  solid  food  entirely.  An  infant  suffering  from  the  oppression  of  pneu- 
monia or  severe  bronchitis  seizes  the  nipple  with  avidity,  swallows  quickly 
several  times,  and  then  pauses  for  breath.  In  older  patients  the  act  of  drink- 
ing, which  should  be  continuous,  is  interrupted  in  the  same  way. 

If  the  finger  be  put  into  the  mouth  of  a  healthy  baby,  it  will  be  vigor- 
ously sucked  for  some  little  time.  The  diminution  of  the  act  of  suction  dur- 
ing a  severe  illness  is  a  sign  of  danger ;  its  re-establishment  a  good  omen. 
In  conditions  of  stupor  and  coma  it  is  noticeably  absent. 

The  Cry. — Crying  is  the  chief,  if  not  the  only,  means  that  the  young 
infant  possesses  of  indicating  his  displeasure,  discomfort,  or  suffering.  Even 
long  after  the  powers  of  speech  have  been  developed,  the  cry  continues  to  be 
the  main  channel  of  complaint.  It  may  be  accepted  as  a  rule  that  a  healthy 
child  rarely  cries.  Of  course,  some  acute  pain,  as  from  a  fall  or  accident  or 
blow,  will  cause  crying  in  the  most  healthy  child,  but  the  storm  is  quickly 
over.  Incessant,  unappeasable  crying  is  due  to  one  of  two  causes — namely, 
earache  or  hunger — and  the  distinction  may  readily  be  made  by  putting  the 
child  to  the  breast  or  offering  a  properly-prepared  bottle.  The  hydrenceplialic 
cry,  denoting  pain  in  the  head,  is  a  sudden,  sharp,  very  loud,  and  paroxysmal 
shriek.  Crying  during  an  attack  of  coughing  or  for  a  brief  time  afterward, 
and  attended  with  distortion  of  the  features,  indicates  pneumonia.  In  acute 
pleuritis  the  cry  also  accompanies  the  cough,  but  it  is  produced  too  by  move- 
ments of  the  body  and  by  pressure  on  the  affected  side.  It  is  louder,  indica- 
tive of  21'eater  suffering,  and  sometimes  most  difficult  to  check.  Intestinal 
pain  causes  crying  just  before  or  after  an  evacuation  of  the  bowels,  and  is 
associated  with  Avriggling  movements  of  the  body  and  pelvis  and  with  eruc- 
tation or  the  passage  of  flatus.  Conditions  of  general  distress  or  malaise 
predispose  to  fits  of  fretful  crying,  the  paroxysms  being  excited  by  any  dis- 
turbing influence,  or  even  by  merely  looking  at  the  little  sufferer. 

When  the  cry  has  a  nasal  tone,  it  indicates  swelling  of  the  mucous  mem- 
brane of  the  nares  or  other  obstructing  condition.  Thickening  and  indistinct- 
ness occur  with  pharyngeal  affections.  A  loud,  brazen  cry  is  a  precursor  of 
spasmodic  croup.  Hoarseness  points  to  a  lesion  of  the  laryngeal  mucous 
membrane,  either  catarrhal  or  syphilitic  in  nature.  In  membranous  croup 
and  in  some  cases  of  extreme  exhaustion  the  cry  is  faint  and  inaudible. 
Finally,  in  severe  croupous  pneumonia,  in  extensive  pleural  effusion,  and  in 
rickets  ordinary  disturbing  causes  are  inoperative  for  the  production  of  fits 
of  crying,  and  there  is  a  seeming  unwillingness  to  cry,  on  account  of  the 
action  interfering  with  the  respiratory  function. 

The  conditions  of  altered  tone  apply  equally  to  the  articulate  voice  in 
children  who  are  old  enough  to  speak. 

The  cough,  too,  must  not  be  disregarded.  Many  of  its  characters  corre- 
spond with  the  voice  and  cry.  It  is  brazen  in  spasmodic  croup,  suppressed 
in  true  croup,  hoarse  in  laryngeal  catarrh,  and  so  on.  But  it  has  certain  fea- 
tures of  its  own.  In  bronchitis  it  is  more  or  less  paroxysmal,  evidently  dry 
in  the  early  stages,  loose  and  rattling  as  the  catarrh  "breaks  up."     In  the 


CLINICAL    INVESTIGATION   OF  DISEASE.  7 

painful  pulmonary  affections,  pneumonia  and  pleurisy,  it  is  choked  back,  and 
whenever  it  occurs  an  expression  of  pain  passes  like  a  cloud  over  the  face. 
In  pertussis  the  peculiar  spasmodic  cough  is  the  pathognomonic  symptom. 
Cough  is  always  unproductive — that  is,  unattended  by  expectoration — in 
children  under  seven  years  of  age. 

The  formation  of  tears  rarely  begins  before  the  third  or  fourth  month 
of  life.  Subsequently,  an  alteration  in  this  secretion  may  be  of  aid  in  fore- 
casting the  result  of  disease.  The  prognosis  is  bad  when  the  tears  become 
suppressed ;  good  when  the  secretion  continues  during  an  illness  or  when  it 
reappears  after  being  suppressed. 

There  are  several  other  sources  of  information  which  should  be  investi- 
gated before  proceeding  to  the  physical  examination,  although,  strictly  speak- 
ing, they  do  not  come  under  the  head  of  inspection  of  the  child.  These  are 
the  alterations  in  the  odor  of  the  breath,  and  the  characters  of  the  faecal  evacu- 
ations, of  the  urine,  and  of  material  ejected  by  vomiting. 

The  Breath. — The  breath  of  a  healthy  child  is  odorless,  or,  as  the  nurse 
will  say,  "sweet,"  except  perhaps  immediately  after  taking  nourishment,  when 
it  may,  for  a  short  time,  have  the  smell  of  milk  or  other  food.  Any  persist- 
ent odor  is  abnormal. 

Any  morbid  condition  of  the  system  that  prevents  the  elimination  of  meta- 
morphosed nitrogenous  tissue  through  the  mucous  membrane  of  the  intestines 
or  retards  the  passage  of  decomposing  detritus  along  the  bowels  will  cause  an 
offensive  breath.  Under  this  head  are  conditions  characterized  by  high  tem- 
perature, catarrhal  inflammation  of  the  gastro-intestinal  tract,  chronic  debili- 
tating diseases,  etc.  The  same  result  also  frequently  attends  structural  lesions 
of  the  kidneys.  The  reason  for  this  is,  that  the  system,  in  order  to  get  rid 
of  poisonous  matter — for  accumulated  waste  is  poison — and  to  maintain  the 
balance  between  the  constant  construction  and  destruction  of  tissue,  must 
throw  off  elsewhere  what  the  intestinal  glands  and  the  kidneys  fail  to  excrete; 
so  the  lungs  take  on  vicarious  activity  and  the  expired  air  becomes  tainted. 
Purely  local  causes  of  halitosis  also  exist.  These  are  decayed  teeth,  caries 
of  the  nasal  and  maxillary  bones,  ulceration  of  the  mucous  membrane  of  the 
mouth,  nose,  larynx,  trachea,  and  bronchial  tubes,  and  gangrene  of  the  cheeks. 
Chronic  poisoning  by  lead,  arsenic,  or  mercury,  though  not  very  common 
in  childhood,  is  another  cause  of  ill-smelling  breath. 

To  speak  in  general  terms,  the  breath  may  become  sour,  catarrhal,  foetid, 
gangrenous,  ammoniacal,  and  stercoraceous.  Sour  breath  is  present,  in  infants 
more  especially,  when  there  is  gastric  fermentation.  Catarrhal  breath  has 
numerous  shades  of  difference.  In  chronic  catarrh  of  the  pharynx  there  is  a 
"heavy"  odor,  not  noticeable  far  from  the  patient's  face.  It  is  always  most 
marked  during  and  after  sleep.  Should  there  be  associated  follicular  tonsilli- 
tis, the  breath,  while  still  heavy,  becomes  extremely  offensive,  with  a  scent 
somewhat  like  that  of  decaying  cheese,  and  is  very  penetrating.  This  odor, 
too,  is  worse  after  sleeping.  At  the  onset  of  acute  catarrh  of  the  stomach 
the  breath  sometimes  has  a  vinous  odor,  at  others  it  is  sweetish,  and  again  it 
has  the  same  quality  as  after  an  inhalation  of  ether.  Later  in  the  attack  it 
becomes  sour  or  has  the  odor  of  sulphuretted  hydrogen.  What  is  known  as  a 
"  feverish  breath  "  has  a  heavy,  sweetish  smell.  It  is  met  with  in  diseases  of  high 
temperature ;  thus,  it  is  very  marked  and  rapid  in  appearance  in  scarlatina. 

Foetor  of  the  breath  is  observed  in  its  mildest  form  in  such  affections  as 
aphthae  and  ulcerative  stomatitis.  It  is  better  developed  in  ozaena  and  necrosis 
of  thfe  maxillary  bones.  Decaying  teeth  give  much  the  same  odor,  though  it 
is  lees  strong  and  penetrating. 


8         AMEIUCAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Noma  gives  rise  to  a  gangrenous  odor,  and  a  patient  so  affected  will  fill 
the  room  in  which  he  lies,  or  even  a  -whole  dwelling,  with  the  most  sickening 
stench.  Cases  of  empyema,  with  ulceration  of  the  lung  and  discharge  of  pus 
through  the  bronchial  tubes,  have  an  almost  equally  offensive  breath,  but  here 
there  is  often  a  superadded  flavor  of  garlic. 

Ammoniacal  breath  is  observed  only  in  patients  suffering  with  ur?emic 
poisoning.  A  purely  stercoraceous  breath  is  rare,  and  when  met  with  is  an 
accompaniment  of  fiecal  tumor  or  of  intussusception. 

The  different  metallic  poisons  give  rise  to  no  characteristic  odor,  and  it  is 
necessary  to  look  to  the  clinical  history  to  determine  the  special  poison. 

The  F^cal  Evacuations. — The  daily  number  of  evacuations  natural 
for  a  child  varies  greatly  with  its  age.  For  the  first  six  weeks  there  should 
be  three  or  four  stools  every  twenty-four  hours.  After  this  time,  up  to  the 
end  of  the  second  year,  two  movements  a  day  is  the  normal  average.  Sub- 
sequently, the  frequency  of  defecation  is  usually  the  same  as  in  adults — once 
per  diem.  During  the  first  period  the  stools  have  the  consistence  of  thick 
soup,  are  yellowish-white  or  orange-yellow  in  color,  with  sometimes  a  tinge  of 
green,  have  a  faint  faecal,  slightly  sour  odor,  and  are  acid  in  reaction.  In  the 
second  they  are  mushy  or  imperfectly  formed,  of  uniform  consistence  through- 
out, brownish-yellow  in  color,  and  have  a  more  ftecal  odor.  The  last  two  charac- 
ters become  more  marked  as  additions  are  made  to  the  diet.  After  the  comple- 
tion of  the  first  dentition  the  motions  have  the  same  appearance  as  in  adult 
life;  they  diXe formed,  and  brownish  in  color,  with  a  decided  fjecal  odor. 

Many  alterations  occur  in  disease.  The  frequency  of  the  movements  may 
be  increased,  constituting  diarrhoea,  or  lessened,  constituting  constipation.  In 
the  former  condition  the  consistency  is  diminished,  in  the  latter  increased. 
Instead  of  being  uniform  throughout,  the  stool  may  be  mixed,  partly  liquid, 
partly  solid,  indicating  imperfect  digestion,  and  curds  of  milk  and  pieces  of 
undigested  solid  food  may  be  mingled  with  the  mass.  Flaky,  yellowish,  or 
yellowish-green  evacuations,  containing  whitish,  cheesy  lumps,  are  also  met 
in  cases  of  indigestion.  Scanty,  scybalous  stools,  dai'k-brow  n  or  black  in 
color,  and  mixed  with  mucus,  are  characteristic  of  intestinal  catarrh.  Doughy, 
grayish,  or  clay-colored  motions  show  a  deficiency  of  bile.  An  intermixture 
of  blood,  altei'ed  blood-clots,  and  shreds  of  mucous  membrane  indicate  some 
breach  of  continuity  in  the  intestinal  lining,  such  as  occurs  in  follicular  ente- 
ritis, typhoid  fever,  dysentery,  and  tubercular  disease.  Watery,  almost  odor- 
less stools  occur  in  the  latter  stages  of  entero-colitis.  most  offensive,  carrion- 
like motions  in  both  catarrhal  and  tuberculous  ulceration  of  the  intestines, 
and  sour-smelling  evacuations  in  the  diarrhoea  of  sucklings.  The  discovery 
of  worms  or  their  ova  in  the  stools  is  the  certain  evidence  of  the  existence 
of  intestinal  parasites. 

This  outline  of  the  changes  that  may  take  place  will  serve  to  show  how 
much  may  be  learned  from  the  stools,  and  the  importance  of  making  a  per- 
sonal examination  of  them. 

The  Urixe. — It  is  impossible  to  make  a  definite  statement  as  to  the  num- 
ber of  times  the  urine  is  voided  by  a  healthy  infant  in  each  twenty-four  hours. 
In  any  given  case  the  frequency  will  differ  very  much  from  day  to  day,  depend- 
ing upon  the  temperature  of  the  surrounding  air,  the  amount  of  moisture  that 
it  contains,  and  so  on.  Sometimes  it  will  be  necessary  to  change  the  diaper 
every  hour  during  the  day  and  three  or  four  times  at  night.  Again,  it  may 
remain  dry  for  six.  eight,  or  even  ten  hours.  Neither  condition  indicates  dis- 
ease, and  between  the  two  extremes  there  is  a  wide  range  of  variation.  Should 
the  urine  not  be  passed  for  twelve  hours  or  more,  a  careful  examination  should 


CLINICAL   INVESTIGATION    OF  DISEASE.  9 

be  made  to  discover  and  remedy  retention.  As  the  child  grows  older  the  fre- 
quency diminishes,  and  at  the  age  of  three  years  the  number  of  voidin^s  will 
be  reduced  to  six  or  eight  during  the  waking  hours,  and  perhaps  one  at  night. 
When  the  desire  does  arise  during  sleep,  the  child,  if  in  a  normal  state,  wakes 
up  and  demands  the  chamber,  and  never  passes  urine  unconsciously.  Wetting 
the  bed,  therefore,  or  the  involuntary  passage  of  the  urine  during  sleep,  is  indic- 
ative of  an  abnormal  condition  and  requires  investigation.  Painful  micturition 
points  to  inflammation  of  the  urethra,  a  narrow  preputial  orifice,  a  highly  acid 
condition  of  the  excretion,  or  stone  in  the  bladder. 

The  urine  of  a  healthy  infant,  while  it  wets,  should  not  stain  the  diaper, 
the  fluid  being  clear  and  almost  colorless.  It  has  a  low  specific  gravity — 
1.003  to  1.006 — and  an  acid  reaction.  As  age  advances  the  adult  characters 
are  more  and  more  nearly  approached,  though  during  the  whole  of  childhood 
the  urine  is  paler  and  of  lower  specific  gravity  than  in  adult  life.  The  normal 
daily  amount  excreted  cannot  be  stated  absolutely,  but  the  following  figures 
are  approximate :  Between  two  and  five  years,  15-25  oz. ;  five  and  nine 
years,  25-35  oz. ;  nine  and  fourteen  years,  35—40  oz.  Other  characters  of 
the  urine  in  childhood  will  be  considered  under  appropriate  headings  in  subse- 
quent sections. 

Vomiting. — Both  vomiting  and  regurgitation  are  of  ready  production  and 
frequent  occurrence  in  infancy,  on  account  of  the  vertical  position  and  cylin- 
drical outline  of  the  stomach  at  this  period  of  life.  Babies  suckled  at  an  abun- 
dant breast,  and  who  are  in  perfect  health,  often  vomit  habitually.  In  these 
cases,  the  supply  of  food  being  large,  the  infant  as  it  lies  at  the  breast  is  apt 
to  draw  more  than  it  can  digest.  The  stomach  rids  itself  of  this  over-supply 
by  an  act  which  more  nearly  resembles  regurgitation  than  vomiting,  and  which 
must  be  regarded  as  an  evidence  of  health  rather  than  the  reverse.  There  is 
no  violent  effort  or  retching;  the  material  ejected  is  the  breast-milk  alone,  either 
entirely  unaltered  or  slightly  curdled ;  and  there  are  no  symptoms  of  nausea, 
such  as  paleness,  languor,  and  faintness.  In  older  children  vomiting  may  also 
occur  after  the  stomach  has  been  overladen.  If  the  act  be  followed  by  relief 
from  the  general  distress,  headache,  and  epigastric  pain,  it  must  not  be  regarded 
as  a  symptom  of  disease. 

Vomiting  attended  with  the  train  of  symptoms  embraced  under  the  term 
nausea  is  not  a  pathognomonic  symptom.  It  may  indicate  disease  of  the 
stomach,  of  the  intestines,  of  the  lungs  and  pleura,  and  of  the  brain,  or  it 
may  be  a  prodrome  of  one  of  the  eruptive  fevers.  Which  condition  is  pres- 
ent can  only  be  determined  by  watching  the  case.  The  character  of  the  ejecta 
is  more  definite.  For  instance,  the  expulsion  of  mucus  is  a  symptom  of  gas- 
tric catarrh.  The  regurgitation  of  mouthfuls  of  curdled  milk,  partially  digested 
food,  and  liquid  so  sour  that  it  causes  a  grimace  to  pass  over  the  face,  is  an 
indication  of  dyspepsia,  with  fermentation  and  the  formation  of  acid.  The 
appearance  of  lumbricoid  worms  in  the  vomit — a  not  infrequent  occurrence — 
of  course  shows  conclusively  the  existence  of  these  parasites  in  the  alimen- 
tary canal. 

3.  Physical  Examination. 

The  methods  of  physical  exploration  in  children  are  identical  with  those 
employed  in  adults,  and  the  results  do  not  differ  in  kind.  Since,  however,  the 
object  of  exploration  is  to  elicit  the  greatest  amount  of  information  with  the 
least  possible  disturbance  of  the  child,  and  as  this  very  disturbance  alters  the 
character  of  some  of  the  information  obtained,  it  is  well  to  adopt  a  somewhat 
different  order  of  examination,  and  one  which  at  first  sight  may  seem  irregular. 


10       AMEHICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Thus  it  is  best  first  to  ascertain  the  character  of  the  respiration  and  the  pulse, 
then  to  strip  the  body  to  determine  the  degree  of  muscuUir  development  and 
the  condition  of  the  skin,  next  to  investigate  the  physical  condition  of  the  lungs, 
heart,  and  abdominal  organs,  and  last  of  all  to  examine  the  mouth  and  throat. 
In  this  order,  then,  the  nonnal,  as  well  as  the  more  prominent  abnormal,  fea- 
tures connected  with  the  different  organs  vrill  be  considered. 

The  Respiration. — In  children  the  respiration  is  chiefly  abdominal  in 
type,  irrespective  of  sex,  and  it  is  not  until  just  before  the  age  of  puberty  that 
the  movements  in  the  female  change,  becoming  superior  costal.  Consequently, 
in  estimating  the  number  of  movements  per  minute,  it  is  best  to  place  the  fingers 
lightly  on  the  ei)igastrium.  The  count  should  ahvays  be  made  by  the  watch, 
and  the  most  convenient  time  for  the  observation  is  while  the  child  sleeps. 

Soon  after  birth  the  number  of  movements  per  minute  is  44.  between  the 
ages  of  two  months  and  two  years.  35,  and  between  two  and  twelve  years,  23. 
During  sleep  the  frequency  is  reduced  about  20  per  cent. 

Children  under  two  years,  Avhile  awake,  breathe  unevenly  and  irregularly. 
In  sleep  there  is  greater  regularity.  After  the  second  year  the  movements 
become  steady  and  even.  All  children,  however,  but  particularly  the  very 
young,  are  subject  to  a  great  increase  in  the  rapidity  of  respiration  under  excite- 
ment, either  muscular  or  mental. 

Accelerated  breathing  may  be  caused  by  an  elevation  in  the  body  temper- 
ature, by  an  interference  with  the  blood  aeration,  and  by  thoracic  or  abdominal 
pain.  As  the  increase  in  frequency  may  be  unattended  by  any  apparent  efibrt 
or  true  dyspnoea,  it  is  well  to  make  a  rule  of  counting  the  respirations  in  every 
case  in  which  the  diagnosis  is  doubtful. 

Diminished  frequency  is  noted  in  certain  brain  aff'ections,  as  in  chronic 
hydrocephalus,  and  in  the  later  stages  of  tubercular  meningitis.  In  such 
cases  the  rhythm  may  be  greatly  altered — a  tidal  form  being  assumed ;  this 
is  termed  ''  Cheyne-Stokes  respiration."  Another  form  of  breathing,  in  which 
the  alteration  is  mainly  in  the  rhythm,  is  termed  expiratory  respiration.  It  is 
characterized  by  the  pause  coming  between  inspiration  and  expiration,  instead 
of  between  expiration  and  inspiration,  as  is  the  normal  rule.  This  alteration 
occurs  most  frequently  in  young  children,  and  is  an  evidence  of  dangerous 
pulmonary  embarrassment. 

Perfectly  healthy  children  breathe  through  the  nose,  and  so  softly  that  it 
is  difiicult  to  hear  the  breezy  sound  of  the  ingoing  and  outgoing  air.  A  dry, 
hissing  sound  or  a  moist  sound  of  snufiiing  indicates  partial  obstruction  of  the 
nasal  passages  ;  oral  respiration,  complete  occlusion.  Difficult  breathing  with 
prolonged  inspiration — inspiratory  dyspnoea — shows  an  impediment  to  the 
entrance  of  air  into  the  lungs  and  indicates  laryngeal  obstruction,  due,  most 
commonly,  to  spasm  or  to  the  formation  of  false  membrane.  In  such  cases  the 
inspiratory  act  is  also  attended  by  a  loud,  piping,  or  rasping  sound.  Labored 
breathing  with  prolonged  wheezing  respiration — expiratory  dyspnoea — occurs 
when  the  escape  of  air  is  impeded.  The  causative  lesion  is  to  be  found,  not 
in  the  larynx,  but  in  the  lungs.  It  may  be  a  bronchial  catarrh  with  excessive 
secretion,  emphysema,  or  asthma.  In  both  forms  of  dyspnoea  the  movements 
are  slow  as  well  as  difficult,  and  a  combination  of  the  two  forms  is  met  with 
in  cases  of  marked  laryngeal  stenosis. 

Yawning,  if  it  recur  frequently,  denotes  great  failure  of  the  vital  powers. 

The  Pulse. — To  obtain  any  reliable  data  from  the  pulse  it  must  be  felt 
while  the  patient  is  perfectly  quiet.  The  best  time  is  during  sleep,  but  if  the 
child  cannot  be  caught  in  this  condition,  advantage  may  be  taken  of  its  pla- 
cidity while  nursing  at  the  breast,  feeding  from  a  bottle,  or  amused  by  a  toy. 


CLINICAL   INVESTIGATION   OF  DISEASE.  11 

With  very  young  infants  it  is  sometimes  impossible  to  feel  the  beat  of  the  radial 
artery,  and  it  is  necessary  to  ascertain  the  frequency  of  the  pulse  by  directly 
auscultating  the  heart.  After  the  second  month  palpation  of  the  pulse  at  the 
wrist  in  the  ordinary  way  presents  no  difficulties. 

The  child's  pulse  differs  from  the  adult's  by  being  much  more  frequent, 
more  irregular,  and  more  irritable,  and  necessarily  of  smaller  volume. 

The  frequency,  or  the  number  of  beats  per  minute,  varies  with  the  age. 
The  following  is  the  average  rate : 

From  birth  to  the  second  month 160  to  130 

From  the  2d  to  the  6th  month      130  to  120 

"       6th     "      12th     "           120  to  110 

"       1st     "        3d  year         . 110  to  100 

«        3d      "         5th  "            100  to    90 

"       5th    "       10th  "           90  to    80 

"     10th    "      12th  "            80  to    70 

These  figures  represent  the  pulse  in  a  waking  but  passive  state.  During  sleep 
the  frequency  is  less.  Thus,  between  the  second  and  ninth  years  there  are 
about  sixteen  beats  less  per  minute  while  asleep  than  when  awake ;  between 
the  ninth  and  twelfth  years,  eight  less  ;  and  between  the  twelfth  and  fifteenth 
years,  only  two  less.  Below  the  age  of  two  years  the  disparity  is  even  greater. 
The  irregularity  of  the  pulse  in  childhood  is  confined  to  an  alteration  of  the 
rhythm.  It  is  most  marked  in  infants,  and  is  greatest  during  sleep,  when  the 
pulse  is  slowest.  The  feature  of  irritability — that  is,  the  facility  with  which  its 
frequency  is  increased  by  muscular  activity  and  mental  excitement — is  greatei 
in  proportion  to  the  youth  of  the  child.  A  rise  of  20,  30,  or  even  40  beats  a 
minute  is  not  uncommon  in  early  infancy  under  the  excitement  of  the  slightest 
effort  or  disturbance.  On  account  of  these  wide  variations  in  health  little 
symptomatic  meaning  need  be  attached  to  alterations  of  the  rhythm  and  fre- 
quency while  unassociated  with  other  abnormal  features.  When  so  associated 
they  become  important  in  diagnosis. 

Increased  frequency  is  a  constant  attendant  of  the  febrile  state.  The  extent 
of  the  increase  corresponds  with  the  degree  of  elevation  of  the  temperature, 
though  the  pulse  curve  always  runs  higher  than  the  temperature  curve.  The 
more  frequent  the  pulse  the  higher  the  fever  is  the  rule,  but  in  estimating  the 
prognostic  value  of  the  increase  the  law  of  the  fever  in  question  must  be  taken 
into  consideration.  For  example,  in  scarlatina  a  pulse  of  160  is  usual  and  not 
indicative  of  special  gravity,  whereas  in  measles  the  same  degree  of  accelera- 
tion would  be  abnormal  and  show  great  danger.  Jaundice  and  parenchymatous 
nephritis  are  accompanied  by  a  diminution  in  the  rate.  Irregularity  is  met 
with  in  diseases  of  the  brain  and  heart,  and  sometimes  in  nervous  and  anaemic 
children. 

The  Temperature  must  be  estimated  before  removing  the  clothing,  and  a 
clinical  thermometer  must  always  be  used.  The  instrument  is  usually  placed  in 
the  rectum  or  groin  ^  of  the  infant  and  young  child ;  in  the  axilla  or  mouth 
of  an  older  and  more  controllable  child.  It  should  remain  in  position  from 
one  to  five  minutes,  according  to  the  delicacy  of  the  instrument. 

During  the  first  week  of  life  the  temperature  fluctuates  considerably.  After 
that  the  puerile  norm — 98.5°  to  99°  F. — is  established,  but  until  the  fourth  or 
fifth  month  it  is  greatly  influenced  by  healthy  causes  of  variation,  the  fluctua- 
tions ranging  between  0.9'^  and  3.6°.  By  the  fifth  month  regular  morning  and 
evening  oscillations  begin  and  certain  definite  laws  are  followed.     There  is  a 

^  The  rectal  temperature  is  normally  1°  higher  than  the  axillary ;  that  of  the  groin  about 
1°  lower. 


12       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

fall  in  the  evening  of  1°  or  2°.  The  greatest  fall  occurs  between  7  and  9  P.  M., 
and  the  minimum  is  reached  at  or  before  2  a.  m.  After  2  a.  m.  there  is  a  grad- 
ual rise,  the  maximum  being  reached  between  8  and  10  a.  m.  Throughout  the 
day  the  oscillation  is  trifling.  These  variations  are  independent  of  eating  and 
sleeping. 

In  disease  there  may  be  either  a  rise  above  or  a  fall  beloAv  the  normal 
standard.  Fever  is  always  associated  with  an  elevation  of  the  temperature. 
Rapid  and  transient  rises  attend  slight  catarrhs  and  passing  indigestions ;  pro- 
longed rises,  inflammatory  and  essential  fevers.  The  degree  of  elevation  marks 
the  type  of  the  pyrexia.  This  is  moderate  when  the  mercury  stands  at  102°, 
severe  at  104°  or  105°,  and  very  grave  above  107°.  The  duration  of  the  ele- 
vation and  the  peculiar  range  of  the  oscillations — for  there  are  oscillations  in 
disease  as  well  as  in  health — determine  the  nature  of  the  fever.  The  febrile 
oscillations  differ  from  the  healthy  in  that  the  lowest  marking  is  noticed  in 
the  morning,  the  highest  in  the  evening.  Variations  in  the  typical  range  of 
any  given  fever  are  important  prognostic  omens :  a  sudden  fall  of  temperature, 
together  with  improvement  in  the  general  symptoms,  indicates  the  beginning 
of  convalescence ;  a  similar  fall,  with  an  increase  of  the  general  symptoms, 
is  a  precursor  of  death.  When  the  morning  temperature  is  equal  to  that 
of  the  preceding  evening,  there  is  great  danger ;  if  higher,  greater  danger 
still.  Marked  remission  in  continued  fevers  is  generally  a  forerunner  of  con- 
valescence. 

Abnormal  depression  of  temperature  is  occasioned  by  haemorrhage  and  by 
the  loss  of  fluids  in  profuse  watery  diarrhoea.  It  is  also  met  with  in  antemia, 
in  atrophy  from  insufiicient  nourishment,  in  diseases  of  the  heart  and  lungs 
attended  by  imperfect  blood-aeration,  and  it  constantly  attends  collapse  and 
the  death  agony.  A  maintained  temperature  of  97°  F.  is  dangerous  in  chil- 
dren, and  for  every  degree  of  reduction  below  this  point  the  risk  to  life  is 
more  than  proportionately  increased. 

The  General  Development. — The  healthy  child  under  two  years  of 
age  is  plump  of  body  and  round  of  limb,  with  well-developed  fat  cushions 
and  firm  flesh,  and  with  the  head  and  abdomen  large  in  proportion  to  the  rest 
of  the  frame.  As  age  advances  the  figure  gradually  assumes  the  characteris- 
tics of  adolescence. 

To  be  robust,  the  newly-born  child  must  have  a  certain  average  size  and 
weight.  Subsequently,  under  normal  circumstances,  there  is  a  regular  rate 
of  increase  in  both  of  these  respects.  At  birth  the  length  is  about  19  inches. 
Growth  is  quickest  in  the  first  weeks  of  life.  In  the  first  year  there  is  an 
increase  of  from  5  to  6|  inches :  in  the  second,  from  2f  to  2>^  inches ;  in  the 
third,  from  2^  to  2|  inches ;  in  the  fourth,  about  2  inches ;  and  from  the  fifth 
to  the  sixteenth  year  the  annual  growth  amounts  to  from  If  to  2  inches.  The 
average  weight  at  birth  is  from  6  to  8  pounds.  The  daily  increase  in  weight 
should  range  from  i  to  |  of  an  ounce.  "With  these  data  it  is  quite  possible 
to  estimate  what  should  be  the  normal  size  and  weight  of  a  child  at  any.  age. 
Consequently,  if,  on  being  measured  and  Aveighed,  he  be  found  to  fall  short  of 
the  normal  standard,  it  is  proper  to  infer  the  existence  of  some  fault  in  the 
nutritive  processes — a  conclusion  still  further  borne  out  by  a  want  of  rotund- 
ity of  outline  and  by  flabbiness  of  the  muscles. 

The  age  at  which  the  child  sits  erect,  at  which  it  walks,  and  at  which  the 
anterior  fontanelle  becomes  ossified  are  points  closely  connected  with  the  sub- 
ject of  development  and  nutrition.  For  some  time  after  birth  the  child,  if 
noticed  while  sitting  upon  the  lap,  will  be  observed  to  hold  the  head  and. 
shoulders  forward  or  to  "stoop"  a  little,  the  spine  from  the  cervical  region 


CLINICAL   INVESTIGATION    OF  DISEASE.  13 

to  the  sacrum  forming  a  continuous  curve,  with  the  convexity  directed  back- 
ward. Toward  the  end  of  the  eighth  month  the  position  begins  to  become 
more  erect,  and  in  a  few  weeks  is  perfectly  so,  the  spine  assuming  an  almost 
perpendicular  line.  Any  marked  delay  in  this  change  indicates  general 
debility.  At  the  end  of  the  fourteenth  month  the  child  should  be  able  to 
walk  alone.  The  spine  then  assumes  the  S-like  curve  seen  in  healthy  adults. 
A  delay  in  walking  may  be  due  to  systemic  weakness  or  infantile  paralysis 
affecting  one  or  both  legs.  If  the  walking  be  done  on  the  toes  chiefly,  if  the 
gait  be  limping,  and  especially  if  knee-pain  be  complained  of  and  manipulation 
of  the  limbs  causes  suffering,  the  chances  are  that  hip-joint  disease  is  com- 
mencino-.  The  anterior  fontanelle  should  be  ossified  or  completely  closed  at 
some  period  between  the  fifteenth  and  twentieth  months.  The  closure  is  much 
retarded  in  rickets,  which  is  pre-eminently  a  disease  of  malnutrition.  Hydro- 
cephalus has  a  like  effect.  In  a  state  of  health  the  opening,  while  still  mem- 
branous, is  level  with  the  cranial  bones  or  very  slightly  depressed.  Conditions 
of  systemic  exhaustion  cause  marked  sinking,  and  this  depression  is  one  of  the 
best  indications  of  the  necessity  of  stimulation.  Bulging  of  the  fontanelle  is 
a  symptom  of  chronic  hydrocephalus. 

Conditions  of  the  Skin. — In  addition  to  the  characters  already  described, 
the  skin  of  a  healthy  child  has  a  velvety  smoothness  and  softness,  a  scarcely 
perceptible  moisture,  and  a  great  degree  of  elasticity. 

•  "Mucous  disease"  is  attended  with  a  dry,  harsh  skin,  which  is  muddy  in 
color,  and  covered,  especially  on  the  extensor  surfaces  of  the  arms  and  legs, 
by  a  more  or  less  thick  layer  of  exfoliating  epidermis.  Chronic  abdominal 
affections,  particularly  tuberculosis  of  the  intestines  and  mesenteric  glands, 
lead  to  harshness,  acridity,  scurfiness,  and  a  wrinkled  appearance  of  the  skin 
covering  the  abdomen  and  thorax,  with  enlargement  of  the  superficial  abdom- 
inal veins.  Protracted  diarrhoea,  and,  still  more,  vomiting  combined  with 
diarrhoea,  cause  absorption  of  the  subcutaneous  fat  and  wasting  of  the  mus- 
cles. The  skin  becomes  too  large  for  the  body,  is  dry,  harsh,  discolored,  and 
so  inelastic  that  it  falls  into  wrinkles  over  the  joints  when  the  limbs  are  moved, 
and  if  pinched  up  retains  the  fold  for  a  long  time.  The  condition  of  general 
atrophy  popularly  known  as  "marasmus"  presents  these  features  most  strik- 
ingly. Dryness  is  a  concomitant  of  the  febrile  state ;  excessive  moisture,  of 
prostration  and  collapse.  Eruptions  appear  upon  the  integument  in  the  skin 
diseases  proper,  in  the  exanthemata,  in  constitutional  syphilis,  and  in  certain 
digestive  disorders.  (Edema  of  the  subcutaneous  connective  tissue  may  be 
due  to  affections  of  the  heart,  liver,  or  kidneys.  The  cardiac  variety  usually 
shows  itself  first  in  the  feet ;  the  renal,  in  the  eyelids ;  the  hepatic,  in  the  feet 
and  legs,  secondarily  to  ascites. 

While  examining  the  surface  it  is  well  to  look  for  enlargement  of  the  super- 
ficial lymphatic  glands  and  swelling  of  the  joints.  The  former  occurs  in  tuber- 
culosis and  syphilis  ;  the  latter,  in  rheumatism. 

Examination  of  the  Abdomen. —  To  examine  this  portion  of  the  body, 
the  child,  still  stripped,  must  be  placed  on  its  back  and  kept  as  quiet  as  possi- 
ble.    Palpation  or  percussion  should  never  be  made  with  cold  hands. 

The  abdomen  of  a  healthy  child  is  prominent,  uniformly  soft,  yielding,  and 
painless  to  the  touch,  and  to  percussion  gives  a  tympanitic  sound,  varying  in 
tone  according  to  the  region  percussed.  The  tympanitic  note  is  lowest  in  pitch 
over  the  epigastric  and  left  hypochondriac  regions,  the  seat  of  the  stomach ; 
highest  over  the  umbilical  region,  the  position  of  the  small  intestine. 

In  disease  inspection  reveals  any  disproportion  in  the  size  or  form  of  the 
abdomen,  the  state  of  the  integuments,  of  the  superficial  veins,  and  of  the 


14       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

umbilicus.  Palpation  shows  the  teuipej'ature,  pliability,  moisture,  and  tension 
of  the  walls,  and  the  presence  or  absence  of  tenderness,  of  fluctuation,  and  of 
enlargement  of  the  mesenteric  glands  and  other  solid  viscera.  Percussion  serves 
to  demonstrate  the  nature  of  enlargements,  whether  due  to  accumulation  of  gas 
or  liquid  or  to  solid  growths.  By  it,  also,  the  outline  and  size  of  the  liver 
and  spleen  may  be  determined. 

Distention  of  the  abdomen  is,  in  the  vast  majority  of  instances,  due  to 
flatulence.  In  this  condition  the  skin  feels  tense,  the  umbilicus  is  level  or 
slightly  prominent,  there  is  no  tenderness  on  pressure,  and  percussion  is 
markedly  tympanitic.  Drum-like  distention,  with  great  tenderness,  and  mufiled 
tympanitic  percussion-note  occur  in  general  peritonitis.  Uniform  distention, 
again,  may  be  due  to  ascites.  The  abdomen  is  barrel-shaped,  painless  to  the 
touch,  and  there  is  extended  fluctuation.  Percussion  is  dull  over  the  position 
of  the  fluid,  but  in  nearly  every  instance  there  is  an  area  of  tympany  which 
changes  its  position.  Localized  distention  may  be  traced  to  gaseous  accu- 
mulation, to  enlargement  of  the  liver  and  spleen,  to  fgecal  accumulation,  to 
circumscribed  peritonitis,  and  to  distention  of  the  bladder.  Collections  of 
gas  are  always  tympanitic  on  percussion.  The  extent  of  liver  dulness  is  to 
be  estimated  by  percussion,  or  palpation  with  the  warmed  hand.  An  enlarged 
spleen  may  be  felt  by  placing  the  fingers  of  the  right  hand  on  the  back,  directly 
below  the  twelfth  rib  and  outside  of  the  lumbar  muscles,  the  fingers  of  the 
left  on  the  abdomen,  directly  opposite,  then  bringing  the  hands  toward  one 
another.  The  fact  that  both  the  liver  and  spleen,  though  still  unenlarged, 
may  be  more  readily  felt  than  natural  when  pressed  downward  by  the  dia- 
phragm, must  not  be  overlooked.  A  faecal  accumulation  is  distinguished  by 
the  absence  of  tenderness,  by  the  oblong  shape  of  the  tumor,  by  the  situation 
in  the  region  of  the  transverse  or  descending  colon,  to  which  its  long  axis  cor- 
responds, and  by  its  shape  being  capable  of  some  modification  by  pressure. 
Percussion  over  such  a  mass  is  dull.  Distention  of  the  bladder  gives  rise  to 
a  bulging  tumor  in  the  hypogastric  region,  which  is  elastic  to  the  touch  and 
dull  on  percussion. 

A  shrunken  or  scaphoid  condition  of  the  abdomen  is  met  with  in  serious 
brain  affections,  notably  tubercular  meningitis,  also  in  entero-colitis,  follicu- 
lar enteritis,  and  dysentery. 

Tenderness  to  pressure  indicates  inflammatory  lesion  of  the  intestines.  The 
presence  or  absence  of  this  sign  in  an  infant  can  be  determined  by  forcing  the 
attention,  by  bringing  it  before  a  strong  light,  for  instance,  and  then  making 
pressure  on  the  abdomen.  If  crying  be  produced,  there  is  tenderness  ;  if  not, 
the  reverse. 

Examination  of  the  Chest. — The  stethoscope  and  pleximeter  are  unne- 
cessary in  examining  the  lungs.  In  the  case  of  the  heart  the  former  may  be 
occasionally  required  to  localize  murmurs.  When  used,  it  is  better  to  give  the 
instrument  to  the  child  to  handle  and  become  familiar  with  before  application. 
The  thoracic  end  must  never  be  adjusted  without  being  warmed.  The  quieter 
the  patient,  the  more  complete  and  satisfactory  will  be  the  results  of  the  explo- 
ration. Unfortunately,  though,  it  is  too  often  necessary  for  one  to  do  the  best 
possible  in  the  midst  of  cries  and  struggling.  However,  by  skilfully  seizing 
opportune  moments  much  reliable  information  may  be  gained. 

The  steps  of  the  examination  are — first,  inspection  ;  second,  auscultation  ; 
third,  palpation  ;  and  fourth,  percussion.  The  reason  for  making  the  order 
diff'erent  from  that  practised  in  adults  is  to  place  the  most  disturbing  element 
last.  Mensuration  and  succussion  are  infrequently  resorted  to  in  children.  If 
required,  they  are  best  postponed  until  the  end  of  the  examination. 


CLINICAL    INVESTIGATION   OF  DISEASE.  15 

Inspection. — The  sitting  posture,  the  child  being  stripped  and  in  a  good 
light,  is  the  best  for  this  process.  Note  is  to  be  taken  of  the  shape  of  the 
chest,  the  character  of  the  breathing,  and  the  position  of  the  apex-beat  of 
the  heart. 

In  the  new-born  baby  the  chest  is  nearly  circular  in  shape ;  later,  the 
lateral  diameter  considerably  exceeds  the  antero-posterior.  The  intercostal 
spaces  are  poorly  marked,  and  the  scapulae  lie  so  close  that  their  outline  is 
scarcely  perceptible.  The  circular  shape  of  the  chest  allows  of  little  lateral 
expansion,  and  for  this  reason  the  respiration  is  chiefly  abdominal  in  type. 
Together  with  the  movement  of  the  abdominal  walls,  every  act  of  inspiration 
is  attended  by  a  certain  amount  of  recession  of  the  lower  part  of  the  chest- 
walls,  the  yielding  ribs  being  forced  inward  by  the  pressure  of  the  external 
air  before  they  can  be  sufficiently  supported  by  the  expanding  lung.  The 
rise  and  fall  of  the  cardiac  apex  can  be  seen — except  when  there  is  a  great 
accumulation  of  fat — a  short  distance  below  and  to  the  right  of  the  left 
nipple. 

Disease  may  alter  all  of  these  conditions.  The  tuberculous  diathesis  is 
characterized  by  a  small  chest,  and  one  which  has  either  the  ala?'  or  the  fiat 
shape.  In  rickets  the  thorax  becomes  irregularly  triangular  in  outline.  Em- 
physema causes  a  barrel-shaped  chest,  with  stooping  shoulders  and  round  back. 
Pleuritis  with  large  effusion  produces  bulging  of  the  affected  side,  and  some- 
times prominence  of  the  intercostal  spaces.  After  absorption  has  taken  place 
there  may  be  marked  retraction,  sinking  of  the  interspaces,  falling  of  the 
shoulders,  and  curvature  of  the  spine  toward  the  healthy  side.  Cessation  of 
the  costal  respiratory  movements  indicates  inflammation  of  the  lung  or  pleura 
or  a  large  pleuritic  efiusion ;  cessation  of  the  abdominal  play,  inflammation 
of  the  peritoneum  or  of  the  intestines :  excessive  ascites  and  gaseous  accu- 
mulations produce  the  same  effect.  Rachitic  softening  of  the  "ribs,  and  those 
diseases  of  the  lungs  which  offer  a  direct  obstacle  to  the  entrance  of  air,  are 
associated  with  a  great  increase  in  the  normal  recession  of  the  lower  portion 
of  the  chest  on  inspiration.  The  position  of  the  apex-beat  is  altered  by  car- 
diac diseases,  by  pleuritis,  and  occasionally  by  gaseous  distention  of  the  stom- 
ach. When  the  left  ventricle  is  enlarged,  it  is  shifted  downward  and  to  the  left. 
Transmitted  epigastric  pulsation  shows  enlargement  of  the  right  ventricle.  An 
extended  impulse  is  not  necessarily  a  sign  of  disease,  since  the  chest-walls  are 
so  elastic  in  childhood  that  the  normal  impact  of  the  apex  is  apt  to  affect  a  wide 
area.  The  effusion  of  pleurisy  pushes  the  heart  to  the  right  or  left,  while  the 
retraction,  after  absorption  or  evacuation,  draws  it  in  one  or  other  direction. 
The  apex  is  pushed  upward  and  to  the  left  in  gastric  flatulence.  Emphysema, 
by  pushing  the  heart  away  from  the  thoracic  wall,  diminishes  or  hides  the 
impulse. 

Auscultation. — With  infants  the  back  of  the  chest  is  most  conveniently 
ausculted  when  the  child  is  held  in  the  nurse's  left  arm,  with  his  breast  against 
hers,  his  chin  resting  upon  her  left  shoulder,  his  left  arm  around  her  neck,  and 
his  head  kept  in  position  by  her  disengaged  hand ;  the  front,  when  reclining 
on  the  back  on  a  pillow ;  the  sides,  when  sitting  upright  on  the  lap,  first  one 
arm  and  then  the  other  being  lifted  up  to  allow  the  observer's  ear  to  be  applied. 
Older  children  may  be  made  to  take  the  same  position  as  adults.  It  is  not  suf- 
ficient to  auscult  the  posterior  aspect  of  the  thorax  alone,  as  is  stated  by  some 
authors.  The  whole  chest  should  be  examined,  particularly  in  doubtful  cases. 
The  signs  of  croupous  pneumonia  are  most  frequently  discoverable  at  one  or 
other  base,  posteriorly ;  the  friction-sound  of  pleuritis  at  the  junction  of  the 
middle  and  lower  third  of  the  chest,  laterally ;  and  the  signs  of  emphysema  at 


16       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  apices,  anteriorly.  Therefore,  unless  the  exploration  be  thorough,  import- 
ant lesions  may  be  overlooked. 

In  healthy  infants  the  inspiratory  act  in  ordinary  breathing  is  superficial, 
and  the  respiratory  murmur,  as  a  consequence,  feeble.  If,  however,  a  deep 
inspiration  be  taken,  a  frequent  occurrence  under  excitement  and  during  cry- 
ing, the  murmur  becomes  loud,  or  puerile.  After  the  age  of  two  years  puerile 
respiration  is  habitual.  The  breathing  is  loudest  over  the  anterior,  lateral,  and 
posterior  inferior  regions  of  the  thorax  ;  faintest  over  the  scapulae  and  the  prae- 
cordial  area.  Sometimes  the  expiratory  element  is  wanting  in  young  children 
over  the  lower  posterior  portions  of  the  lungs.  In  the  interscapular  region 
there  is  often  an  approach  to  the  bronchial  type  of  breathing.  If  the  child 
speaks,  cries,  or  coughs  while  the  ear  is  applied  to  the  chest,  a  muffled  rumbling 
sound,  the  normal  vocal  resonance,  will  be  heard.  At  the  same  time  vibra- 
tion of  the  walls,  the  vocal  fremitus,  can  be  felt. 

The  cardiac  sounds  are  readily  heard  when  the  ear  is  placed  on  the  prjecor- 
dia.  In  young  infants  the  examination  is  somewhat  difficult,  but  after  the  first 
year,  the  circulation  becoming  slower  and  more  regular,  there  is  little  trouble 
in  distinguishing  the  sounds,  and  even  slight  alterations  in  them.  The  first 
sound  is  longer  and  graver  than  the  second,  the  rhythm  is  ordinarily  quite 
regular,  and  the  area  of  distribution  is  extended. 

Palpatio7i. — In  practising  palpation  the  palmar  surface  of  the  well-warmed 
hand  must  be  applied  to  the  naked  chest.  This  method  of  exploration  is  use- 
ful as  a  means  of  determining  the  number  of  respiratory  movements,  the  degree 
of  expansion  of  the  thoracic  Avails,  the  position  of  the  cardiac  apex-beat,  the 
presence  or  absence  of  painful  regions  and  of  pleural  or  bronchial  fremitus,  the 
existence  of  fluctuation  in  the  intercostal  spaces,  and  the  character  of  vocal 
fremitus. 

Percussion. — In  percussing  the  diiferent  surfaces  of  the  chest  the  child 
must  be  placed  in  the  same  position  as  for  auscultation.  When  contrasting 
the  two  sides,  percussion  should  be  made  in  identical  regions  and  during  the 
same  period  of  the  respiratory  movement.  Babies  when  constrained  or  when 
disturbed  hold  their  breath  in  the  intervals  of  crying,  and  as  they  always  do 
so  at  the  end  of  an  inspiration,  this  is  a  favorable  time  to  seize  for  the  compar- 
ative examination.  The  percussion  strokes  must  be  lighter  than  in  the  adult, 
but  in  other  respects  the  operation  in  no  wise  diff"ers. 

In  health  the  resonance  will  be  found  to  correspond  closely  with  the  res- 
piratory murmur.  Thus  in  infants  under  one  year,  the  respiratory  murmur 
being  feeble,  percussion  is  rather  insonorous,  but  so  soon  as  puerile  respiration 
becomes  established  the  resonance  is  uniformly  intense.  With  the  exception 
of  this  greater  intensity  the  sound  is  exactly  similar  to  that  obtainable  in  adults. 
It  is  always  attended,  too,  by  a  sensation  of  elasticity,  appreciated  by  the  finger 
used  as  the  pleximeter. 

Different  portions  of  the  thorax  possess,  normally,  different  degrees  of  sonor^ 
ousness.  In  front,  the  right  side  is  markedly  resonant  from  the  clavicle  dow^n 
to  the  fifth  interspace  or  the  upper  border  of  the  sixth  rib  in  the  mammary 
line,  where  the  liver  dulness  begins.  On  the  left  side  the  resonance  is  equally 
intense,  but  it  is  encroached  upon  by  the  gastric  tympany,  which  extends 
upward  as  high  as  the  seventh  or  sixth  rib,  as  well  as  by  the  area  of  car- 
diac dulness.  The  latter  is  never  so  decidedly  marked  as  in  adults.  Later- 
ally, both  axillary  regions  are  very  resonant.  The  upper  portions  of  the  infra- 
axillary  regions  are  a  degree  less  resonant,  and  the  lower  portions  are  dull  on 
account  of  the  presence  of  the  liver  on  the  right  and  the  spleen  on  the  left  side. 
The  superior  border  of  the  liver  dulness  is  found  in  the  seventh  interspace,  or 


CLINICAL   INVESTIGATION    OF  DISEASE.  17 

at  the  eighth  rib  ;  that  of  the  spleen,  at  the  upper  edge  of  the  ninth  rib.  Gas- 
tric tympany  may  supplant  the  pulmonary  resonance  over  the  left  infra-axillary 
region.  Posteriorly,  there  is  little  resonance  in  the  scapular  region,  partic- 
ularly the  supraspinous  portions.  Over  the  interscapular  space  the  sound 
improves,  but  it  is  less  resonant  than  anteriorly  or  laterally.  Over  the  infra- 
scapular  regions  the  resonance  is  but  little  less  pure  than  in  front,  until  the 
tenth  rib  is  reached  on  the  right  side  and  the  liver  dulness  is  again  met  with. 
On  the  left  side  the  resonance  extends  to  the  very  base,  the  posterior  splenic 
dulness  being  detected  with  difficulty.  The  right  base  is,  therefore,  naturally 
less  resonant  than  the  left,  and  this  difference  is  especially  marked  during  expi- 
ration, the  liver  rising  higher  at  that  time. 

Affections  of  the  lungs  produce  various  alterations  in  the  percussion  sound. 
The  chief  of  these  are  the  substitution  of  tympany,  of  dulness,  and  of  flatness 
for  the  normal  resonance,  and  of  increased  resistance  to  the  finger  for  elasticity. 
Cardiac  diseases  cause  changes  in  both  the  extent  and  the  shape  of  the  area  of 
preecordial  dulness. 

Examination  of  the  Mouth  and  Fauces. — This  portion  of  the  exami- 
nation is  most  apt  to  cause  crying,  but  it  must  never  be  omitted.  In  infants 
gentle  pressure  of  the  fingers  upon  the  chin  is  sufficient  to  cause  wide  opening 
of  the  mouth.  An  older  child  will  frequently  open  the  mouth  when  requested, 
but  if  he  refuse,  some  smooth,  flat  instrument  may  be  inserted  in  the  mouth, 
and  downward  pressure  made  upon  the  tongue,  when  the  jaws  will  be  widely 
separated.  The  fauces  can  sometimes  be  seen  by  directing  the  mouth  to  be 
opened  wide  and  the  tongue  to  be  alternately  protruded  and  retracted,  or  a  pro- 
longed sound  of  "^A  "  to  be  made.  With  the  refractory,  and  always  with 
infants,  the  tongue  has  to  be  held  down  by  a  spoon-handle  or  tongue-depressor. 

The  healthy  oral  mucous  membrane  has  a  deep  pink  color  and  is  smooth, 
moist,  and  warm  to  the  touch.  The  color  is  deeper  on  the  lips  and  cheeks, 
lighter  on  the  gums.  The  latter,  up  to  the  sixth  month,  as  a  rule,  have  a  mod- 
erately sharp  edge.  Subsequently,  the  edge  begins  to  broaden  and  soften,  and 
the  color  of  the  investing  mucous  membrane  deepens  to  a  vivid  red,  and  becomes 
hot  as  the  teeth  begin  to  force  their  way  through.  The  first,  or  milk  teeth — so 
called  from  their  color — are  twenty  in  number,  all  told,  ten  to  each  jaw;  the 
two  lower  central  incisors,  the  first  of  the  set,  make  their  appearance  at  some 
time  between  the  fourth  and  seventh  months,  the  others  following  at  stated 
intervals.^  The  permanent  teeth,  thirty-two  in  number,  begin  to  appear 
about  the  sixth  year. 

The  tongue  should  be  freely  movable.  It  is  pink  in  color,  and  the  dorsum, 
or  upper  surface,  marked  in  the  centre  by  a  slight  longitudinal  depression,  has 
a  velvety  appearance,  and  is  soft,  moist,  and  warm  to  the  finger.  The  hard  pal- 
ate is  roughened  anteriorly  by  transverse  ridges.  The  soft  palate  is  smooth,  and 
its  mucous  membane  is  paler  than  that  of  the  rest  of  the  mouth.  The  fauces, 
on  the  contrary,  are  redder.  In  the  triangular  recess  between  the  half-arches 
of  the  palate  the  tonsils  can  always  be  seen.  They  should  be  about  the  size 
and  shape  of  almond-kernels,  and  they  present  a  number  of  circular  open- 
ings, the  orifices  of  pouches  into  which  the  follicles  open.  The  uvula  is  short 
and  tongue-shaped.  The  posterior  wall  of  the  pharynx  should  be  red,  smooth, 
and  moist. 

Disease  produces  a  great  variety  of  changes  in  the  mouth,  tongue,  and 
fauces.  Fever  makes  the  mouth  hot  and  dry  and  causes  the  tongue  to  be 
frosted  or  coated.  Affections  of  the  gastro-intestinal  tract  are  always  attended 
by  coating  of  the  tongue,  and  the  various  appearances  of  this  coating  are  of 

'  See  article  on  Dentition. 
2 


18       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

important  diagnostic  and  therapeutic  significance.  Inflammation  of  the  mouth 
itself  reddens  the  mucous  membrane,  makes  it  hot  and  tender  to  the  touch, 
increases  its  moisture,  alters  the  surface  of  the  tongue,  and  leads  to  the  forma- 
tion of  aphthfe,  to  ulceration,  and  even  to  gangrene.  The  eruptions  of  scar- 
let fever,  measles,  varicella,  and  varioloid  make  their  appearance  first  on  the 
mucous  membrane  of  the  palate  and  fauces.  Finally,  the  conclusive  evidences 
of  diphtheria  and  of  the  various  tonsillar  aff"ections  are  found  in  the  fauces. 

Irregular  dentition  indicates  faulty  nutrition ;  delayed  dentition,  rickets ; 
and  certain  peculiarities  in  the  formation  of  the  permanent  teeth,  constitu- 
tional syphilis. 

n.  THE   GENERAL   MANAGEMENT   OF   CHILDREN. 
1.  Feeding. 

The  whole  question  of  feeding  bears  so  close  a  relation  to  age  that  it  is 
necessary  to  study  it  from  the  standpoint  of  the  two  stages  of  a  child's  life 
already  mentioned. 

An  infant  may  be  fed  in  one  of  three  ways  :  1st,  from  the  mother's  breast  J 
2d,  from  the  breast  of  a  wet-nurse  ;  and  3d,  from  a  bottle  by  the  method  known 
as  artificial  or  hand-feeding. 

1st.  Feeding  from  the  3Iatemal  Breast. — This,  being  the  natural,  is  the 
proper  method  of  nourishing  the  human  infant ;  and  every  mother  who  is 
able  should  nourish  her  child  solely  from  her  breast  up  to  the  age  of  eight 
months,  and  partially  to  the  end  of  the  first  year,  or,  failing  in  either  limit,  so 
long  as  possible. 

The  infant  should  be  put  to  the  breast  as  soon  as  the  mother  has  recovered 
somewhat  from  the  fatigue  of  labor — some  four  or  eight  hours  after  birth.  Of 
course  no  milk  can  be  drawn  at  this  early  date,  but  the  babe  gets  a  small 
quantity  of  colostrum,  which  aflPords  sufiicient  nourishment,  and  from  its  laxa- 
tive properties  clears  out  the  infant's  intestinal  canal.  This,  too,  is  of  great 
advantage  to  the  mother,  for  it  ensures  proper  uterine  contraction,  draws  out 
the  nipples,  and  encourages  the  fonnation  of  milk.  Put  the  child  to  the 
breast  every  two  hours  while  the  mother  is  awake,  and  up  to  the  fourth  day 
there  need  be  no  fear  of  starvation.  Usually  on  the  fourth  day  milk  is 
secreted  and  regular  lactation  commences.  Before  this  time  the  administra- 
tion of  gruel  or  any  form  of  artificial  food  is  more  than  useless,  as  it  lessens 
the  activity  of  sucking  and  frequently  deranges  the  stomach. 

Many  untrained  mothers  make  a  failure  of  nursing  because  they  know 
nothing  of  the  manner  of  giving  suck  ;  of  the  length  of  time  the  child 
should  be  kept  at  the  breast ;  of  the  proper  time  for,  and  interval  between, 
feedings :  and  of  the  importance  of  regularity. 

While  nursing  the  infant  must  be  held  partly  on  its  side,  on  the  right  or 
left  arm  according  to  the  gland  about  to  be  drawn,  while  the  mother  must 
bend  her  bodv  forward,  so  that  the  nipple  may  fall  easily  into  the  child's 
mouth,  and  steady  the  breast  and  regulate  the  flow  of  milk  with  the  first  and 
second  finger  of  the  disengaged  hand  placed  above  and  below  the  nipple. 
Each  of  the  breasts  should  be  drawn  alternately,  and  a  healthy  child  may  be 
allowed  to  nurse  until  satisfied.  Usually  during  the  first  six  weeks  the  breast 
is  required  every  second  hour  from  5  a.  m.  until  11  p.  m..  and  in  some  cases 
once  during  the  night ;  but  this  night-nursing  should  be  given  up  as  soon  as 
possible,  that  the  mother  may  secure  essential  repose.  Regularity  in  meal 
hours  is  most  important,  and  a  little  perseverance  will  form  the  habit  of 
waking  to  suck  the  breast  with  almost  the  precision  of  the  clock.     This  rule, 


GENERAL    MANAGEMENT   OF    CHILDREN.  19 

however,  is  not  rigid,  some  infants  requiring  food  less,  others  more,  frequently. 
These  exceptions  can  only  be  determined  by  observation  of  individual  charac- 
teristics, and  every  mother  must  early  learn  to  distinguish  the  cry  of  hunger  from 
that  due  to  the  pain  of  indigestion,  and  avoid  the  dangerous  practice  of  resort- 
ing to  constant  feeding  as  a  means  of  pacifying  crying. 

After  the  sixth  week  the  interval  between  nursings  may  be  slowly  increased 
until,  by  the  fourth  month,  it  reaches  three  hours.  During  this  period,  also, 
the  time  of  lying  at  the  breast  may  be  gradually  lengthened,  for  the  quantity 
of  milk  secreted  and  the  child's  appetite  and  capacity  for  food  are  all  aug- 
mented as  the  days  pass  by.  At  the  end  of  the  sixth  month  feeding  every 
fourth  hour  suits  some  children  well,  but  as  a  rule  the  three-hour  interval  must 
be  adhered  to  from  the  fourth  month  to  the  end  of  lactation. 

After  the  sixth  or  eighth  month  "mixed  feeding" — breast- and  bottle- 
feeding  alternatino; — is  advisable  if  the  babe  ceases  to  thrive  on  the  breast 
alone.  Otherwise,  the  maxim  of  not  interfering  with  any  course  that  is 
doing  well  is  as  applicable  here  as  elsewhere,  and  the  breast  may  be  relied  upon 
entirely  until  the  time  comes  for  weaning.  Should  additional  nutriment  be 
required,  the  food  must  be  selected  with  due  reference  to  age  and  prepared  in 
the  same  manner  as  in  regular  hand-feeding. 

The  date  of  weaning  cannot  be  fixed  for  all  cases,  since  it  depends  upon 
the  health  of  the  mother  and  the  development  of  the  child.  When  the  former 
continues  to  be  robust  and  the  child  steadily  grows  and  gains  flesh,  lactation 
can  be  prolonged  until  the  tenth  or  twelfth  month.  If  persevered  in  longer, 
the  mother's  strength  usually  begins  to  fail,  her  milk  is  lessened  in  quantity 
or  becomes  poor  in  quality,  the  child's  nutrition  suiFers,  and  it  grows  pale, 
thin,  and  flabby,  and  may  develop  the  disease  known  as  rickets. 

Weaning  may  be  accomplished  gradually  or  suddenly.  In  gradual  wean- 
ing about  four  weeks  are  required  to  prepare  for  the  absolute  withdrawal  of 
the  breast.  For  instance,  if  suck  be  given  every  three  hours  from  5  A.  M. 
until  11  P.  M.,  or  seven  times  a  day,  there  should  be,  during  the  first  week 
of  preparation,  one  artificial  feeding  and  six  nursings  daily ;  during  the  sec- 
ond, two  and  five,  and  so  on  until  the  breast  is  entirely  withheld.  Carefully 
prepared  milk  food,  administered  from  a  bottle,  is  the  best  substitute.  At  the 
age  of  ten  months  a  mixture  that  ordinarily  agrees  well  is — 

»'/ 
Cream f  |ss.  ^.j^ 

Milk f|iv. 

Sugar  of  milk 3j. 

Water f  giss. 

Should  fever  or  disordered  digestion  occur  during  the  period  of  prepara- 
tion, the  number  of  artificial  feedings  must  be  reduced  or  the  breast  resumed 
until  the  disturbance  be  passed ;  then  the  course  may  be  begun  again  and  car- 
ried to  its  completion. 

Sudden  weaning  is  more  difiicult  to  accomplish,  and  is  not  advisable  unless, 
while  the  breast  is  being  presented,  there  is  an  absolute  refusal  to  take  artificial 
food,  or  unless  the  mother's  health  becomes  so  aff"ected  as  to  render  any  further 
sucking  a  positive  peril  to  the  child's  life :  attacks  of  erysipelas  or  of  small- 
pox are  instances  in  point. 

The  physician  is  often  forced  to  decide  upon  the  advisability  of  premature 
weaning.  His  decision  must  be  made  cautiously  and  after  thorough  investi- 
gation of  two  propositions — namely  («)  the  efi"ect  of  further  lactation  upon  the 
health  of  the  mother ;  and  (h)  the  requirements  of  the  child. 

(a)  Lactation,  being  a  physiological  process,  is  not  a  drain  upon  the  sys- 


20      AMERICAN  TEXT-BOOK  OF  DISEASES  ^I   CHILDREN. 

temic  strength  so  long  as  the  functions  of  nutrition  are  actively  performed,'  but 
under  other  circumstances  it  very  frequently  becomes  so.  Premature  weaning 
is  necessary  Avhen  the  mother  is  attacked  by  any  acute  disease  threatening  dan- 
gerous temporary  prostration,  such  as  typhoid  or  typhus  fever.  A  change  must 
also  be  made  if  pulmonary  consumption  be  developed,  or,  being  already  pres- 
ent, rapidly  advances  under  the  drain  of  milk-secretion.  Usually,  however, 
the  general  condition  that  leads  to  withdrawal  of  the  breast  is  one  of  simple 
loss  of  strength  and  flesh  on  the  part  of  the  mother,  and  one  which  may  often 
be  overcome  by  attention  to  her  health. 

If  the  trouble  be  merely  diminished  milk-secretion,  it  may  often  be  reme- 
died by  the  free  use  of  animal  broths,  chocolate,  gruel,  or  milk,  and  some- 
times the  moderate  employment  of  stimulants,  in  the  form  of  ale  and  porter, 
may  be  necessary.  Such  tonics  as  malt  extract,  ferrated  elixir  of  cinchona, 
bitter  wine  of  iron,  and  the  preparation  known  as  "  beef,  wine,  and  iron,"  are 
useful  when  there  is  anremia  or  when  the  general  failure  of  strength  cannot  be 
overcome  by  food  and  attention  to  hygienic  rules. 

The  ordinary  local  conditions  indicating  the  necessity  of  premature  wean- 
ing on  the  mother's  account  are  fissures  of  the  nipple  and  mammary  abscess. 

(6)  On  the  part  of  the  infant  there  are  several  indications  for  premature 
weaning.  It  must  be  done  if  the  occurrence  of  pregnancy  or  the  recurrence 
of  menstruation  renders  the  milk  unwholesome ;  if  the  mother  contract  a  dan- 
gerous contagious  disease,  as  small-pox,  scarlet  fever,  or  erysipelas ;  if  the 
mammary  glands  become  inflamed ;  if  the  breast  does  not  afford  sufficient 
nourishment  and  artificial  food  be  refused ;  and,  finally,  if  dentition  be  mark- 
edly delayed  and  the  premonitory  symptoms  of  rickets  appear. 

Upon  deciding  to  anticipate  the  time  of  weaning,  the  next  point  to  con- 
sider is  whether  the  infant  shall  be  brought  up  by  hand  or  by  a  wet-nurse. 

2d.  Feeding  by  a  Wet-nurse. — The  advantage  of  this  mode  of  feeding  is 
that  the  mother's  milk  is  substituted  by  the  milk  of  another  woman ;  in  other 
words,  that  natural  feeding  is  continued — a  matter  of  moment  in  all  cases,  and 
of  inestimable  importance  with  delicate  children.  The  disadvantage  consists 
in  the  difficulty  of  finding,  in  a  woman  belonging  to  the  class  from  which  wet- 
nurses  come,  all  the  moral  and  physical  characters  essential  to  a  good  substitute, 
and  in  the  fact  that  a  stranger  is  introduced  into  the  household,  often  to  deceive 
and  annoy  the  family,  and  on  the  slightest  provocation  to  leave  her  charge  to 
fate  or  to  the  tender  mercies  of  another  of  her  kind.  For  these  reasons  it 
is  preferable,  in  the  majority  of  instances,  to  trust  to  careful  bottle-feeding. 
Nevertheless,  as  some  children  must  have  human  milk  if  their  lives  are  to  be 
saved,  the  rules  for  selecting  a  wet-nurse  must  be  understood. 

The  woman  chosen  must  be  strong  and  robust,  but  rather  spare  than  fiit. 
Her  bill  of  health  must  be  perfectly  free  from  hereditary  tendency  to  mental 
or  physical  disease  and  from  taint  of  syphilis,  consumption,  or  scrofula.  She 
must  be  cheerful,  good-natured,  active,  careful,  and  temperate  in  habits.  Her 
age  should  be  between  twenty  and  thirty  years ;  she  should  understand  the 
care  of  an  infant  and  the  manner  of  giving  suck  ;  her  child  ought  to  be  nearly 
of  the  same  age  as  the  infant  to  be  adopted,  and  she  must  be  able  to  afford  an 
abundant  supply  of  good  milk.  The  last  quality  can  be  estimated  by  inspect- 
ing the  breasts,  by  examining  some  of  the  milk  drawn  by  a  pump,  and  by  ascer- 
taining the  condition  of  the  woman's  own  child.  The  breasts  of  a  good  nurse 
are  not  necessarily  large,  but  are  firm  to  the  touch  and  pyriform  in  shape,  with 
well-developed,  prominent  nipples,  and  with  the  skin  distinctly  marbled  with 
large  blue  veins.  The  milk,  which  ought  to  flow  readily  on  pressure  or  on 
suction,  should  be  opaque  and  dull  white  in  color,  have  a  specific  gravity  of 


GENERAL    MANAGEMENT    OF    CHILDREN.  21 

1.031,  an  alkaline  reaction,  and  show,  Tvhen  placed  under  tlie  microscope,  a 
number  of  minute,  equal-sized  fat-globules.  Its  quantity  may  be  ascertained 
by  weighing  the  child  before  and  after  sucking,  the  normal  gain  being  from 
three  to  six  ounces.  There  is,  however,  no  better  or  more  readily  applied  test 
of  the  quality  of  a  nurse  than  the  size,  weight,  and  general  development  of 
her  own  child ;  and  if  it  be  weak  and  ill-nourished,  no  amount  of  fitness  in 
other  respects  can  warrant  her  engagement.  Even  when  a  woman  is  found 
fulfilling  in  her  single  person  all  the  required  conditions — a  rare  thing,  indeed 
— it  does  not  necessarily  follow  that  her  milk  will  suit  the  babe  to  be  suckled. 
Then  changes  and  new  trials  must  be  made  until  the  desired  end  be  attained. 

3d.  Artificial  Feeding. — There  are  many  women  who,  no  matter  how  will- 
ing, are  completely  unable  to  suckle  their  babies,  and  a  vast  number  in  whom 
the  secretion  of  milk  fails  after  a  few  weeks  or  months  of  lactation.  These 
must  resort  to  a  wet-nurse  or  to  artificial  feeding.  Usually,  they  select  the 
latter  method. 

To  ensure  success  in  hand-feeding — always  a  difiicult  task — it  is  important 
to  make  a  detailed  study  of  the  following  questions :  a,  the  selection  of  a 
proper  substitute  for  the  natural  food — the  breast-milk  ;  h,  the  quantity  to  be 
given ;  c,  the  method  of  preparation ;  d,  the  mode  of  administration ;  and,  e, 
the  means  of  preservation. 

a.  Healthy  breast-milk  must  be  taken  as  the  type  of  infants'  food,  and  the 
nearer  an  artificial  substance  can  be  made  to  approach  it  in  chemical  composi- 
tion and  physical  properties  the  more  perfect  it  is.  Nonnal  breast-milk  has  a 
specific  gravity  of  1.031.  It  is  a  persistently  alkaline  fluid,  having  a  some- 
what animal,  usually  disagreeable,  and,  very  rarely,  sweetish  taste.  It  is 
bluish-white  in  color  and  thin  and  watery  in  consistence.  It  contains  nitro- 
genous material  (caseine),  carbohydrates  (milk-sugar  and  fat),  salts,  and  water 
— all  the  elements  essential  to  repair  tissue-waste,  to  supply  hew  material  for 
growth,  and  to  maintain  body  heat,  or,  in  other  words,  to  constitute  a  perfect 
aliment ;  and  these,  too,  are  so  proportioned  in  the  combination  as  to  most 
easily  and  completely  meet  the  demands. 

In  seeking  a  substitute  for  human  milk  one  naturally  turns  to  the  domestic 
animals  for  the  source  of  supply ;  cows'  milk  is  usually  selected,  because,  being 
plentiful,  it  is  easily  obtained  and  cheap. 

Cows'  milk  (market  milk)  has  a  lower  specific  gravity  than  human  milk — • 
namely,  1.029  ;  notwithstanding  this,  it  is  richer-looking — that  is,  whiter  and 
more  opaque ;  its  reaction  is  slightly  acid  unless  perfectly  fresh  from  pasture- 
fed  animals,  when  it  may  be  neutral  or  alkaline.  Its  component  ingredients  are 
similar  to  those  of  human  milk,  but  nitrogenous  material  exists  in  greater,  the 
fat  in  somewhat  less,  and  the  sugar  in  far  less  proportion.  The  nitrogenous 
material  also  differs  in  quality,  containing  a  much  larger  proportion  of  albumin 
coagulable  by  acids.  This  difference  is  readily  tested  by  adding  rennet  to  the 
two  fluids.  In  the  case  of  cows'  milk  the  caseine  is  coagulated  into  large,  firm 
masses,  while  with  human  milk  a  light,  loose  curd  is  formed.  In  the  stomach 
the  acid  gastric  juice  has  the  same  effect,  producing  in  the  first  instance  a  coag- 
ulum  most  difficult  to  digest ;  in  the  other,  one  readily  attacked  and  broken 
down  by  the  gastro-intestinal  solvents.  These  chemical  and  physical  proper- 
ties of  cows'  milk  can  be  altered  by  various  methods  of  preparation,  and 
unless  this  be  done  there  are  few  instances  in  which  it  will  not  prove  a  poor 
substitute  for  the  natural  food. 

Condensed  milk  is  frequently  recommended  by  physicians,  and  largely  used 
by  the  laity  on  their  own  responsibility.  It  keeps  better  than  cows'  milk,  and 
is  supposed  to  be  more  readily  digested  by  young  infants.     The  latter  suppo- 


22      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

sition  is  a  mistaken  one,  and  arises  from  the  overlooked  fact  that  condensed 
milk  is  always  given  dissolved  in  a  large  proportion  of  water,  while  cows'  milk 
is  too  frequently  used  insufficiently  diluted  or  otherwise  improperly  prepared. 
Condensed  milk  contains  a  large  proportion  of  sugar,  forms  fat  quickly,  and 
thus  makes  large  babies ;  sugar  also  counteracts  the  tendency  to  constipation 
— often  a  troublesome  complaint  in  hand-feeding.  These  advantages  are 
unquestioned,  and,  together  with  the  ease  of  preparation,  are  those  which  place 
it  so  high  in  the  esteem  of  monthly  nurses.  It  is  equally  true,  however,  that 
as  a  food  it  contains  too  much  cane-sugar,  and  not  enough  nutrient  material 
to  supply  the  wants  of  a  growing  baby.  Infants  fed  upon  it,  though  fat,  are 
pale,  lethargic,  and  flabby ;  although  large,  they  are  far  from  strong,  have 
little  power  to  resist  diseases,  often  cut  their  teeth  late,  and  are  very  liable 
to  drift  into  rickets.  It  must  be  remembered  also  that  condensed  milk,  when 
long  kept  or  when  packed  in  imperfect  cans,  not  unfrequently  undergoes 
decomposition,  and  thus  becomes  utterly  unfit  for  use.  For  a  temporary 
change  of  diet,  however,  and  as  a  substitute  during  travelling  or  under  cir- 
cumstances in  which  sound  cows'  milk  cannot  be  obtained,  it  may  be  resorted 
to  with  advantage. 

The  farinaceous  substances  so  often  selected,  especially  by  the  poor,  to  replace 
breast-milk,  are  not  only  bad  foods,  but  have  both  directly  and  indirectly  a  delete- 
rious eff"ect  upon  the  processes  of  nutrition.  They  are  bad  for  two  reasons  :  First, 
they  dilFer  materially  in  chemical  composition  from  human  milk.  For  example, 
in  arrowroot,  which  is  the  favorite,  the  proportion  of  the  tissue-building  to  the 
heat-producing  element  is  as  one  to  twenty,  while  in  human  milk  it  is  about 
one  to  five.  Secondly,  the  heat-producing  principle,  starch,  must  be  converted 
into  sugar  before  it  can  be  absorbed.  This  change  is  accomplished  in  the  body 
by  the  saliva  and  pancreatic  juice — secretions  that  are  not  fully  established 
until  the  fourth  month.  While  the  starch  lies  undigested  in  the  gastro-intes- 
tinal  canal  it  is  subject  to  fermentation,  resulting  in  the  formation  of  irritant 
products  that  rapidly  induce  catarrh  of  the  mucous  membrane — a  condition 
directly  interfering  with  the  digestion  and  absorption  of  food.  Again,  perfect 
nutrition  demands  rapid  waste  and  removal  of  effete  tissues  as  well  as  repair 
of  the  same.  This  is  effected  by  oxidation.  Now,  sugars  are  known  to  have 
a  much  greater  affinity  for  oxygen  than  albuminates,  and  when  the  diet  con- 
sists of  farinaceous  material  the  small  amount  of  sugar  formed  and  absorbed 
appropriates  oxygen  that  otherwise  would  go  toward  the  removal  of  waste,  and 
so  retards  the  necessary  changes.  Farinaceous  food,  as  such,  is  never  permis- 
sible before  the  fourth  month  ;  earlier,  it  is  only  to  be  employed  for  its  mechan- 
ical action  as  an  addition  to  milk  preparations.     This  will  be  mentioned  later. 

The  nutrient  value  of  the  cereals  and  their  products  as  they  exist  in  so-called 
"infants'  foods  "  has  been  imperfectly  determined.  They  are  undoubtedly  use- 
ful as  mechanical  attenuants,  but  it  is  very  certain  that  none  of  them, 
unless  prepared  with  milk,  can  permanently  meet  the  demands  of  nutrition. 
At  the  same  time,  it  is  quite  probable  that  the  soluble  albuminoid  substances 
obtained  by  Liebig's  process  have  a  food  value  of  their  own,  making  them  more 
serviceable  than  the  starches. 

I.  The  quantity  of  food  to  be  allowed  each  day  varies  with  the  appetite 
and  age,  and  the  question  of  the  correct  amount  in  a  given  case  must  be 
answered  by  observation.  Nevertheless,  it  is  well  to  have  some  guide.  (See 
table,  page  24  et  seq.) 

After  the  twelfth  month  the  quantity  depends  upon  whether  additions  be 
made  to  the  diet  or  milk  food  be  used  exclusively.  When  the  daily  amount 
reaches  three  pints,  the  limit  of  the  capacity  of  the  stomach  is  usually  attained, 


GENERAL    MANAGEMENT    OF    CHILDREN.  23 

and  the  greater  demand  for  nutriment,  as  growth  advances  month  by  month, 
must  be  met  by  adding  to  the  strength  of  the  food  rather  than  by  increasing 
its  bulk.  These  two  factors,  strength  and  quantity,  are  intimately  associated 
throughout  the  whole  period  of  infancy,  and  in  the  earlier  months  a  mere 
increase  in  the  latter  is  not  always  sufficient  to  maintain  the  balance  of 
nutrition. 

e.  The  object  to  be  accomplished  in  the  preparation  of  cows'  milk  is  to  make 
it  resemble  human  milk  as  much  as  possible  in  chemical  composition  and  phys- 
ical properties.  To  do  this  it  is  necessary  to  reduce  the  proportion  of  caseine, 
to  increase  the  proportion  of  fat  and  sugar,  and  to  overcome  the  tendency  of 
the  caseine  to  coagulate  into  large,  firm  masses  upon  entering  the  stomach. 
Dilution  with  water  is  all  that  need  be  done  to  reduce  the  amount  of  caseine 
to  the  proper  level ;  but  as  this  diminishes  the  already  insufficient  fat  and 
sugar,  it  is  essential  to  add  these  materials  to  the  mixture  of  milk  and  water. 
Fat  is  best  added  in  the  form  of  cream,  and  of  the  sugars  either  pure  white 
loaf  sugar  or  sugar  of  milk  may  be  used.  The  latter  is  greatly  preferable,  as 
it  is  little  apt  to  ferment  and  contains  some  of  the  salts  of  milk,  which  are  of 
nutritive  value.  Firm  clotting  may  be  prevented  by  the  addition  of  an  alkali 
or  a  small  quantity  of  some  thickening  substance.  Lime-water  is  the  alkali 
usually  selected.  It  acts  by  partially  neutralizing  the  acid  of  the  gastric  juice, 
so  that  the  caseine  is  coagulated  gradually  and  in  small  masses,  or  passes,  in 
great  part,  unchanged  into  the  intestine,  to  be  there  digested  by  the  alkaline 
secretions.  As  it  contains  only  half  a  grain  of  lime  to  the  fluidounce,  the 
desired  result  cannot  be  attained  unless  at  least  a  third  part  of  the  milk  mix- 
ture be  lime-water.  Instead  of  lime-water,  two  to  four  grains  of  bicarbonate 
of  sodium  may  be  added  to  each  bottle,  or,  better  still,  from  five  to  fifteen 
drops  of  the  saccharated  solution  of  lime. 

This  solution  is  made  in  the  following  way : 

Take  of— 

Slaked  lime 1  ounce. 

Refined  sugar,  in  powder 2  ounces. 

Distilled  water 1  pint. 

Mix  the  lime  and  sugar  by  trituration  in  a  mortar.  Transfer  the  mixture  to 
a  bottle  containing  the  water,  and,  having  closed  this  with  a  cork,  shake 
it  occasionally  for  a  few  hours.  Finally,  separate  the  clear  solution  with 
a  siphon  and  keep  it  in  a  stoppered  bottle. 

Thickening  substances — attenuants,  such  as  barley-water,  gelatin,  or  one 
of  the  digestible  prepared  foods — act  purely  mechanically  by  getting,  as  it 
were,  between  the  particles  of  caseine  during  coagulation,  preventing  their 
running  together  and  forming  a  large,  compact  mass.  To  prepare  the  former, 
put  two  teaspoonfuls  of  washed  pearl  barley,  with  a  pint  of  cold  filtered  water, 
into  a  saucepan ;  boil  slowly  down  to  two-thirds  and  strain.  The  liquid  ob- 
tained does  not  possess  the  disadvantages  of  farinaceous  foods  generally.  To 
be  efficient,  it  must  be  used  as  a  diluent  instead  of,  and  in  the  same  proportion 
as,  water.  Gelatin  is  prepared  in  the  following  way  :  Put  a  piece  of  plate  gel- 
atin, an  inch  square,  into  a  half-tumblerful  of  cold  water,  and  let  it  stand  for 
three  hours ;  then  turn  the  whole  into  a  teacup  ;  place  this  in  a  saucepan  half 
full  of  water  and  boil  until  the  gelatin  is  dissolved.  When  cold  this  forms  a 
jelly;  from  one  to  two  teaspoonfuls  may  be  added  to  each  bottle  of  milk  food. 
When  an  "  infants'  food  "  is  used  to  act  mechanically,  care  should  be  taken  to 
select  one  in  which  the  starch  has  been  converted  into  maltose  and  dextrin 
by  the  process  of  manufacture. 


24      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


The  following  table  and  schedule  will  aid  in  the  practical  understanding 
of  the  method  of  preparing  food : 

Table  of  the  Inyredienls,  Hours  and  Intervals  of  Feeding,  and  Total  Quantity  of  Food  from  Birth  to 

the  End  of  Seventh  Month. 


Milk- 

Intervals 

Total 

Age. 

Cream. 

Whey. 

Milk. 

Water. 

sugar. 

Salt.          Feeding. 

of 
Feeding. 

Quantity. 

Daring  1st  week  . 

fSiJ 

^iy 

fSiiJ 

gr.  XX 

5  A.  M.  to  11 
P.  M. 

Occasionally 

2  hours. 

i'axij. 

once       or 

i     twice      at 

From    2d    to    6th 

night. 

week 

f3ij 

f^S8 

f^i 

gr.  XX 

a  pinch.  5  A.  M.  to  11 

2  hours. 

to^^ij- 

From  6th  week  to 

P.  M. 

end  of  2d  montli 

f^ss 

i^x 

i7,X 

3SS 

a  pinch.  5  A.  M.  to  1 1 

2  hours. 

f5xxx. 

From  3d  month  to 

1      p.  M. 

6th  month     .    . 

f^ss 

f^ij 

fgss 

3J 

a  pinch.  5   A.    m.    to 

2J  hrs. 

fgxxxij. 

During  6th  and  7th 

10.30  p.  M. 

months  .... 

f§ss 

fgiijss 

f5y 

3J 

a  pinch.  7  A.  M.  to  10 

I      p.  M. 

3  hours. 

f^xxxvj. 

Throughout  the  eighth  and  ninth  months  five  meals  a  day  will  be  suflScient. 
First  meal,  at  7  a.  m. — 

Milk f§vi. 

Cream f§ss. 

Milk-sugar 3j. 

Water f^j^^- 

Second  meal  at  10.30  a.  m. — Milk,  cream,  and  water  in  the  same  propor- 
tion;  a  reliable  ''infants'  food."  two  teaspoonfuls.  Third  meal  at  2  P.  M. — 
same  as  second.  Fourth  meal  at  6  p.  m. — same  as  second.  Fifth  meal  at  10 
p.  M. — same  as  first.  This  gives  forty  fluidounces  of  food  per  diem.  Instead 
of  "infants'  food,"  a  teaspoonful  of  "flour-ball"  may  be  added.  To  make 
flour-ball,  take  a  pound  of  good  wheat  flour — unbolted,  if  possible ;  tie  it  up 
very  tightly  in  a  strong  pudding-bag ;  place  it  in  a  saucepan  of  water  and  boil 
constantly  for  ten  hours ;  when  cold,  remove  the  cloth,  cut  away  the  soft,  outer 
covering  of  dough  that  has  been  formed,  and  reduce  the  hard-baked  interior 
by  grating.  In  the  yellowish-white  powder  obtained  almost  all  the  starch  lias 
been  converted  into  dextrin  by  the  process  of  cooking,  and  the  proportion  of 
the  nitrogenous  principle  to  the  calorifacient  is  as  one  to  five — nearly  the  same 
as  human  mi'lk.  Tavo  meals  of  flour-ball  daily — the  second  and  fourth — are 
all  that  can  be  digested.  To  prepare  these,  rub  one  teaspoonful  of  the  powder 
with  a  tablespoonful  of  milk  into  a  smooth  paste,  then  add  a  second  tablespoon- 
ful  of  milk,  constantly  rubbing  until  a  cream-like  mixture  is  obtained.  Pour 
this  into  eight  ounces  of  "hot  milk,  stirring  well,  and  it  is  then  ready  for  use. 
The  other  meals  should  be  composed  of  miFk,  cream,  sugar  of  milk,  and  water, 
as  already  given.  Flour-ball  is  best  suited  for  infants  having  a  tendency  to 
too  frei^uent  and  liquid  fecal  evacuations,  as  it  has  a  somewhat  astringent 
action,  and  is  to  be  avoided  in  cases  of  sluggish  bowels  and  constipation. 
Under  the  latter  conditions  a  more  laxative  food,  such  as  oat-meal,  crushed 
wheat,  or  barley,  should  be  employed,  the  quantity  of  each  being  determined 
by  the  eff'ect  to  be  produced. 

Diet  from  the  tenth  to  fourteenth  month — five  meals  daily : 
First  meal,  7  a.  M. — 


GENERAL    MANAGEMENT   OF    CHILDREN  25 

Milk ■   .  f  gviiiss.  . 

Cream f  iss. 

One  of  the  Liebig  foods 5ss. 

(Or  barley  jelly 3ij.) 

Water fijss. 

Occasionally,  about  the  end  of  the  first  year  a  child  may  require  a  more 
varied  and  substantial  diet ;  for  example  :  First  meal,  7  A.  m. — milk  mixture 
as  above.  Second  meal,  10.30  A.  m. — a  breakfast-cupful  (f  Bviij)  of  warm 
milk.  Third  meal,  2  p.  M. — the  yelk  of  an  egg  lightly  boiled,  with  stale 
bread-crumbs.  Fourth  meal,  6  P.  M. — same  as  first.  Fifth  meal,  10  P.  M. — 
same  as  second.  On  alternate  days  the  third  meal  may  consist  of  a  teacupful 
(six  fluidounces)  of  beef  tea^  containing  a  few  stale  bi'ead-crumbs.  A  further 
variation  can  be  made  by  occasionally  using  mutton,  chicken,  or  veal  broth 
instead  of  beef  tea. 

As  much  more  difiiculty  is  experienced  in  feeding  infants  during  the  first 
twelve  months  than  during  the  second,  it  would  be  well  to  pause  here  to  con- 
sider what  had  best  be  done  in  case  the  food  described  should  disagree. 

If,  after  feeding,  vomiting  occur,  with  the  expulsion  of  large,  firm  clots  of 
caseine,  the  effect  of  adding  lime-water  or  barley-water  must  be  tried,  both 
being  added  in  the  same  quantity  as  the  ordinary  diluent — water. 

Sometimes,  particularly  if  there  be  diarrhoea,  boiling  makes  the  milk  more 
tolerable ;  condensed  milk,  too,  can  be  employed  temporarily,  making,  for  an 
infant  of  six  weeks,  each  portion  of — 

Condensed  milk Sj. 

Cream fgss. 

Hot  water f  ^iiss. 

Should  further  alteration  be  necessary,  goats'  or  asses'  milk  may  be  substi- 
tuted for  cows'  milk,  the  strong  odor  of  the  former  and  the  laxative  properties 
of  the  latter  being  removed  by  boiling.  The  milk  should  be  used  warm  from 
the  udder. 

"  Strippings  "  is  another  good  substitute  for  cows'  milk.  It  is  obtained 
by  remilking  the  cow  after  the  ordinary  daily  supply  has  been  drawn,  and  con- 
tains much  cream  and  but  little  curd.  One  part  of  strippings  to  two  of  water 
or  an  equal  measure  of  barley-water  makes  an  easily  digested  mixture. 

The  process  of  predigestion  or  peptonization  enables  us  to  overcome  many 
of  the  difficulties  encountered  in  bottle-feeding.  Pancreatin  is  the  agent  to. 
be  employed.  That  manufactured  under  the  name  of  extractum  pancreatis  by 
Fairchild  Brothers  &  Foster  of  New  York  has  proved  most  efficient  in  my  hands. 
To  accomplish  artificial  digestion  put  into  a  clean  quart  bottle  five  grains  of 
extractum  pancreatis,  fifteen  grains  of  bicarbonate  of  sodium,  and  four  fluid- 
ounces  of  cool  filtered  water  ;  shake  thoroughly  together,  and  add  a  pint  of 
fresh,  cool  milk.  Place  the  bottle  in  water,  not  so  hot  but  that  the  whole 
hand  can  be  held  in  it  for  a  minute  without  discomfort,  and  keep  the  bottle 
there  for  exactly  thirty  minutes.  At  the  end  of  that  time  put  the  bottle  on 
ice  to  check  further  digestion  and  to  keep  the  milk  from  spoiling.  The  fluid 
obtained,  while  somewhat  less  white  in  color  than  milk,  does  not  differ  from  it 
in  taste :  if,  however,  an  acid  be  added,  the  caseine,  instead  of  being  coagu- 

^  Beef  tea  for  an  infant  is  made  in  the  following  way :  Half  a  pound  of  fresh  rump-eteak, 
free  from  fat,  is  cut  into  small  pieces  and  put,  with  one  pint  of  cold  water,  into  a  covered  tin 
saucepan.  This  must  stand  by  the  side  of  the  fire  for  four  hours,  then  be  allowed  to  simmer 
gently  (never  boil)  for  two  hours,  and,  finally,  be  thoroughly  skimmed  to  remove  all  grease. 


26       AMEBICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

latecl  into  large,  firm  curds,  takes  the  form  of  minute  soft  flakes  or  readily 
broken-down,  feathery  masses  of  small  size.  When  the  process  is  carried  just 
to  the  point  described,  the  caseine  is  only  partly  converted  into  peptone,  but 
every  succeeding  moment  of  continued  warmth  lessens  the  amount  of  caseine 
until  peptonization  is  complete.  Then  the  liquid  is  grayish-yellow  in  color, 
has  a  distinctly  bitter  taste,  and  shows  no  coagulation  whatever  on  the  addition 
of  an  acid. 

"Peptogenic  milk  powder,"  prepared  by  the  same  chemists,  has  given  me 
even  better  results  than  the  pancreatin  and  soda.  This  powder  contains  a 
digestive  ferment,  pancreatin ;  an  alkali,  bicarbonate  of  sodium ;  and  a  due 
proportion  of  milk-sugar.     The  mode  of  employment  is  as  follows :         , 

Take  of— 

Milk fsij. 

Water f^ij- 

Cream fiss. 

Peptogenic  milk  powder       3J.^ 

This  mixture  is  to  be  heated  slowly  to  boiling,  ten  minutes  being  occupied, 
and  then  quickly  cooled.  When  properly  prepared  the  resultant,  so-called 
"humanized  milk,"  presents  the  albuminoids  in  a  minutely  coagulable  and 
digestible  form ;  has  an  alkaline  reaction ;  contains  the  proper  porportion  of 
salts,  milk-sugar,  and  fat ;  is  not  bitter  in  taste,  being  but  partially  peptonized, 
and  in  appearance  as  well  as  chemical  composition  resembles  human  milk. 

The  great  advantages  of  partial  peptonization  are  that  the  necessity  for 
lime-water,  barley-water,  and  thickening  substances  to  keep  apart  the  curd  is 
done  away  with,  and  that,  when  the  digestive  disturbance  requiring  a  careful 
preparation  of  food  is  removed,  an  ordinary  milk  diet  can  be  gradually  resumed 
by  regularly  diminishing  the  time  artificial  digestion  is  allowed  to  progress. 
This  changes  the  caseine  in  a  less  and  less  degree,  until,  finally,  it  is  taken  in 
its  natural  form. 

"  Sterilization"  is  another  process  of  importance.  As  milk  exists  in  the 
healthy  cow's  udder  it  is  aseptic — i.  e.  free  from  any  poisonous  or  dangerous 
ingredient — but  during  milking  and  subsequent  handling  and  transportation 
various  foreign  materials  get  into  it  ajid  are  apt  to  set  up  some  injurious  change. 
To  deprive  these  accidentally  introduced  organic  impurities  of  their  activity — 
or,  in  other  words,  to  sterilize — it  is  necessary  to  subject  the  fluid  to  high  heat 
under  pressure. 

Several  admirable  implements  have  been  devised  for  conducting  the  process; 
one  of  the  most  simple,  made  after  a  design  of  my  own,  is  shown  in  Fig.  1. 

This  apparatus  is  made  of  tin,  and  consists  of  an  oblong  case  provided  with 
a  well-fitting  cover,  and  having  a  movable  perforated  false  bottom  (d),  which 
stands  a  short  distance  above  the  true  one  and  has  attached  a  framework  capa- 
ble of  holding  ten  six-ounce  nursing-bottles.  On  the  outside  of  the  case  is  a 
row  of  supports  (b)  for  holding  inverted  bottles  while  drying,  and  at  the  proper 
distance  below  these  a  gradually  inclining  gutter  (c)  for  carrying  off"  the  drip. 
A  movable  water-bath  (a)  is  hung  to  the  side ;  in  this  each  bottle  of  food  may 
be  warmed  at  the  time  of  administration.  Ten  graduated  nursing-bottles  are 
used,  so  that  the  whole  supply  of  milk  intended  for  a  day's  consumption  can 
be  prepared  at  once.  Each  bottle  is  provided  with  a  perforated  rubber  cork, 
which  in  turn  is  closed  by  a  well-fitting  glass  stopper. 

Sterilization  should  be  performed  in  the  morning  as  soon  as  possible  after 
^  Measure  provided  with  jar  only  to  be  used  when  preparing,  at  once,  the  whole  quantity 
of  food  to  be  given  in  a  day. 


GENERAL   MANAGEMENT   OF   <JHILDBEN 


27 


the  milk  has  been  served.  The  process  is  as  follows-:  First,  see  that  the  ten 
bottles  are  perfectly  clean  and.  dry ;  pour  into  each  six  fluidounces  of  milk ; 
insert  the  perforated  rubber  corks,  without  the  glass  stoppers,  however ; 
remove  the  false  bottom  and  place  the  bottles  in  the  frame ;   pour  into  the 


Fig.  1. 


Author's  Sterilizer. 


case  enough  water  to  fill  it  to  the  height  of  about  two  inches  ;  replace  the  false 
bottom  carrying  the  bottles  ;  adjust  lid  and  put  the  whole  on  the  kitchen  range. 
Allow  the  water  to  boil,  and,  by  occasionally  removing  the  lid,  ascertain  that 
the  expansion  that  immediately  precedes  boiling  has  taken  place  in  the  milk ; 
then  press  the  glass  stoppers  into  the  perforated  corks,  and  thus  hermetically 
close  each  bottle.  After  this  keep  the  apparatus  on  the  fire  and  the  water 
boiling  for  twenty  minutes.  Finally,  remove  the  false  bottom  with  the  bot- 
tles ;  pour  out  the  water,  replace  and  carry  the  whole,  covered  with  the  lid, 
to  the  nursery. 

Milk  sterilized  by  this  process  will  remain  sound  for  many  days  :  it  is  espe- 
cially useful  in  travelling,  Avhen  fresh  milk  cannot  be  obtained ;  for  use  in 
cities  during  the  heat  of  summer,  when  milk  is  most  apt  to  undergo  injurious 
changes  ;  for  a  temporary  change  of  food  in  delicate  children  or  for  those  suffer- 
ing from  disease  of  the  stomach  or  intestinal  canal.  It  must  be  remembered, 
however,  that  the  prolonged  heating  produces  certain  changes  in  the  compo- 
sition of  the  milk  which  make  it  more  difficult  to  digest,  and  that  on  this 
account  many  children  do  not  thrive  upon  it. 

Another  process  of  sterilization,  suggested  by  Leeds,  is  free  from  this  dis- 
advantage, and  has  proved  most  useful  in  my  practice.  It  consists  in  heating 
the  milk,  rendered  feebly  alkaline  with  lime-water  or  sodium  bicarbonate,  to 
155°  F.  for  six  minutes,  or,  better  still,  of  applying  the  same  amount  of  heat 
to  milk  with  pancreatin  and  bicarbonate  of  sodium  or  with  peptogenic  milk 
powder.  By  the  latter  method  the  milk  is  both  predigested  and  sterilized  ;  if 
not  used  at  "once,  it  must  be  momentarily  heated  to  the  boiling-point  to  check 
peptonization  before  the  development  of  a  bitter  taste. 

According  to  Rowland  G.  Freeman,  the  problem  that  presents  itself  in  the 
sterilization  of  milk  for  food  is  to  devise  a  method  which  shall  destroy  by 
efficient  means  the  contained  germs,  and  yet  in  the  least  possible  degree 
interfere  with  its  nutritive   qualities.      The  experiments  of  Leeds  show  that 


28       A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

sterilization  at  the  boiling-point  of  Avater  causes  the  folloAving  modifications : 
the  starch-liquefying  ferment  is  destroyed  and  coagulated  ;  caseine  is  rendered 
less  coagulable  by  rennet,  and  is  acted  on  slowly  and  imperfectly  by  pepsin 
and  pancreatin ;  proteid  matters  attach  themselves  to  fat-globules,  and  prob- 
ably bring  about  a  less  perfect  assimilation  of  fat;  while  milk-sugar,  by  pro- 
longed heating,  is  completely  destroyed.  Koplik  states  that  "from  the  temper- 
atui-e  of  75°  0.  upward  there  is  a  separation  of  the  serum-albumin  of  the  milk ; 
the  caseine  loses  its  coagulability  to  rennet,  and  at  85°  C.  amounts  of  rennet 
which  for  the  raw  condition  of  milk  are  found  sufficient  to  act  cease  to  be  effec- 
tive." Hueppe  considers  that  from  a  physiological  standpoint  milk  is  best 
sterilized  under  a  temperature  of  75°  C,  while  other  experimenters  have  shown 
that  temperatures  lower  than  100°  C,  if  continued  for  a  short  time,  will  destroy 
a  very  large  proportion  of  the  germs,  and  will  destroy  with  certainty  many 
pathogenic  germs  which  find  their  way  into  milk  either  from  the  cow  or  as 
external  contaminations. 

Dr.  Freeman,  therefore,  feels  satisfied  that  Pasteurization  offers  the  most 
rational  solution  of  the  question  under  consideration.  The  elaborate  and 
recent  experiments  of  Yersin,  Granchier,  Lidoux-Libard,  and  Bitter  show 
that  the  bacillus  tuberculosis  in  milk  will  be  destroyed  in  ten  minutes  by  an 
exposure  to  75°  C,  in  fifteen  minutes  to  70°,  and  in  thirty  minutes  to  68°. 
Concerning  other  bacteria,  Van  Geuns  found  that  a  few  seconds'  exposure  to 
60°  would  kill  the  cholera  spirilla,  the  Finkler-Prior  bacillus,  the  typhoid 
bacillus,  and  the  pneumococcus  of  Friedlander. 

It  may,  therefore,  be  concluded  that  a  temperature  of  not  less  than  158°  F. 
will  render  milk  sufficiently  germ-free  for  infant  food,  and  that  a  temperature 
of  less  than  176°  F.  will  not  injure  milk  materially.  Methods  of  Pasteurizing 
milk  in  bulk  have  been  brought  forward  both  in  Germany  and  in  this  coun- 
try ;  and  now  the  procedure  has  been  brought  down  to  an  easily-managed 
system  for  household  use.  This  depends  upon  the  theory  that  the  tempera- 
ture of  the  milk  to  be  treated  may  be  raised  to  about  the  desired  point 
(167°  F.)  by  immersing  a  certain  definite  quantity  of  milk  in  a  properly  pro- 
portioned bulk  of  boiling  water,  the  source  of  heat  having  been  removed. 
The  apparatus  consists  of  two  parts,  a  graduated  pail  for  the  w^ater  and  a 
receptacle  for  the  bottles  of  milk.  This  receptacle  consists  of  a  series  of 
seven  or  ten  hollow  zinc  cylinders  fastened  together,  which  fits  into  the  pail 
containing  the  boiling  water.  Each  of  these  cylinders  is  large  enough  to  hold 
one  of  the  bottles  of  milk,  the  series  of  seven  cylinders  accommodating  seven 
eight-ounce  bottles,  and  the  series  of  ten  cylinders  being  intended  for  ten  six- 
ounce  bottles.  When  the  bottles  are  in  place  water  is  poured  around  them 
to  secure  perfect  conduction  of  the  heat.  After  the  w^ater  in  the  pail  is  thor- 
oughly boiling,  it  is  removed  from  the  stove  and  placed  on  a  non-conducting 
surface.  The  cylinders  are  now  introduced,  and  the  pail  covered  and  left 
standing  for  thirty  minutes,  after  which  the  milk  is  rapidly  cooled  in  a  refrig- 
erator or  by  cold  water  or  ice  and  water.  Milk  thus  treated  and  put  imme- 
diately into  a  refrigerator  usually  shows  no  change  for  several  days. 

Sometimes  milk,  in  every  form  and  however  carefully  prepared,  ferments 
soon  after  being  swallowed  and  excites  vomiting,  or  causes  great  flatulence  and 
discomfort,  while  it  affords  little  nourishment.  With  these  cases  the  best  plan 
is  to  withhold  milk  entirely  for  a  time  and  try  some  other  form  of  food.  The 
following  are  good  substitutes  : 

Veal  broth  (J  lb.  of  meat  to  the  pint) f  giss. 

Barley-water f  Siss. 


GENERAL   MANAGEMENT    OF    CHILDREN  29 

Or,  Whey fgiss. 

Barley-water f^iss. 

Milk-sugar      gss. 

For  one  portion ;  to  be  given  every  two  hours  at  the  age  of  two  months. 

A  teaspoonful  of  the  juice  of  raw  beef  every  two  hours  will  usually  be 
retained  when  everything  else  is  rejected.  Such  foods  are  only  to  be  used 
temporarily  until  the  tendency  to  fermentation  within  the  alimentary  canal 
.  ceases ;  then  milk  may  be  gradually  and  cautiously  resumed. 

When  infants  approaching  the  end  of  the  first  year  become  affected  with 
indigestion,  it  is  often  sufiicient  to  reduce  the  strength  and  quantity  of  the  food 
to  a  point  compatible  with  digestive  powers.  For  instance,  at  eight  months 
the  food  may  be  reduced  to  that  proper  for  a  healthy  child  of  six  months  or 
even  less.  Here,  too,  predigestion  of  the  food  is  very  serviceable.  If  a  few 
grains  of  extractum  pancreatis  be  added  to  a  gobletful  of  thick,  well-boiled 
starch  gruel  at  a  temperature  of  100°  F.,  the  gelatinous  mucilage  quickly  grows 
thinner,  and  soon  is  transformed  into  a  fluid,  the  starch  having  been  rendered 
soluble  by  the  action  of  the  pancreatin ;  by  still  longer  contact  the  hydrated 
starch  is  converted  into  dextrin  and  sugar.  Advantage  may  be  taken  of  this 
property  to  render  the  foods  containing  starch  assimilable.  Thus,  to  a  mixture 
of  barley  jelly  and  milk — e.  g. 

Barley  jelly 3ij, 

Milk  sugar 3j, 

Warm  milk f^viij, 

add  three  grains  of  extractum  pancreatis  and  five  grains  of  bicarbonate  of 
sodium,  and  keep  warm  for  half  an  hour  before  administering. 

The  same  process  may  be  employed  with  food  containing  oatmeal,  arrow- 
root, or  wheaten  flour,  or  in  the  case  of  meat  broths,  with  a  view  of  converting 
the  starchy  and  albuminoid  ingredients  into  digestible  elements  without  mate- 
rially altering  the  taste. 

Returning  to  the  regimen  of  the  healthy  infant,  it  will  be  found  that  after 
the  fourteenth  month  far  less  change  is  required  in  the  food. 

Diet  from  the  fourteenth  to  the  eighteenth  month,  five  meals  per  day : 
First  meal,  7  a.  m. — a  slice  of  stale  bread,  broken  and  soaked  in  a  breakfast- 
cup  (eight  fluidounces)  of  new  milk.  Second  meal,  10  A.  M. — a  teacup  of 
milk  (six  fluidounces),  with  a  soda  biscuit  or  thin  slice  of  buttered  bread. 
Third  meal,  2  P.  m. — a  teacup  of  meat  broth  (six  fluidounces),  with  a  slice  of 
bread;  one  good  tablespoonful  of  rice-and-milk  pudding.  Fourth  meal, 
6  P.  M. — same  as  first.  Fifth  meal,  10  P.  m. — one  tablespoonful  of  Mellin's 
Food,  with  a  breakfast-cupful  of  milk. 

To  alternate  with  this :  First  meal,  7  A.  M. — the  yelk  of  an  egg  lightly 
boiled,  with  bread-crumbs  ;  a  teacupful  of  new  milk.  Second  meal,  10  A.  M. — 
a  teacupful  of  milk,  with  a  thin  slice  of  buttered  bread.  Third  meal,  2  p.  M. — 
a  mashed  baked  potato,  moistened  with  four  tablespoonfuls  of  beef  tea ;  two 
good  tablespoonfuls  of  junket.  Fourth  meal,  6  p.  m. — a  breakfast-cupful  of 
milk,  with  a  slice  of  bread  broken  up  and  soaked  in  it.  Fifth  meal,  10  p.  M. 
— same  as  second. 

The  fifth  meal  is  often  unnecessary,  and  sleep  should  never  be  disturbed 
for  it ;  at  the  same  time,  should  the  child  awake  an  hour  or  more  before  the 
first  meal,  he  must  break  his  fast  upon  a  cup  of  warm  milk,  and  not  be  allowed 
to  go  hungry  until  the  set  breakfast  hour. 

Diet  from  eighteen  months  to  the  end  of  two  and  a  half  years,  four  meals 


30       A3IEJRICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

a  day :  First  meal,  7  a.  m. — a  breakfast-cupful  of  new  milk  ;  the  yelk  of  an 
egg  lightly  boiled;  two  thin  slices  of  bread  and  butter.  Second  meal,  11  A.  M. 
— a  teacupful  of  milk,  with  a  soda  biscuit.  Third  meal,  2  P.  M. — a  bi-eakfost- 
cupful  of  beef  tea,  mutton  or  chicken  broth ;  a  thin  slice  of  stale  bread ;  a 
saucer  of  I'ice-and-milk  pudding.  Fourth  meal,  6.30  p.  m. — a  breakfast-cupful 
of  milk,  with  bread  and  butter. 

On  alternate  days :  First  meal,  7  a.  m. — two  tablespoonfuls  of  thoroughly 
cooked  oatmeal  or  wheaten  grits,  with  sugar  and  cream ;  a  teacupful  of  new 
milk.  Second  meal,  11  A.  M. — a  teacupful  of  milk,  with  a  slice  of  bread  and 
butter.  Third  meal,  2  p.  m. — one  tablespoonful  of  underdone  mutton  pounded 
to  a  paste ;  bread  and  butter,  or  mashed  baked  potato  moistened  with  good 
plain  dish  gravy  ;  a  saucer  of  junket.  Fourth  meal,  6.30  P.  M. — a  breakfast- 
cupful  of  milk,  a  slice  of  soft  milk  toast  or  a  slice  or  two  of  bread  and  butter. 

When  sickness  supervenes,  all  that  is  ordinarily  necessary  is  a  reduction  of 
the  diet  to  plain  milk  or  some  easily  digestible  milk  mixture. 

An  important  point,  often  neglected,  is  the  matter  of  drink.  Even  the 
youngest  infant  requires  water  several  times  daily,  and  the  demand  increases 
with  age.  The  water  must  be  as  pure  as  possible,  and  should  not  be  too  cold. 
In  the  heat  of  summer,  however,  bits  of  ice  and  water  moderately  cooled  by 
ice  can  be  allowed  without  harm. 

The  foregoing  schedule  must,  of  course,  be  regarded  only  as  an  average. 
Many  children  can  bear  nothing  but  milk  food  up  to  the  age  of  two  or  even 
three  years,  and,  provided  enough  be  taken,  no  fear  for  their  nutrition  need 
be  entertained.  If  a  child  be  thriving  on  milk,  he  is  never  to  be  forced  to  take 
additional  food  merely  because  a  certain  age  has  been  reached ;  let  the  healthy 
appetite  be  the  guide. 

d.  Success  in  hand-feeding  depends  quite  as  much  on  the  administration 
as  upon  the  preparation  of  the  food. 

From  birth  up  to  such  time  as  broth,  bread,  and  eggs  are  added  to  the  diet 
all  the  food  should  be  taken  from  a  bottle.  Even  after  this,  as  the  bottle  is  a 
comfort  and  ensures  slow  feeding,  it  may  be  allowed  for  milk  preparations  until 
the  child,  of  his  own  accord,  tires  of  it.  The  only  feeding  apparatus  to  be 
admitted  to  the  nursery  is  the  simple  bottle  and  tip.  The  bottle  made  after 
my  suggestion,  and  known  as  the  "graduated  nursing-bottle,"  has  an  interior 
surface  free  from  angles,  so  that  it  is  readily  kept  clean,  and  is  provided  with 
a  scale  for  the  measurement  of  ounces  and  half-ounces.  It  is  made  of  trans- 
parent flint  glass,  so  that  the  slightest  foulness  can  be  detected  at  a  glance, 
and  may  vary  in  capacity  from  six  to  twelve  fluidounces  according  to  the  age 
of  the  child.  Two  should  be  on  hand  at  a  time,  to  be  used  alternately.  Im- 
mediately after  a  meal  the  bottle  must  be  thoroughly  washed  out  with  scalding 
water,  filled  with  a  solution  of  bicarbonate  or  salicylate  of  sodium — one  tea- 
spoonful  of  either  to  a  pint  of  water — and  thus  allowed  to  stand  until  next 
required ;  then,  the  soda  solution  being  emptied,  it  must  be  thoroughly  rinsed 
with  cold  water  before  receiving  the  food.  The  tips  or  nipples,  of  which  there 
should  also  be  two,  must  be  composed  of  soft,  flexible  India-rubber,  and  a  con- 
ical shape  is  to  be  preferred,  as  being  more  readily  everted  and  cleaned ;  the 
opening  at  the  point  must  be  free,  but  not  large  enough  to  permit  the  milk  to 
flow  in  a  stream  without  suction.  At  the  end  of  each  feeding  the  nipple  must 
be  removed  at  once  from  the  bottle,  cleansed  externally  by  rubbing  with  a  stiff 
brush  wet  with  cold  water,  everted  and  treated  in  the  same  way,  and  then  placed 
in  cold  water  and  allowed  to  stand  in  a  cool  place  until  again  wanted. 

Next  to  cleanliness  of  the  feeding  apparatus  it  is  important  to  insist  upon 
the  separate  preparation  of  each  meal  immediately  before  it  is  to  be  given.     The 


GENERAL    MANAGEMENT    OF    CHILDREN.  31 

practice  of  making,  in  the  morning,  the  whole  day's  supply  of  food,  though  it 
saves  trouble,  is  a  most  dangerous  one.  Changes  almost  invariably  take  place 
in  the  mixture,  and  by  the  close  of  the  day  it  becomes  unfit  for  consumption. 

The  food  must  be  administered  at  a  temperature  of  about  95°  F.  It  may  be 
heated  by  steeping  the  bottle  containing  the  food  in  hot  water  or  by  placing 
it  in  a  water-bath  over  an  alcohol  lamp  or  gas-jet. 

When  feeding,  the  child  must  occupy  a  half-reclining  position  in  the  nurse's 
lap.  The  bottle  should  be  held  by  the  nurse,  at  first  horizontally,  but  gradu- 
ally more  and  more  tilted  up  as  it  is  emptied,  the  object  being  to  keep  the 
neck  always  full  and  prevent  the  drawing  in  and  swallowing  of  air.  Ample 
time — say  five,  ten,  or  fifteen  minutes,  according  to  the  quantity  of  food — should 
be  allowed  for  the  meal.  It  is  best  to  withdraw  the  bottle  occasionally  for  a 
brief  rest,  and  after  the  meal  is  over  sucking  from  the  empty  bottle  must  not 
be  allowed,  even  for  a  moment. 

e.  For  children  residing  in  cities  an  honest  dairyman  must  be  found  who 
will  serve  sound  milk  and  cream  from  country  cows  once  every  day  in  winter, 
and  twice  during  the  day  in  the  heat  of  summer.  The  milk  of  ordinary  stock 
cows  is  more  suitable  than  that  from  Alderney  or  Durham  breed,  as  the  latter 
is  too  rich,  and  therefore  more  difiicult  to  digest.  The  mixed  milk  of  a  good 
herd  is  to  be  preferred  to  that  from  a  single  animal :  it  is  less  likely  to  be 
afi"ected  by  peculiarities  of  feeding,  and  less  liable  to  variation  from  alterations 
in  health  or  different  stages  of  lactation. 

The  care  of  the  herd  and  of  the  milk  is  of  great  consequence.  The  cows 
should  be  healthy,  and  the  milk  of  any  animal  that  seems  indisposed  should 
be  excluded.  The  cows  must  not  be  fed  upon  swilFor  the  refuse  of  breweries, 
glucose-factories,  or  any  other  fermented  food.  They  must  not  be  allowed  to 
drink  stagnant  water,  and  must  not  be  heated  or  worried  before  being  milked. 
The  pasture  must  be  free  from  noxious  weeds,  and  the  barn  and  yard  must  be 
kept  clean.  The  udder  should  be  washed,  if  dirty,  before  the  milking.  The 
milk  must  be  at  once  thoroughly  cooled.  This  is  best  accomplished  by  placing 
the  can  in  a  tank  of  cold  spring-water  or  in  ice- water,  the  water  being  the  same 
depth  as  the  milk  in  the  can.  It  is  well  to  keep  the  water  in  the  tank  flowing; 
indeed,  this  is  necessary  unless  ice-water  be  used.  The  can  should  remain 
uncovered  during  the  cooling,  and  the  milk  should  be  gently  stirred.  The 
temperature  should  be  reduced  to  60°  F.  within  an  hour,  and  the  can  must 
remain  in  the  cold  water  until  the  time  for  delivering.  In  summer,  when  ready 
for  delivery,  the  top  should  be  placed  in  position  and  a  cloth  wet  in  cold  water 
spread  over  the  can,  or  refrigerator  cans  may  be  used.  At  no  season  should 
the  milk  be  frozen,  and  at  the  same  time  no  buyer  should  receive  milk  having 
a  temperature  over  Qb°  F. 

For  transportation  from  the  dairy  it  is  safer  for  the  family  to  provide  two 
sets  of  small  cans — one  set  to  be  thoroughly  cleansed  and  aired,  while  the  other 
is  taken  away  by  the  milkman  to  bring  back  the  next  supply.  So  soon  as  this 
arrives  in  the  morning,  or  in  the  morning  and  evening  in  hot  weather,  the  milk 
should  be  emptied  into  separate  and  absolutely  clean  earthenware  or  glass  pitch- 
ers, and  these  put  at  once  into  a  refrigerator  reserved  exclusively  for  them. 
This  may  stand  in  some  convenient  spot  near  the  nursery,  but  not  in  it,  and 
especially  not  in  an  adjoining  bath-room.  With  a  good  refrigerator  there  is 
no  difficulty  in  keeping  milk  perfectly  sweet  for  twenty-four  hours  in  winter 
and  for  twelve  hours  in  summer,  except  on  intensely  hot  days ;  then  it  may 
be  necessary  to  scald,  slightly  boil,  or  sterilize  the  whole  of  the  supply  when 
received,  in  order  to  prevent  change. 

Childhood. — Children  who  have  cut  their  milk  teeth  may  be  fed  for  » 


32       AMEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

twelvemonth — namely,  up  to  the  age  of  three  and  a  half  years — in  the  follow- 
ing way :  First  meal,  7  A.  M. — one  or  two  tumblerfuls  of  milk,  a  saucer  of 
thoroughly  cooked  oatmeal  or  wheaten  grits,  and  a  slice  of  bread  and  butter. 
Second  meal,  11  a.  m.  (if  hungry) — a  tumblerful  of  milk  or  a  teacupful  of  beef 
tea  with  a  biscuit.  Third  meal,  2  P.  M. — a  slice  of  underdone  roast  beef  or 
mutton  or  a  bit  of  roast  chicken  or  turkey,  minced  as  fine  as  possible  ;  a  baked 
potato  thoroughly  mashed  with  a  fork  and  moistened  with  gravy ;  a  slice  of 
bread  and  butter ;  a  saucer  of  junket  or  rice-and-milk  pudding.  Fourth 
meal,  7  p.  m. — a  tumblerful,  of  milk  and  one  or  two  slices  of  well-moistened 
milk  toast. 

From  three  and  a  half  years  up  the  child  must  take  his  meals  at  the  table 
with  his  parents,  or  with  some  reliable  attendant  who  will  see  that  he  eats 
leisurely.  The  diet,  while  plain,  must  be  varied.  The  following  list  will 
give  an  idea  of  the  food  to  be  selected : 

BREAKFAST. 

Every  Day.  One  Dish  only  Each  Day. 

Milk.  Fresh  fish.  Eggs,  plain  omelette. 

Porridge  and  cream.  Eggs,  lightly  boiled.  Chicken  hash. 

Bread  and  butter.  "     poached.  Stewed  kidney. 

"     scrambled.  "       liver. 

Sound  fruits  may  be  allowed  before  and  after  the  meal,  according  to  taste,  as  oranges,  grapes 
(seeds  not  to  be  swallowed),  peaches,  thoroughly  ripe  pears,  and  cantaloupes. 

DINNER. 

Every  Day.  Two  Dishes  Each  Day. 

Clear  soup.  Potatoes,  baked.  Hominy. 

Meat,  roasted  or  broiled,  "         mashed.  Macaroni,  plain. 

and  cut  into  small  Spinach.  Peas. 

pieces.  Stewed  celery.  String-beans,  young. 

Bread  and  butter.  Cauliflower.  Green  com,  grated. 

Junket,  rice-and-milk,  or  other  light  pudding,  and  occasionally  ice  cream,  may  be  allowed 
for  dessert. 

SUPPER. 

Every  Day. 
Milk. 

Milk  toast  or  bread  and  butter. 
Stewed  fruit. 

Fried  food,  highly  seasoned  or  made-up  dishes  are  to  be  excluded,  and  no 
condiment  but  salt  is  to  be  used.  Eating,  however  little,  between  meals  must 
be  absolutely  avoided.  Keep  a  young  child  from  knowing  the  taste  of  cakes 
or  bonbons,  or,  having  learned  it,  let  him  feel  that  they  are  as  unattainable 
as  the  thousand  other  things  beyond  his  reach,  and  he  soon  ceases  to  ask  for 
them.  Even  a  piece  of  bread  between  meals  should  be  forbidden.  His 
appetite  then  remains  natural,  and  he  will  eat  proper  food  at  his  regular  meal 
hours.  As  to  the  quantity,  a  healthy  child  may  be  permitted  to  satisfy  his 
appetite  at  each  meal,  under  the  one  condition  that  he  eats  slowly  and  masti- 
cates thoroughly.  Filtered  or  spring  water  should  be  the  only  drink,  tea, 
coffee,  wine,  or  beer  being  entirely  forbidden. 

In  case  of  illness  the  diet  must  be  reduced  in  quantity  and  quality,  accord- 
ing to  the  rules  that  are  applicable  to  adults. 

2.  Bathing. 

During  the  first  two  and  a  half  years  of  life  a  child  ought  to  be  bathed 
once  every  day.     The  bath  should  be  given  at  a  regular  time,  and  it  is  best  to 


GENERAL   MANAGEMENT   OF   CHILDREN.  33 

select  some  hour  in  the  early  morning,  midway  between  two  meals — ten  o'clock, 
for  instance.  The  tub  should  be  placed  near  the  fire  or  in  a  warm  room  in 
winter,  and  away  from  currents  of  air  in  summer.  It  should  contain  enough 
water  to  cover  the  child  up  to  the  neck  when  in  a  reclining  posture,  and  the 
temperature  must  be  about  95°  F.  Upon  undressing  the  child  the  first  step  is 
to  wet  his  head;  then  he  is  to  be  plunged  into  the  water  and  thoroughly  washed 
with  a  soft  rag  or  sponge  and  pure,  unscented  castile  soap.  After  remaining 
in  the  water  from  three  to  five  minutes  the  surface  must  be  well  dried  and  rubbed 
with  a  flannel  cloth  or  soft  towel ;  then  the  body  must  be  enveloped  in  a  light 
blanket  and  the- infant  either  returned  to  his  crib  to  sleep  or  kept  in  the  lap 
for  ten  or  fifteen  minutes  until  thoroughly  warm  and  rested,  and  finally  dressed. 
If  there  be  repugnance  to  the  bath,  the  tub  may  be  covered  over  with  a  blanket, 
and  the  child,  being  placed  upon  it,  may  be  slowly  lowered  into  the  water  with- 
out seeing  anything  to  excite  his  fears.  In  very  hot  weather,  in  addition  to 
the  morning  full  bath,  the  body  may  be  sponged  twice  daily  with  water  at  a 
temperature  of  90°  F. ;  this,  contrary  to  what  might  be  expected,  has  a 
greater  and  more  permanent  cooling  effect  than  bathing  with  cold  water. 

After  the  third  year  three  baths  a  week  are  'quite  sufficient.  An  evening 
hour  is  now  to  be  preferred,  but  the  water  must  still  be  heated  to  90°.  About 
the  tenth  year  cooler  baths  can  be  begun,  from  72°  to  75°  being  the  proper 
temperature.  The  cold  sponge  or  cold  plunge  is  not  admissible  as  a  daily 
routine  until  youth  is  well  advanced. 

The  hot  bath — 95°  to  100°  F. — is  employed  for  various  purposes,  notably 
for  a  derivative  action,  to  cause  diaphoresis,  to  relieve  nervous  irritability,  and 
to  promote  sleep.  Whether  a  full  bath  or  merely  a  foot-bath  be  required,  five 
minutes  is  a  sufiicient  time  for  immersion ;  then,  with  or  without  drying, 
according  to  the  degree  of  sweating  desirable,  the  whole  body,  or  only  the 
feet  and  legs  in  case  of  a  foot-bath,  must  be  enveloped  in  a  blanket,  and  the 
child  put  to  bed.  To  render  these  baths  more  stimulating,  from  a  teaspoonful 
to  a  tablespoonful  of  mustard  flour  may  be  added,  and  the  child  held  in  the 
water  until  the  arms  of  the  nurse  begin  to  tingle.  It  is  important  not  to  con- 
tinue a  hot  bath  too  long,  lest  the  primary  stimulating  effect  be  followed  by 
depression. 

Cold  baths,  by  shocking  the  system,  first  produce  depression ;  but  this  is 
temporary  and  is  followed  by  reaction,  during  which  the  skin  grows  red  and 
the  pulse  becomes  fuller  and  stronger.  They  have,  therefore,  a  general  stimu- 
lant and  tonic  action,  promoting  nutrition  and  giving  tone  to  the  body.  On 
account  of  the  shock,  the  extent  of  which  depends  directly  upon  the  coldness  of 
the  water,  these  baths  must  be  used  with  caution,  and  are  not  to  be  employed  in 
very  young  or  feeble  subjects.  When  giving  a  cold  bath,  the  child  must  be 
stripped  in  a  warm  room,  and  thoroughly  rubbed  with  the  palm  of  the  hand 
until  the  whole  body,  especially  the  spinal  region,  is  reddened ;  he  must  then 
stand  in  a  tub  containing  enough  hot  water  to  cover  the  feet,  and  be  rapidly 
sponged  with  the  cold  water.  The  temperature  of  the  latter  must  never  be 
below  60°,  and  the  addition  of  half  an  ounce  of  sea-salt  or  a  tablespoonful  of 
concentrated  sea-water  to  the  gallon  renders  it  more  stimulating  and  ensures  a 
complete  reaction.  After  the  sponging  the  surface  must  be  thoroughly  and 
quickly  dried  with  a  soft  towel  and  shampooed  with  the  open  hand  until 
aglow. 

The  cooled  bath  may  be  employed  with  advantage  in  extreme  conditions 
of  hyperpyrexia.  The  child  is  first  immersed  in  water  at  95°,  and  this  is 
gradually  lowered  to  70°  by  the  addition  of  cold  water,  the  process  occupying 
from  fifteen  to  thirty  minutes. 


34       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

3.  Clothing. 

Infants  and  young  children  have  little  power  of  resisting  cold,  and  on  this 
account  require  Avarm  clothing.  The  condemnation  of  the  fashion  of  allowing 
children  to  go,  even  while  in  the  house,  with  bare  legs  and  knees  must  be 
absolute.  Occasionally  during  the  most  oppresive  heat  of  a  summer  midday 
the  legs  may  be  left  uncovered  ;  but  with  this  exception  the  rule  is  to  keep  the 
whole  body  encased  in  woollen  underclothing.  The  thickness  of  this  must 
vary,  of  course,  with  the  season.  Providing  this  be  done,  the  outer  clothing 
may  be  left  to  the  taste  of  the  mother  ;  but  all  garments  should  fit  loosely, 
that  the  functions  of  the  different  viscera  may  not  be  impeded  by  pressure. 

The  best  pattern  of  a  winter  night-dress  is  a  long,  plain  slip,  with  a  draw- 
ino-'String  at  the  bottom,  to  prevent  exposure  of  the  feet  and  limbs  should  the 
child  kick  off  the  bed-covering.  This  should  be  made  of  flannel  or  the  more 
easily  washed  canton  flannel.  In  summer  a  loose  muslin  one  may  be  put  on, 
without  the  drawing-string.  A  flannel  under-vest  should  always  be  worn  at 
night,  light  gauze  in  summer  and  heavier  wool  in  winter ;  care  must  be  taken, 
however,  to  have  one  for  night  alone,  discarding  that  worn  in  the  daytime. 

In  infants  under  a  year  old  a  broad  flannel  abdominal  bandage,  extending 
from  the  hips  well  up  to  the  thorax,  or,  better  still,  a  knitted  worsted  band 
shaped  to  fit  the  form,  is  very  useful  in  keeping  the  abdominal  organs  warm, 
aiding  digestion  and  preventing  pain. 

All  clothing  should  be  changed  sufiiciently  frequently  to  ensure  cleanliness. 

Shoes  must  be  large,  well  shaped,  and  made  of  soft  leather  with  pliable 
soles,   so  as  to  allow  the  feet  to  grow  freely. 

When  dressing  a  child  for  exercise  in  the  open  air  in  cold  weather,  the 
outer  clothing  must  not  be  put  on  until  just  before  leaving  the  house,  and 
removed  immediately  on  return.  It  is  important  to  protect  the  head  from  cold 
in  winter  by  a  close-fitting,  thick  cap,  and  from  the  direct  rays  of  the  sun  in 
summer  by  a  broad-brimmed,  light  straw  hat.  Rubber  shoes  are  necessary  in 
wet  weather  to  keep  the  feet  warm  and  dry  while  walking  out  of  doors. 

4.  Sleep. 

For  some  time  after  birth  infants  spend  the  intervals  between  being  fed, 
■washed,  and  dressed,  in  sleep,  and  thus  pass  fully  eighteen  out  of  the  twenty- 
four  hours.  As  age  advances  the  amount  of  sleep  required  becomes  less,  until 
at  two  years  thirteen  hours,  and  at  three  years  eleven  hours,  are  enough.  This 
matter,  though,  is  perhaps  more  a  question  of  training  than  any  other  item 
of  nursery  regimen,  and  one  cannot  too  soon  begin  to  form  the  good  habit  of 
reo-ularity  in  sleeping  hours.  So  far  as  circumstances  will  admit,  the  follow- 
ing rules  may  be  enforced  : 

From  birth  to  the  end  of  the  sixth  or  eighth  month  the  infant  must  sleep 
from  11  P.  M.  to  5  A.  m.,  and  as  many  hours  during  the  day  as  nature  demands 
and  the  exigencies  of  feeding,  washing,  and  dressing  will  permit.  From  eight 
months  to  the  end  of  two  and  a  half  years  a  morning  nap  should  be  taken  from 
12  M.  to  1.30  or  2  p.  m.,  the  child  being  undressed  and  put  to  bed.  The  night's 
rest  must  begin  at  7  P.  M.  If  a  late  meal  be  required,  the  child  can  be  taken 
up  at  about  ten  o'clock  ;  but  if  past  the  age  for  this,  he  may  sleep  undisturbed 
until  he  wakes  of  his  own  accord  some  time  between  6  and  8  A.  M.  From  two 
and  a  half  to  four  years,  an  hour's  sleep  may  or  may  not  be  taken  in  the  morn- 
ing, according  to  the  disposition  of  the  subject;  but  in  every  case  the  bed 
must  be  occupied  from  7.30  p.  m.  to  6  or  7  o'clock  on  the  following  morning. 
After  the  fourth  year  few  children  will  sleep  in  the  daytime  ;  they  are  ready  for 


GEXERAL    REMARKS    ON   TREATMENT.  35 

bed  by  8  p.  m..  and  should  be  allo-wed  to  sleep  for  ten  hours  or  more.  A  later 
retiring  hour  than  9  p.  m.  ought  not  to  be  encouraged  until  after  the  twelfth 
or  fifteenth  year. 

When  feasible,  different  rooms  should  be  used  for  the  day  nursery  and  the 
sleeping  apartment.  If  an  apartment  has  to  be  occupied  during  both  the  day 
and  night,  it  must  be  vacated  for  half  an  hour  or  more  in  the  evening  and 
well  aired  before  the  child  is  put  to  bed.  The  temperature  of  the  room  must 
be  as  uniform  as  possible,  the  proper  degree  of  heat  being  from  64°  to  68°  F. 

5.  Exercise. 

A  certain  amount  of  muscular  exercise  is  necessary  for  development  and  for 
the  proper  performance  of  the  digestive  functions.  Infants  before  they  are 
able  to  stand  will  use  their  muscles  sufficiently  if,  when  loosely  clad,  they  are 
placed  upon  their  backs  in  a  bed  and  allowed  to  kick  and  turn  about  at  pleas- 
.ure.  After  the  age  of  nine  or  ten  months  a  healthy  child  will  begin  to  creep ; 
at  the  end  of  a  year  he  will  make  efforts  at  standing,  and  from  four  to  eight 
months  later  will  be  able  to  walk  by  himself;  children,  however,  present  great 
differences  in  this  respect,  and  a  delay  of  a  few  months  must  not  be  considered 
as  abnormal.  So  soon  as  efforts  at  creeping  are  made  there  need  be  no  fear 
that  insufficient  exercise  will  be  taken ;  the  care  should  be  rather  to  prevent 
over-fatigue.  Fresh  air  and  sunlight  are  as  necessary  as  muscular  exercise. 
The  child  must  be  taken  out  of  doors  every  day,  weather  permitting,  after 
arriving  at  the  proper  age :  this  is  four  months  for  children  born  in  the  early 
fall  and  winter,  and  one  month  for  those  born  in  summer.  In  cool  weather 
babies  who  are  unable  to  walk  should  be  taken  out  in  a  coach  or  in  the  nurse's 
arms  for  an  hour  in  the  morning  and  half  an  hour  in  the  afternoon,  while  the 
sun  is  shining.  In  summer  they  may  pass  the  greater  part  of  the  waking 
hours  in  the  open  air,  provided  they  be  well  protected  from  the  direct  rays  of 
the  sun.  Children  old  enough  to  walk  may  spend  a  longer  time  in  the  air  in 
winter,  and  may  be  out  all  day  in  summer.  But  until  the  fourth  year  it  is 
better  to  let  them  play  about  at  will  than  take  a  long  set  walk.  Until  well 
advanced  in  childhood  the  house  is  the  safest  place  in  damp  and  rainy  weather, 
when  there  is  a  strong  east  or  north  wind  blowing,  and  when  the  thermom- 
eter stands  below  15°  F. 

in.  GENERAL   REMARKS   ON  TREATMENT. 

It  is  difficult  to  formulate  a  precise,  reliable,  or  handy  posological  table ; 
in  fact,  the  whole  matter  of  dosage  for  children  is  one  of  experience,  and  with 
practice  every  one  makes  his  own  dose-list  in  his  mind,  and  the  proper  amount 
of  a  given  drug  for  a  given  age  requires  as  little  effort  of  memory  as  in  the 
case  of  adults.  Nevertheless,  as  a  guide  to  the  student.  Cowling's  rule  is 
serviceable — namely,  the  proportionate  dose  for  any  age  under  adult  life  is 
represented  by  the  number  of  the  following  birthday  divided  by  24 — i.  e. 
for  one  year,  -^  =  yS"  ;  for  two  years,  -^  =  i ;  and  so  on. 

All  powerful  drugs  must  be  given  with  caution  to  children,  but  opium  re- 
quires the  greatest  care.  Infants  bear  it  only  in  infinitesimal  proportions,  and 
in  these  its  use  is  to  be  avoided  as  much  as  possible ;  still,  combined  with  cas- 
tor oil,  it  is  a  useful  drug  in  bad  cases  of  flatulent  colic,  the  average  commen- 
cing dose  in  the  first  six  weeks  of  life  being  not  more  than  1TL -gV  of  the  tincture 
(laudanum).  After  the  second  or  third  month  the  extreme  susceptibility  to 
the  drug  disappears,  and  Itll  of  laudanum  may  be  given  for  a  dose. 


36       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Bromide  of  potassium,  a  most  valuable  remedy  in  many  diseases,  must  be 
given  to  infants  with  -watchfulness,  as  it  sometimes,  even  in  small  doses,  pro- 
duces severe  local  inflammations  of  the  skin  and  localized  patches  of  soft, 
warty  growths. 

Belladonna  and  arsenic  are  illustrations  of  an  opposite  tendency,  for  chil- 
dren are  very  tolerant  of  these  drugs,  particularly  the  first.  A  child  of  four 
or  five  years  can  readily  take  from  tAvo  to  five  minims  of  tincture  of  bella- 
donna, and  in  cases  in  which  it  is  necessary  to  administer  arsenic  to  choreic 
children  of  six  years  and  upward  a  commencing  dose  of  five  minims  of  Fow- 
ler's solution  may  often  be  given  three  times  daily,  and  a  considerable  increase 
in  this  be  attained  if  required.  Such  initial  doses  are,  however,  occasionally 
productive  of  the  symptoms  of  mild  arsenical  poisoning,  and  therefore  it  is 
well  to  begin  with  one-  or  two-minim  doses  and  increase  rapidly.  This  rule 
applies  especially  to  children  belonging  to  the  wealthier  classes,  for  these,  like 
their  parents,  are  much  more  sensitive  to  drugs  than  hospital  patients — an 
undoubted  physiological  fact  of  wide  bearing. 

Alcohol  is  frequently  indicated  and  is  of  great  value,  but  it  must  be  used 
with  judgment.  It  is  most  useful  in  broncho-pneumonia,  severe  febrile  condi- 
tions ;  in  the  prostration  fallowing  measles,  diphtheria,  and  whooping  cough ;  and 
in  the  collapse  that  frequently  attends  severe  thoracic  or  abdominal  disease. 

All  drugs  should  be  made  as  palatable  as  possible. 

In  conclusion,  it  must  be  remembered  that  children  do  not  often  require 
energetic  treatment  with  drugs.  Proper  feeding  and  hygiene  are  of  most 
importance  in  the  management  of  disease  in  earl}-  life. 

Antipyretics. — Antipyrine  especially,  and  phenacetin  to  a  less  degree 
only,  must  be  used  with  extreme  caution  in  the  febrile  aff"ections  of  early  life, 
on  account  of  their  marked  tendency  to  produce  cardiac  depression.  Spong- 
ing the  surface  at  proper  intervals  with  tepid  or  cool  water  is  a  much  safer 
method  of  reducing  temperature,  but  in  every  instance  the  law  of  the  temper- 
ature-curve of  the  disease  under  treatment  must  be  taken  into  consideration ; 
and  it  is  a  safe  rule  not  to  interfere  unless  the  temperature  excess  be  great 
and  maintained.  For  example,  in  pneumonia,  a  disease  in  Avhich  antipyretic 
drugs  are  especially  dangerous  and  most  frequently  abused,  an  evening 
temperature  of  105°  is  to  be  expected,  and  unless  maintained  is  neither  cause 
for  alarm  nor  for  the  use  of  a  powerful  drug  that  tends  to  sap  the  strength 
of  the  cardiac  muscle,  the  very  keystone  of  the  bridge  leading  to  recovery. 


THE  CHEMISTRY  OF  MILK  AND  OF  ARTIFICIAL 
FOODS  FOR  CHILDREN. 


By  albert  R.  LEEDS,  Ph.  D., 

HOBOKEN. 


I.  The  Chemistry  op  Milk. 

The  peculiar  adaptation  of  milk  to  the  feeding  of  the  young  depends  upon 
its  unique  combination  of  chemical  and  physical  properties.  It  contains  in 
well-balanced  proportions  the  three  essential  elements  of  nutrition — the  nitrog- 
enous, or  tissue-building ;  the  carbohydrate,  or  heat-giving  ;  and  the  fats. 
Along  with  these  are  a  sufficiency  of  saline  substances  to  carry  on  the  chemical 
metamorphoses  of  cell-formation,  of  secretion  and  excretion,  and  an  ample 
supply  of  water  as  the  universal  solvent.  These  substances  are  held  partly  in 
a  state  of  solution,  partly  in  a  state  of  semi-solution,  conferring  upon  milk  its 
slightly  colloidal  consistency,  and  partly  in  suspension,  producing  its  appear- 
ance of  density  and  opacity.  But  it  contains  no  waste  material  like  the  indi- 
gestible fibre  and  cellulose  of  flesh,  fruit,  and  vegetables.  Neither  does  it 
exhibit  a  development  of  one  or  two  elements  of  nutrition  at  the  expense  of 
the  third,  as  is  the  case  with  all  other  foods, — even  eggs,  which  most  nearly 
approach  milk  in  this  respect,  not  being  excepted.  Finally,  almost  no  prepara- 
tion before,  during,  or  after  swallowing  is  requisite  for  the  absorption  of  milk 
through  the  rudimentary  digestive  apparatus  of  the  young. 

The  chemistry  of  woman's  milk  can  be  well  and  effectively  studied  for  our 
present  purposes  only  in  connection  with  that  of  cow's  milk.  For  at  the  very 
outset  a  peculiar  difficulty  is  experienced  in  attempting  to  procure  a  sample  of 
the  former,  which  does  not  exist  in  the  case  of  the  latter.  Some  sort  of  a 
breast-pump  or  similar  appliance  must  be  used,  and  this  unnatural  process 
yields  at  the  best  but  a  partial  sample.  This  fact  explains  many  of  the  great 
and  anomalous  variations  exhibited  in  the  analyses.  It  also  renders  the  con- 
clusions drawn  from  an  isolated  analysis  of  little  value;  and  in  practice  it  is 
wiser  to  base  any  conclusions  as  to  the  sufficiency  and  quality  of  the  breast- 
milk  upon  the  condition  and  yield  of  the  gland,  upon  the  physical  condition 
and  nutrition  of  the  mother,  and,  most  of  all,  upon  the  development  of  the 
child  and  its  deportment  in  nursing. 

On  the  other  hand,  innumerable  analyses  of  complete  samples  of  cow's  milk 
exist,  embracing  every  variety  of  breed,  under  every  condition  of  climate,  age, 
culture,  and  feeding. 

Co-w's  Milk. — On  no  other  article  of  food  has  such  elaborate  care  been 
expended,  both  as  to  its  production  and  chemical  investigation.  Most  civilized 
communities  have  enacted  laws  to  protect  its  purity,  and  recognize  no  evidence 
in   courts  of  law  except  when  substantiated  by  adequate  chemical  testimony. 

37 


38      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Similar  investigations  are  being  constantly  made  with  a  view  of  so  adjusting 
the  feeding  and  the  breed  as  to  obtain  the  largest  quantity  of  milk  or  the 
greatest  richness,  or  both.  Beginning  with  cattle  of  small,  imperfectly- 
developed  udders,  the  cow  has  become  through  generations  of  culture  the  incom- 
parable milk-secreting  animal  of  modern  nations,  and  has  so  far  displaced  the 
ass,  goat,  mare,  and  others  that  it  is  useless  to  consider  their  milk  as  an  avail- 
able substitute. 

For  similar  reasons,  the  cow's  milk  which  must  be  considered  from  the 
standpoint  of  general  dietetics  is  such  sound,  whole  country  milk  as  is  ordi- 
narily supplied  by  reputable  dealers.  It  is  useless  to  quote  the  analyses  of  the 
milk  of  Alderney,  Jersey,  and  Guernsey  cattle,  obtainable  only  by  the  few ; 
and  when  obtained,  such  milk,  with  its  higher  percentage  of  proteids  and  its 
greater  liability  to  variation  from  idiosyncrasy  in  condition  or  health  of  indi- 
vidual cattle,  is  not  to  be  preferred  over  that  of  the  average  milk  of  large 
herds  properly  bottled  before  being  sent  to  market.  So  likewise  as  to  the  com- 
position of  the  "  strippings  "  of  the  udder.  They  are  not  usually  procurable, 
and  their  greater  richness  in  fat  and  deficiency  in  casein  can  be  better  arrived 
at,  even  when  ordinary  whole  milk  is  used,  by  appropriately  modifying  its 
composition. 

Limiting  our  consideration  strictly  to  commercial  bottled  milk,  it  becomes 
of  the  greatest  importance  to  inquire  into  the  present  conditions  regulating  its 
production  and  handling  at  the  farm,  during  transit,  and  in  delivery  to  the  con- 
sumer. Hitherto,  these  conditions  have  fallen  far  short  of  the  requirements 
which  chemical  and  medical  science  should  rightly  impose  upon  milk  as  the 
prime  article  of  artificial  infant  nutrition.  The  State  laws  have  checked  the 
adulteration  of  milk  by  addition  of  water  and  removal  of  cream,  but  as  yet 
have  done  little,  and  that  only  incidentally,  in  the  way  of  guaranteeing  its 
wholesomeness  and  improving  its  quality.  In  fact,  enlightened  public  senti- 
ment, assisted  and  directed  by  the  medical  profession,  will  do  more  in  this 
direction  than  can  be  expected  at  present  from  the  State.  And  the  same 
remark  is  true  of  the  efforts  of  the  dairyman.  What  is  being  done  and  should 
be  done  is  best  exemplified  by  a  recital  of  the  provisions  of  a  legal  contract 
drawn  up  between  a  committee  of  certain  medical  societies  in  the  vicinity  of 
New  York  on  the  one  hand  and  a  competent  dairyman  on  the  other.  The 
latter  undertakes  that  his  herd  of  Holstein  and  Jersey  cattle  shall  be  regularly 
and  frequently  inspected  by  a  veterinarian  selected  by  the  committee  and  paid 
by  the  dairyman.  All  cattle  that  are  pronounced  by  the  surgeon,  for  any  cause 
whatsoever,  disqualified  to  produce  pure  sound  milk  are  forthwith  excluded 
from  the  herd.  Interbreeding  more  frequently  than  the  fourth  generation  is 
interdicted.  The  cattle  must  be  kept  in  a  large,  well-ventilated,  Avell-lighted 
stable,  with  ample  space  and  no  overcrowding,  with  abundance  of  pure  water 
for  drinking  and  cleansing ;  with  perfect  drainage  ;  with  dry  cemented  floors  ; 
with  clean  fresh  bedding  of  hay ;  and  with  arrangements  for  securing  them  in 
the  stall  which  shall  give  ample  liberty  to  the  movements  of  the  head  and  for 
lying  down,  but  shall  do  away  with  the  necessity  of  chains  or  other  fastening. 
Separate  stalls  and  partitions,  as  interfering  with  ventilation  and  cleanliness, 
are  done  away  with.  The  cow-stables  must  be  removed  from  those  in  which 
horses,  chickens,  and  other  stock  are  kept  by  so  great  a  distance  that  the 
cattle  can  in  no  wise  come  in  contact  with  the  other  animals.  The  cows  must 
be  groomed  daily,  and  the  teats  washed  before  each  milking.  The  milkmen 
must  perform  their  own  toilets  before  milking,  being  especially  required  to  thor- 
oughly cleanse  their  hands  and  to  remove  the  dirt  beneath  the  finger-nails,  wear- 
ing also  unsoiled  clothing.     The  feeding  is  to  be  regulated  by  the  season  in  such 


CHEMISTRY   OF  MILK  AND   ARTIFICIAL   FOODS.  39 

wise  that  the  milk  produced  shall  conform  to  the  highest  feasible  standard  of 
excellence.  Abundance  of  wholesome  pasture,  hay,  meal,  fodder,  and  ensilao-e 
is  demanded,  but  the  refuse  of  glucose-factories,  brewers"  grains,  swill  in  any 
form,  etc.  are  interdicted.  There  are  also  provisions  in  the  contract  that  the 
cattle  shall  not  be  worried,  heated,  or  driven,  or  milked  except  after  proper 
interval  after  calving.  The  milking  must  be  done  with  scrupulously  cleansed 
vessels  ;  the  milk  filtered  through  fine  metallic  gauze,  then  cooled  in  a  dust- 
free  atmosphere  in  such  wise  as  to  lower  the  temperature  as  rapidly  as  possible, 
and  also  to  permit  the  escape  of  the  gases  along  with  the  animal  heat ;  and, 
finally,  transferred  to  bottles  rendered  as  nearly  sterile  by  cleansing  with  boil- 
ing water  and  steam  as  possible.  These  jars,  which  must  be  entirely  full,  are 
closed  by  a  metallic  cover,  sealed,  transferred  to  boxes  with  a  layer  of  ice  on 
top  of  them,  and  delivered  at  an  early  hour  in  the  day,  the  temperature  of  the 
milk  never  being  allowed  to  rise  in  the  interval  above  50°  F.  The  dairvman 
further  undertakes  to  pay  for  the  services  of  a  competent  chemist  and  bioloc^ist, 
who  shall  frequently  test  the  milk,  and  whose  analyses  and  certificates  shall 
accompany  it.  He  also  undertakes  to  have  his  stables,  cattle,  feed,  bottlino- 
arrangements,  etc.  open  at  all  proper  times  to  inspection,  and  to  comply  with 
all  other  requirements  of  the  committee  which  they  in  their  judgment  shall 
deem  essential  to  securing  the  highest  attainable  degree  of  quality  and  purity. 
The  only  obligation  which  the  committee  assumes  is  that  it  permits  the  milk  to 
be  sealed  with  a  label  bearing  the  name  of  the  dairy  and  the  dairyman,  and 
the  legend  •'  Certified  Milk,"  and  to  be  accompanied  by  the  certificate  of  purity 
bearing  the  name  of  the  committee,  the  chemist,  biologist,  and  veterinarian. 

Milk  in  the  human  gland  or  cow's  udder,  when  tuberculosis  or  kindred  dis- 
ease is  absent,  contains  no  bacteria.  Indeed,  by  rejecting  the  first  portions 
and  excluding  floating  particles  in  the  air,  sterile  cow's  milk  can  be  obtained, 
and  contrivances  to  this  end  have  been  patented ;  but  they  are  quite  imprac- 
ticable. So  likewise  is  the  proposition  to  sterilize  all  the  milk  before  it  leaves 
the  farm  by  heating  it  at  230°  F.  for  a  sufiicient  length  of  time  completely  to 
destroy  every  spore  which  might  by  any  possibility  be  present.  Consumers 
would  not  pay  for  the  skill,  time,  and  apparatus  required,  and  the  process  itself 
produces  unfavorable  changes  in  the  milk.  The  first  poi'tion  of  this  objection 
applies  also  to  the  proposition  that  the  milking  should  be  done  directly  into 
sterilized  bottles,  and  the  milk  then  Pasteurized  by  heating  to  a  temperature 
of  160°-1T0°  for  twenty  minutes. 

Any  of  the  bacteria  present  in  the  air,  water,  ground,  or  derived  from  the 
diseased  or  filthy  condition  of  those  who  handle  the  milk  at  any  time,  or  arising 
from  the  animals  themselves,  may  possibly  find  their  way  into  milk.  And,  inas- 
much as  this  fluid  is  an  excellent  culture-medium,  they  multiply  with  great 
rapidity.  But  these  things  demand  suitable  care  for  their  prevention,  and  not 
a  care  involving  the  compulsory  sterilization  of  all  milk.  The  author  believes 
that  no  more  should  be  required  of  the  dairyman  than  the  reasonable  precau- 
tions above  detailed,  which  self-interest  also  demands.  Then  a  false  security 
will  not  be  placed  in  legal  requirements  sure  to  be  evaded  or  neglected,  and 
necessitating  an  army  of  skilled  inspectors,  veterinarians,  and  chemists  to 
enforce.  The  few  ounces  of  milk  needed  for  artificial  nursing  are  best  sterilized 
immediately  before  use,  and  this  is  best  done  in  the  course  of  the  preparation 
essential  to  adapt  it  for  infant  feeding,  either  just  before  transfer  to  the  bottle 
or  in  the  bottle  itself.  By  so  doing,  the  fact,  usually  lost  sight  of,  will  be  kept 
constantly  in  mind — that  the  same  precautions  as  to  the  bottle,  nipple,  the 
water  used,  the  exclusion  of  floating  particles  from  the  milk,  and  the  keeping 
of  it  in  a  refrigerator  are  as  essential  to  preserving  the  sterility  of  the  milk  as 


40      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

its  sterilization  in  the  first  instance.  Washing  in  boiling  water  cannot  be 
trusted  to  remove  the  adherent  skin  of  fat  and  casein  on  the  milk-vessels;  some 
soda  must  be  used ;  the  rubber  nipple  should  be  turned  inside  out  over  the 
finger  and  scrubbed  with  a  brush  and  precipitated  chalk. 

Supposing  that  the  present  enlightened  public  sentiment  has  secured  such 
a  legalized  system  of  sanitary  cattle-inspection  and  milk-control  as  to  make 
the  reasonable  precautions  now  exercised  voluntarily  by  honorable  dairymen 
obligatory  upon  all,  bottled  milk,  which  I  shall  tei-m  "sound  dairy  milk," 
presents  the  following  characteristics :  In  color  it  varies  from  white  to  yellow. 
Even  when  allowed  to  fall  in  drops  from  the  end  of  a  rod  it  exhibits  a  dense 
white  opacity  and  consistency,  the  fluidity  and  bluish-white  color  of  watered  or 
inferior  milk  being  absent.  It  is  almost  neutral,  reddening  litmus-paper  very 
feebly.  On  standing,  the  cream  rises  in  the  neck  of  the  quart  bottle  com- 
monly used  until  it  forms  a  layer  about  two  and  a  half  inches  in  depth.  These 
physical  characters  are  all  that  need  be  noted.  If  they  are  absent,  if  the  milk 
is  thin  and  watery,  if  it  has  a  bluish,  blue,  strong  yellow,  or  red  color,  if  it  is 
stringy,  lumpy,  or  glutinous,  if  it  has  a  flat,  stale,  sour,  or  any  abnormal  taste 
or  odor, — it  is  simply  to  be  rejected,  and  its  investigation  left  to  the  milk 
inspector  and  chemist. 

Many  analyses  of  such  bottled  milk  afibrd  me  the  following  average  results, 
which  are  given  as  preliminary  to  the  still  better  figures  that  will  come  with 
*' certified  milk:" 

Fats 3.75  per  cent. 

Lactose  (milk-sugar) 4.42        " 

Albuminoids 3.76       " 

Ash 0.68       " 

Total  solids 12.61  per  cent. 

In  some  of  the  States  the  legal  standard  calls  for  12.5  per  cent,  of  total 
solids  and  3  per  cent,  of  fat.  It  is  much  to  be  deplored  that  in  other  States, 
as  in  New  Jersey,  the  standard  demands  only  12  per  cent.,  and  unless  the  fat 
falls  below  2\  the  milk  is  assumed  to  be  unskimmed.  It  was  made  thus  low 
in  order  that  no  lack  of  care  in  housing  and  cleanliness,  no  inadequacy  of  feed- 
ing, no  abstraction  of  cream  from  the  evening  milk  (half-skimming),  and  no 
accidental  or  judicious  watering  should  bring  the  owner  or  vendor  under  con- 
demnation of  laAv.  For  the  same  reasons  it  is  assumed  that  any  milk  which 
has  a  higher  specific  gravity  than  1.029  at  60°  F.  (100°  on  the  lactometer  scale) 
is  pure,  whereas  the  average  of  sound  dairy  milk  should  be  1.0297. 

Human  Milk. — Having  given  the  above  general  characteristics  of  cow's 
milk,  it  is  necessary  to  do  the  same  for  human  milk,  and  then  proceed  to  a 
more  specific  comparison  of  their  resemblances  and  differences.  And  in  the 
first  place,  while  all  the  conditions  and  environment  are  arranged  to  develop 
the  milk-secreting  function  of  milch  cattle,  in  the  human  family,  on  the  other 
hand,  they  are  more  and  more  ignored  as  women  become  burdened  with  the 
increasing  duties  and  dissipations  of  modern  society.  The  regular  life  with 
moderate  enjoyments,  exercise,  and  occupation,  the  simple  nourishing  diet, 
with  abundance  of  fresh  air  and  rest,  which  are  most  favorable  to  the  milk- 
secretion,  are  sacrificed,  with  the  result  of  arresting  or  diminishing  the  flow  and 
deteriorating  the  quality  of  the  milk.  Stimulants,  narcotics,  improper  or 
highly-seasoned  food,  functional  disorders  with  their  attendant  medicines, 
violent  emotions  and  paroxysms  of  grief,  anger,  and  pain,  render  the  milk 
unwholesome  and  sometimes  dangerous.     As  a  contribution  to  the  chemistry 


CHEMISTRY   OF  MILK  AND    ARTIFICIAL    FOODS.  41 

of  this  subject  I  give  in  an  accompanying  table  the  results  of  80  analyses  of 
samples  of  milk  obtained  from  women  of  different  nationalities,  age,  stage  of 
lactation,  and  physical  constitution,  but  all  living  in  a  lying-in  hospital  under 
the  same  conditions  and  eating  the  same  food.     (See  pp.  42  and  43.) 

The  analyses  are  ai-ranged  according  to  the  period  of  lactation,  except  in 
cases  where  several  samples  were  taken,  these  following  consecutively.  Many 
hundred  analyses  would  be  required  to  determine  what  differences,  if  any,  are 
due  to  nationality  or  to  the  physical  characteristics  of  the  mother — whether 
black,  blonde,  or  brunette,  or,  more  minutely,  the  color  of  the  eyes,  hair,  com- 
plexion, etc.  But  the  influence  of  the  physical  condition  was  pronounced,  the 
best  milk  not  coming  from  women  of  robust  habit  (Column  I.),  but  from  those 
whose  nourishment  appeared  rather  in  the  milk-secretion  than  in  the  fattening 
of  the  mother  (Column  II.) : 

I.  (6  cases).  II.  (6  cases.) 

Fats 3.71  ....  3.96 

Lactose 6.94  ....  6.74 

Albuminoids    . 1.44  ....  2.12 

Ash 0.25  ....  0.22 

Total  solids 12.34  ....  13.04 

The  reaction  of  every  sample  was  alkaline,  the  alkaline  reaction  persisting 
during  one  or  more  days.  The  color  varied  from  bluish-white  through  chalky- 
white  to  strong  yellow,  but  the  color  was  not  a  necessary  index  of  the  compo- 
sition:  the  milk  of  a  German  (No.  34),  which  was  the  richest  in  fats  (6.89  per 
cent.),  lactose,  and  total  solids,  was  chalky-white  in  color,  Avhile  that  of  another 
German  (No.  8),  which  was  yellow,  was  very  low  in  fats,  having  only  2.31  per 
cent.  Though  the  amount  of  lactose  is  more  than  a  third  greater  than  in  cow's 
milk,  yet  the  taste  can  hardly  be  called  sweet,  and  while  the  total  solids 
(13.27)  and  the  specific  gravity  (1.0313)  are  both  higher  than  in  cow's  milk, 
yet  the  consistency  is  much  thinner.  This  is  due  to  its  much  smaller  content 
of  albuminous  matters,    more  especially  of  the  caseinous  or  cheesy  material. 

The  average  amount  of  nitrogenous  matters  (albuminoids)  is  somewhat 
greater  at  beginning  of  lactation,  but  the  difference  is  not  very  marked.  In 
truth,  the  feature  brought  out  by  this  long  series  of  analyses,  which  over- 
shadows every  other  in  significance,  is  the  fact  that  there  is  no  progressive 
change  in  the  composition  of  milk  during  lactation,  but  after  the  function  has 
been  normally  established  the  milk  remains  substantially  the  same  during  the 
entire  period.  This  is  what  might  be  anticipated  from  what  much  larger  expe- 
rience teaches  in  regard  to  cow's  milk,  but  it  is  at  variance  with  notions  com- 
monly  entertained,  and. which  have  led  to  elaborate  and  utterly  useless  dieta- 
ries for  infant  nutrition.  The  child  obtains  more  nutriment  day  by  day,  but 
it  is  by  spontaneously  increasing  the  quantity  according  to  the  best  rule,  which 
is  that  of  normal  appetite,  and  not  by  absorbing  "  stronger  and  stronger  food." 

Comparison  of  Cow's  Milk  and  Human  Milk. — Before  proceeding 
farther,  the  general  characteristics  may  advantageously  be  summed  up  in  the 
following  comparison  : 

Sound  Dairy  Milk.  Woman's  Milk. 

Reaction  ......      Feebly  acid Persistently  alkaline. 

Specific  gravity 1.0297 1.0313 

Bacteria Always  present Absent. 

Fats 3     to  6     — average,  3.75  ...  2       to  7      — average,  4.13 

Lactose  ...  3.5  to  5.5—  "  4.42  ...  5.4  to  7.9  —  "  7.0 
Albuminoids  .  3  to  6  —  "  3.76.  .  .  0.85  to  4.86—  '^  2.0 
Ash 0.6  to  0.9—     "         0.68  .    .    .  0.13  to  0.37—     "        0.2 


42      AMERICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


< 
o 

M 

Eh 

< 


■< 


s 

1 
i 

15.08 
14.18 
15.40 
16.46 
12.78 
13.11 
13.82 
12.13 
12.94 

oi  0 

~  -c  L-:  I-  i-O  -r  X  -r  -^  ft  c;  c  t-  -H  fM-O  rt  a 

■C  I-  -.C  C:  01  -S-  01  1.0  C  —  t-  tS  f5  1-1  in  ®  ^  — 

-^  •^"  oi  oi  —  0!  -1"  oi  d  d  d  --'  d  oi  oi  -r  i.o  r 

oi  i^ 
oid 

1-1  tH 

m 

•-• 

< 

(M  i^  ?»  *»  —  -H  s  -?■  s;  -CO)  c  c  c  r  71  X  -.r  c  =-.  7!  -?  L-:  in  L-  X  —  T-  L-  ~  ^:  2 
<M  w  rt  7»  oj  ei  ;i  ■?»  —  -^  w  ■?»  oi  ii  ?»  r?  ?<  —  re  ^  ?;  -;  ?f  ^:  '-.'-.  ~*  '^.  —  "-;  '^  "^ 

d  d  d  d  d  d  d  d  d  d  d  d  d  d  d  d  d  d  d  d  d  c  c  c  o  c  o  c  c  c  c  o 

1-1 

i 

c  d  =:  r?  d  ;^  S  5i  £  X  S  #!  X  c  -.=  r:  n  -?  I-  X    .  »  x  i-  x  c:  sj  l-  -.  -.c  c  «> 

d  ■^'  L':'  'T  ?j  m'  re  rt  r?  ci  d  r:  ;!  i.':'  ri  n  7i  oi  -^  n    _  is  «  ?j  lo  ?j  •*  lc  Lt  ft  ft  ui 

f-i 

1 

ic-*t<-(M5i-<s'C-*!»inox»-Hi'e5^QDQDao    ■•^tOLOwmgciSLOLtcoig 
•*-*-*c;Mco-<j"?Jo;r^i.'5c;x->9'05«5i.':-*ciq    .aDTi;«.-<5it-.c:  i-'?.  cs» 
d  d  d  i-^  i-^  i>  L-;  i>  d  d  ic  d  d  t^  d  d  d  t-'  r-^  d      d  t-^  d  t-^  i>  la  d  cc  i^  i^  » 

d 

{        iH 

1 
1 

£2 

01  c^  ?:  ft  ?i  ei  -^  -H  "<  ?i  d  t!  —  oi  ^  cj  ?i  o>j  ^  cj      »-?!■?!•?  — i  ?  ^  ?!  -^  o  c* 

ci 

ii3iiiiii||Biiili|i|:ii§|i|||iii 

e5 

S 
"5 

•  •     •  c    ■     ■     ■  X    ' 

•  •    ■  •;;    ■    ■    ■  ~ 

;  .'lio J  11  = 

^ 

> 

.ill  -il  -.1  -Ifii  •  -III 

•  & 

■  "3 

t^ 

C  "  s 

M          C 

01  OJ  12     ■     ■   ■     01  Lt  M  (M        01     ■      ■  C  C  ;^  01  C  O  ^  O  ^  C  —  f:  C  t!  -*'  -tL-:  01 

«D 

n 

4= 

3 

^jjjjj^  '-jjjj--  'j'-s-^-^  :^^^.4^^.i^.4^^ 

1 

.  .2^2s  .wcdj^s;  .  .  .  .=i^^    c5««p^cs««K  .«MM«  .  . 

■O 

li 

•           73 

;:-^«2?i''''''^^'^^^t^^'^'"-''-'^--^^SSnEJ32i^S§^8 

« 

"5 
"S 

u 
o 

a 

:||:-::f'    If    ' 'r  :  i  J  J  j  ^  J  '  1 

ii  ■ :  jil  P  illlillilililiiili 

M 

a 
o 

1 

! ! ;  i    ! .' ; 

S 

c 

.    .    .    ^.-  .    s    .    .    .     !2 

3  3.3   '^^    g  ,^£S     S 

oo-r-     e-     scso       * 

"     ?:  i  5  i      •  -  S  =  •  ■  •   •  i  =  «  -  i 

1  liiiiiiEt^i^^iti^i 

M 

r 

sss  :    §?5s§j     :    s?;§sss2?sss  :§i§5^§g5ss 

ri 

1 

C.  -H 

12 

23^SgS^^«^S2§i  Signs'"  i*S:5o;?5^??i§''^^SS 

CHEMISTRY   OF  MILK  AND    ARTIFICIAL    FOODS, 


43 


cDt>(>}i>coi^oiincooocowocoinrtOjTj<n}i>coTj(inoi(MO  ■>* 

wqoqrHcocoq(>!qqqcoqcD(>!C'!cOi-;i>i>s>cooi-^QD  o 

•^■^"r-iMr-irH'#-*(>j-^o^dcoi-Hin-*in(jioicQco(>}coc^coco  co 

iHr-lr-(THrHi— liHi— IrHi— IrHtHi-lTHi— I,— liHi-HiHrHi— (iHt-ItHiHtH  r-l 


CO  in      CO  o  CO 


ajooooT-(iMoi>t^oooa)t^rHcot^(>!inooooiniHrH,-iw.-i 

WlHrHWWOJr-lrHOJCOOJiHOOOJi-HO^OjTHi-lTHOJCQOJCOOiCQ 

c 

0 

0 

^§1 

do 

0.37 
0.13 
0.201 

coojwinco^oowcc 
cocDrHini-'*inoc 
•^'  TjH  oj  CO  (>i  oj  in  in  o: 

■  CQ  i-l  00  •*  00  -^  -^ 

.  q  r-;  c^  •<*  i>  q  oc 

_  -^  OJ  ^  W  CO  r^  10 

■  0  t-co 
.  I-;  i>  r-; 

CO  CO  ^ 

•*  03  in  •<* 
CO  q  i>  q 

"*T  ^  ^  ^ 

m 

oc 

CO 

Oir-I 

l>  01 

COCO 

O)  rH  CO 
00  rH  r-l 

co'oj'^ 

•<f7-icocoi>i>oi>a- 
'^coojinooiojcoo- 

■  T-l  05  CO  O  CD  i>  C 

.  CO  rH  CD  o  t>  in  c 

_  CD  1>  CC'  i>  CO  CO  i> 

■  -^  OJ  oo 
.  CO  CO  CO 

1-1  ■*  05  in 

00  OJ  CO  Oi 
J>  i>  CO  CD 

7.41 

7.23 

7.55 

OJO  CO 

CR  Tt  03 

i>incD 

t^COOlOOiHCO-^OlOC 
OiiHrHTHr^rHiHrH,- 

■  o  CO  OJ  CB  in  00  cc 

.  iH  ■<:(<  00  CJJ  iH  -^  r- 

_  oJ  th  1-!  1-i  oJ  oi  OJ 

1.50 
1.50 
1.97 

05  in  CD  0 
•^  CO  0  0 

tH  r-i  OJ  OJ 

cc 

CO  0 
'*  CO 
OJ  rA 

4.86 
0.85 
1.995 

i>CO         .Hi>         r-l 

rHinoinoiHOQ-*,- 
cocococococococop- 
qqqqqqqqc 

THiHiHr-HiHrHrHiHl- 

■  O  O  Oi  rH  O  CO  Ol 

.  55  55  5*  5?  5?  «^  5: 
0  q  0  0  0  0  c 

■  r-I  T-i  T-i  r-i  T-i  r-i  r- 

1.030 
1.031 
1.031 

0  tH  tH  tH 
CO  CO  CO  CO 

iH  T-i  iH  r-i 

cc 

1.0297 

1.031 
1.032 

1.0353 
1.0260 
1.0313 

o  o 

3 

^-2 

33 

Chalky-white  .    . 
White 

White 

White 

White 

White 

'i 

■3 

•  ^ 

Maximum  .    . 
Minimum   .    . 
Average  .    .    . 

3 

a 

in 

" 

p2 

3   3-    -     p 

o  c           c 
,3,3           ^ 

,H;^CO  CQ-C 

5  hours. 
5      " 

3    '  "' 

33        = 

0       c 
,3      ,c 

HmH  IT 

!- 

C 

,0 

OJ«h 

33    3 

0 

,3 

fOJCOO 

1  hour. 

2  hours. 
2      '• 

2      " 

r-t 

33  3  3 

0 
,3 

*  OJ  OJ  OJ  OJ 

in 

5     •• 
5     " 

1  hour. 

2  hours. 

OJOI 

H?i        H?i     .1-^      'r^r-^        HN     ^         i-^KH-F^H^        -^ -<i  Hd  H?^  HN  H?i  Hn  H?i  H:^^  Hf^  ^+^  Hf^  Hf» 


eoincoi>OrHino5coocoojooa)Ocoincooj©i>oocoi>OrHOJi>0500cooJ    ■♦^ 
OJOJOJOJco'^-'*in<-<!t(ininooooooai05rHOJcoincoooQOoor-(t>oJrHOJr-irH02ino3     S 

rH  r-l  rH  r-l  rH  1-1  r-l  rH  OJ  OJ  OJ  rH  ^ 


3 


■    ^ 


,3   If 
beg  .  ^ 

3  W  M  Q  ( 


3-^ 


-^3  3 


p  p 
3  3,3.3  £3  3  3 


3  3  3 
s:  ^  ^ 


^1 

2p 

r<00     .hnOOO'Obr&rOO'^-?OOOhrin<bIihI.b£iOn^"        '" 


P< 


ppp&CcsM&fcbXiOcSbC 


^.         w 3.     .3.   3 

S3..  3.  3"  „  3. 2 -2  .3,a3..SS.,^§_0§.        3..rt... 

eacSi:3c«®c33a,d         cS.2c8  eS.2       .S2-"S-3        ^c8  -g 

aa,3,3a,3aga?2-S/aa'«a,3,3as,3'oSiSa3,35a,ri,:33,3,3,3 

^HtHCCtO!HtOMCBtH2,3oCG-J'rHCOtOr<nCOga'73rtaiorHtDtOaitOtOtD 

OOmmOmO     OaQWcoMOQQOMMO<lMa!<lS<»lMCcOMMp"^MhHHH 


OOeOinOJCOOJrHJ>i-HOCOOCOi>OJlOin05-^COOJO(Tl<COOO>OrHOJCOCDI>0003CO!> 

to      CO  rH   i-i  rH  OJ  OJ  rH  in  01  in  in  OJ  iH  in -^ -^  OJ  •^ -^  in  Tji  CO  CO  CO  CO  in  in  in  in  CO  CO 


44      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

On  an  average,  human  milk  has  about  J  of  1  per  cent,  more  fat  than 
average  sound  dairy  milk,  and  2|  per  cent,  more  lactose.  On  the  other  hand, 
it  has  ^  of  1  per  cent,  less  mineral  matter,  and,  what  is  most  important, 
but  2  per  cent,  of  albuminoids,  or  about  half  the  quantity  in  cow's  milk.  The 
fat  is  the  most  variable  constituent,  as  is  the  case  in  cow's  milk  also.  But 
in  both  the  sum  of  all  the  other  constituents  besides  fat  is  a  nearly  constant 
quantity,  amounting  in  the  vast  majority  of  samples  to  about  9  per  cent. 
The  significance  of  this  physiological  fact  must  not  be  lost  sight  of.  It  shows 
that  the  final  tendency  and  result  of  the  complicated  metabolic  changes,  Avhich 
take  place  in  the  protoplasmic  cells  of  the  mammary  gland,  is  to  secrete  a  nearly 
constant  total  amount  of  nitrogenous,  carbohydrate,  and  saline  material,  while 
alloAving  the  secreted  fat  to  exhibit  a  wide  and  independent  variability.  An 
increase  in  the  amount  of  nitrogenous  food  does  not  increase  the  nitrogenous 
element  in  the  milk  secreted  by  a  nursing  woman  beyond  the  general  limit 
implied  in  the  above  rule,  the  metabolism  in  this  case  resulting  in  an  increase 
of  the  fat.  An  excess  of  fat,  on  the  other  hand,  diminishes  the  metabolism. 
And,  as  a  practical  deduction  from  the  above,  there  results  the  necessity  of 
feeding  a  nursing  woman  on  a  diet  which  shall  contain  a  sufficiency  of  pro- 
teid  matters,  but  not  on  a  rich  food,  the  former  yielding  by  transformation  not 
only  the  albuminoids,  but  also  the  fats  and  lactose  of  the  milk,  whilst  tl>e 
latter  may  not  in  this  sense  be  nourishing,  and  may  impair  the  metabolic 
activity  whereby  the  due  proportion  of  the  various  constituents  of  the  milk  is 
normally  maintained. 

It  is  necessary  to  the  further  understanding  of  the  problem  of  infant  nutri- 
tion, and  especially  of  artificial  feeding,  to  study  in  detail  the  similarities  and 
diff"erences  of  the  individual  constituents  of  woman's  and  cow's  milk. 

Lactose. — The  lactose  in  the  two  secretions  is  chemically,  physically,  and 
physiologically  identical.  The  statements  based  on  clinical  results  to  the  effect 
that  the  lactose  of  cow's  milk  exerted  a  peculiar  diuretic  action  and  produced 
glycosuria  and  set  up  abnormal  digestive  fermentations,  etc.  will  have  to  be 
reviewed.  Until  very  recently  all  the  samples  of  lactose  coming  into  my  lab- 
oratory, even  those  supplied  by  manufacturers  of  highest  repute  as  chemically 
pure,  were  far  from  being  so.  They  contained  residues  of  the  proteids  of  milk 
and  spores,  the  taste,  appearance,  and  properties  of  the  lactose  being  thereby 
altered.  So  great  is  the  present  use  of  lactose  in  medicinal  preparations  that 
correspondingly  great  improvements  have  been  made  in  its  manufacture,  result- 
ing in  the  production  of  a  very  pure,  hard,  white,  transparent,  crystalline 
substance. 

The  carbohydrate  element,  Avhich  is  made  up  of  starches,  the  many  varieties 
of  sugar,  etc.  in  the  food  of  adults,  and  which  constitutes  the  largest  part  of 
most  vegetables  and  fruits,  is  represented  in  milk  by  lactose  only.  This  body 
is  intermediate  in  its  chemical  properties  between  cane-sugar  and  starch,  being, 
like  the  former,  soluble,  but  with  a  taste  hardly  perceptibly  sweet.  Its  main 
function  is  to  supply  by  oxidation  the  animal  heat,  and,  inasmuch  as  the  human 
infant  cannot  maintain  its  animal  heat  by  locomotion,  and  yet  at  the  same  time 
this  heat  must  be  preserved  at  even  a  higher  temperature  than  that  of  the  adult, 
the  lactose  is  relatively  the  largest  constituent  of  human  milk,  forming  more 
than  one-half  its  total  solid  matter.  Being  already  in  a  soluble  condition,  it  is 
directly  assimilable,  and,  unlike  starch,  requires  little  or  no  expenditure  of 
energy  to  effect  its  transformation  prior  to  digestion.  Under  the  influence  of 
certain  bacteria,  acting  as  ferments,  the  lactose  is  decomposed,  with  the  forma- 
tion of  lactic  acid.  Up  to  the  present  time  ten  varieties  of  bacteria,  including, 
along  with  the  bacillus  acidi  lactici,  certain  species  of  micrococci  and  sphsero- 


CHEMISTRY   OF  MILK  AND    ARTIFICIAL    FOODS.  45 

cocci,  have  been  described  as  more  especially  concerned  in  the  lactic  fermen- 
tation of  milk.  They  all  bring  about  the  curdling  of  the  milk,  but  some  of 
them  at  the  same  time  give  rise  to  the  formation  of  gas  and  alcohol,  and  others 
do  not.  The  primary  change  is  due  to  the  simple  splitting  of  the  molecule  of 
lactose  into  four  molecules  of  lactic  acid  by  addition  of  a  molecule  of  water : 

Lactose.  Lactic  acid. 

This  change,  which  is  the  ordinary  normal  one,  ensiires  the  curdling  and 
the  development  of  lactic  acid  initiative  to  milk  digestion.  Under  the  influence 
of  other  ferments  the  molecule  of  lactic  acid  may  break  up  into  a  molecule 
of  alcohol  and  carbonic  acid  (CgHgOj  =  CgHgO  -{-  COg),  but  this  decomposi- 
tion is  secondary  and  abnormal,  and  takes  place  less  readily  and  more  slowly 
than  the  decomposition  of  grape-sugar,  glucose,  or  dextrose  into  alcohol  and 
carbonic  acid  under  like  circumstances. 

Besides  this  fermentation,  which  results  in  the  separation  of  a  curd  by 
means  of  lactic  acid,  there  is  another  fermentation,  which  is  accompanied  by 
the  development  of  a  neutral  or  alkaline  reaction.  In  this  case  the  curd  first 
formed  may  all  eventually  pass  into  solution,  being  converted  into  soluble  pep- 
tones. The  bacteria  giving  rise  to  these  changes  originate  two  soluble  sub- 
stances acting  as  ferments,  one  actino;  like  rennet  to  curdle  the  milk,  the  other 
dissolving  the  curd  and  exerting  a  peptonizing  action.  There  is  also  produced 
leucin,  tyrosin,  ammonia,  and,  more  especially,  butyric  acid,  which  last  body 
gives  its  name  to  this  kind  of  fermentation.  Artificially,  it  is  induced  by  con- 
tact with  putrid  cheese.  In  the  digestive  tract  the  butyric  fermentation  is 
usually  brought  about  by  the  prolonged  stay  in  the  bowels  of  the  undigested 
curds  of  milk  or  of  a  foreign  irritant  substance  like  starch,  or  by  both.  It 
is  essentially  a  process  of  putrefactive  decomposition,  not  present  in  normal 
digestion.     In  its  simplest  form  the  change  may  be  represented  by  the  formula 

2C3H3O3   =    QJ1,0,    +    2CO2    +    2H,0 

Lactic  acid.  Butyric  acid.      Carbonic  acid.         Water. 

While  starch  is  the  principal  carbohydrate  of  adult  food,  it  cannot  properly 
be  used  in  infant  feeding  on  account  of  the  absence  of  the  ferment  essential  to 
its  digestion.  This  starch-digesting  ferment  exists  under  the  name  of  ptyalin 
in  the  saliva,  and  also  is  present  to  some  extent  in  the  pancreatic  juice,  but 
its  amount  in  infants  is  very  small,  and  its  secretion  is  not  established  until 
after  the  third  month.  By  its  action  the  starch  is  made  to  take  up  a  molecule 
of  water  and  then  decompose  into  maltose  and  dextrin,  the  latter  body,  by  con- 
tinuance of  the  same  action,  passing  into  dextrose ;  thus : 

3(CeH,oO,)  +  H,0  =  C,3H,,0n  +  CgH^oO^ 

starch.  Maltose.  Dextrin. 

2(CeH,„0,)  +  2H,0  =  2(CeH,A) 

Dextrin.  Dextrose. 

Liebig  proposed  to  effect  this  change  by  means  of  the  diastase  contained  in 
malt,  and  his  suggestion  has  been  extensively  followed.  But  the  objection  still 
remains  that  the  saccharine  substances  thus  produced,  like  the  vegetable  sugars 
in  general,  are  not  the  same  carbohydrate  which  is  normally  present  in  milk, 
and  it  has  not  as  yet  been  satisfactorily  established  that  they  undergo  in  diges- 
tion the  same  series  of  changes  and  oppose  equal  resistances  to  abnormal  fer- 


46     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

mentation.  Though  cane-sugar  or  sucrose,  malt-sugar  or  maltose,  and  milk- 
sugar  or  lactose,  all  belong  to  the  same  general  class  of  sugars  known  as  sac- 
charoses, with  the  formula  C^^^O-^-^,  yet  their  physical  and  chemical  properties 
are  essentially  different,  and  so  also  their  behavior  when  in  presence  of  certain 
ferments. 

Pat.— So  far  as  is  known  at  present,  the  principal  difference  between  the 
fat-globules  of  Avomans  and  cow's  milk  is  in  the  relatively  greater  size  of  the 
former,  which  vary  between  0.001 — 0.02  mm.,  while  the  latter  average 
0.00014 — 0.0063  mm.  in  diameter.  The  assumption  that  each  globule  is 
surrounded  by  a  membranous  envelope  has  been  disproved,  the  finely-divided 
fat  existing  as  naked  globules,  on  the  surface  of  each  of  which  a  number  of 
albuminous  molecules  are  condensed  by  molecular  attraction,  and  the  coalescence 
of  the  fat  particles  thereby  hindered. 

Albuminoids. — While  the  lactose  of  human  and  cow's  milk  is  identical, 
and  the  fats  are  very  similar,  the  nitrogenous  portion  presents  so  many  and 
important  differences  that  the  question  of  the  successful  substitution  of  cow's 
milk  for  human  principally  depends  upon  whether  or  no  these  differences  can 
be  compensated  or  overcome.  In  both  secretions  the  nitrogenous  portion  con- 
sists mainly  of  casein  and  lactalbumin.  In  addition,  there  are  substances  of 
the  nature  of  peptones,  in  small  quantities,  but  to  what  extent  they  exist 
naturally,  and  to  what  degree,  in  the  case  of  cow's  milk,  they  are  formed  by 
the  peptonizing  action  of  bacteria,  is  not  at  present  determined.  Casein  is  an 
acid  body  existing  in  milk  in  combination  with  alkali,  forming  principally 
potassium  caseinate.  But  the  reactions  of  this  body  are  complicated  by  the 
presence  of  other  mineral  bodies,  and  more  especially  of  calcium  phosphate. 
When  dilute  acid  is  added  the  casein  of  cow's  milk  readily  precipitates  in  coarse 
coagula  or  clots,  but  that  of  woman's  milk  requires  more  acid  for  its  precipita- 
tion and  separates  not  in  lumps,  but  in  a  fine  powder  which  dissolves  in  excess 
of  the  acid.  The  lactalbumin  remains  in  solution  in  the  whey  after  separation 
of  the  casein.  By  boiling  it  is  rendered  insoluble.  It  closely  resembles 
serum-albumin.  While  in  cow's  milk  the  total  fraction  of  the  albuminoids 
precipitable  by  acid  (casein)  exceeds  by  about  four  times  the  non-coagulable 
portion,  in  human  milk  these  proportions  are  reversed,  the  non-coagulable  part 
being  about  twice  the  coagulable  portion.  Similar  differences  exist  in  the 
coagulum  formed  by  the  acid  gastric  juice :  in  the  one  case  an  excess  of  insol- 
uble cheesy  masses,  in  the  other  a  relatively  small  amount  of  finely  divided 
soluble  flakes,  being  formed.  Taking  equal  weights  of  the  two  secretions,  the 
coagulum  of  woman's  milk  is  but  one-fifth  as  much  as  that  of  cow's  milk. 
The  coniparative  smallness  of  this  quantity  must  be  as  carefully  considered 
as  the  difference  in  the  compactness  and  solubility  of  the  coagula  themselves. 
It  explains  the  rapidity  with  which  infant  digestion  is  overtaxed  even  by  small 
amounts  of  undiluted  cow's  milk. 

Inorganic  Matter. — The  mineral  matter  in  cow's  milk  is  more  than  three 
times  that  in  woman's  milk,  and  especially  great  is  the  excess  of  calcium 
phosphate,  which  is  four  times  larger.  This  excess  is  due  to  the  correspond- 
ingly larger  amount  of  casein  in  cow's  milk,  with  which  substance  the  calcium 
phosphate  and  the  potash  are  principally  combined.  The  soda  appears  to  exist 
in  solution  along  with  the  lactalbumin  as  common  salt.  It  is  noteworthy  that 
the  lime  is  already  relatively  greater  in  the  cow's  than  in  human  milk,  and  it 
is  open  to  serious  question  whether  the  practice  of  using  cow's  milk  alkalized 
by  excess  of  lime  is  as  desirable,  in  the  case  of  normal  digestion,  as  it  was 
thought  to  be  before  the  composition  and  properties  of  the  constituents  of 
milk,  were  known.     The  following  table  presents  the  relative  composition  of 


CHEMISTRY   OF  MILK  AND    ARTIFICIAL   FOODS.  47 

the  ash  of  cow's  milk  (Fleischmann)  and  of  woman's  milk  (Konig),  and  also  the 
percentages  of  each  constituent  (Bunge)  : 

Cow's  Milk.  Woman's  Milk. 

Potash 24.5  0.18  33.78  0.07 

Soda .  11.0  0.11  9.16  0.03 

Lime 22.5  0.16  16.64  0.03 

Magnesia      2.6  0.02  2.16  0.01 

Oxide  of  iron      0.3  0.0004  0.25  0.0006 

Phosphoric  acid      26.0  0.2  22.74  0.05 

Sulpliuric  acid 1.0  —  1.89  — 

Chlorine 15.6  0.17  18.38  0.04 

n.  The  Chemistry  op  Artificial  Foods. 

Two  methods  have  been  followed  in  the  attempt  to  solve  the  problem  of 
artificial  feeding.  The  easier,  and  that  most  generally  adopted,  which  would 
also  appear  to  be  the  more  natural  method,  is  that  of  attempting  to  produce 
a  food  which  should  resemble  as  closely  as  possible  woman's  milk.  The 
other  method  aims  to  produce  a  food  or  foods  which  should  be  especially 
adapted  to  the  demands  of  nutrition  for  each  particular  infant  in  health  or 
disease :  it  is  open  to  great  diversities  of  opinion,  due  to  opposing  clinical 
experiences,  and  is  adapted  rather  to  the  treatment  of  special  cases  of  dis- 
ordered digestive  and  other  functions  than  to  common  use.  By  general  con- 
sent the  advocates  of  the  first  method  have  selected  cow's  milk  as  the  basis 
upon  which  to  build.  The  difficulty  of  obtaining  cheaply,  readily,  and  of 
proper  quality  the  milk  of  the  ass,  the  goat,  or  of  any  other  animal  than  the 
cow,  has  rendered  the  discussion  of  the  possible  advantages  of  such  milk  quite 
useless. 

Dilution. — The  first  expedient  in  connection  therewith  was  that  of  dilution 
with  water  until  the  percentage  of  albuminoids  and  salts  should  approximate 
to  that  in  woman's  milk.  But  no  amount  of  dilution  with  water  alone  is 
adequate  to  prevent  the  separation  of  the  curd  in  coarse,  indigestible  lumps  in 
presence  of  the  acid  secretions  of  the  stomach.  The  next  device  was  the 
addition  of  an  excess  of  lime-water,  so  as  to  partly  neutralize  the  gastric  juice 
and  alloAV  much  of  the  milk  to  pass  unchanged  from  the  stomach  and  undergo 
digestion  in  the  bowels.  As  the  chemistry  of  the  milk  salts  indicates,  the 
excess  of  lime  is  abnormal,  and  its  addition  is  an  expedient  to  meet  a  thera- 
peutic condition  connected  with  an  over-development  of  acidity,  and  not  to 
change  the  nature  of  the  difficultly  digestible  casein  itself. 

Predig-estion. — To  eifect  this  latter  change  previous  digestion  with  dilute 
acid  and  pepsin  was  resorted  to,  and  latterly  this  gave  place  to  the  more  suc- 
cessful digestion  with  pancreatin  in  alkaline  solution.  Both  methods  were 
confined  to  cases  of  greatly  impaired  digestion,  and  the  predigestion  was  carried 
as  far  as  possible.  But  inasmuch  as  in  woman's  milk  there  naturally  remains 
about  one-fifth  of  the  albuminoids  in  a  caseinous  condition,  the  most  recent 
practice  is  that  of  using  a  limited  amount  of  pancreatin,  acting  for  so  short  a 
period  that  the  process  shall  initiate  the  peptonization,  and  then  be  arrested  by 
the  destruction  of  the  ferment.  The  casein  is  thereby  left  in  such  a  condition 
that  it  separates  on  acidifying  as  a  fine  white  powder,  while  the  biuret  reaction 
for  the  albuminates  becomes  strongly  developed. 

Sterilization. — Recently  the  fact  that  woman's  milk  contains  no  bacteria, 
while  cow's  milk  usually  contains  large  numbers  and  many  kinds,  patho- 
genic species  possibly  included,  has  been  strongly  insisted  upon.  To  overcome 
this  objection  the  practice  of  sterilizing  the  milk  by  repeated  heating  to  a 
temperature  above  the  boiling-point  of  water  has  been  extensively  followed. 


48      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

rio  far  as  the  destruction  of  all  bacteria  and  their  spores  is  concerned,  the  pro- 
cess is  successful,  but  the  clinical  results  which  have  attended  the  use  of  such 
sterilized  milk  have  revealed  serious  drawbacks.  It  prevents  the  spread  of 
zymotic  diseases  through  the  medium  of  milk  ;  it  is  efficacious  in  checking 
many  gastro-intestinal  disorders ;  but  its  continued  use  is  accompanied  by  a 
failure  to  aflFord  adequate  nutrition.  Besides  the  destruction  of  the  bacteria, 
the  prolonged  heating  to  or  above  the  boiling-point  brings  about  other  changes 
which  are  in  the  nature  of  deteriorations.  More  especially  the  lactalbumin 
loses  its  solubility,  and  the  fat-globules  are  made  to  coalesce  with  one  another 
and  some  of  the  insoluble  albuminous  matter.  For  these  reasons  the  appli- 
cation of  continued  heat  in  the  process  of  sterilization  is  inadvisable,  and  is 
now  being  discontinued. 

Sterilization  at  a  Low  Temperature  (Pasteurization). — In  this  process 
of  preparation  the  milk  is  kept  for  a  brief  interval,  ten  to  twenty  minutes, 
at  a  temperature  of  160°-170°  F.,  or  raised  during  heating  continued  for  ten 
minutes  just  to  the  boiling-point.  While  this  process  will  not  destroy  all  the 
germs  which  are  in  the  form  of  spores,  it  will  destroy  the  spores  of  tubercu- 
losis, scarlet  fever,  pneumonia,  and  typhoid,  and  almost  completely  inhibit  the 
existence  of  the  developed  spores,  or  bacteria,  of  every  kind. 

Pasteurization  -with  Partial  Predigestion  (Humanized  Milk). — The 
adjustment  of  the  lactose  and  the  bringing  about  of  a  permanently  alkaline 
reaction  are  effected  by  the  presence  in  the  diluted  sterilized  milk  of  such  an 
amount  of  lactose  and  of  the  alkaline  milk  salts  as  will  effect  this  result.  In 
order  to  raise  the  percentage  of  fat  to  that  contained  in  woman's  milk,  cream 
may  be  added,  or  some  vegetable  oil  like  olive  or  cocoa,  or  animal  oil  like  that 
of  cod-liver.  At  present,  by  the  aid  of  the  Leval  separator,  cream  has  become 
a  commercial  article  easily  obtained,  and  its  use  is  more  convenient  and  better 
understood  than  that  of  the  other  fat  substitutes,  which  require  to  be  further 
investigated.  Inasmuch  as  it  contains  some  casein  and  ba.cteria,  due  allowance 
must  be  made  for  both  in  the  process  of  modification  heretofore  explained.  In 
practice,  by  the  use  of  a  preparation  of  pancreatin,  lactose,  and  alkaline  milk 
salts  originated  by  Fairchild  Brothers  &  Foster  of  New  York,  and  known  as 
"Peptogenic  Milk-powder,"  the  author  has  found  that  with  ordinary  bottled 
milk,  cream,  and  water  a  modified  sterilized  milk  is  obtained  which  corresponds 
so  closely  to  woman's  milk  that  he  has  given  it  the  name  of  "humanized" 
milk.     The  proportions  recommended  are — 

Milk .  i  pint. 

Water J  pint. 

Cream 4  tablespoonfuls. 

Peptogenic  Milk-powder 1  large  measure. 

The  mixture  is  heated  on  a  hot  range  or  gas-stove  with  constant  stirring,  the 
heating  being  so  conducted  that  at  the  end  of  ten  minutes  it  is  brought  to  the 
boiling-point.  The  temperature  of  160°  to  170°  is  high  enough  to  destroy  the 
ferment,  and  this  temperature,  continued  for  twenty  minutes,  kills  the  bacteria 
also.  But  it  is  so  much  easier  to  quickly  raise  the  temperature  for  a  moment 
to  the  boiling-point,  which  also  effects  both  objects,  that  the  latter  method  is 
to  be  preferred  when  by  a  process  of  partial  peptonization,  as  in  the  process 
described,  the  main  portion  of  the  albuminoids  has  been  brought  to  a  perma- 
nently soluble  form. 

The  milk  thus  prepared  is  slightly  alkaline  and  sterile.  It  contains,  accord- 
ing to  the  author's  analyses,  bottled  market  milk  being  used  in  its  preparation, 
the  following  proportions  of  constituents : 


CHEMISTRY   OF  MILK  AND    ARTIFICIAL    FOODS.  49 

Fat 4.5  per  cent. 

Albuminoids       2.0       " 

Lactose 7.0       " 

Ash 0.3       " 

Total  solids 1.3.8  per  cent. 

When  lime  is  used  to  counteract  not  only  the  slight  acidity  of  market  milk, 
but  also  with  the  object  of  forming  a  soluble  calcium  caseinate  which  will  not 
be  decomposed  by  the  acid  of  the  gastric  juice  and  curds  of  casein  thereby  pre- 
cipitated, the  lime  must  be  added  in  considerable  quantities.  A  mixture  of 
2  ounces  of  milk,  2  ounces  of  lime-water,  and  2  ounces  of  cream,  to  which  a 
teaspoonful  of  sugar  of  milk  has  been  added,  contains  only  a  grain  of  lime,  a 
quantity  too  small  to  effect  any  notable  chemical  change  of  the  casein.  If  this 
mixture  is  stei'ilized,  it  should  be  done  at  a  temperature  between  160°  and  170°, 
since  heating  to  the  boiling-point  causes  some  decomposition  of  the  albuminoids 
in  presence  of  alkali. 

"Condensed  Milk." — When  condensed  milk  is  used  the  preceding  remarks 
require  to  be  somewhat  modified  on  account  of  the  different  modes  of  preparing 
this  substance.  This  will  be  readily  understood  by  comparing  the  composition 
of  (I.)  milk  condensed  with  added  cane-sugar,  mean  of  forty-one  analyses; 
(II.)  the  same  diluted  with  eight  times  its  weight  of  water;  (III-)  Anglo-S^v^iss 
milk,  preserved  without  added  sugar;  (IV.)  American-Swiss,  preserved;  (V.) 
No.  III.  diluted  with  five  times  water. 

I. 

Fat 12.10 

Albuminoids 16.07 

Lactose    ....••..  16.62 

Sucrose 22.26 

Ash 2.61 

Total  soUds 69.66  8.70  41.64  40.78  8.32 

Water 30.34  91.30  58.36  59.22  91.68 

When  largely  diluted  with  water,  so  that  the  percentage  of  albuminoids  is 
approximately  the  same  as  in  human  milk,  the  fat  and  lactose  are  brought  far 
beloAv  the  quantity  proper  for  infant  nutrition.  Nor  is  the  deficiency  adequately 
supplied  by  the  added  sucrose  of  the  milks  condensed  with  this  substance. 
Referring  to  these  points.  Dr.  Louis  Starr  justly  remarks :  "  Condensed  milk 
is  frequently  recommended  by  physicians,  and  largely  used  by  the  laity  on 
their  own  responsibility.  It  keeps  better  than  cow's  milk,  and  is  supposed  to 
be  more  readily  digested  by  infants.  The  latter  supposition  is  a  mistaken  one, 
and  arises  from  the  overlooked  fact  that  condensed  milk  is  always  given  dis- 
solved in  a  large  proportion  of  water,  while  cow's  milk  is  too  frequently  used 
insufficiently  diluted  or  otherwise  improperly  prepared.  The  author  is  con- 
vinced of  the  accuracy  of  this  statement  from  a  number  of  years'  close  study 
of  the  subject.  Condensed  milk  contains  a  large  proportion  of  sugar,  forms 
fat  quickly,  and  thus  makes  large  babies  ;  sugar  also  counteracts  the  tendency 
to  constipation — often  a  troublesome  complaint  in  hand-feeding.  These  advan- 
tages are  unquestioned,  and,  together  with  the  ease  of  preparation,  are  those 
which  place  it  so  high  in  the  esteem  of  monthly  nurses.  It  is  equally  true,  how- 
ever, that  as  a  food  it  does  not  contain  enough  nutrient  material  to  supply  the 

wants  of  a  growing  baby It  must  be  remembered  also  that  condensed 

milk,  when  long  kept  or  when  packed  in  imperfect  cans,  not  infrequently 
undergoes  decomposition,  and  thus  becomes  utterly  unfit  for  use." 

Attenuation. — An  entirely  different  method  of  increasing  the  digestibility 

4 


11. 

III. 

IV. 

V. 

1.51 

13.21 

11..55 

2.64 

2.01 

11.36 

14.10 

2.27 

2.08 

15.29 

13.04 

3.05 

2.78 

0.32 

1.78 

2.09 

0.36 

50      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  the  casein  is  that  of  adding  farinaceous  or  gummy  substances,  the  action  oi 
which  is  not  chemical,  but  mechanical,  and  depends  upon  the  separation  Avhich 
they  effect  of  the  otherwise  cheesy  masses  into  a  multitude  of  fine  particles. 
Experiments  in  the  laboratory  of  the  author  showed  that  when  diluted  cow's 
milk,  to  which  a  solution  of  cane-sugar,  grape-sugar,  barley-water,  starch-water, 
or  gelatin  had  been  added,  was  treated  with  acid,  the  precipitated  casein  car- 
ried down  with  it  from  one-third  to  more  than  twice  its  Aveight  of  the  added 
substance.  Gelatin  more  especially  must  be  used  in  very  small  quantity,  since 
otherwise  it  entirely  arrests  the  precipitation  of  the  casein.  One  of  the  simplest 
and  best  of  these  attenuants  is  barley-water,  added  to  one-third  its  volume  of 
milk.  It  may  be  prepared  by  boiling  two  teaspoonfuls  of  pearl  barley  in  a 
pint  of  water  in  an  open  saucepan  until  the  bulk  is  reduced  to  two-thirds,  and 
then  straining.  Instead  of  barley,  oatmeal  may  be  used,  or  gelatin.  To  pre- 
pare the  latter  put  a  piece  of  plate  gelatin  an  inch  square  into  a  half-tumbler- 
ful of  cold  water,  and  let  it  stand  for  three  hours ;  then  turn  the  whole  into  a 
teacup,  place  this  in  a  saucepan  half  full  of  water,  and  boil  until  the  gelatin  is 
dissolved.  When  cold  this  forms  a  jelly:  two  teaspoonfuls  are  sufficient  to 
thicken  a  mixture  of  three  ounces  of  milk  and  five  of  Avater. 

Dextrinized  Attenuants. — A  gummy  material  like  dextrin,  or  a  gelat- 
inous substance,  or  a  saccharine  body,  or  a  finely-divided  starch  like  that 
occurring  in  barley-  or  oatmeal- water,  along  with  more  or  less  glutinous  extrac- 
tive matter,  is  far  better  adapted  to  serve  mechanically  as  an  attenuant  of  the 
coagulated  casein  than  farinaceous  foods  in  their  ordinary  condition.  Many 
different  preparations  are  sold  in  which,  by  prior  heating  (dextrinizing)  or  by 
digestion  with  diastase,  wheat  and  barley  flours  are  modified  to  this  end.  By 
the  action  of  heat  at  300°  to  400°  the  principal  substance  which  is  formed  is 
dextrin,  a  body  differing  from  starch  by  its  being  soluble  and  by  having  the 
physical  characters  of  a  gum.  Diastase  produces  principally  maltose  along  with 
dextrin.  The  flour  selected  for  either  treatment  should  be  highly  albuminous, 
made  of  wheat  groAvn  at  certain  seasons  and  of  certain  grades,  and  should  be 
the  best  grade  of  that  made  by  the  roller  process.  Grouping  together  under 
the  head  of  soluble  carbohydrates  the  sucrose,  dextrose,  maltose,  and  dextrin 
originally  present  or  made  by  treatment,  the  changes  can  be  traced  in  the  fol- 
lowing table.  The  first  column  gives  the  composition  of  a  wheat  flour,  the 
second  the  same  after  baking.  The  remaining  columns  exhibit  similar  products 
from  other  specimens  of  wheat  flour,  the  process  having  been  carried  further  in 
some  of  the  dextrinized  foods  than  in  others  : 


Wheat  flour. 

Same  baked. 

Blair's 
Wheat  Food. 

Imperial 
Granum. 

Ridge's  Food. 

Schuma- 
cher's Food, 

Water 

9.02 

7.78 

9.85 

5.49 

9.23 

6.26 

Fat 

1.01 

0.41 

1. 

1.01 

0.63 

1.89 

Starch 

76.07 

67.60 

64.80 

78.93 

77.96 

39.81 

Soluble  carbohy- 

drates       .... 

5.66 

14.29 

13.69 

3.56 

5.19 

36.57 

Albuminoid.s    .    .    . 

7.47 

7.16 

10.51 

9.24 

13.54 

Gum,  cellulose,  etc. 

undetermi'd 

2.94 

0.50 

0.49 

Ash 

a 

1.06 

1.16 

6.60 

1.44 

By  heating,  the  albuminous  substances  also  become  considerably  more 
soluble  in  water.  Wheat  flour,  which  in  its  original  condition  yields  a  vei-y 
considerable  amount  of  crude  gluten  on  washing,  after  baking  leaves  a  much 
smaller  quantity.     For  the  same  reason  a  baked  wheat  flour  may  be  mistaken 


CHEMISTRY   OF  MILK  AND    ARTIFICIAL    FOODS.  51 

for  barley  flour,  which  has  a  non-glutinous  dough.  Along  with  these  analyses 
may  be  given  that  of  Robinson's  Patent  Barley,  which  is  flour  prepared  from 
ground  pearl  barley,  and  "  A  B  C  "  cereal  milk,  which  is  made  from  wheat  and 
barley  meal : 

Robinson's  Patent  Barley.       "  A.  B.  C."  Cereal  Milk. 

Water 10.10  9  33 

Fat 0.97  1.01 

Starch 77.76  58.42 

Soluble  carbohydrates 4.11  20.00 

Albuminoids 5.13  11.08 

Gum,  cellulose,  etc 1.33  1  is 

Ash 1.93 

Flour-ball. — Much  has  been  written  on  the  use  of  "flour-ball"  prepared 
by  long-continued  boiling  of  superior  wheat  flour  tied  up  tightly  in  a  bao-.  A 
sample  thus  prepared  by  Dr.  J.  Lewis  Smith  and  analyzed  at  his  request 
afforded  the  following  results.  It  was  boiled  for  five  days,  fifteen  hours  a  day, 
or  seventy-five  hours  in  all,  the  bag  being  taken  out  of  the  water  over  night. 
The  original  flour  was  white  ;  the  boiled  flour,  after  thorough  drying  and 
pulverizing,  of  a  light-yellow  color.  Its  taste  was  remarkably  flat  and  insipid, 
the  long-continued  boiling  dissolving  out  the  fat,  some  of  the  soluble  albumi- 
noids, and  mineral  matters.  It  is  possible  that  very  diff"erent  results  might  have 
been  obtained  from  a  flour  of  diff"erent  character  and  boiled  for  a  much  shorter 
interval  (Dr.  Eustace  Smith  recommends  but  ten  hours) : 

Original  Flour.  Same  Boiled. 

Water 9.546  10.55 

Fat 0.766  none. 

Starch 71.924  72.362 

Soluble  carbohydrates 5.120  5.178 

Albuminoids 11.280  10.520 

Gum,  cellulose,  etc 0.835  1.028 

Ash 0.506  0.42 

Liebig-'s  Foods. — In  the  preparation  of  the  flour  by  means  of  diastase 
(Liebig's  foods)  equal  parts  of  wheat  flour  and  barley  malt,  a  certain  amount  of 
wheat  bran  (added,  it  is  said,  for  the  sake  of  the  adherent  phosphates  and 
nitrogenous  matter),  together  with  1  per  cent,  of  potassium  bicarbonate,  are 
mixed  with  sufficient  water  to  make  a  thin  paste.  The  mixture  is  allowed  to 
stand  at  ordinary  temperatures  for  several  hours,  and  then  heated  to  150°  until 
the  conversion  of  the  starch  into  maltose  and  dextrin  is  completed.  It  is  then 
strained  and  the  residue  pressed  and  exhausted  with  warm  water.  The  extract 
is  evaporated  in  vacuum-pans  at  as  low  a  temperature  as  consistent  with  rapid- 
ity of  working,  and  then  dried  with  stirring  at  a  higher  temperature,  so  as  to  be 
brought  into  pulverulent  porous  lumps.  The  author's  latest  examinations  of 
samples  of  foods  belonging  to  this  class  are  as  follows : 

Savory 
Mellin's  Food.      Horliek's  Food.  and 

Moore's. 

Water 12.37  9.70  8.34 

Fat 0.18  0.34  0.40 

Albuminoids 10.07  10.43  9.63 

Soluble  carbohydrates 68.18  76.83  44.83 

Starch    ... •  36.36 

Gum,  cellulose,  etc 5.45  0.50  0.44 

Ash 3.75  2.20  0.89 

The  starch  is  absent  when  the  process  is  complete,  and  such  was  the  case 
with  some  of  the  samples  tested ;  in  other  samples  a  considerable  portion 
remained. 


52      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  preceding  foods  are  ordinarily  employed  "with  milk,  the  mixture  being 
made  at  time  of  feeding.  .  Still  another  class  remains  in  which  the  dextrinized 
or  malted  flour  has  already  been  evaporated  with  milk,  and  which  is  prepared 
with  the  aid  of  water  only.  They  are  of  very  different  composition,  as  will  be 
seen  from  the  following  table  : 


Water 

Fat ... 

Albuminoids    .... 
Soluble  carbohydrates 

Starch 

Cellulose,  gum,  etc. .  . 
Ash 


5.00 

4.25 

11.00 

40.91 

36.86 

0.28 

1.70 


6.50 

4.91 

10.26 

46.43 

29.48 

0.40 

2.02 


2.21 
9.56 
44.76 
35.00 
0.48 
1.21 


5.68 

5.81 

10.54 

45.35 

30.00 

0.41 

1.21 


4.43 

3.70 

13.00 

46.09 

30.86 

0.50 

1.42 


5e^ 
■g-o 


7.76 

1.64 

11.85 

39.00 

36.43 

0.71 

2.61 


'3  3 


24.32 
15.32 

8.23 
49.43 

Undet. 

« 

2.60 


2.18 

5.30 

15.83 

66.99 

5.57 

3.13 


In  the  preparation  of  these  foods  the  flour  is  first  made  into  a  dough  and 
baked.  The  resulting  biscuit  is  then  finely  ground  and  mixed  with  various 
amounts  of  condensed  milk  and  dried  by  a  slow  heat  at  a  moderate  tempera- 
ture. This  leaves  a  mixture  in  which  the  starch  has  been  partly  changed  into 
dextrose,  maltose,  and  dextrin;  the  albuminoids  of  the  flour  have  undergone 
the  partial  decomposition  spoken  of  in  the  case  of  the  farinaceous  foods;  the 
casein  has  been  dried  into  separate  particles,  and  the  lactalbumin  has  been 
coagulated.  On  the  addition  of  water  the  saccharine  and  a  small  portion  of 
the  albuminoids  dissolve;  the  main  portion  of  the  albuminoids,  the  casein,  and 
the  starch,  are  left  undissolved. 

In  the  actual  preparation  of  farinaceous,  Liebig's,  and  milk  foods  for  use 
in  the  feeding-bottle,  the  adjustment  of  the  relative  proportions  should  be  such 
as  to  afford  a  ratio  between  the  fats,  albuminoids,  and  saccharine  materials  as 
nearly  the  same  as  that  in  human  milk  as  possible.  By  making  the  cow's  milk 
the  principal  article  of  the  mixture,  and  basing  the  approximation  on  such  a 
ratio  as  will  render  the  albuminoids  not  very  different  in  their  gross  amount 
from  that  in  woman's  milk,  foods  of  the  following  character  may  be  obtained. 
Of  course  the  constituents  other  than  the  albuminoids  differ  widely  in  their 
gross  amounts,  and  what  has  been  said  before  in  relation  to  their  relative  values 
in  nutrition  must  here  be  borne  in  mind  also.  Selecting  one  food  of  each  class, 
Column  I.  represents  a  mixture  of  3  parts  of  thoroughly  dextrinized  flour,  47 
parts  of  cow's  milk,  and  50  parts  of  water;  Column  II.  the  same  relative 
amounts  of  Mellin's  food,  milk,  and  water;  and  Column  III.  a  mixture  of  1 
part  of  Nestle's  food  and  6  of  water: 

I. 

Fat 1.91 

Soluble  carbohydrates     .    .    .    3.17 

Starch 1.94 

Albuminoids 2.27 

Ash 0.36 

Total  solids 9.65 

Water 90.35 


II. 

III. 

1.86 

0.71 

4.11 

6.82 

6.14 

1.89 

1.83 

0.43 

0.28 

8.29 

15.78 

91.71 

84.22 

MODIFIED  MILK  AND  PERCENTAGE  MILK- 
MIXTURES. 

By  THOMPSON  S.  WESTCOTT,  M.  D., 
Philadelphia. 


Modified  Milk. — Modified  milk  is  a  term  applied  to  the  product  of  a 
recently  introduced  method  which  aims  to  effect  a  recombination  of  the  fats, 
proteids,  and  lactose  of  cow's  milk,  so  as  to  produce  mixtures  yielding 
any  desired  percentage  of  each  of  these  three  essential  ingredients.  While 
mother's  milk  is  to  be  taken  as  the  type  of  Avhat  such  a  mixture  should 
be,  it  is  possible  by  this  synthetic  process  to  vary  the  percentage  of  any  or 
all  of  its  three  elements  to  meet  any  desired  modification.  The  method 
originated  with  Dr.  Thomas  M.  Rotch  of  Boston,  and  was  perfected  with  the 
collaboration  of  Mr.  G.  E.  Gordon,  a  dairyman  of  wide  experience.  The 
result  of  their  labors  has  been  the  establishment  of  milk-laboratories,  the 
first  of  which  was  opened  in  Boston  in  1891 ;  and  since  that  time  other 
laboratories  have  been  started  in  several  of  the  principal  cities  of  the  Eastern 
and  Southern  States,  in  Montreal,  and,  most  recently,  in  London.  Each 
laboratory  is  supplied  exclusively  by  a  dairy  under  its  absolute  control, 
situated  within  a  short  distance  by  rail,  so  that  not  more  than  three  to  six 
hours  shall  intervene  between  milking  and  delivery  at  the  laboratory.  By 
this  means  the  laboratory  has  complete  supervision  of  the  handling  of  the 
milk  and  the  control  of  its  herd  of  cows.  No  cow  is  accepted  until  proven 
to  be  free  from  tuberculosis  by  the  tuberculin  test,  and  the  health  of  each 
animal  of  the  herd  is  carefully  watched.  Moreover,  the  feeding  is  carried 
out  in  a  thoroughly  scientific-  manner ;  no  silage  or  pasture-feeding  is 
allowed,  and  only  measured  quantities  of  wholesome  fodder  are  given,  for 
the  purpose  of  maintaining  a  constant  analysis  of  the  milk.  Upon  this 
principle  of  feeding  depends  the  uniformity  of  results,  for  it  has  been  found 
that  the  daily  variation  from  the  standard  analysis  of  4  per  cent,  fat,  4.5 
per  cent,  sugar,  and  4  per  cent,  proteids  is  so  small  as  to  be  practically 
unnoticeable  in  the  laboratory  modifications. 

Not  only  is  the  health  of  the  animals  taken  into  consideration,  but  equal 
attention  is  paid  to  the  employes  of  the  farm  and  the  laboratory,  looking  to 
personal  cleanliness  and  the  exclusion  of  any  possibility  of  contamination 
from  infectious  disease.  More  than  this,  sterilization  of  all  bottles,  imple- 
ments, or  utensils  likely  to  contaminate  the  milk  is  carried  out  as  a  routine 
procedure.  In  a  word,  every  effort  is  made  to  secure  a  practical  asepsis  of 
handling  by  attention  to  all  the  details  now  carried  out  in  modern  aseptic 
surgery.  The  result  of  all  these  painstaking  precautions  is  shown  in  the 
production  of  a  relatively  sterile  milk  yielding  a  definite  percentage  of  its 
constituents. 

63 


54       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Briefly  stated,  the  materials  from  which  modified  milk  is  produced  are — 
centrifugal  cream  of  16  per  cent,  fat-strength  (rarely  a  32  per  cent,  cream  is 
required  for  certain  prescriptions) ;  separated  milk,  from  which  practically 
all  fat  has  been  removed  by  the  centrifugation  yielding  the  cream  ;  a  sugar- 
of-milk  solution  of  20  per  cent,  strength ;  and  ordinary  sterilized  lime-water. 
By  combining  these  ingredients  in  varying  proportions  and  making  up  to 
the  required  total  quantity  with  distilled  water,  almost  any  desired  combina- 
tion of  percentages  of  fat,  sugar,  and  proteids  can  be  produced  with  great 
accuracy. 

The  method  at  present  does  not  include  a  modification  of  the  inorganic 
salts,  nor  does  it  attempt  to  vary  the  proportions  of  casein  and  lactalbumin, 
but  treats  the  total  proteids  as  a  unit. 

After  the  materials  have  been  combined  in  the  total  quantity  required 
for  a  day's  feeding  the  mixture  is  divided  up  into  as  many  portions  as  there 
are  to  be  feedings ;  these  are  poured  into  sterilized  nursing-bottles,  which  are 
then  stopped  with  cotton  plugs.  If  so  ordered,  these  bottles  are  subjected  in 
the  sterilizing  apparatus  to  any  desired  degree  of  heat  for  the  purpose  of 
pasteurizing  or  sterilizing ;  they  are  then  packed  in  convenient  baskets,  and 
are  ready  for  delivery.  By  this  means  the  infant  receives  the  proper  quan- 
tity for  a  meal  directly  from  a  sterile  bottle,  without  any  chance  of  contami- 
nation, after  leaving  the  laboratory,  from  exposure  to  air  or  from  unclean 
vessels. 

These  laboratories  are  managed  just  like  a  reputable  pharmacy,  and 
refuse  to  prescribe  over  the  counter.  Blanks  are  furnished  in  prescription 
form,  a  copy  of  which,  with  a  sample  prescription,  is  as  follows: 


^ 


Per  cent. 


Kemarks. 


Fat. 

•    3 

Number  of  feedings  . 

8 

Milk-sugar 

.    6 

Amount  at  each  feeding 

_5  oz. 

Albuminoids  . 

.    1 

^^ 

Infant's  age 

^  mos. 

Mineral  matter 

Infant's  weight 

14  lbs. 

Total  solids     . 

.   _ 

Alkalinity 

3% 

Water 

100 

00 

Heat  at      .        .         . 

13 j^  F. 

Ordered  for     (Baby  (Doe, 

^ogo  (Blank  Avenue. 


Date, 


Jan.  1st,  1895 


Signature, 


©r.  A.  (3.  C. 


For  sake  of  illustration  it  may  be  stated  that  a  mixture  conforming  to 
the  above  prescription  will  be  made  up  of  cream,  1^  ounces ;  separated  milk, 
sugar  solution,  94;  ounces ;    lime-water,  2  ounces ;    and  distilled 


5f  ounces 


Avater,  15^  ounces. 


A  3-6-2  mixture  would  contain  cream  7|^ 


ounces. 


sepa- 


rated milk  13^  ounces,  sugar  solution  7f  ounces,  lime-water  2  ounces,  and 
distilled  water  9i|^  ounces.  It  will  thus  be  seen  that  for  the  same  percentage 
of  fat  the  quantity  of  cream  remains  constant  for  the  same  total  quantity, 
and  that  as  the  proteid  percentage  rises  the  quantity  of  separated  milk 
increases,  the  sugar  solution  undergoing  a  slight  decrease  because  of  the 
greater  proportion  of  milk-sugar  present  from  the  larger  quantity  of  sep- 
arated milk. 


MODIFIED  MILK  AND  PERCENTAGE  MILK-MIXTURES.      55 

The  experience  of  a  large  number  of  physicians  in  feeding  healthy  infants 
on  modified  milk  has  enabled  the  Walker- Gordon  laboratories  to  tabulate  the 
average  percentages  and  quantities  of  mixtures  that  have  proven  satisfactory 
for  varying  ages,  as  follows  : 


Theoretical  Basis  for  Feeding  a 


Premature  infant, 

Birth  at  term, 

1st 
2d 
3d 

4th  to  6th 
6th  to  8th 
8th  to  16th 
16th  to  24th 
24th  to  32d 
32d  to  36th 
36th  to  40th 
40th  to  44th 
44th  to  48th 
48th  to  52d 


Age. 


Hours. 
24  to  36 
Week, 


deeding  a  j 

Healthy 

Infant. 

Gastric 

Prescription 

Capacity. 

Per  ct. 

Per  ct. 

Per  ct. 

Fat. 

Milk-sugar. 

Proteids. 

^  f5i  p  n  \Y\  a 

ri.oo 

3.00 

0.20 

\  1.00 

4.00 

0.50 

id    \j 

(l.oO 

4.50 

0.75 

Oz. 

1 

5.00 

1 

2.00 

5.00 

0.75 

1^ 

2.50 

6.00 

1.00 

2 

3.00 

6.00 

1.00 

2*-3 

3.50 

6.50 

1.00 

3  -3i- 

3.50 

6.50 

1.50 

'6\-^\ 

4.00 

7.00 

1.50 

4^5f 

4.00 

7.00 

2.00 

5|-7 

4.00 

7.00 

2.00 

7 

4.00 

7.00 

2.25 

7  -8 

4.00 

6.50 

2^50 

8  -8J 

4.00 

5.00 

3.00 

8i 

4.00 

4.50 

3.50 

9 

4.00 

4.50 

4.00 

These  figures,  it  must  be  remembered,  are  to  be  taken  simply  as  averages, 
since  the  weight,  as  well  as  the  age,  of  the  child  must  be  taken  into  account 
as  a  guide  of  its  digestive  capacity.  Each  infant's  needs  must  be  studied 
before  a  satisfactory  modification  may  be  secured.  If  anything,  these  aver- 
ages are  a  little  too  high  for  any  but  infants  in  perfect  health  and  with 
unimpaired  digestion. 

Laboratory  modification  has  given  most  satisfactory  results  in  almost 
all  cases  where  artificial  feeding  was  required,  but  more  especially  in  cases 
of  chronic  gastric  or  intestinal  catarrh,  where  proteids  are  digested  with 
difficulty  and  variations  in  their  proportions  from  day  to  day  keep  the 
digestion  constantly  disturbed.  Such  an  infant  may  fail  to  digest  a  modifi- 
cation containing  1  per  cent,  of  proteids,  but  will  begin  to  thrive  when  this 
percentage  has  been  reduced  for  a  time  to  0.75,  0.50,  or  even  lower.  In 
such  cases  the  physician  is  enabled  to  accurately  vary  the  dosage  of  any  one 
or  more  of  the  ingredients  of  his  mixture.  The  method  ofi"ers  a  decided 
advance  upon  any  method  hitherto  introduced  for  the  feeding  of  infants 
with  a  substitute  for  mother's  milk.  It  is  at  once  scientific,  accurate,  and 
rational. 

As  a  general  rule,  it  may  be  stated  that  after  a  satisfactory  formula  has 
been  found  the  strength  of  the  food  may  be  increased  gradually,  but  as 
rapidly  as  the  child's  digestion  will  permit. 

In  reference  to  the  changes  in  formula  that  may  be  required  in  any  par- 
ticular case  after  a  prescribed  mixture  fails  to  exactly  suit  the  conditions,  it 
may  be  permitted  to  quote  Holt's  admirable  summing  up : 

"  If  not  gaining  in  weight,  without  special  signs  of  indigestion,  increase 
the  proportion  of  all  the  ingredients  ;  if  habitual  colic,  diminish  the  proteids ; 
for  frequent  vomiting  soon  after  feeding,  reduce  the  quantity ;  for  the  re- 
gurgitation of  sour  masses  of  food,  reduce  the  fat,  and  sometimes  also  the 
proteids;    for  obstinate  constipation,  increase  both  fat  and  proteids." 


66       A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

As  a  corollary  to  this  it  may  be  added  that,  except  in  hot  weather  or  in 
cases  of  pre-existing  milk-infection,  sterilization  or  even  pasteurization  is 
unnecessary,  and  that  either  of  these  processes  may  favor  or  directly  cause 
constipation.  Lime-water  may  also  have  the  same  effect.  For  a  child  with 
healthy  digestion  lime-water  may  often  be  omitted,  at  first  tentatively,  with- 
out any  bad  results. 

Home  Modifications. — It  is  readily  understood  that  milk-laboratories 
are  as  yet  inaccessible  to  a  large  number  of  physicians,  and  that  the  process  is 
somewhat  costly.  Fortunately,  it  is  quite  possible  to  apply  its  principles  to 
home  modification,  provided  the  mother  have  ordinary  intelligence  and  will 
appreciate  the  importance  of  scrupulous  cleanliness  in  all  the  necessary 
manipulations.  Several  methods  have  been  suggested.  Rotch  (^Pediatrics) 
uses  gravity  cream  and  under-milk,  obtained  by  allowing  a  quart  of  good 
milk  (averaging  4  per  cent,  fat,  4.50  per  cent,  sugar,  and  4  per  cent,  pro- 
teids)  to  stand  in  a  jar  in  ice-water  for  six  hours,  and  siphoning  off  24 
ounces  from  the  bottom,  Avhich  leaves,  according  to  his  estimate,  8  ounces  of 
a  10  per  cent,  cream  in  the  jar.  Holt,  in  his  recent  text-book  (Diseases  of 
Infancy  and  Childhood),  proposes  dilutions  of  various  percentage  creams 
with  solutions  of  milk-sugar  varying  in  strength  from  5  to  10  per  cent. 
According  to  this  method,  16  per  cent.,  12  per  cent.,  or  8  per  cent,  cream  and 
whole  milk  (4  per  cent,  fat)  are  used  with  solutions  of  milk-sugar  of  5,  6,  7, 
8,  and  10  per  cent,  strengths.  An  important  fact  to  be  remembered  is  that 
cream  is  practically  a  superfatted  milk,  essentially  differing  otherwise  from 
milk  in  containing  a  slightly  lower  percentage  of  proteids,  which  vai'y  from 
8.20  for  20  per  cent,  cream  to  3.90  for  8  per  cent,  cream,  as  contrasted  with 
4.00  in  the  average  whole  milk  from  which  the  creams  are  obtained  ;  and  that 
the  sugar  percentage  is  also  slightly  less  than  that  of  the  milk. 

Sixteen  per  cent,  of  butter-fat  is  about  the  strength  of  ordinary  skimmed 
cream  which  has  had  about  twelve  hours  to  rise.  It  averages  3.60  pro- 
teids. 

The  12  per  cent,  cream  may  be  obtained  by  mixing  two  parts  of  16  per 
cent,  cream  and  one  part  of  whole  milk,  or  by  skimming  average  milk  after 
standing  in  a  jar  in  iced  Avater  for  about  six  hours.  It  averages  3.80 
proteids. 

Eight  per  cent,  cream  may  be  obtained  by  mixing  one  part  of  gravity 
cream  and  two  parts  of  whole  milk,  or  by  skimming  the  milk  after  standing 
four  to  five  hours.  Removal  of  the  lower  milk  by  siphoning  is  less  likely  to 
disturb  the  cream  layer,  and  thus  partially  dilute  the  cream.  Eight  per 
cent,  cream  averages  3.90  proteids.^ 

These  percentages  are  approximately  correct,  provided  the  whole  milk 
maintains  a  fairly  constant  average  value  of  4  per  cent,  fat  and  4  per  cent, 
proteids.  Variations  here  will  of  course  disturb  the  cream  percentages,  but 
for  ordinary  cases  the  results  are  sufficiently  close. 

The  sugar  solutions  may  be  made  by  dissolving  an  ounce  of  milk-sugar  in 
20  ounces,  16|  ounces,  14^  ounces,  12|^  ounces,  or  10  ounces  of  boiled  or 
distilled  water  to  produce  5,  6,  7,  8,  or  10  per  cent,  solutions  respectively. 
The  use  of  solutions  of  such  varying  strengths  enables  the  modifications  to 
be  made  without  the  use  of  additional  plain  water,  and  thus  simplifies  the 
preparation. 

For  comparison  the  following  tables  of  dilutions  of  cream  have  been 
accurately  worked  out : 

^  The  percentage  figures  used  by  Rotch  and  Holt,  and  also  in  the  cream  and  whole-railk  mod- 
ification later  described,  are  the  standard  analyses  of  the  products  of  the  Walker-Gordon  dairies. 


MODIFIED  MILK  AND  PERCENTAGE  MILK-MIXTURES. 

Table  1.— Sixteen  Per  cent.  Cream. 

(Fat,  16.00  ;  Sugar,  4.20  ;  Proteids,  3.60.) 
'  P^V5'par7sT^''s;^gar  solution^Fat,  1.00  ;     Sugar 


57 


15 

15      ' 

9      ' 

9      ' 

9      ' 

7      • 

7      ' 

7      ' 

5.4 

5.4 

5.4 

4.3 

4.3 

4.3 

3.6 

3.6 

3.6 

3 

3 

3 

3 


1.00 

1.60 

1.60 

1.60 

2.00 

2.00 

2.00 

2.50 

2.50 

2.50 

3.02 

3.02 

3.02 

3.48 

3.48 

3.48 

4.00 

4.00 

4.00 

4.00 


4.95  ; 
5.89  ; 
6.82 ; 
4.92 ; 
5.82 ; 
6.72  ; 
4.90; 
5.77; 
6.65; 
4.87; 
5.72; 

6.56; 

4.85 ; 

5.66  ; 

6.47; 

4.83; 

5.61; 

6.39; 

4.80; 

5.55  ; 

6.30; 

7.05; 


Proteids,  0.23 
0.23 
"  0.23 

«  0.36 

"  0.36 

«  0.36 

"  0.45 

"  0.45 

"  0.45 

"  0.56 

«  0.56 

"  0.56 

0.68 
«  0.68 

0.68 
0.78 
"  0.78 

"  0.78 

«  0.90 

"  0.90 

0.90 
«  0.90 


Table  IL—TioeJve  Per  cent.  Cream 
(Fat,  12.00;  Sugar,  4.30;  Proteids,  3.80.) 

1  part  of  Cream  to—  v  ^  i  on 

^     11  parts  5  %  Sugar^^solution  =  Fat,  1.00 


11 
11 

7 

5 

3.8 

3 

2.4 

2 


6 

7 

5-7 

5-7 

5-8 
5-8 

5-8 
5-8 


1.00 
1.50 
2.00 
2.50 
3.00 
3.53 
4.00 


Sugar,  4.94 ; 

"  5.86 ; 

"  6.77 ; 

"  4.91-6.67 ; 

"  4.88-6.55 ; 

"  4.85-7.12 ; 

»  4.82-7.07 ; 

"  4.65-6.76 ; 

"  4.77-6.77 ; 


Proteids,  0.32 
0.32 


0.32 
0.48 
0.63 
0.79 
0.95 
1.12 
1.27 


Table  lll.—Mght  Per  cent.  Cream. 

(Fat,  8.00  ;  Sugar,  4.40  ;  Proteids,  3.90.) 

1  part  of  Cream  to—  ,     Sugar,  4.92-6.67  ; 

7  parts  5-7f.  Sugar  solution  =  Fat,  1.00,     ^ugar,  ^^^^_^  .^^  , 

3      "     5-8  -    „      -Q^:  a      4.77-6.62; 

1-6 ::  1:1^     I      I "  4.oi;    "  4.70-7.20;    " 

Table  IV.—Four  Per  cent.  Cream  (whole  milk) 

(Fat,  4.00  ;  Sugar,  4.50  ;  Proteids,  4.00.) 

1  part  of  Milk  to—  -r  +   n  ^<? 

11  parts  5-7%  Sugar  solution  =  Fat,  0.66 

'  u  _     "      1  00 

^         ^  ic  "    9  no 

1      «     5-10  "  =  ^-"^ 

3  parts  of  Milk  to—  ,,    „  ^.^ 

1  part  5-10  fo  Sugar  solution  =  6-00 


Proteids,  0.49 

0.97 

«  1.44 

1.95 


Sugar,  4.96-6.79  ; 
«  4.94-6.69 ; 
"  4.87-7.12 ; 
"      4.75-7.25 ; 

«      4.62-5.87 ; 


Proteids,  0.33 

«  0.50 

1.00 

"         2.00 

«  3.00 


It  win  be  noticed  tiat  by  tl^e-variou^  dilutions  of  crea.,  »d  ^^ 

:-L"rr.crtbrdJ:tirLrde!"  t:v.ean  phages  .u. 


68       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

with  high  percentages  of  proteids  cannot  be  obtained  without  additional 
proteids  from  skimmed  milk.  The  practical  value  of  the  method  therefore 
ends  with  a  1  :  1  dilution  of  whole  milk.  Finer  variations  in  the  relative 
proportions  of  fat  and  proteids,  which  are  easily  managed  in  laboratory 
modification,  are  thus  impossible  bv  the  method  of  cream  dilution. 

Modifications  with  Cream  and  Milk. — For  the  reasons  just  stated,  as 
well  as  the  greater  convenience  in  using  whole  milk  as  a  basis  of  the  mixture, 
and  making  up  the  necessary  fat-value  with  additional  cream,  the  writer  has 
for  some  time  been  using  such  a  method  for  home  modification.  It  has  been 
found  that  most  satisfactory  results  can  be  obtained  by  using  a  12  per  cent, 
cream  and  whole  milk  (averaging  fat  4.00,  sugar  4.50,  and  proteids  4).  It  is 
first  necessary  to  decide  upon  the  number  of  ounces  of  total  mixture,  and  fix 
the  proteid  and  fat  percentages  desired.  Then  the  number  of  ounces  of 
mixed  milk  and  cream  can  be  found  by  the  proportion 

(1)  3.90:  F::  Q:x, 

in  which  Q  is  the  total  quantity  of  mixture,  and  P  the  proteid  percentage : 
the  value  of  x  gives  the  number  of  ounces  of  milk  and  cream  required  to  give 
the  chosen  percentage  of  proteids.  The  value  of  x  being  found,  it  remains 
to  divide  this  quantity  into  two  parts.  C  and  31.  the  first  of  which  represents  the 
quantity  of  cream  required,  the  second  the  quantity  of  milk.  This  is  readily 
done  by  means  of  the  formula 


in  which  Q  represents  the  total  quantity  of  mixture,  F  the  fat  percentage  de- 
sired, and  X  the  quantity  of  mixed  milk  and  cream  already  determined  by 
formula  (1).  The  quantity  of  milk,  i¥,  is  at  once  found  by  subtracting  the 
value  of  C  from  that  of  x.  To  illustrate  :  let  it  be  desired  to  find  the  quan- 
tities of  milk  and  cream  to  make  a  mixture  of  40  ounces  containing  proteids 
1.50  and  fat  3.00. 

Formula  (1)  becomes 

3.90  :  1.50  :  :  40  oz.  :  x, 
whence  a;  =  15.4oz. 

Equation    (2)   becomes 

^      120-61.6 

0= ^ ==  7.3  oz. 

and  consequently,  M—8.1  oz. 

Taking  the  same  example,  let  it  be  required  to  get  4  per  cent,  of  fat. 
The  total  quantity  of  milk  and  cream  will  be  the  same  as  in  the  previous 
case,  but  the  quantity  of  each  will  difi"er.  Here,  from  formula  (2),  C= 
12.3  oz.,  and  consequently  31=  3.1  oz.  The  remainder  of  the  40  ounces  of 
total  mixture  is  to  be  made  up  by  the  addition  of  boiled  water,  barley-water, 
oatmeal-water,  or  whatever  diluent  is  chosen.  Lime-water,  if  desired,  may 
also  be  added  to  the  mixtm-e  in  the  proportion  of  5  to  10  per  cent.  In  the 
above  examples  2  to  4  oz.  of  the  diluent  would  be  lime-water. 

It  will  readily  be  seen  that  the  calculation  of  proteids  is  not  quite  exact, 
since  the  varying  proportions  of  milk  and  cream  cause  variations  in  the 
average  value  of  the  proteids ;    but,  at  the  most,  these  vary  only  between 


MODIFIED  MILK  AND  PERCENTAGE  MILK-MIXTURES.     59 

3.80  and  4.00,  so  that  an  average  of  3.90  very  satisfactorily  represents  this 
value.  It  is  also  evident  that  this  assumed  constant  factor  cannot  be  used 
for  a  proteid  percentage  higher  than  itself;  but  as  such  a  combination  would 
consist  almost  entirely  of  whole  milk,  the  constant  (3.90)  should  be  taken 
very  close  to  4.00.  For  instance,  if  a  4.00  fat  and  3.90  proteid  mixture 
were  desired,  the  constant  factor  should  be  taken  as  3.99,  and  it  would  be 
found  from  formula  (1)  that  39.1  oz.  of  mixed  milk  and  cream  would  be 
needed,  the  proportions  of  0.4  oz.  cream  and  38.7  oz.  milk  being  obtained 
from  the  other  formula. 

There  are  a  few  exceptions  to  the  universal  application  of  these  formulae 
that  should  be  noted.  .  In  proteid  values  lower  than  1.00,  16  or  even  32  per 
cent,  cream  may  be  required  ;  ^  in  proteid  values  of  1.00  to  1.25,  16  per  cent, 
cream  is  required  for  fat  values  from  3.25  to  4.00  for  the  lower,  and  from  3.75 
to  4.00  for  the  higher  of  these  proteid  percentages ;  also,  in  the  higher  proteid 
percentages  (2.25  to  4.00)  skimmed  milk,  instead  of  cream,  would  be  required 
for  fat  percentages  lower  than  the  proteid  percentage.  In  practice,  however, 
it  is  extremely  rare  to  use  a  fat  percentage  lower  than  the  proteid,  so  that 
this  method  of  combination  will  be  found  to  give  most  satisfactory  working 
results,  which  come  closer  to  accurate  percentages  than  either  cream-and- 
undermilk  or  diluted-cream  mixtures. 

The  estimation  of  the  quantity  of  sugar  to  be  added  for  any  desired  per- 
centage is  considerably  simplified  by  the  fact  that,  since  the  quantity  of 
mixed  milk  and  cream  remains  constant  for  the  same  proteid  value,  the  sugar 
to  be  added  is  also  constant  for  the  same  sugar  percentage  :  the  variations  in 
the  fat  percentage  do  not  alter  it.  The  quantity  of  dry  sugar  of  milk  to  be 
added  to  the  mixture  to  produce  any  desired  percentage  of  sugar,  ^,  is  rapidly 
calculated  from  the  formula 

^X^-4.40:. 
(3)  Sugar  = ^^ • 

In  the  examples  already  given,  to  obtain  a  6  per  cent,  sugar  mixture  there 
must  be  added  about  If  oz.  of  dry  sugar. 

A  distinct  advantage  of  this  method  is  that  if  the  quantity  of  cream  be 
kept  constant  and  the  milk  gradually  increased,  the  total  quantity  of  mixture 
being  kept  constant,  both  the  proteid  and  fat  percentages  are  gradually 
increased  by  an  equal  increment.  When  the  fat  value  surpasses  4.00,  beyond 
which  it  is  rarely  desirable  to  go,  a  half  ounce  may  be  dropped  from  the 
quantity  of  cream  and  its  loss  supplied  by  a  half  ounce  of  milk.  From  this 
point  an  increase  of  two  or  three  ounces  of  milk  may  be  made  before  the  fat 
value  again  rises  above  the  point  desired,  when  another  half  ounce  of  cream 
may  be  replaced  with  milk.  By  this  means  the  strength  of  food  may  be 
gradually  increased  Avithout  necessitating  frequent  changes  of  formula. 

1  When  16  or  32  per  cent,  cream  is  used,  the  denominator  8  in  formula  (2)  should  be 
made  12  or  28,  and  the  constant  factor  in  formula  (1)  should  be  changed  to  3.80  or  3.45,  to 
correspond.     See  papers  on  this  method,  Archives  of  Pediatrics,  Jan.,  Feb.,  1898. 


SEA-AIR  AND  SE  ABATHmG  IN  CONVALESCENCE. 


By  W.  M.  POWELL,  M.  D., 

Atlantic  City. 


The  difference  between  the  air  of  an  inland  town  and  that  of  the  sea-coast 
is  that  the  latter  is  not  only  pure,  but  is  saturated  with  sea-salts  from  the  break- 
ing of  the  waves  upon  the  shore  and  the  dashing  of  spray,  which  is  carried 
toward  the  land  by  air-currents.  If  the  wind  is  blowing  from  the  sea,  this 
characteristic  saline  odor  may  be  noticed  for  some  miles  inland,  but  during  a 
*' land-breeze  "  it  is  hardly  perceptible,  even  upon  the  beach.  E.  Freidick,  in 
the  Southern  California  Practitioner,  quotes  a  large  number  of  observers  who 
have  demonstrated  the  presence  of  sodium  chloride  in  the  air  at  the  seaside, 
and  shows  that  while  there  is  naturally  a  small  proportion  of  salt  in  this  atmo- 
sphere, the  greatest  part  of  it  is  due  to  the  diffusion  of  minute  particles  of  sea- 
water.  The  proportion  of  salt  is  increased  during  strong  winds,  which  blow 
the  fine  spray  inland. 

The  air  of  the  sea  has  a  peculiar  odor  which  is  difficult  to  define,  but  which 
it  is  impossible  to  forget  when  once  it  has  been  inhaled.  This  odor,  which 
is  caused  by  the  evaporation  of  the  extractive  matter  contained  in  sea-water, 
is  stronger  when  the  waves  dash  upon  rocks  covered  with  sea-weed  than  when 
they  bi'eak  gently  upon  a  sandy  shore.  It  is  also  more  perceptible  during  a 
storm  than  when  the  sea  is  calm. 

Upon  the  border  of  the  ocean  the  air  is  under  greater  pressure  than  in  places 
of  greater  elevation,  and  consequently  it  contains  more  oxygen.  The  range  of 
the  barometer,  the  thermometer,  and  hygrometer  is  reduced  to  a  minimum. 
These  facts  are  only  too  often  neglected  in  our  estimates  of  the  qualities  of 
sea-air ;  they  are,  however,  in  a  great  measure  responsible  for  the  benefits 
derived  by   invalids   during  a  residence  at  the  sea-shore. 

Ozone  is  one  of  the  constituents  of  the  atmosphere  which  is  found  in  abun- 
dance on  the  sea  and  adjoining  coast.  Schonbein,  its  discoverer,  believed  it  to 
be  naturally  formed  out  of  atmospheric  oxygen  by  the  electrical  discharges 
constantly  taking  place  in  the  air.  It  is  a  most  powerful  oxidizing  agent,  so 
destructive  to  organic  miasmata  that  its  mere  presence  is  a  warrant  of  the 
absence  of  such  noxious  elements.  It  is  more  abundant  by  the  sea  than 
inland,  and  in  windy  than  in  calm  weather.  It  is  well  known  that  the  climate 
of  any  place  where  ozone  is  found  in  abundance  must  be  healthy  and  exhila- 
rating ;  hence  we  have  at  the  sea-shore  a  pure  air,  containing  oxygen  in  the 
form  of  ozone,  besides  finely  divided  sea-salts,  as  well  as  water  which  is  ren- 
dered stimulating  by  the  presence  of  the  same  salts.  It  most  cases  the  breath- 
ing of  this  air  has  a  marked  invigorating  effect,  causing  a  great  improve- 
ment in  the  appetite,  promoting  digestion  and  almost  immediately  producing  a 
delightful  exhilaration  of  the  entire  system.  "  No  doubt  can  be  entertained, 
in  view  of  often-observed  facts,  that  the  effect  of  exposure  to  sunlight  upon 
animal  life  is  directly  invigorating ;  and  when  with  this  is  combined  the  con- 
stant inhalation  of  salt-air,  and  the  daily  application  of  salt  water  to  the  whole 

60 


SEA-AIB    AND  SEA-BATHING, 


61 


surface  of  the  body  and  limbs,  it  is  easy  to  see  why  children  should  gain  health 
and  strength  at  the  sea-shore." — Packard. 

The  temperature  on  or  near  the  sea  may  certainly  lay  claim  to  greater 
uniformity  than  is  obtained  in  localities  remote  from  the  coast.  During  the 
summer  months  the  heated  air  of  the  land  may  be  replaced  by  the  cool  breeze 
from  the  sea,  while  in  winter  the  temperature  of  the  coast-line  is  raised  by  the 
admixture  of  the  warmer  air  from  the  sea  with  the  colder  air  of  the  land.  It 
is  estimated  that  the  Gulf  Stream  in  this  latitude  during  winter  imparts  to  the 
air  in  contact  with  it  a  temperature  of  at  least  ten  or  fifteen  degrees  above  that 
of  the  atmosphere  of  the  earth,  so  that  the  ocean  air  in  mixing  with  that  of  the 
land  imparts  to  it  an  agreeable  mildness  which  is  unknown  in  the  interior. 
Another  favorable  condition  is  found  in  the  fact  that  the  warmer  air  from  the 
sea  holds  a  large  amount  of  invisible  aqueous  vapor  in  suspension,  and  as  this, 
commingles  with  the  colder  air  of  the  land,  it  is  condensed,  gives  out  its  latent 
heat,  and  becomes  visible  in  the  formation  of  clouds,  especially  at  sundown. 
Thus  that  radiation  of  heat  from  the  earth's  surface  into  space  which  always 
takes  place  on  clear  nights  is  prevented.  We  can  therefore  safely  assume 
that  the  mean  temperature  of  the  sea-coast  is  neither  so  high  in  the  summer 
nor  so  low  in  the  winter  as  that  which  prevails  in  the  interior.  These  facts 
are  well  illustrated  in  the  following  table,  prepared  by  Sergeant  W.  D.  Blythe 
from  the  reports  of  the  United  States  Signal  Office,  giving  for  five  well-known 
localities  the  mean  temperature  for  each  month  and  the  year,  computed  from 
November,  1879,  to  December,  1884,  together  with  the  average  temperature 
for  each  of  the  four  seasons : 


Winter. 

Spring. 

Summer. 

Autumn. 

Year. 

!> 

6 

1 

i 

c 

i 
<-> 

^ 

o 

>■ 

< 

u 
,38.6 

< 
46.7 

57.8 

< 
47.7 

a 

a 

1-5 

66.9 

"3 

•-5 

si 

< 

> 

< 
70.4 

p. 
^68.8 

o 
58.5 

> 
44.5 

■5 

57.31 

o 

a 
< 

Atlantic  City.  N.  J.  .   . 

3G.8  32.4 

a=i.7 

ai.o' 

72.6  71.6 

52.5 

Barnegat,  N.  J 

36.4  31.9 

3.^.1 

34.5! 

38.3 

46.0 

57.2 

43,8 

65  5 

72.2  71.1 

69.9 

68.0 

57.7 

44.2 

56.6' 

52.0 

Boston,  :^^ass 

31.4  26.4 

30.1 

29.3 

33.9 

43.6 

55.3 

44.3 

65.8 

69.9  68.8 

68.2 

63.5 

51.7 

40.0 

58.4  i 

48.4 

Kew  York  City 

34.4|  30.0 

33.6 

32.7 

36.7 

47.0 

59.3 

47.71 

68.3 

72.6  71.6 

70.8 

67.5 

56.2 

43.2 

55.6; 

51.6 

Philadelpliia,  Pa.  .  .  . 

36.1  31.7 

37.1 

35.0 

40.2 

49.9 

62.6 

50.9 

71.5 

75.1  j  73.7 

76.8 

69.3 

57.7 

44.6 

57.2 

54.1 

As  a  sea-breeze  prevails  on  a  large  majority  of  the  days  during  the  summer 
months,  the  average  summer  temperature  is  much  lower  on  the  sea-coast  than 
farther  inland.  On  some  days  the  difference  is  greatly  marked,  and  few  of  us 
have  failed  to  experience  the  relief  afforded  by  the  first  breath  of  sea-air  after 
spending  a  day  in  the  hot  city. 

It  is  self-evident  that  the  pleasantest  climatic  conditions  are  those  which 
present  the  most  even  temperature,  with  only  a  moderate  amount  of  wind  and 
rain.  The  tables  on  the  following  page,  compiled  from  the  same  source,  give 
some  interesting  statistics  of  rainfall,  temperature  and  wind  at  various  well- 
known  stations  of  the  Signal  Office. 

Touching  the  question  of  health,  the  national  mortuary  table  offers  important 
data.  There  we  find  that  while  such  model  cities  of  the  interior  as  Roches- 
ter and  Milwaukee,  swept  as  they  are  by  the  cleansing  winds  of  the  great 
lakes,  show  a  death-rate  respectively  of  "23.39  and  24.52  per  1000;  while 
Philadelphia,  the  healthiest,  save  London,  of  the  world's  great  cities,  shows 
21.20;  and  while  nearly  thirty  people  to  the  thousand  die  annually  in 
Charleston — the  death-rate  among  the  resident  population  of 
town  like  Atlantic  City  is  12.5.  There  are  only  two  places  in 
States — Ashtabula,  Ohio,  and  Los  Angeles,  California — where 
rate  shows  any  approximation  to  this  last  percentage. 


a  sea-coast 
the  United 
the   death- 


62       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDBEN. 


Annual  Precipitation,  in  inches  and  hundredths,  as  recorded  at  the  U.  S.  Weather  Bureau  Stations  on 
or  Tmir  the  Atlantic  Coast,  1882  to  1891,  inclusive;  also  the  Average  Annual  Precipitations,  com- 
puted from  observaiions  covering  periods  of  from  three  to  twenty-one  years. 


Stations. 


Asbury  Park,  N.  J.  .  . 
Atlantic  City,  N.J.  .   . 

Baltimore,  Md 

Baniegat  (closed).  .  . 
Block  Island,  R.  I.  .  . 
Cape  May  closed).  .  . 
Charleston,  S.  C.  .  .  . 
Jacksonville,  Fla  .  .  . 
Narragansett  Pier,  K.  I. 
New  Orleans,  La. .  .  . 
Newport  (closed)  .  .  . 
New  York  City  .... 

Norfolk,  Ya 

Portland,  Me 

Sandy  Hook    

Washington,  D.  0.  .  . 
Wilmington,  N.  C.    .  . 


1882.    1883.    1884.    1885.    1886.    1887.    1888.    1889.    1890.  |  1891.      amoimt^ 


55.29 
42.11 


57.65 


57.01 
53.26 


50.18 

46.61 
57.67 
38.94 
32.14 
46  79 
52.29 


44.64    53.70 
40.52    43.88 


39.69 


51.35 
53.ai 


69.85 

38.83 
54.30 
31.99 
42.09 
45.71 
64.00 


63.05 


60.22 
55.92 


60.01 

55.34 
45.05 
52.51 
52.72 
49.96 
62.70 


38.45 
46.04 


39.87 


67.93 
52.04 


64.18 


44.80    37.76 
53.11    43.59 


54.50    44.55 


65.94    44.61 

54.86    58.60 

.    .    I  50.97 

54.83  !  64.97 


42.32  i  46.73  :  46.63 
43.25    34.33  i  47.74 

52.63  I  49.07 

closed. [ 

58.17  I  45.38 

56.43  i  51.47 


39.75 
38.42 
44.84 
60.42 


44.10 
43.53 


29.18 


49.46 
53.13 
53.66 
45.15 

52.95 
56.64 
34.24 


61.33 
55.07 


57.56 
38.43 
42.35 


32.80 


52.25 
46.22 
57.15 
48.45 

58.68 
70.72 
41.92 


41.59 
59.31 


55.03 
33.04 
46.96 


31.51 


47.84 
47.52 
45.21 
47.17 

52.30 
50.22 
51.97 


52.95 
41.33 


51.64 
43.04 
54.21 


39.03 


45.90 
41.32 
44.46 
38.62 

51.44 
50.63 
43.28 


51.22 
48.00 


3  yrs. 
18  " 
16  " 
8    " 

11  " 
10  " 
16  " 
15  " 

5  " 
23  " 

6  " 
21  " 
21  " 

20  " 

12  " 

21  " 
21  " 


53.44 
42.81 
43.11 
50.20 
44.45 
46.70 
58.92 
51.04 
52.38 
51.78 
59.98 
45.76 
52.21 
42.68 
50.40 
45.06 
56.24 


Monthly 

%nd  Annual  Mean 

Temperatw 

esfor 

1889. 

Stations. 

Jan. 

Feb. 

Mar. 

Apr. 

May. 

June. 

July. 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Mean. 

Asbury  Park,  N.  J.    .   . 
Atlantic  City.  X.  J.   .   . 
New  York  City  .   .    •  • 

36.2 
37.6 
37.6 

28.5 
29.5 
28.0 

40.4 
38.8 
41.5 

49.1      62.5 
48.6      59.0 
51.6      62.0 

69.6 
66.2 
70.4 

71.5 

71.8 
73.5 

70.8 
69.3 
71.5 

66.6 
64.4 
65.8 

51.9 
51.8 
52.0 

45.6 
47.0 
46.0 

42.1 
43.6 
41.4 

52.9 
52.3 
53.5 

Annual  Movement  of  Wind,  in  miles,  at  U.  S.  Weather  Bureau  Stations  on  the  Atlantic  Coast 
for  ten  years,  ending  Dec.  31,  1891. 


Stations. 


Atlantic  City,  N.  J. 
Barnegat,  N.  J. .    . 

Block  Island,  R.  I. 

Cape  May,  N.  J. .  . 

Sandy  Hook,  N.  J  . 


1882. 


1893. 


80.769 
128.939 

132.595  130.575 

123.04l|l28.330 

122.601128.933 


1884.      1885. 


75.232 
125.081 

127.478 


76.150 
124.061 


134.5&4J  closed 
139.149  144.879 


1886. 


79.553 
closed 

125.698 


1887.      1888.      1889. 


74.879|    88.825 j  104.930 
132.975  147.3841 148.944 


138.672  closed 


1890. 


102.520: 106.500 


Avarage. 


87.5a5 
(4  years) 

123.911 
(8  years) 

133.531 
(3  years) 

128.653 
(5  years) 

134.847 


Diseases  benefited  by  Sea-air. — It  is  often  asked,  What  diseased  con- 
ditions are  benefited  bj  a  sojourn  at  the  seaside?  and,  What,  if  any,  are 
acted  upon  unfavorably  ?  Dr.  A.  W.  Bell,  author  of  Climatology  and  31{neral 
Waters  of  the  United  States,  says  that,  considering  the  purity  of  the  vapor 
and  perfect  solubility  of  the  salt,  it  is  difficult  to  conceive  of  any  possible 
state  of  the  human  system  under  which  the  inhalation  of  such  air  would  be 
detrimental.  I  fully  agree  with  this  author,  and  believe  that  sea-air  is  pref- 
erable to  any  other  during  a  tedious  convalescence.  I  know  of  no  place 
where  children  improve  more  quickly  than  at  the  sea-shore.  I  have  stud- 
ied this  subject  closely  since  1883,  when  I  was  resident  physician  at  the 
Children's  Sea-shore  House  at  Atlantic  City,  New  Jersey.  Since  that  time 
T  have  been  connected  with  the  same  institution,  where  upward  of  seven 
hundred  children,  both  convalescents  from  various  acute  (non-contagious) 
diseases  and  those  affected  with  chronic  ailments  and  strumous  manifes- 
tations, are  admitted  yearly  during  the  summer  months.  No  one  without 
experience  can  realize  the  benefit  obtained  by  these  little  suffers,  who  remain 
at  the  Home  for  a  fortnight  to  several  weeks,  according  to  the  gravity  of 
their  cases.  Here  are  sent,  chiefly  from  Philadelphia,  desperate  cases  of 
entero-colitis,  patients  almost  completely  prostrated  by  the  heat,  and  other 
moribunds.     Yet  nearly  all  recover  through  the  influence  of  the  sea-air  and 


SEA- AIR   AND   SEA-BATHING.  63 

clean,  healthful  surroundings,  with  little  or  no  aid  from  medicine.  During  the 
summer  of  1892,  in  the  latter  part  of  July,  and  the  first  week  in  August,  the 
heat  in  Philadelphia  and  vicinity  was  intense.  At  this  time  I  had  more  cases 
of  severe  entero-colitis  than  for  several  years,  but  they  all  recovered  rapidly, 
save  one,  a  child  sixteen  months  old,  who  died  four  hours  after  its  arrival  at 
the  coast.  At  the  Children's  Seashore  House,  where  my  friend  Dr.  W.  H. 
Bennett  was  in  charge,  the  cases  were  more  severe  than  usual,  but  all  termi- 
nated favorably. 

It  is  an  unusual  circumstance  for  entero-colitis  to  develop  at  the  sea-shore, 
and  most  of  the  cases  seen  there  are  brought  from  the  neighboring  cities  or 
interior.      Simple  diarrhoea  from  indigestion,  -teething,  etc.  of  course  occurs. 

Convalescents  from  scarlatina,  measles,  and  the  eruptive  fevers  generally  do 
well  by  the  sea. 

The  subacute  nasal  and  pharyngeal  catarrhs  that  we  so  often  meet  Avith 
in  the  spring  as  the  results  of  repeated  winter  colds,  which  are  usually  so 
obstinate,  invariably  do  well  at  the  shore,  where  a  complete  cure  is  usually 
effected  in  a  few  days.  Even  cases  of  acute  bronchitis  seem  to  recover  much 
more  rapidly,  and  chronic  forms  are  much  improved.  My  experience  with 
phthisis  in  children  at  the  sea-shore  has  been  limited :  I  have  only  seen  a 
few  cases,  and  they  were  far  advanced.  These  children  seemed  to  do  well  for 
the  first  week ;  the  appetite  improved,  and  sleep  was  more  refreshing,  although 
the  cough  remained  about  the  same.  After  this  they  remained  at  a  standstill, 
the  improvement  in  appetite  not  being  maintained  and  rest  becoming  dis- 
turbed again.  These  cases  improved  for  the  first  few  days  when  taken  home, 
but  fell  back  rapidly. 

Asthmatic  patients  are  frequently  sent  to  the  sea-shore,  Avith,  as  a  rule, 
most  favorable  results.  Doubtless  a  long  stay  is  beneficial  to  all  such  cases, 
especially  those  associated  with  chronic  bronchitis.  Patients  arriving  during 
a  paroxysm  nearly  always  experience  an  immediate  relief,  especially  in  cases 
of  hay  asthma ;  but  should  the  attack  orginate  at  the  sea-coast,  removal  to  the 
city  may  in  turn  prove  beneficial.  Hyde  Salter  says  :  "I  think  it  is  a  law,  with- 
out an  exception,  that  nervous  affections  are  less  prone  to  occur  in  proportion 
to  the  general  bodily  vigor,  and  what,  for  want  of  a  more  definite  term,  we 
must  call  the  tone  of  the  nervous  system.  Anything,  therefore,  that  invigor- 
ates renders  asthmatics  less  prone  to  their  attacks.  In  this  way  sea-bathing 
is  often  of  great  service  to  asthmatics.  By  raising  the  standard  of  the  general 
health  it  tends  to  prevent  those  humoral  derangements  which  are  often  the 
exciting  cause  of  asthma." 

Cases  of  a  strumous  origin  invariably  do  well  by  the  sea:  the  appetite 
improves,  the  color  returns  to  their  cheeks,  and  they  gain  in  flesh.  Russel, 
who  was  the  first  to  appreciate  all  the  benefits  derivable  from  the  salt  air, 
always  had  the  hair  of  strumous  children  cut  close,  and  exposed  them  freely 
to  the  cool  sea-air  with  the  neck  uncovered  ;  and  he  sent  them  back  to  their 
homes  wfth  their  limbs  strengthened  and  carrying  in  their  countenances  the 
evidence  of  the  restorative  powers  of  his  remedy.  When  the  strumous  diath- 
esis has  further  advanced,  the  effect  of  sea-air,  although  still  of  great  utility, 
is  much  slower.  There  are  many  cases  of  cure,  even  when  the  glands  of  the 
neck  have  been  greatly  swollen,  under  the  influence  of  two  or  three  seasons 
passed  by  the  sea.  Roccas  tells  us  that  such  a  deeply  ingrained  constitutional 
disease  as  scrofula  cannot  be  eradicated  without  a  prolonged  stay  in  a  marine 
atmosphere.  When  the  glands  are  ulcerated,  Whitt  many  years  ago  recommended 
fomentations  with  sea-water  and  poultices  made  with  it.  It  is  supposed  to  facil- 
itate the  resolution  of  the  swollen  glands,  even  when  they  have  become  very 


64      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

large  and  have  existed  for  a  long  time.  The  following  case,  reported  by  Rob- 
ert of  Marseilles,  fully  confirms  these  assertions :  "A  lady  coming  from  the 
interior  of  France  brought  to  me  her  son,  about  fifteen  years  of  age.  The 
youth  was  enfeebled  to  the  last  degree,  having  been  ill  ever  since  he  was  nine 
years  old.  During  all  -this  time  he  had  labored  under  scrofula  of  the  neck, 
which  was  entirely  surrounded  with  cicatrices  of  old  ulcers.  At  the  time  I 
saw  him  the  right  elbow  and  one  of  the  feet  were  afi"ected ;  the  elbow-joint 
was  not  diseased  interiorly,  but  the  ligaments  which  surrounded  it  were ;  and 
there  were  fistulous  openings  which  had  persisted  for  a  length  of  time.  As 
regards  the  foot,  it  was  puff"y  and  much  enlarged,  and  he  could  scarcely  bear  it 
to  be  placed  upon  the  ground :  abscesses  had  formed  several  times,  which  had 
cicatrized,  but  there  was  another  now  threatening  to  open  on  one  side  of  it. 
The  most  alarming  feature  of  the  case,  however,  was  the  terribly  low  state  of 
the  patient's  constitution.  His  spirits  were  dejected;  his  face  had  the  look 
of  one  prematurely  old :  his  skin  was  dry  and  flabby  ;  and  his  limbs  almost 
entirely  denuded  of  their  flesh.  Moreover,  he  Avas  tormented  with  an  almost 
continual  diarrhoea.  I  advised  the  mother  to  establish  her  son  upon  the  sea- 
coast,  to  make  him  pass  the  whole  day  upon  the  beach,  and  to  make  him  use 
the  sea-baths.  Under  this  influence  his  general  health  began  to  improve,  and 
then  the  swellings  of  the  elbow  and  the  thickening  of  the  foot  began  to  sub- 
side. Afterward  I  recommended  that  he  should  bathe  daily,  and  that  he  should 
learn  to  swim.  He  fulfilled  my  orders  so  literally  that  he  passed  almost  the 
whole  of  the  latter  part  of  the  summer  in  the  water.  Always  on  the  beach, 
he  could  find  no  other  amusement  so  pleasant  as  that  he  derived  from  swim- 
ming. In  a  marvellously  short  time,  considering  the  amount  of  disease,  the 
youth  was  quite  cured,  and  became  what  he  still  remains — a  strong,  healthy, 
and  vigorous  man." 

Rickets  is  another  common  disease  of  childhood  in  which  the  benefits  of 
residence  by  the  sea  are  marked.  The  influence  of  sea-air  upon  this  malady 
seems  to  exert  a  marvellous  amount  of  good,  and  West,  in  recommendation 
of  it,  says  that  "  even  where  marked  deformity  has  already  taken  place 
amendment  will  be  sure  to  follow."  I  fully  agree  with  this  authority,  but 
will  state  that  my  experience  in  the  past  two  years  with  this  affection  has 
been  limited,  as  the  stay  of  my  patients  during  the  summer  months  is  hardly 
sufiicient  to  show  improvement  if  the  disease  is  far  advanced.  But  I  do  believe 
a  prolonged  stay  by  the  sea,  say  a  year  or  more,  will  bring  about  a  complete 
cure. 

Children  suffering  from  Pott's  disease,  hip-joint  disease,  and  arthritis  of  the 
knee  all  do  well,  gaining  in  flesh  and  improving  in  appetite  without  medical 
treatment. 

Rheumatic  cases,  especially  when  chronic,  do  well  by  the  sea-coast,  and  I 
know  of  no  better  treatment  for  this  disease  than  warm  sea-bathing.  Fortu- 
nately for  this  class  of  patients,  most  prominent  sea-coast  resorts  now  can 
offer  all  facilities  for  warm  sea-baths.  These  establishments  are  fitted  with 
every  convenience,  including  a  lounging-room  or  "sun  parlor,"  where  one 
may  take  a  nap  after  the  bath.  In  cases  of  rheumatism  the  best  results  will 
be  obtained  from  baths  given  on  alternate  days,  followed  by  thorough  friction 
of  the  body  by  a  masseur  or  an  intelligent  nurse. 

Cases  of  chorea  during  convalescence  improve  rapidly  at  the  sea-shore. 
Although  many  writers  highly  recommend  sea-bathing  in  this  disease,  I  do  not 
agree  with  them.  Indeed,  in  one  case,  almost  well.  I  am  sure  a  relapse  was 
occasioned  by  fright  caused  by  a  wave  striking  the  child.  Warm  sea-baths, 
followed  by  a  gentle  massage,  are  preferable. 


8EA-AIB    AND   SEA-BATHING.  65 

Sea-air  has  a  very  grateful  influence  in  inducing  sleep.  Often  sick  chil- 
dren brought  to  the  sea-coast  sleep  the  first  night  better  than  for  many  nights 
before.  It  will  be  found  that  many  children  who  are  not  ill  after  a  few  days' 
stay  will  complain  of  drowsiness  and  willingly  take  their  afternoon  nap. 

The  obstinate  bronchitis  which  so  often  remains  for  an  indefinite  time 
after  whooping  cough  is  frequently  cured  by  a  few  weeks'  stay  at  the  shore. 
In  the  paroxysmal  stage  of  the  disease,  while  the  coughing  spells  are  no  less 
violent  than  elsewhere,  children  do  not  seem  to  lose  flesh  and  color,  no  doubt 
because  their  appetite  is  kept  up  by  the  bracing  effect  of  the  clear  atmosphere, 
and  they  are  kept  in  the  open  air  more  than  they  would  be  in  a  city  home. 

Cases  of  infantile  paralysis  make  a  slow  but  steady  improvement  during  a 
long  stay  by  the  sea.  Most  diseases  of  the  skin  and  the  inflammatory  dis- 
eases of  the  eye  are  not  improved  by  sea-air,  unless  these  troubles  have  a 
strumous  origin,  in  which  case  a  long  stay,  by  improving  the  general  health, 
will  indirectly  improve  the  local  condition. 

Sea-bathing-. — It  is  a  popular  belief  that  sea-bathing  is  both  strength- 
ening and  hardening  ;  and  there  is  but  little  doubt  that  this  opinion  is  well 
founded.  It  does  not  follow,  however,  that  it  should  be  practised  by  all  with- 
out medical  advice.  Many  hold  that  a  plunge  into  water  which  is  of  lower 
temperature  than  air  protects  the  system  against  attacks  of  catarrh  and  chill, 
and  renders  it  indifferent  to  sudden  climatic  changes,  whilst  a  few  contend 
that  perfect  immunity  from  colds  may  be  ensured  by  continuing  the  morning 
plunge  throughout  the  year.  We  may  say,  without  doubt,  that  sea-bathing, 
more  than  any  other  agent  known,  renders  the  body  less  sensitive  to  the  influ- 
ence of  cold  and  to  the  injurious  eff"ects  of  prolonged  exposure ;  but  this,  of 
course,  is  due  to  its  invigorating  and  strengthening  properties  alone,  and  not 
to  the  element  of  temperature. 

It  is  a  remarkable  fact  that  many  persons  who  cannot  profitably  bathe  in 
fresh  water  can  do  so  in  the  sea ;  and  the  explanation  doubtless  is  that  the 
abstraction  of  caloric  from  the  body  in  salt  water  is  less  than  in  fresh,  by  rea- 
son of  its  greater  density.  Probably,  also,  the  saline  ingredients  have  a  more 
stimulating  effect  upon  the  skin  and  induce  a  more  energetic  reaction. 

The  most  important  characteristic  of  sea-water  is  its  saline  composition, 
and  it  is  impossible  to  over-estimate  the  influence  of  the  sea-salts  in  marine 
meteorology.  It  has  been  estimated  that  the  average  quantity  of  saline  matter  in 
sea-water  is  3  per  cent.,  consisting  of  chloride  of  sodium,  sulphate  of  magnesium, 
sulphate  of  sodium,  also  muriate  of  magnesium  and  lime,  with  salts  of  iodine 
and  bromine.  Many,  however,  estimate  the  saline  ingredients  at  4  per  cent. 
The  above  constituents  are  uniform  as  to  presence,  but  are  unequal  in  quantity 
in  various  parts  of  the  world,  so  that  in  the  Baltic  a  pint  of  water  contains 
nearly  forty  grains  of  salt ;  on  the  coast  of  Great  Britain  it  contains  more 
than  half  an  ounce ;  in  the  Mediterranean,  much  more ;  and  in  some  ports 
south  of  the  equator  the  quantity  amounts  to  more  than  two  ounces.  It  is 
in  consequence  of  its  saline  character  that  sea-water  does  not  evaporate  from  the 
skin  so  readily  as  fresh  water.  Even  when  the  body  is  carefully  dried  particles 
of  saline  matter  remain  adherent,  and  find  their  way  into  the  pores  of  the  skin 
— as  may  be  proved  by  the  application  of  the  tongue  to  the  surface — and  keep 
up  a  tingling  glow  long  after  the  bath  is  over.  We  all  know  that  persons 
when  soaked  to  the  skin  by  salt  water  do  not  take  cold  as  easily  as  when 
caught  in  a  shower  of  rain.  This  is  explained  by  the  fact  that  the  pungent 
action  of  the  sea-salts  so  stimulates  the  cutaneous  circulation  as  to  enable  it  to 
resist  the  depressing  effects  of  the  cold  produced  by  the  evaporation  of  the 
fluid  portion.     Sea-bathing,  besides  having  all  the  beneficial  effects  of  an  ordi- 

5 


66       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

nary  cold  bath,  has  others  peculiar  to  itself.  The  contact  of  the  salt  water 
and  of  the  salt  which  adheres  after  the  water  left  by  the  bath  has  evaporated 
stimulates  the  skin,  increasing  the  circulation  and  exciting  the  sudoriferous 
glands.  The  beating  of  the  waves  against  the  surface  of  the  body  affords  a 
passive  exercise,  with  some  of  the  advantages  of  massage ;  while  to  the  more 
robust  a  healthful  exhilaration  and  delightful  active  exercise  are  furnished  by 
the  plunge  through  the  waves  and  the  vigorous  movements  constantly  required 
while  in  the  surf. 

At  the  resorts  in  the  neighborhood  of  Xew  York  and  Philadelphia  the  sea- 
bathing season  is  usually  considered  to  be  between  the  first  day  of  June  and 
the  last  day  of  September,  as  in  this  interval  the  temperature  of  the  water 
ranges  higher  than  at  any  other  season. 

The  best  time  for  taking  a  sea-bath  is  just  before  high  tide.  At  that  time 
the  water  has  been  somewhat  warmed  by  passing  over  the  hot  sand.  More- 
over, the  bathing  is  safer,  from  the  fact  that  the  tide  still  coming  in  Avould 
tend  to  wash  the  bather  to  the  shore  if  he  should  lose  his  foothold,  and,  as  the 
water  covers  a  portion  of  the  beach  which  Avas  exposed  to  view  a  few  hours 
before,  there  is  less  risk  from  dangerous  holes  and  quicksands.  But  at  most 
sea-shore  resorts  it  has  been  found  more  convenient  to  bathe  at  the  same  hour 
each  day — namely,  at  about  11  a.  M.,  or  two  or  three  hours  after  breakfast, 
when  the  morning  meal  is  digested  and  the  system  is  beginning  to  feel  the 
efi"ects  of  the  conversion  of  food  into  force,  and  is  therefore  better  prepared 
to  withstand  the  shock  of  the  cold  plunge.  It  is  unwise,  however,  to  bathe 
within  two  hours  after  any  meal :  whilst  digestion  is  proceeding  more  blood 
is  attracted  to  the  digestive  organs,  in  order  that  the  process  may  be  efficiently 
performed.  But  if  we  divert  a  portion  of  the  blood  to  the  surface  of  the 
bodv  by  the  action  of  the  cold  bath,  digestion  is  suddenly  interrupted,  assimi- 
lation checked,  and  congestive  headache,  cramps  in  the  stomach,  etc.  are  caused. 
In  order  to  answer  several  of  the  questions  which  naturally  arise,  it  is  neces- 
sary to  describe  the  phenomena,  which  are  as  follows:  On  entering  the  water 
there  is  a  shock,  accompanied  by  a  sensation  of  chilliness  and  shivering ;  there 
is  a  respiratory  embarrassment  and  a  feeling  of  fulness  in  the  head.  Xext 
follows  a  reaction,  in  which  all  these  symjitoms  are  relieved,  and  there  is  an 
agreeable  sensation  of  warmth.  If  the  bath  is  unduly  prolonged,  there  follows 
another  sensation  of  chilliness :  the  teeth  chatter,  the  fingers  and  lips  become 
blue,  the  respiration  irregular  and  rapid,  and  the  pulse  weak  and  small.  In 
the  sea-bath  each  wave  reproduces  in  a  less  degree  the  first  shock,  and  at 
the  same  time  hastens  the  development  of  the  second  chill.  From  the  above 
description  it  would  appear  that  the  proper  duration  of  the  bath  is  a  period 
short  of  the  second  chill,  and  the  length  of  this  period  must  depend  upon  the 
temperature  of  the  Avater,  the  force  of  the  waves,  the  strength  of  the  patient, 
and  a  number  of  other  circumstances. 

I  do  not  consider  it  wise  to  allow  children  to  remain  in  the  water  over  five 
minutes,  and  then  they  should  be  at  once  taken  to  their  bath-house  and  not 
allowed  to  play  on  the^  beach  in  their  wet  bathing-suits.  Before  entering  the 
Avater  their  heads  should  be  wet,  and  they  should  be  taken  cautiously  to  the 
first  line  of  breakers,  where,  in  a  stooping  posture,  the  waves  may  wash  over 
them.  If  children  are  afraid  of  the  water,  they  should  not  be  forced.  The 
proper  Avav  is  to  accustom  them  gradually  to  the  sea.  HaA^e  them  dressed  in 
their  bathing-clothes  and  allow  them  to  play  on  the  beach,  Avhen  they  Avill  of 
their  own  accord  go  to  the  Avater's  edge  and  gradually  find  their  Avay  in. 
Many  children  do  not  dread  the  water,  and  they  may  do  much  in  allaying  the 
fears  of  the  more  timid.     I  think  three  or  four  sea-baths  a  week  quite  sufficient 


SEA-AIB   AND    SEA-BATHING.  67 

for  even  the  strongest  child.  A  thorough  rubbing  down  should  always  be 
given,  and  the  child  quickly  dressed,  and  allowed  to  resume  its  play  in  a  sunny 
spot  unexposed  to  the  wind.  There  is  no  advantage  in  taking  an  infant  (under 
two  years)  into  the  sea,  and  the  practice  as  usually  carried  out  seems  almost 
inhuman;  for  these  the  heated  salt-water  bath  is  an  excellent  substitute. 

The  Manag-ement  of  Children  at  the  Sea-shore. — At  all  times  of  the 
year  the  sea-shore  is  most  beneficial  to  sick  children,  but  it  has  only  been 
a  comparatively  few  years  since  the  practice  of  going  to  the  sea-side  resorts 
during  the  winter  and  spring  months  came  in  vogue  ;  previously,  the  three 
summer  months  Avere  the  only  ones  considered  advisable  to  spend  by  the 
sea.  At  the  present  time  it  is  deemed  almost  as  necessary  to  take  a  child 
convalescing  from  an  illness  to  the  sea-shore  in  the  winter  and  sprino-  months 
as  in  summer. 

In  selecting  a  place  of  residence  by  the  sea  it  is  well  to  be  near  the  surf. 
Houses  situated  at  a  distance  from  the  beach  are  never  as  cool  as  those  close  to 
it.  Therefore,  in  taking  a  sick  child  to  the  shore  it  is  always  advisable, 
especially  during  the  summer  months,  to  select  a  house  in  close  proximity  to 
the  sea.     Here  the  exhilarating  breeze  comes  uncontaminated  from  the  ocean. 

The  clothing  of  the  child  during  its  stay  at  the  sea-shore  should  be  slightly 
heavier  than  that  worn  in  the  city  or  country  ;  hence  it  is  always  better  to  use 
woollen  under-garments,  light  and  loose  in  texture.  Long  stockings  should 
invariably  be  worn,  even  in  the  warmest  weather,  as  toward  evening  the  air 
becomes  several  degrees  cooler,  and,  if  the  breeze  is  blowing  from  the  sea, 
at  times  almost  cold. 

Little  change  need  be  made  in  the  food  of  children  during  their  stay. 
The  advantages,  claimed  by  some  authors,  of  a  largely  marine  diet  have 
probably  been  over-estimated,  and  much  blame  has  been  attached  by  others  to 
fish,  oysters,  etc.  for  the  frequent  disorders  of  the  digestive  apparatus  from  which 
adults  suffer  at  the  sea-shore.  From  my  own  experience,  however,  the  acute 
attacks  of  indigestion  that  we  occasionally  see  are  usually  brought  about  by 
the  elaborate  menu  which  is  found  at  our  largest  hotels,  in  contrast  to  the 
plainer  home  table  which  most  are  accustomed  to.  On  arriving  at  the  sea- 
shore the  appetite  is  naturally  sharpened  by  the  change  of  air,  and  over-eating 
is  the  result. 

Much  thought  should  be  given  to  the  necessity  of  exercise.  Children 
seldom  need  much  urging,  but  the  want  of  it  among  adults  probably  interferes 
with  many  of  the  benefits  which  otherwise  would  be  gained. 

For  very  young  children,  next  to  the  walk  in  the  nurse's  arms,  the  drive 
upon  the  beach  should  be  recommended.  The  perfect  evenness  of  the  surface 
renders  it  possible  to  take  a  very  ill  child  into  the  open  air  frequently  with  the 
greatest  benefit.  One  of  the  best  forms  of  exercise  for  sick  children  is  play- 
ing in  the  warm,  dry  sand.  A  spot  should  be  selected  where  the  sun  does  not 
beat  too  strongly,  but  which  is  at  the  same  time  perfectly  dry.  It  is,  as  we 
all  know,  an  unceasing  source  of  amusement  to  children,  and  the  harmless 
character  of  their  little  falls  and  tumbles  during  play  often  encourage?  ihem 
to  efibrts  which  they  would  not  otherwise  attempt. 


PART  I. 

WJURIES  mCIDENT  TO  BIRTH  AND  DISEASES 
OF  THE  NEAV-BORK 

By  EDWARD  P.  DAVIS,  A.  M.,  M.  D., 

Philadelphia. 


The  mortality  of  the  first  year  of  life  is  variously  estimated.  Bernheim, 
from  an  extensive  series  of  statistics,  places  it  at  37  j^  per  cent,  of  all  chil- 
dren born.  Winckel  states  that  10  per  cent,  of  children  born  perish  before 
the  eleventh  day  of  life;  of  these,  -^  per  cent,  perish  during  labor  itself,  3^ 
per  cent,  die  as  a  consequence  of  some  injury  received  during  labor,  Avhile 
2^  per  cent,  perish  from  diseases  contracted  at  or  after  birth.  We  shall 
first  consider  morbidity  and  mortality  among  children  arising  from  injuries 
received  at  birth. 

Caput  Succedaneum. 

The  most  frequent  lesion  sustained  by  the  foetus  during  delivery  is  the 
formation  of  a  tumor  upon  the  head,  usually  known  as  caput  succedaneum : 
this  is  commonly  recognized  after  deliver}^  as  a  soracAvhat  boggy  tumor,  formed 
by  infiltration  of  the  scalp  and  fascia  over  the  cranium,  and  usually  situated 
upon  the  parietal  bone  opposite  to  that  which  came  most  in  contact  with  the 
bony  pelvis  of  the  mother.  The  mechanism  of  its  production  is  commonly 
thought  to  be  as  follows :  In  a  normal  presentation  and  position,  the  back  of 
the  child  being  to  the  left  side  of  the  mother's  pelvis,  and  the  vertex  occupy- 
ing the  left  anterior  half  of  the  pelvis,  during  the  stage  of  expulsion  the  left 
half  of  the  vertex  of  the  child's  skull  receives  the  greater  portion  of  the 
impact  of  force  during  descent  and  rotation.  The  continued  pressure  upon 
this  portion  of  the  foetal  skull  temporarily  checks  the  free  circulation  of  blood 
and  lymph  through  the  tissues  of  the  scalp  and  fiiscia.  There  remains  upon 
the  opposite  half  of  the  vertex  a  portion  of  the  head  less  pressed  upon  by  the 
bony  pelvis ;  here,  naturally,  the  blood  and  lymph  of  the  scalp-tissues  are  pre- 
vented from  circulating  through  the  left  side  of  the  foetal  head  by  pressure, 
and  accumulate  and  distend  the  tissues  of  the  right  half  of  the  vertex.  The 
result  is  a  tumor  upon  the  side  of  the  foetal  head  opposite  that  which  actually 
engaged  during  the  first  stage  of  labor.  The  position  which  the  child's  head 
occupied  in  the  mother's  pelvis  may  then  be  reasonably  inferred  from  the  loca- 
tion of  the  caput  succedaneum  :  thus  in  the  usual  labor  this  tumor  occurs  in 
the  right  parietal  region  of  the  head.  Should  the  child  occupy  a  second  posi- 
tion, its  back  to  the  right  of  the  mother,  its  vertex  situated  in  the  right  ante- 

68 


INJURIES  AND    DISEASES    OF    THE   NEW-BOBN.  69 

rior  half  of  her  pelvis,  the  caput  succedaneum  can  be  found  upon  the  left 
parietal  portion  of  the  foetal  head.  Caput  succedaneum  is  usually  of  no  prac- 
tical importance,  as  it  disappears  in  a  few  days  after  labor.  The  infiltrated  con- 
dition of  its  tissues,  however,  forms  an  excellent  field  for  the  growth  of  infect- 
ing bacteria.  Should  the  mother's  birth-canal  be  in  a  septic  condition  during 
labor,  or  should,  through  the  carelessness  of  the  nurse  in  washing  the  child, 
some  injury  occur  to  the  tumor,  the  entrance  of  septic  infection  results  in 
inflammation,  and,  in  rare  cases,  in  abscess  of  the  scalp.  The  caput  succeda- 
neum is  larger  the  longer  the  labor  lasts,  is  usually  of  a  bluish-red  color,  and 
does  not  distinctly  fluctuate  or  pit  upon  pressure. 

Occasionally  the  tumor  embraces  both  parietal  bones :  this  may  be  caused 
by  long  delay  in  the  expulsion  of  the  child,  the  head  remaining  for  some  time 
in  the  external  genitals  of  the  mother.  Upon  post-mortem  examination  extrav- 
asations of  blood  varying  in  size  may  be  found  in  the  vicinity  of  the  tumor, 
and  do  not  indicate  criminal  violence  after  birth.  Two  of  these  tumors  may  be 
found,  a  primary  and  secondary  :  the  first  is  formed  in  the  usual  manner ;  the 
second  is  produced  while  the  head  is  upon  the  pelvic  floor  and  after  ante- 
rior rotation  has  occurred.  If  delivery  then  be  delayed,  a  secondary  tumor  will 
form,  and  may  be  distinguished  from  the  first  by  its  situation  in  the  median  line. 
In  shoulder  presentations  the  tumor  is  found  upon  the  shoulder  which  pre- 
sents. 

So  far  as  the  treatment  is  concerned,  Bouchut  suggests  the  application  of  a 
solution  of  ammonium  chloride,  a  solution  of  camphor,  or  an  alcoholic  mixture 
containing  camphor.  If  this  does  not  secure  the  disappearance  of  the  tumor, 
he  would  aspirate  it.  Winckel  and  other  obstetric  authorities  incise  the  tumor 
if  it  persists  beyond  the  sixth  or  eighth  day,  and  make  pressure  upon  the 
parts  with  salicylated  cotton.  If  abscess  forms,  incision  and  irrigation  with 
a  J  per  cent,  solution  of  creolin  are  indicated. 

Cephalhematoma. 
By  cephalhematoma  Naegele,  who  first  described  it,  designated  a  blood- 
tumor  on  the  foetal  head,  called  true  cephalhsematoma  when  beneath  the 
periosteum  of  the  skull,  and  false  cephalhsematoma  when  beneath  the  aponeu- 
rosis of  the  scalp.  Virchow  explains  the  formation  of  cephalbf^matoma  by 
referring  to  the  way  in  which  the  pericranium  grows — namely,  by  proliferation 
of  inner  layers  of  the  periosteum.  If,  then,  the  pericranium  is  separated 
from  the  cranium  by  the  extravasation  of  blood,  the  bone-producing  layers 
of  the  periosteum  are  still  formed,  but  are  prevented  by  the  blood-clot  from 
uniting  with  that  portion  of  the  bone  for  which  they  were  intended.  They 
join,  however,  to  the  bone  at  the  border  of  the  extravasated  clot,  where  the 

bone  is  still  attached. 

Fig.  1. 


Vertical  Section  through  Cephalhematoma. 


Much  discussion  has  arisen  as  to  the  method  of  formation  of  cephalhse- 
matoma.     Some  ascribe  its  presence  to  traumatism  only,  while  others  seek  an 


70       AlfEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

explanation  in  a  pre-existing  condition  of  the  infant's  tissues.  It  is  to  be 
differentiated  from  caput  succedaneum  by  several  important  distinctions.  The 
latter  arises  during  birth,  is  born  with  the  child,  appears  upon  that  portion  of 
the  head  turned  during  labor  toward  the  excavation  of  the  pelvis,  is  more 
prominent  after  difficult  labors,  has  an  ill-defined  border,  frecjuently  crosses 
sutures,  is  discolored  in  appearance,  and  doughy  upon  manipulation,  and  tends 
to  disappear  rapidly  after  delivery.  On  the  contrary,  cephalhtematoma  does 
not  occur,  as  a  rule,  after  difiicult  labor,  appears  usually  upon  that  parietal 
bone  which  did  not  present  in  the  pelvic  excavation,  has  a  sharply-defined 
border,  does  not  extend  across  sutures,  does  not  discolor  the  scalp  above  the 
tumor,  and  usually  gives  the  sensation  of  fluctuation  in  the  centre  of  the  mass. 
Cephalhjematoma  also  tends  to  increase  steadily  in  size  for  some  time  after  labor. 

With  such  radical  differences  the  pathology  of  these  tumors  must  differ 
widely.  That  of  caput  succedaneum  has  been  already  given.  In  studying 
the  pathology  of  cephalhoematoraa  we  have  been  struck  by  the  fact  that 
instances  under  our  observation  have  been,  as  a  rule,  in  ill-nourished  children 
born  without  especially  difficult  labor.  In  the  wards  of  the  Philadelphia 
Hospital  we  have  frequently  observed  these  cases  in  children  born  of  ill- 
nourished  mothers  and  poorly  nourished  at  the  time  of  birth.  This  leads  us 
to  believe  that  a  pre-existing  malnutrition  lies  at  the  basis  of  these  tumors  ; 
thus,  cases  are  reported  where,  in  addition  to  the  cephalhsematoma,  a  profoundly 
an?emic  condition  of  various  organs  of  the  child's  body  was  present.  In  no 
case  does  this  tumor  occur  as  an  extravasation  of  blood  beneath  the  internal 
periosteum  of  the  skull ;  but  extravasations  of  blood  within  the  cranial  cavity 
are  also  described  under  the  title  of  "  intracranial  cephalhsematoma."  Partridge 
describes  two  cases  in  which  coagulated  blood  was  found  beneath  the  dura 
mater.  No  injury  to  the  bones  of  the  cranium  existed  in  these  cases,  the 
brain-substance  Avas  softened,  and  the  blood  found  beneath  the  membranes  and  at 
the  base  of  the  brain  seemed  to  have  been  extravasated  from  the  sinuses  and  from 
the  laceration  of  minute  blood-vessels.  One  of  these  children  died  very 
shortly  after  labor ;  the  other  survived  for  several  days.  We  recall  a  similar 
case  where  delivery  was  easily  effected  by  the  forceps ;  the  child  perished, 
however,  in  thirty-six  hours  after  birth,  and  upon  post-mortem  examination 
blood  was  found  extravasated  beneath  the  membranes,  while  the  underlying 
cerebral  matter  was  softened.  Here  also  no  injury  to  the  bones,  membranes, 
or  sinuses  could  be  detected. 

Cephalhaematoma  is  more  frequently  found  in  males  than  females,  according 
to  Burchard,  in  the  proportion  of  more  than  three  to  one.  The  tumor  is 
usually  found  upon  the  right  side  of  the  head.  The  children  of  primipars 
are  most  liable  to  this  complication  in  the  proportion  of  three  to  one.  As  a 
rule,  cephalhsematoma  does  not  pulsate,  although  isolated  cases  are  reported  in 
which  indistinct  pulsation  Avas  observed.  While  fluctuation  is  usually  present, 
it  may  be  very  obscure.  This  results  from  the  presence  of  coagulated  blood, 
as  well  as  the  breaking  down  of  the  clot  in  the  centre  of  the  tumor.  It  is 
observed  that  if  the  tumor  be  opened  soon  after  formation,  bright-red  blood 
escapes ;  later  the  blood  resembles  the  fluid  found  after  old  extravasation. 
The  deposition  of  bony  material  on  the  under  surface  of  the  periosteum 
occasions  a  crackling  sensation  when  the  tumor  is  palpated.  The  fluid  escapes 
irregularly  from  beneath  the  tumor ;  sensitiveness  is  very  rarely  a  prominent 
feature.  The  bony  ring  surrounding  the  tumor  forms  gradually ;  thus 
Bouchut  observed  a  case  before  birth  in  which  no  ring  was  present.  Semmel- 
weis  is  said  to  hav"e  seen  cephalhfematoma  in  a  child  delivered  by  Csesarean 
section. 


INJURIES   AND    DISEASES    OF   THE   NEW-BOBN.  71 


a  case 


Several  tumors  may  develop  in  the  same  individual ;  thus  we  recall „^ 

under  observation  in  the  Philadelphia  Hospital  in  which  double  cephalhse- 
matoma  appeared  on  the  head  of  a  male  child  born  after  a  normal  labor.  Triple 
cephalhsematoma  has  been  observed  by  Oui  after  a  precipitate  birth  in  which 


Fig.  2. 


Double  Cephalhsematoma. 


the  infant  fell  to  the  ground,  the  cord  rupturing  three  or  four  centimetres  from 
the  umbilicus.  Upon  examination  a  tumor  was  found  upon  each  parietal  bone, 
and  one  upon  the  occipital.  The  tumors  were  treated  by  incision  and  evacua- 
tion under  careful  antiseptic  precautions,  and  uninterrupted  recovery  ensued. 

The  occurrence  of  cephalhsematoma  is  readily  understood  when  the  loose 
attachment  of  the  pericranium  to  the  bone  is  remembered ;  Valleix  found  that 
in  almost  all  infants  ecchymosis  between  the  pericranium  and  the  skull  is 
present  after  labor.  It  requires,  then,  but  a  constitutional  liability  to  ecchy- 
mosis by  reason  of  malnutrition  to  readily  account  for  the  occurrence  of 
such  tumors.  Cephalhsematoma,  again,  may  develop  after  birth  as  a  surgical 
injury,  as  instanced  in  cases  described  by  Treves  and  Kdlaton,  as  also  in  a  re- 
markable case  in  a  bleeder  reported  by  St.  Germain. 

Cephalhsematoma  may  be  also  produced  by  injudicious  pressure  exercised 
during  the  child's  toilette.  Hliter  observed  double  cephalhsematoma  occurring 
on  the  fifth  day  after  birth,  and  caused  by  the  carelessness  of  a  midwife,  who, 
in  washing  the  child,  rubbed  its  head  with  undue  force.  The  tumors  persisted 
as  long  as  the  individual  had  charge  of  the  child,  but  disappeared  soon  after 
she  was  discharged. 

No  one  cause  can  be  invariably  assigned  for  the  production  of  cephalhse- 
matoma :  the  size  of  the  mother's  pelvis  seems  to  exercise  but  little  effect,  for 
Merttens  in  21  cases  found  6  in  which  the  pelvis  was  normal,  and  only  5  in 
which  slight  pelvic  contraction  was  present.  In  these  cases  the  contraction 
was  not  of  such  nature  as  to  interfere  with  labor.  That  the  pressure  of  the 
pelvis  has  sometimes  nothing  to  do  with  these  cases  is  shown  by  Spiegelberg's 
observation  of  a  case  of  premature  birth  at  six  months,  in  which  the  child 
perished  before  the  rupture  of  the  membranes ;  he  was  able  to  examine  the 
head  in  utero,  and  detected  the  tumors  before  the  expulsion  of  the  child.  ^  He 
considered   the  tumors  caused   by  interference  with   the  oxygenation  of  the 


72       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

foetal  blood,  and  oftentimes  by  premature  efforts  at  respiration.  Merttens 
reports  a  similar  case  in  which  he  diagnosticated  this  complication  before 
delivery.  The  foetus  in  this  latter  instance  had  a  congenital  hernia  of  the 
diaphragm,   and   hsematomata  were  found  in  other  portions  of  the  body. 

The  diagnosis  of  cephallu\jmatoma  in  distinction  from  caput  succedaneum 
has  already  been  stated.  Hernia  cerebri  may  be  present,  but  occurs  usually 
in  the  occipital  region  and  in  the  line  of  sutures.  Pressure  upon  the  hernia 
produces  symptoms  of  positive  disturbance  of  the  nervous  system. 

Aneurism  presents  a  pulsating  tumor  of  darker  color,  which  neither  has 
the  appearance  nor  affords  the  history  of  cephalhaematoma.  The  effort  to 
class  this  affection  among  tlie  hydrocephali  is  scarcely  successful  in  the  light 
of  our  present  knowledge  of  both.  Blood-tumors  found  in  the  occipital  region 
in  the  dead  foetus  are  often  caused  by  difficult  labor,  and  are  dark  in  color 
from  the  decomposition  of  effused  blood.  In  encephalocele  direct  examination 
of  the  head  by  palpation  will  enable  the  physician  to  make  the  diagnosis. 
Tumors  in  living  children,  the  result  of  direct  violence,  are  usually  painful  on 
pressure  and  lack  the  sharp  outline  of  cephalhaematoma.  Occasionally,  in 
advanced  rachitis,  where  craniotabes  is  present,  soft  pieces  of  bone  in  the  skull 
may  simulate  a  blood-tumor  when  palpation  is  made  through  the  scalp. 

The  usual  plan  of  treatment  consists  in  making  gentle  pressure  by  a  pad 
of  antiseptic  cotton  conveniently  held  in  place  by  a  night-cap.  Occasionally 
lotions  containing  dilute  alcohol  or  some  acetous  preparation  are  employed,  but 
there  is  no  evidence  of  their  positive  value.  It  must  be  remembered  that  the 
tumor,  as  a  rule,  will  have  reached  its  largest  size  six  or  eight  days  after  the 
birth  of  the  child.  Unless  haemorrhage  be  excessive  and  the  tumor  becomes 
rapidly  very  large,  it  may  be  let  alone  for  the  first  ten  days  of  the  child's 
life.  Should  infection  occur  and  inflammation  supervene,  it  must  be  freely 
opened  at  once,  emptied  of  its  contents,  and  the  sac  thoroughly  disinfected, 
while  continuous  but  gentle  pressure  is  made  by  an  antiseptic  dressing.  If  no 
complication  occurs,  at  the  end  of  the  first  eight  or  ten  days  of  the  child's  life  the 
scalp  over  the  tumor  should  be  shaved,  the  surface  thoroughly  disinfected, 
preferably  with  boric  acid,  and  the  tumor  punctured  with  a  bistoury  or  large 
trocar.  After  evacuating  the  fluid  contents  pressure  by  an  antiseptic  dressing 
is  indicated.  Some  prefer  free  incision  in  place  of  simple  puncture.  We  have 
met  with  a  case  in  which  puncture  and  evacuation  were  followed  by  reaccumu- 
lation  of  fluid,  and  in  which  it  was  finally  necessary  to  open  the  tumor  freely, 
empty  it,  and  pack  it  with  iodoform  gauze,  the  gauze  having  to  be  renewed 
several  times  before  adhesion  between  the  bleeding  surfaces  took  place. 
Occasionally  the  loss  of  blood  in  these  cases  is  considerable ;  as  a  rule,  how- 
ever,  haemorrhage  is   not  a   serious  complication. 

The  susceptibility  of  infants  to  poisoning  by  antiseptics  should  be  remem- 
bered in  treating  cephalhsematoma.  Mercurial  and  carbolic  solutions  may  be 
preferably  replaced  by  solutions  of  thymol,  1 :  1000,  or  saturated  solutions 
of  boric  acid.  Iodoform  gauze  may  be  employed  without  hesitation  as  tampon 
material. 

H-S3MATOMA    OF   THE    StERNO-ClEIDO-MaSTOID    MuSCLE. 

A  peculiar  induration  is  frequently  observed  in  the  sterno-mastoid  muscle 
of  new-born  children,  regarding  which  different  beliefs  have  been  held.  Ana- 
tomical study  of  the  subject  shows  that  the  lesion  is  an  intramuscular  fibrosis, 
caused  by  direct  violence  to  the  neck  of  the  child,  usually  occurring  at  deliv- 
ery.    Most  of    these  cases  result  from  delivery  in  breech  presentation ;  the 


INJURIES  AND    DISEASES    OF    THE   NEW-BOBN.  73 

forceps  causes  some  ;  and,  rarely,  the  lesion  follows  spontaneous  birth.  Schmidt 
reports  the  case  of  a  child,  seven  days  old,  delivered  by  the  breech,  in  which 
the  right  sterno-mastoid  was  shortened,  and  the  right  half  of  the  face  smaller 
and  flatter  than  the  left.  The  report  of  a  post-mortem  examination  upon  a 
case  pointing  to  a  possible  intra-uterine  origin  of  this  condition  is  made  by 
Heusinger.  The  head  was  directed  toward  the  left,  the  right  sterno-mastoid 
muscle  was  9  cm.  long,  the  left  only  6^,  and  was  a  soft,  white,  tendinous  sub- 
stance. In  23,293  children  examined  at  birth  at  the  Paris  Maternity,  Guyon 
found  132  cases  of  monstrosity,  but  no  case  of  torticollis,  which  militates 
against  the  congenital  occurrence  of  hematoma  of  the  sterno-mastoid.  In  64 
post-mortem  examinations  Euge  found  13  cases  of  this  complication.  In  a 
recent  valuable  paper  Spencer  describes  15  cases  found  in  300  autopsies :  his 
researches  show  that  both  sexes  and  the  muscles  of  both  sides  of  the  neck  are 
equally  affected.  Small,  prematurely-born  children  are  especially  liable  to  this 
injury.  Breech  or  footling  presentation  was  observed  in  10  of  the  15.  The 
forceps  had  been  employed  in  2  cases,  while  in  2  no  instrumental  aid  was 
employed  :  in  2  of  the  bodies  examined  both  muscles  were  affected.  Spencer 
notes  but  two  cases  of  contracted  pelvis  ;  one  of  his  cases  was  that  of  triplets, 
complicated  by  placenta  previa  centralis,  with  extraction  through  perforation 
in  the  placenta.  His  microscopic  sections  show  clearly  rupture  of  muscular 
fibre,  with  extensive  effusion  of  blood.  It  has  been  shown  by  Witzel  that,  as 
a  consequence  of  this  complication,  contracting  fibrous  bands  may  form,  giving 
rise  to  permanent  wry  neck.  Jacobi  believes  that  the  forceps  is  frequently  the 
effective  agent  in  producing  this  injury  to  the  foetus. 

HEMORRHAGE   IN   THE   NeW-BORN. 

A  considerable  number  of  cases  of  foetal  death  occurring  within  the  first 
forty-eight  hours  after  labor  are  preceded  by  obscure  symptoms  which  render 
an  exact  diagnosis  difiicult  or  impossible.  The  intelligent  study  of  such  cases 
by  post-mortem  examinations  shows  us  that  haemorrhage  is  usually  the  cause  of 
the  fatal  issue.  As  in  the  adult,  haemorrhage  may  denend  upon  an  alteration 
in  the  condition  of  the  blood  itself,  and  also  upon  direct  mechanical  injuries 
which  result  in  its  escape  from  the  vessels.  In  the  first  category  of  cases  it 
has  long  been  a  familiar  observation  that  syphilitic  children,  stillborn,  show 
extensive  disintegration  of  blood,  with  extravasation  of  blood-serum  from  the 
serous  surfaces  of  the  body.  Children  dying  from  acute  infections  on  the  part 
of  the  mother,  and  stillborn  or  perishing  soon  after,  often  display  such  a  tend- 
ency to  haemorrhage ;  thus,  small-pox,  typhus,  typhoid,  scarlatina,  and,  as  a 
rule,  the  acute  infections  as  a  class,  predispose  to  the  occurrence  of  haemor- 
rhage. There  is  also  direct  proof  from  bacteriological  examination  that  the 
foetus  in  utero  may  be  infected  by  various  micrococci,  and  that  this  infection 
may  result  in  hfemorrhage  and  death  at  labor  or  very  soon  afterward.  The 
occurrence  of  multiple  punctate  haemorrhages  accompanying  umbilical  sepsis  is 
a  not  infrequent  illustration  of  this  form  of  hBemorrhage.  In  the  recent  litera- 
ture of  the  subject  Tavel  and  Quervian  report  a  case  of  multiple  hemorrhage 
following  umbilical  infection  by  streptococci.  Death  occurred  on  the  thirteenth 
day,  the  infection  having  occurred  very  shortly  after  birth.  A  thorough  exami- 
nation of  the  specimens  showed  infection  with  streptococci  and  other  bacteria 
to  be  the  cause  of  the  haemorrhages.  These  haemorrhages  were  found  in  the 
connective  tissue  beneath  the  epidermis,  beneath  the  serous  membranes  and 
mucous  membranes,  and  also  in  the  kidneys.  A  second  illustrative  case  is  also 
reported,  in  which,  in  a  prematurely-born  child,  death  occurred  with  symptoms 


74       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  pneumonia.  Examination  revealed  the  fact  that  the  pneumonia  had  been 
caused  by  infection  Avith  staphylococci.  The  peculiar  form  of  the  haemorrhage 
— namely,  into  the  parenchyma  of  various  organs — excluded  hjiemorrhage  from 
mechanical  injury.  Further,  the  rapid  and  easy  birth  of  a  small  foetus  tended 
to  exclude  the  possibility  of  mechanical  injury. 

By  far  the  most  frequent  cause,  however,  of  hiTcmorrhage  in  the  new-born 
is  direct  mechanical  injury  received  during  birth.  Such  injury  is  usually 
suspected  after  difficult  extraction  by  the  forceps  or  by  version.  As  pel- 
vimetry is  more  extensively  practised  the  induction  of  premature  labor  will 
render  these  cases  more  and  more  infrequent ;  but  at  present  they  occur  with 
sufficient  frequency  to  form  an  important  complication  of  labor.  Under  the 
head  of  apoplexy  neo7iatorum  Ashby  and  Wright  describe  cases  of  haemor- 
rhage from  the  pia  mater  following  compression  of  the  umbilical  cord  and 
pressure  upon  the  brain-substance  during  birth.  Convulsions  may  be  present 
in  such  cases,  and  if  paralysis  occurs  it  is  probably  peripheral,  resulting  from 
eifusion  of  blood  at  the  base  of  the  brain,  on  the  pons,  or  the  origins  of  the 
cranial  nerves.  McNutt  has  reported  10  cases  of  cerebral  haemorrhage  follow- 
ing labor  ;  in  7  of  these  cases  the  head  presented ;  in  3,  the  breech.  In  all 
the  latter  cases  paralysis  occurred,  but  only  localized  convulsions.  McNutt 
infers  that  haemorrhage,  limited  to  the  convexity  of  the  cerebral  hemispheres, 
is  more  apt  to  follow  delivery  in  breech  presentation. 

Various  forms  of  cerebral  haemorrhage  are  described  by  other  observers, 
and  especially  in  cases  following  prolonged  application  of  the  forceps  or  forcible 
extraction  after  version.  In  our  own  observation  we  recall  the  case  of  an 
infant  delivered  with  axis-traction  forceps  without  especial  difficulty  ;  progress- 
ive feebleness  of  respiration,  failure  to  nurse,  and  apparent  exhaustion  caused 
death  in  thirty-six  hours  after  birth.  On  post-mortem  examination,  over  the 
parietal  regions  of  the  skull  the  tissues  of  the  scalp  were  intensely  congested, 
although  no  gross  lesion,  as  rupture  or  fracture,  could  be  discerned.  Beneath 
these  portions  of  the  skull  and  scalp  the  cortex  of  the  cerebrum  was  filled  with 
punctate  haemorrhages,  and  over  the  point  of  greatest  convexity  the  brain- 
substance  was  materially  softened.  Similar  cases,  which  would  not  be  found 
infrequent  if  post-mortem  examinations  in  such  patients  were  extensively  held, 
are  readily  explained  by  the  anatomy  of  the  cranium  and  its  contents  in  the 
new-born.  Virchow  and  others  have  shown  that  the  blood-vessels  of  the 
infant's  brain  are  thin  and  small,  and  most  readily  injured  by  abnormal  pres- 
sure. An  interesting  example  of  this  fragility  is  found  in  cerebral  haemor- 
rhage following  death  from  asphyxia,  where  mechanical  injury  to  the  cranium 
can  be  excluded. 

In  medico-legal  practice  Richardiere  emphasizes  the  fact  that  such  cerebral 
haemorrhage  may  be  differentiated  from  haemorrhage  occurring  later  in  life  by 
the  absence  of  inflammation  of  the  arachnoid  and  of  the  dura  mater.  Menin- 
geal haemorrhage  in  the  new-born  is  often  accompanied  by  subpleural  ecchy- 
moses  ;  death  usually  results  suddenly.  A  most  valuable  recent  contribution  to 
the  literature  of  this  subject  is  that  of  Spencer.  In  a  total  of  180  bodies  exam- 
ined, 130  were  in  a  condition  which  enabled  a  critical  examination  of  the 
tissues  to  be  made:  in  85  injuries  to  the  brain  were  found,  consisting  of  con-, 
gestion  and  haemorrhage ;  these  conditions  varied  in  severity,  in  situation,  and 
in  extent.  (Edema  was  a  frequent  accompaniment.  The  children  had  been 
delivered  in  various  ways,  and  many  of  the  cases  occurred  in  children  the 
subjects  of  disease.  The  accompanying  plate  shows  a  typical  condition  of 
meningeal  haemorrhage  (Plate  I.).  Its  frequency  will  be  appreciated  when 
it  is  known  that  4^  per  cent,  of   all   haemorrhages  occurring  in  the  new- 


PLATE  I. 


Visceral  Hcemorrhage  in  tlie  Newborn  (Spencer,  Tiansactions  Obstetrical  Society,  Lmidon,  vol  33). 


INJURIES  AND    DISEASES    OF    THE   NEW-BOBN  75 

born  are  meningeal  in  character.  Spencer  also  describes  a  case,  similar 
to  the  one  which  we  have  mentioned,  of  haemorrhage  into  the  substance  of 
the  brain.  It  is  interesting  to  note  that,  so  far  as  the  causation  of  cerebral 
haemorrhages  is  concerned,  the  forceps  is  the  most  frequent  agent  in  producing 
them,  and  next  presentation  by  the.  breech  or  foot.  As  determining  causes 
softness  of  the  skull  and  relaxation  of  the  sutures  are  of  considerable 
importance. 

In  Spencer's  cases,  next  in  frequency  and  importance  to  haemorrhage  into 
the  brain  comes  parenchymatous  haemorrhage  into  the  liver,  kidneys,  and  supra- 
renal capsules.  Well-marked  congestion  was  frequently  observed;  haemor- 
rhage was  present  in  28j^  per  cent..  This  haemorrhage  was  often  upon 
the  upper  surface  of  the  liver  and  followed  birth  in  head  presentations.  Such 
haemorrhages  usually  appeared  as  blebs  filled  with  blood.  Of  equal  frequency 
was  haemorrhage  into  the  substance  of  the  kidneys,  usually  beneath  the  cap- 
sule. Such  cases  were  most  frequent  in  breech  presentations  (Plate  I.). 
The  suprarenal  capsules  were  also  the  seat  of  frequent  haemorrhage.  Injuries 
to  the  lungs  in  the  form  of  congestion  and  haemorrhage  were  next  in  fi-e- 
quency.  Most  often  this  took  the  form  of  subpleural  bleeding  ;  less  frequently, 
as  haemorrhage  into  the  lung-substance. 

These  pulmonary  apoplexies  are  often  followed  by  pneumonia,  and  are  a 
frequent  cause  of  death.  Such  infants  are  usually  cold  and  blue,  with  sub- 
normal temperature  and  feeble  cry,  and  do  not  nurse.  The  abdominal  and 
pelvic  viscera,  besides  those  mentioned,  are  also  the  frequent  site  of  congestion 
and  haemorrhage.  As  regards  the  causes,  Spencer  recognizes  a  delicate  condi- 
tion of  the  blood-vessels  as  of  great  importance.  Alteration  of  the  blood, 
already  described,  is  also  recognized,  while  asphyxia  predisposes  to  haemorrhage. 
Direct  mechanical  violence  is  a  familiar  exciting  agent. 

Experience  abundantly  proves  that  most  cases  of  severe  haemorrhage  arise 
where  disproportion  in  size  between  the  foetus  and  the  pelvis  exists;  there 
can  be  no  rational  prophylaxis  of  these  injuries  that  does  not  rest  upon  an  esti- 
mate of  the  mother's  size  and  the  relative  size  of  the  foetus.  We  cannot  too 
strongly  urge,  as  we  have  already  done,  that  pelvimetry  be  uniformly  practised 
by  obstetricians,  and  that,  in  addition,  an  effort  be  made  in  all  cases  to  estimate 
the  relative  size  of  the  foetus  and  the  birth-canal.  To  be  of  service  to  the  patient 
such  efforts  at  diagnosis  should  be  made  between  the  seventh  and  eighth  months 
of  pregnancy. 

So  far  as  the  treatment  of  the  infectious  disorders  which  attack  the  blood, 
resulting  in  haemorrhage,  is  concerned,  the  faithful  practice  of  antiseptic  pre- 
cautions will  diminish  very  largely  these  complications.  The  need  for  such 
observances  is  proven  by  the  familiar  fact  that  at  the  present  time  the  mortality 
of  infants  in  private  houses  is  greater  than  in  well-conducted  maternities,  the 
reason  being  that  the  practitioner  considers  the  private  house  and  the  private 
patient  objects  for  less  anxiety  than  the  hospital  patient;  neglecting  antiseptic 
precautions  because  the  patient  is  a  private  one  the  result  is  often  disastrous. 

Asphyxia. 

Interference  with  the  oxygenation  of  the  foetal  blood  results  in  asphyxia. 
By  far  the  most  common  and  dangerous  causes  of  this  complication  are 
those  which  arise  while  the  child  is  still  in  the  uterus,  and  which  have 
nothing  to  do  with  the  access  of  the  external  atmosphere  to  the  child's  lungs. 
When  this  is  kept  in  mind,  it  will  be  seen  that  asphyxia  is  a  complication  of 
labor  itself,  not  so  much  a  condition  arising  at  delivery  and  requiring  subse- 


76       A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

quent  treatment.  The  most  frequent  cause  of  this  condition  is  pressure  upon 
vessels  of  the  placenta  or  umbilical  cord,  resulting  in  blood-stasis  in  the  foetus; 
or  occasionally  sudden  collapse  and  death  on  the  part  of  the  mother.  The 
symptoms  of  asphyxia  in  the  foetus  are  those  of  carbon-dioxide  poisoning — a 
rapid,  feeble  pulse,  pallid  appearance  of  the  surface  of  the  body,  with  the  phe- 
nomena caused  by  intense  congestion  of  various  organs,  ending  in  heart-failureo 
Asphyxia  has  been  variously  divided,  some  writers  describing  an  apoplectic 
form  and  others  a  pallid  form.  These  are  but  variations  of  the  same  condition, 
and  are  distinctions  without  essential  differences.  During  the  first  stages  of 
asphyxia  the  phenomena  of  congestion  predominate  :  the  face  of  the  child  is 
suifused,  the  mucous  membranes  bluish,  the  heart-beat  at  first  slow  and  more 
vigorous  than  normal,  while  the  reflexes  still  remain.  As  the  process  goes  on 
and  congestion  has  been  followed  by  engorgement  and  oedema,  the  surface  of 
the  body  is  pale,  the  pulse  small,  rapid,  and  feeble,  while  the  mucous  mem- 
branes have  the  peculiar  grayish-blue  appearance  characteristic  of  impending 
death.  In  the  first  stages  of  asphyxia  the  pulse  in  the  umbilical  cord  is  pres- 
ent, and  may  be  vigorous.  In  the  second  stage  the  cord  is  pulseless,  and  shares 
the  pallid  appearance  of  the  foetus. 

The  complications  of  labor  which  most  frequently  cause  asphyxia  are  par- 
tial detachment  of  the  placenta,  compression  of  the  umbilical  cord,  pressure 
upon  any  large  portion  of  the  foetal  body,  especially  upon  the  head  and  brain, 
or  the  sudden  death  of  the  mother.  So  soon  as  the  tissues  experience  what  has 
been  styled  "  hunger  for  oxygen,"  there  ensue  reflex  respiratory  movements  : 
by  experiment  these  may  be  demonstrated  to  happen  within  the  uterus  before 
the  rupture  of  the  membranes ;  they  fre({uently  occur  during  the  second  stage 
of  complicated  labor.  They  result  in  the  inspiration  of  amniotic  liquid  or  the 
secretions  of  the  mother's  birth-canal ;  if  these  respiratory  efforts  are  vigorous 
and  prolonged,  inspiration  pneumonia  may  result — a  catarrhal  pneumonia 
caused  by  the  inspiration  of  mucus  or  pus,  developing,  if  the  child  survives, 
immediately  after  birth,  and  frequently  proving  fatal. 

The  child  before  labor  is  in  a  condition  of  physiological  apnoea.  The  blood 
of  the  foetus  contains  an  excess  of  h?emoglobin  at  the  moment  of  birth,  stated 
by  Cattaneo  to  be  relatively  120^-2^  per  cent.  No  diff"erences  can  be  distin- 
guished between  arterial  and  venous  blood  in  the  umbilical  cord  in  the  amount 
of  hnemoglobin  contained.  So  perfect  is  the  provision  of  nature  for  supplying 
the  foetus  with  oxygen  that  anaemia  on  the  part  of  the  mother  does  not  seem 
to  influence  the  amount  of  hremoglobin  in  the  foetal  blood  nor  in  the  blood  of 
the  child  immediately  after  birth.  The  rapidity  and  ease  with  which  the  foetal 
blood  absorbs  oxygen  is  illustrated  by  the  fact  that  in  from  thirty-six  to  forty- 
eight  hours  after  birth  the  blood  of  the  new-born  contains  its  greatest  amount  of 
haemoglobin.  Late  ligation  of  the  umbilical  cord  results  in  more  haemoglobin  in 
the  foetal  blood.  Curiously  enough,  a  small  placenta  increases  the  amount  of 
haemoglobin  in  the  foetal  blood,  while  a  large  placenta  diminishes  it.  At  the 
moment  of  birth  the  circulation  of  blood  in  the  placenta  and  the  child  is 
markedly  interrupted,  oxygenation  is  materially  lessened,  and  the  foetus 
undergoes  a  period  of  more  or  less  danger.  It  can  be  readily  understood 
how  delayed  labor,  where  the  exhausted  uterus  in  tetanic  contraction  presses 
upon  the  child  and  the  placenta,  may  occasion  death  from  asphyxia,  and 
this  without  extensive  gross  lesions. 

Asphyxia,  again,  may  depend  upon  defective  muscular  and  nervous  develop- 
ment in  the  foetus.  As  a  result,  the  foetus  fails  to  make  respiratory  movements 
after  delivery,  and  perishes  from  actual  weakness.  Diseases  which  aff'ect  the 
respiratory  apparatus,  either  by  structural  changes  or  mechanical  pressure,  may 


INJURIES  AND    DISEASES    OF    THE   NEW-BOBN.  77 

cause  asphyxia.  Pulmonary  syphilis,  enlargement  of  the  liver,  dropsy,  and 
various  tumors  come  under  this  head.  These  cases  usually  perish  from  atelec- 
tasis. The  blood-vessels  in  such  cases  rupture  easily,  and  small  multiple  haemor- 
rhages abound. 

Prognosis  in  cases  of  asphyxia  depends  upon  the  condition  of  the  ner- 
vous centres.  If  the  asphyxia  is  but  partial,  and  the  stage  of  congestion  be 
present,  as  evidenced  by  the  dark  reddish-purple  complexion  of  the  child  and 
the  slow  but  full  pulsations  of  the  heart  and  umbilical  cord,  recovery  in 
the  majority  of  cases  will  ensue.  If,  however,  the  child  is  pallid,  the  heart- 
beat rapid  and  feeble,  and  the  cord  pulseless,  the  prognosis  is  grave.  More 
than  1  per  cent,  of  children  born  living  perish  from  asphyxia ;  while  cases  have 
been  reported  where  children,  born  asphyxiated,  subsequently  developed  serious 
pathological  conditions  of  the  nervous  system.  Recalling  what  has  been  stated 
regarding  the  richness  of  the  foetal  blood  in  haemoglobin,  cases  where  children 
born  asphyxiated  have  survived  for  hours,  although  thought  to  be  dead,  are 
readily  explained.  Beale  described  a  case  in  which  the  mother  died  from  post- 
partum haemorrhage  shortly  after  delivery  ;  the  midwife  in  charge  reported  the 
birth  of  dead  twins,  which  she  put  in  a  basket  in  a  shed ;  on  examination  three 
hours  afterward,  one  child  was  found  breathing  feebly.  Efforts  to  establish 
respiration  were  fruitless.  The  temperature  in  the  shed  was  very  low,  the 
weather  being  cold.  Children  have  respired  feebly  eighteen  minutes  after 
birth  and  twenty-five  minutes  after  birth  in  breech  presentation.  Beale  reports 
successful  efforts,  lasting  several  hours,  to  resuscitate  a  child  thought  to  be  dead. 
A  case  is  reported  where  a  child  was  buried  a  foot  under  ground,  and  not 
exhumed  for  five  hours,  when  evidences  of  life  resulted  from  efforts  at  resusci- 
tation continued  for  two  hours.  It  is  curious  to  observe  that  the  chances  of 
recovery  in  asphyxia  are  much  better  when  the  infant  is  exposed  to  cold  than 
when  to  heat,  probably  from  the  fact  that  a  low  temperature  retards  the  metabol- 
ism of  the  cell-elements  of  the  body,  and  thus  the  nervous  centres  retain  their 
irritability  longer. 

Treatment  of  asphxyia  is  prophylactic  and  curative.  In  prophylaxis  the 
conditions  which  will  result  in  prolonged  labor  should  be  anticipated  and 
removed.  Complicating  factors  which  will  subject  the  child  to  great  pressure 
must  also  be  obviated.  The  judicious  use  of  the  forceps  is  a  direct  prophylaxis 
against  asphyxia,  as  are  version  and  extraction.  On  the  other  hand,  both  of 
these  procedures  are  direct  causes  of  asphyxia  in  unsuitable  cases.  We  must 
again  repeat  that  no  intelligent  prophylaxis  of  asphyxia  can  be  undertaken 
which  does  not  include  a  preliminary  examination  of  the  mother's  birth-canal 
and  an  estimation  of  the  relative  size  of  the  foetus  and  the  mother.  Prolapse 
of  the  umbilical  cord,  resulting  in  pressure  and  asphyxia,  is  best  treated  by 
anaesthetizing  the  mother  and  terminating  labor,  if  possible,  by  manual  inter- 
ference ;  thus,  the  cord  may  be  taken  in  the  hand  and  passed  up  into  the 
uterus,  the  head  brought  into  a  proper  position,  and  delivery  expedited  by  the 
forceps ;  or,  if  pulsation  in  the  cord  has  ceased,  version  and  extraction  may  be 
performed.  There  is  no  repositor  for  the  cord  comparable  to  the  hand  of  the 
obstetrician,  for  the  hand  can  recognize  pulsation,  can  remedy  coiling  of  the 
cord  about  the  foetus,  and  may  so  change  the  position  of  the  cord  as  to  lead  to 
the  recovery  of  the  foetus. 

In  cases  of  contracted  pelvis,  or  in  disproportion  between  the  foetus  and 
the  pelvis,  operative  procedures  have  for  one  of  their  purposes  the  saving  of 
the  child  from  asphyxia,  which  otherwise  must  prove  fatal.  So  soon  as  the 
head  is  accessible  during  labor,  the  practitioner  should  ascertain,  if  possible, 
whether  the  cord  is  coiled  about  the  neck ;  if  so,  it  should  be  gently  drawn 


78       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

down  and  loosened ;  and  if  the  head  be  born,  the  cord  tightly  coiled  about  the 
neck,  and  a  large  body  and  shoulders  hinder  delivery,  it  is  well  to  cut  the  cord 
and  deliver  the  child  rapidly.  The  cord  may  be  clamped  with  artery-forceps, 
or,  better,  tied.  'The  diagnosis  of  cord  around  the  child  may  sometimes  be 
made  before  expulsion  by  hearing  a  murmur  in  the  umbilical  cord  during 
auscultation  of  the  abdomen. 

The  treatment  of  the  actual  condition  of  asphyxia  after  delivery  will 
depend  largely  upon  the  degree  of  asphyxia  present.  There  are  certain  precau- 
tions which  should  be  taken  in  every  birth.  The  nurse  should  have  ready 
a  saturated  solution  of  boracic  acid  to  Avhich  has  been  added  a  teaspoonful  of 
glycerin  to  the  half  pint.  This  should  be  at  hand  in  a  small,  clean  earthen 
bowl.  In  the  bowl  should  be  a  half-dozen  pieces  of  old,  soft  handkerchief, 
two  inches  square.  When  the  head  is  born,  the  physician  turns  the  mouth  and 
eyes  of  the  child  in  such  a  position  that  they  will  not  come  in  contact  with  the 
discharges  of  the  mother.  The  nurse  or  physician  should  then  thoroughly 
cleanse  the  mouth  and  fauces  with  the  bits  of  linen  soaked  in  the  boracic  solu- 
tion. Mucus  or  secretions  in  the  child's  mouth  will  thus  be  removed,  and 
one  danger  of  asphyxia  obviated.  In  the  stage  of  asphyxia  where  congestion 
is  the  principal  symptom,  the  stimulus  of  contact  with  the  external  air  will 
often  secure  respiratory  movements  :  spanking  the  child  is  a  familiar  method 
of  procedure  which  undoubtedly  has  good  results.  In  such  cases  the  cord  may 
be  promptly  tied  and  cut;  and  if  the  congestion  be  pronounced,  it  is  well  to  allow 
a  drachm  or  two  of  blood  to  flow  from  the  foetal  cord  before  ligation.  The 
child  should  then  be  promptly  inverted  to  favor  the  expulsion  of  mucus  from 
the  air-passages.  If  the  heart-beat  be  good,  a  little  cold  water  sprinkled  upon 
the  chest  will  usually  result  in  the  establishment  of  respiration.  Should  the 
heart-l^eat  be  good,  but  respiration  not  ensue,  the  child  may  be  laid  in  a  bath- 
tub filled  with  water  at  a  temperature  of  100  °  F.,  and  passive  respiratory 
movements  may  be  instituted.  Cold  water  also  may  be  sprinkled  upon  the 
chest.  In  these  cases  a  prognosis  may  be  based  upon  the  action  of  the  heart ; 
if  that  be  strong,  the  physician  should  not  despair  of  securing  respiratory  move- 
ments. 

In  the  more  severe  forms  of  asphyxia  the  child  can  endure  no  loss  of  blood  ; 
it  may  be  promptly  inverted  and  held  in  that  position  for  several  moments,  its 
mouth  being  thorougiily  emptied  of  mucus  and  secretions :  passive  respiration 
is  then  to  be  instituted,  and  to  secure  the  actual  entrance  of  air  into  the  lungs 
the  Schultze  method  is  undoubtedly  pre-eminent.  It  consists  in  taking  the 
child  with  both  hands,  the  child's  head  raised  between  the  upper  portion  of 
the  palms,  the  fingers  grasping  the  scapulie  of  the  child,  the  thumbs  resting 
upon  the  anterior  surfiice  of  the  thorax.  The  child  is  then  raised  above  the 
head  of  the  physician  until  it  turns  a  three-quarter  somersault  :_  it  is  then 
brought  down  with  a  swinging  motion  to  within  a  short  distance  of  the  floor. 
When  the  body  of  the  child  is  raised  over  the  head  of  the  physician  expira- 
tion results  :  as  the  child  swings  forward  and  downward  the  action  of  gravity 
and  the  pressure  of  the  physician's  hands  result  in  a  powerful  inspiratory 
action.  The  value  of  the  Schultze  method  consists  in  its  efficiency  in  intro- 
ducing air  into  the  lungs  ;  it  is  not,  however,  a  stimulus  to  the  reflex  excita- 
bility of  the  nervous  system,  and  if  this  has  been  lost,  an  infant's  lungs  may  be 
filled  with  air  and  yet  the  child  readily  perish.  The  dangers  of  this  method 
have  been  pointed  out  by  Meyer  and  Heydrich.  Fracture  of  the  clavicle  with 
perforation  of  the  lung  and  emphysema  ai'e  reported  by  these  observers  as  occa- 
sionally fijllowing  this  method  of  resuscitation. 

A  manifest  objection  to  the  Schultze  method  is  the  disturbance  and  shock 


IXJURIES   AND    DISEASES    OF    THE   NEW-BORN.  79 

which  must  necessarily  follow;  in  deeply  asphyxiated  children,  where  the 
heart-beat  is  scarcely  perceptible,  it  is  preferable  to  practise  the  inverted 
posture,  with  the  application  of  warm  flannel  to  the  surface  of  the  body  and 
the  continuation  of  gentle  respiratory  movements.  Air  may  be  introduced 
into  the  lungs  by  mouth-to-mouth  insufflation  or  by  the  passage  of  a  tracheal 
tube.  Lusk  advises  the  use  of  the  catheter,  not  only  to  remove  mucus,  but  to 
favor  direct  insufflation ;  or  the  chest-walls  may  be  compressed  to  secure 
expiration.  TThen  circulation  reappears,  Silvester's  method  is  then  of  service, 
the  tongue  of  the  child  being  drawn  forward.  When  heart-beats  are  perceptible, 
the  warm  bath,  with  sprinklings  of  cold  water  upon  the  face,  is  useful. 
Finally,  he  advises  Schultze's  method  to  favor  complete  re-establishment 
of  the  circulation.  Schultze  claims  for  his  method  an  immediate  action  in 
relieving  overloaded  blood-vessels,  the  swinging  of  the  child  producing  empty- 
ing of  the  ventricles  and  favoring  the  return  current  from  the  pulmonary  vein. 
The  value  of  direct  insufflation  by  the  catheter,  preceded  by  the  removal 
of  mucus,  can  scarcely  be  over-estimated.  AVe  recall  a  case  in  a  foreign 
hospital  where  the  assistant  in  charge  had  abandoned  an  asphyxiated  infant  as 
dead  :  permission  was  given  sevei'al  American  students  to  practise  the  passage 
of  the  balloon  catheter,  an  English  catheter  having  a  rubber  bulb  at  the 
distal  end,  whose  compression  and  expansion  favor  suction  and  insufflation. 
To  our  surprise,  the  child  became  resuscitated  under  the  use  of  the 
catheter,  and  ultimately  recovered.  Forest  places  the  child  first  on  its  face, 
its  head  down,  and  expels  fluids  from  the  mouth  by  pressure  upon  the  back. 
The  child  is  then  put  in  a  bath  or  tub  of  hot  water  in  a  sitting  posture, 
supported  by  one  of  the  operator's  hands  across  its  back,  its  head  bent  back- 
ward. The  physician  grasps  the  child's  hands  with  his  other  hand,  carries 
them  upward  until  the  child  is  suspended  by  the  arms,  leans  forward  himself 
and  blows  air  into  the  child's  mouth  ;  the  infant's  arms  are  then  lowered,  its 
body  is  doubled  forward,  and  its  thorax  pressed  between  the  hands  of  the 
physician.  Air  is  thus  expelled.  Especial  advantage  is  claimed  for  this 
method  from  the  fact  that  the  hot  water  maintains  capillary  circulation  and 
tends  to  assist  in  promoting  the  action  of  the  heart.  Reynolds  places  the 
infant  upon  its  back,  head  downward,  resting  upon  the  operator's  foreann, 
held  nearly  perpendicularly  to  the  floor,  retained  in  that  position  by  his 
fingers  hooked  over  its  shoulders.  In  this  position  the  child's  arms  fall  down- 
Avard  by  the  sides  of  its  head,  and  their  Aveight.  aided  by  that  of  the  thorax 
itself,  draws  the  ribs  into  the  position  of  complete  expansion  of  the  chest. 
The  thorax  is  compressed  against  the  forearm  by  the  other  hand,  and  suddenly 
released,  when  a  most  satisfactory  respiration  is  the  result.  This  method 
combines  a  favorable  posture  for  the  escape  of  fluids  from  the  trachea  and  for 
the  afflux  of  blood  to  the  brain,  with  a  ready  method  of  artificial  respiration. 
Duke  places  the  infant  face  doAvnward.  its  thorax  resting  upon  the  open  palm 
of  the  left  hand :  the  ribs  are  gently  compressed  by  the  other  hand :  the 
mouth  is  cleansed,  and  the  finger  passed  down  the  pharynx  to  admit  air.  If 
this  is  not  successful,  the  child  is  plunged  into  a  hot  bath.  Richardson  urges 
that  the  child's  body  remain  quiet  during  efforts  to  establish  respiration.  The 
feeble  condition  of  the  heart  strongly  contraindicates  violent  disturbance  to 
the  child.  The  position  of  the  body  should  be  horizontal.  Air  introduced 
should  be  Avarmed  to  90°  F.  ^^lanual  respiration  by  Silvester's  or  Hall's 
method  is  recommended,  and  Richardson  describes  an  apparatus  composed  of  a 
pair  of  bulbs  by  which  air  may  be  pumped  into  the  respiratory  passages.  Tavo 
pieces  of  tubing  are  passed  to  tlie  nostril,  and  a  bulb  upon  one  injects  air, 
while  a  bulb  upon  the  other  favors  the  discharge  of  mucus  and  vitiated  air. 


80       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


He  also  describes  a  method  of  using  a  simple  bellows  in  connection  with  a 
nasal  tube.  The  treatment  of  asphyxia  by  tracheotomy  is  seldom  successful ; 
there  is  rarely  an  impediment  in  the  respiratory  passages  of  the  child  which 
cannot  be  overcome  by  the  introduction   of  the  catheter. 

In  reviewing  the  treatment  of  asphyxia  we  desire  to  call  attention  to  the 
pathology  of  the  aifection  and  to  the  relative  value  of  different  methods  of 
treatment.  The  removal  of  mucus  from  the  nostril,  trachea,  and  bronchial 
tubes  can  be  most  readily  effected  by  suspending  the  child  in  an  inverted 
position ;  this  favors  also  afflux  of  blood  to  the  medulla  and  respiratory  centre. 
Gentle,  passive  respiratory  movements  should  be  employed,  but  so  conducted 
as  to  give  the  child  the  least  disturbance  possible.  The  return  of  the  circula- 
tion and  the  reflexes  should  be  eagerly  awaited,  and  so  soon  as  these  phenomena 
are  present  the  prognosis  becomes  much  more  favorable.  The  warm  bath 
and  the  application  of  a  mild  counter-irritant — cold  water,  spirits,  simply  a 
current  of  air  from  bellows  directed  against  the  epigastrium — usually  cause 
respiratory  movements.  In  strong  children,  when  the  reflexes  are  present 
and  the  heart-beat  becomes  perceptible,  Schultzes  method,  practised  gently 
for  a  short  time,  is  of  value.  Should  the  circulation  fjiil,  it  is  admissible  to 
inject  hypodermatically  y^  of  a  grain  of  strychnia  and  a  few  minims  of 
tincture  of  digitalis.  If  mucus  is  not  expelled  by  the  inverted  position,  the 
use  of  the  catheter  with  suction  and  insufflation  is  advisable.  When  respiratory 
efforts  have  become  established,  but  repeatedly  fail,  a  mild  faradic  current  of 
electricity  and  the  inhalation  of  oxygen  under  pressure  are  of  decided  value. 
One  pole  of  the  faradic  battery  should  be  placed  at  the  back  of  the  neck,  and 
the  other  over  the  thorax  and  alternately  over  the  epigastrium.  Bonnaire 
obtained  good  results  in  foetal  asphyxia  by  inhalation  of  oxygen — a  procedure 
which  we  have  repeated  with  like  good  results  in  foetal  asphyxia  and  that  of 
older  children  complicating  pneumonia.  As  Lusk  remarks,  in  cases  of  deep 
asphyxia  patience,  watchfulness,  and  a  hopeful  spirit  are  prerequisites  of 
success. 

Following  asphyxia,  the  infant  is  exposed  to  danger  of  death  from  inani- 
tion, and,  as  has  been  stated,  fi'om  catarrhal  pneumonia.  The  use  of  the 
incubator  is  of  especial  value  in  maintaining  the  circulation  in  these  cases, 
and  favoring  the  gradual  expansion  of  the  lungs  if  atelectasis  be  present, 
Winckel  has  obtained  good  results  from  the  permanent  hot  bath  at  a  tempera- 
ture of  98.6°  to  100°  F.  every  twelve  to  twenty-four  hours.  Such  children  are 
fed  every  two  hours.     The 

bowels  are  promptly   emp-  Fig.  3. 

tied  by  rectal  injections. 
Winckel  has  devised  a  bath- 
tub for  such  cases,  an  illus- 
tration of  which  is  append- 
ed. We  add  also  an  illus- 
tration of  a  modification  of 
Auvard's  incubator,  Avhich 
we  have  used  successfully 
in  the  Philadelphia  Hos- 
pital and  in  the  Maternity 
Department  of  the  Jeffer- 
son Hospital. 

The  interior  of  the  box  is  divided  into  two  parts  by  an  incomplete  horizon- 
tal partition,  placed  about  six  inches  above  the  bottom  of  the  box.  In  the 
lower  part,  which  is  intended  for  hot  cans,  tAvo  openings  are  necessary — one  at 


The  Permanent  Bath 


INJUBIES   AND    DISEASES    OF    THE   NEW-BORN. 


81 


the  side,   occupying   the  whole  length   of  the   side,  closed  by  a  sliding   door 
opened  at  pleasure  from  either  end,  as  a  means  of  placing  the  hot  cans.     The 


Fig.  4. 


Incubator. 

&,  6,  lid  with  glass  plate;  v,  glass  plate  ;  H,  ventilating  tube ;  O,  slide  closing  hot-air  chamber ;  M,  hot-water  cans. 

other  opening  is  at  one  end  of  the  box,  closed  by  a  door  not  fitting  tightly,  to 
admit  a  small  amount  of  air.     The  upper  part,  arranged  to  receive  the  infant, 

P'iG.  5, 


Interior  of  Incubator. 


On  the  top  is  also  arranged  a  small 
Fig.  6. 


is  covered  on  top  by  a  plate  of  glass,  fitting  completely,  with  tvro  buttons  or 
knobs  to  admit  of  its  being  easily  raised. 
metal  tube  containing  a  small  rotary  fan 
very  easily  moved  by  a  weak  current  of 
air.  In  the  opening  where  the  two  com- 
partments join  a  sponge  is  placed,  wet 
with  water  to  humidify  the  air.  and  a 
thermometer  by  which  to  regulate  the 
temperature. 

Cases  are  not  infrequently  met  Avith 

where  death  occurs  soon    after  labor  with  Hot-water  can  for  incubator. 


82       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

symptoms  of  partial  asphyxia  :  a  clear  diagnosis  is  often  impossible,  until  post- 
mortem examination  reveals  partial  heart-clot,  syphilis,  atelectasis,  or  lobular 
inspiration  pneumonia  as  the  cause  for  this  mortality. 

HEMORRHAGES    FROM   MuCOUS    SURFACES. 

The  new-born  infant  often  presents  hiTemorrhages  from  mucous  surfaces  of 
the  body.  Among  the  most  frequent  of  these  is  a  discharge  of  blood  from  the 
vagina,  occurring  at  birth  and  persisting  afterward.  An  examination  of  the 
mucous  membrane  in  these  cases  frequently  detects  a  condition  of  capillary 
granulation  which  bleeds  easily  upon  the  slightest  movement  of  the  child.  In 
a  case  recently  under  our  observation  at  the  Maternity  Department  of  the 
Jefferson  College  Hospital  an  ill-developed  female  child  presented  this  phe- 
nomenon at  birth.  A  blood-count  made  of  this  child,  and  compared  with  that 
of  a  healthy  infant,  shows  the  following : 

Healthy  Child. — Red  corpuscles  per  cubic  millimetre,  5,450,000,  by 
counting  forty  squares  (Thoma-Zeiss  hnemocytometer).  White  corpuscles  per 
cubic  millimetre,  11,000.  Proportion  of  white  to  red,  1  :  495.  Haemoglobin, 
65  per  cent,  of  normal.  Blood-plates  by  objective,  blood  prepared  by  means 
of  Hay  em's  solution :  the  number  was  much  less  than  the  usual  amount,  which 
should  be  about  250,000.  The  red  corpuscles  were  irregularly  formed,  some 
crenated,  some  small  and  granular,  others  apparently  rolled  or  turned  upon 
themselves,  resembling  very  much  a  bread  roll.  While  this  irregularity 
existed,  their  appearance  was  that  of  normal  corpuscles,  and  the  percentage 
of  haemoglobin  (65)  proved  them  to  be  almost  normal.  In  children  the  per- 
centage of  haemoglobin  is  not  so  great  as  in  adults;  in  the  young  or  in  any 
case  where  the  growth  is  rapid  the  red  corpuscles  are  always  irregular  in 
appearance,  which  is  not  at  all  indicative  of  disease.  The  slight  increase 
in  red  corpuscles  is  normal  to  the  new-born.     (Plate  II.  Fig.   1.) 

Ancemic  Child. — Red  corpuscles  per  cubic  millimetre,  2,000,000.  White 
corpuscles  per  cubic  millimetre,  12,000.  Proportion  of  white  to  red,  1 :  166. 
Haemoglobin,  35  per  cent,  of  normal.  By  careful  examination  no  blood- 
plates  could  be  found.  In  this  case  the  red  corpuscles  were  irregular,  crenated, 
granular,  and  many  disintegrated.  By  actual  count  this  specimen  would  give 
over  five  million  red  corpuscles  per  cubic  millimetre,  but  counting  normal 
corpuscles  would  give  only  two  million.  The  object  of  the  count  being  to 
know  the  number  of  oxygen-carriers  per  cubic  millimetre,  it  would  give  a 
wrong  idea  to  enumerate  those  disintegrated  and  diseased  corpuscles.  There 
was  a  slight  increase  in  the  number  of  white  cells,  but  their  appearance  was 
normal.^    (Plate  II.  Fig.  2.) 

The  condition  underlying  such  haemorrhage  is  that  of  anaemia  or  malnutri- 
tion of  the  blood,  with  resulting  ecchymoses.  In  parts  accessible  to  treatment, 
as  the  mouth,  vagina,  rectum,  or  bladder,  injections  of  hot  dilute  creolin  solu- 
tion or  boracic  solution  are  indicated.  Treatment  of  the  anaemia,  however, 
by  administration  of  food,  by  arsenic,  inunctions  with  oil,  and  the  administra- 
tion of  olive  or  cod-liver  oil  will  result  in  gradual  recovery. 

Obstetric  Paralysis  and  Injuries  to  the  Nervous  System. 

Direct  injury  to  the  nervous  system  received  during  birth  has  long  been 
recognized  as  among  the  dangers  to  which  the  infant  is  exposed.    Paralysis  of 

^  For  the  examination  and  description  of  the  blond  in  these  cases  I  am  indebted  to  Dr.  D. 
B.  Kyle,  Instructor  in  the  Examination  of  the  Blood  in  the  Jefferson  Medical  College.  Dr. 
W.  H.  Wells,  one  of  the  physicians  to  the  Jefierson  Maternity,  has  prepared  the  drawings 
illustrating  the  appearance  of  the  corpuscles. 


Blood  of  Healthy  Child  one  month  old.    Hajmoglohin  normal.    Drawn  from  Thoma-Zeiss  Hfemocy- 
tometer.    Objective  I  Reicherts.     Blood-count  by  Dr.  Kyle ;  drawing  by  Dr.  Wells. 


Fig.  2. 


Blood  of  Aneemie  Child  suffering  from  Hemorrhage  from  Mucous  Membranes.    Total  corpuscles, 
5,000,000,  of  which  2,000,000  were  normal.    Blood-count  and  drawing  as  in  preceding  hgure. 


INJURIES  AND    DISEASES    OF   THE   NEW-BOBN  83 

the  facial  nerve  caused  by  pressure  -witli  the  forceps  upon  the  nerve  at  its  fora- 
men of  exit  often  follows  instrumental  delivery.  The  brachial  plexus  is  also 
frequently  injured  by  the  same  agent.  Hemiplegia,  idiocy,  and  impaired  cere- 
bral development  have  been  ascribed  as  consequences  of  injury  received  at 
birth.  The  view  previously  held,  that  the  forceps  is  a  valuable  agent  for 
compressing  the  foetal  head  and  exercising  leverage  and  forcible  rotation,  has 
given  place  to  the  belief  that  the  forceps  is  essentially  a  tractor,  and  that  the 
mechanism  of  rotation  depends  upon  the  relation  in  size  and  symmetry  betAveen 
the  head  and  the  pelvis,  and,  as  well,  the  resistance  of  the  pelvic  floor.  Murray 
has  shown  by  experiment  and  clinical  observation  that  the  foetal  skull  is  com- 
pressible in  an  antero-posterior  direction  by  the  sliding  of  the  occipital  and 
frontal  bones  under  the  ends  of  the  parietal  bones.  This  compression  is  not 
accompanied  by  any  appreciable  increase  of  the  transverse  diameter.  The 
antero-posterior  shortening  is  compensated  for  by  a  vertical  elongation  of  the 
skull,  providing  for  the  accommodation  of  the  cranial  contents.  These  con- 
clusions are,  however,  based  upon  the  employment  of  axis-traction,  without 
which  such  compensatory  elongation  cannot  be  confidently  assumed.  Murray 
was  also  careful  to  avoid  forcible  traction.  Under  such  circumstances  it  may- 
be held  that  moderate  pressure  with  forceps,  resulting  in  compensatory  elonga- 
tion of  the  vertical  diameter  of  the  foetal  skull,  need  not  be  expected  to  cause 
paralysis,  haemorrhage,  or  fracture.  This  pressure,  however,  must  be  gradually 
applied,  and  traction  made  in  the  axis  of  the  pelvis ;  otherwise  a  portion  of 
the  head  will  be  forced  against  the  promontory  of  the  sacrum,  and  injury  must 
result.  "When  gentle  axis-traction  fails  to  cause  the  head  to  descend,  a  diag- 
nosis of  disproportion  between  the  head  and  the  pelvis  should  be  made,  and 
efforts  at  forcible  delivery  should  cease. 

The  results  of  injudicious  delivery  with  forceps  are  well  illustrated  by 
Lane.  A  boy  sixteen  years  old,  delivered  at  birth  with  forceps,  exhibited  a 
groove  three  and  a  quarter  inches  long  from  the  right  coronal  suture  to  the 
lambdoid  ;  the  floor  of  this  groove  seemed  one-fourth  of  an  inch  below  the  scalp ; 
the  left  arm  was  weaker  than  the  right,  and  its  movements  defective.  The 
left  leg  was  weak.  Reflexes  were  exaggerated  and  clonus  was  present.  The 
depressed  portion  of  bone  was  raised  ;  the  bottom  of  the  depression  encroached 
upon  the  area  of  the  skull.  Prompt  amelioration  of  the  epilepsy  followed. 
Duchenne,  Gueniot,  De  Paul,  Rogers,  and  others  have  described  injuries  to 
the  brachial  plexus  caused  by  forceps  and  by  manual  extraction  of  the  child. 
Erb  has  clearly  described  injuries  to  the  brachial  plexus  accompanying  delivery 
in  breech  presentation.  Hoedamaker  describes  injury  to  the  fifth  and  sixth 
cervical  nerves  resulting  from  delivery  in  breech  presentation  when  the  arms 
become  extended  above  the  head.  Feriberg  describes  a  case  of  paralysis 
caused  by  pressure  upon  the  brachial  plexus  during  delivery  after  version ; 
paralysis  was  but  temporary,  the  patient  subsequently  making  a  good  recovery. 

The  medico-legal  aspect  of  injuries  to  the  new-born  child  requires  the  dif- 
ferentiation of  lesions  received  during  birth  by  forceps  or  the  pressure  of  the 
mother's  pelvis,  and  injuries  occurring  by  precipitate  labor  without  assistance 
or  by  the  wilful  act  of  the  mother  or  an  accomplice.  Dittrich  reports  cases  of 
depression  in  foetal  bone,  bounded  by  a  well-defined  ridge,  following  applica- 
tion of  the  forceps  in  cases  of  contracted  pelvis.  Kiistner  describes  funnel- 
shaped  depressions  in  the  foetal  skull  following  forcible  delivery  by  forceps. 
Von  Hofmann  has  found  a  spoon-shaped  depression  the  most  frequent  form  of 
lesion  in  a  considerable  number  of  cases.  Fracture  of  the  orbital  region  of  the 
skull  has  been  observed  by  Lihotzky  to  follow  forcible  forceps  delivery.  Rup- 
ture of  a  meningeal  vein  and  death  from  hemorrhage  have  been  observed  and 


84       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

reported  by  Koffer  in  the  clinic  of  Gustav  Braun.  Kundrat  reports  an  inter- 
esting case  of  depi'ession  upon  the  parietal  bone  of  a  new-born  infant,  with 
cerebral  haemorrhage,  in  which  the  evidence  seemed  to  show  that  the  lesion 
was  caused  by  direct  violence  on  the  part  of  the  mother  after  the  birth  of  the 
child.  Von  Hofmann  has  further  drawn  attention  to  injuries  to  the  foetal 
cadaver  which  might  occasion  suspicion  of  intentional  violence  during  birth. 
Naturally,  defects  in  the  ossification  of  the  skull  may  result  in  lesions  accom- 
panying normal  labor  and  simulating  injuries  at  birth. 

Fritsch  describes  the  characteristics  of  injuries  caused  by  precipitate  labor, 
the  child  falling  upon  the  floor  or  ground,  to  be  as  follows  :  The  fracture  begins 
in  a  suture,  and  extends  outward  to  the  middle  of  the  bone ;  usually  there  is 
but  one  fissure,  which  ends  where  the  bone  is  thickest.  The  parietal  bone  is 
most  often  affected,  the  fissure  ending  in  the  parietal  eminence.  As  a  general 
distinction,  it  is  to  be  observed  that  direct  violence  is  accompanied  by  haemor- 
rhage;  that  injuries  examined  immediately  after  birth,  where  fracture  occurs, 
show  frequently  a  well-defined  border  to  the  lesion,  which  tends  to  grow  less 
sharp  in  contour  if  the  child  survives.  Kundrat  also  lays  stress  upon  the  rela- 
tive breadth  of  the  sutures  as  a  factor  in  influencing  heemorrhage  during  birth. 

A  most  interesting  question  arises  as  to  the  bearing  of  these  injuries  upon 
the  future  health  and  development  of  the  child.  Osier  found,  in  the  records  of 
the  Philadelphia  Infirmary  for  Nervous  Diseases,  9  cases  of  paralysis  following 
forceps  delivery  ;  in  6  of  these  it  was  reported  that  the  forceps  injured  the 
child  :  some  of  them  had  scars  following  labor.  In  all  cases  the  paralysis  grad- 
ually appeared  within  a  short  time  after  labor.  M.  Allen  Starr  describes 
cases  of  brain-atrophy  manifesting  itself  in  hemiplegia,  mental  defects,  and 
sensory  defects,  accompanied  frequently  by  epileptiform  seizures,  and  result- 
ing from  congenital  conditions  or  lesions  occurring  at  birth.  Sachs  and  Peter- 
son in  49  cases  of  congenital  cerebral  palsy  found  16  in  which  some  difficulty 
in  labor  occurred.  These  statistics  are  now  more  comprehensive  than  those 
of  Little  and  Gaudard,  Wallenberg  and  Osier.  Sachs  and  Peterson,  however, 
include  all  forms  of  cerebral  paralysis  and  of  tedious  labor  as  well  as  instrumental 
delivery.  Sachs  has  expressed  the  opinion  that  prolonged  labor  does  more 
injury  to  the  child's  brain  than  the  proper  application  of  forceps. 

We  have  considered  the  prophylactic  treatment  of  these  conditions  under 
that  of  the  treatment  of  visceral  haemorrhage.  The  question  arises,  however, 
What  shall  be  done  in  a  case  in  which  a  child  is  born  and  survives  with  such 
an  injury  ?  Although  we  find  no  record  that  such  a  procedure  has  been  at- 
tempted, yet  the  suggestion  of  Nancrede  and  other  surgeons  that  depressed  bone 
be  elevated  by  surgical  interference  is  certainly  rational.  We  believe  that  where 
pressure-symptoms  are  present,  or  where  the  lesion  is  extensive  and  follows 
severe  pressure,  such  should  be  the  line  of  treatment.  The  success  attained  in 
operating  immediately  after  birth  upon  cases  of  umbilical  hernia  gives  encour- 
agement to  the  belief  that  surgical  interference  in  these  cases  is  justifiable.  It 
is  interesting  to  note  a  superstition  common  among  the  laity  in  some  quarters 
to  the  eff"ect  that  the  doctor  by  manual  pressure  and  counter-pressure  is  ex- 
pected to  shape  the  head  of  the  child  during  the  first  few  days  after  its  birth. 

Fractures  and  Dislocations  of  the  Trunk  and  Extremities. 

The  skeleton  of  the  foetus  may  be  fractured  while  in  the  uterus.  Such 
fractures,  however,  must  be  carefully  distinguished  from  congenital  malforma- 
tion, which  closely  simulate  fracture.  Amniotic  adhesions  during  the  first  and 
second  months  of  intra-uterine  life  are  the  most  frequent  causes  of  these  mal- 


INJURIES   AND    DISEASES    OF    THE   NEW-BOBN.  85 

formations.  An  apparent  scar  is  often  present  in  these  cases,  and  must  be 
referred  to  precipitate  flexion  of  undifferentiated  layers  in  the  embryo.  Spurious 
callus  may  be  present,  caused  by  defective  development  of  the  bone,  although 
the  amount  of  callus  is  less  than  after  actual  fracture.  Sperling  would  dis- 
tinguish between  malformation  and  fracture  by  the  fact  that  in  malformation 
the  fingers  and  toes  of  the  limb  affected  show  defective  development,  while  in 
fracture  such  defective  development  of  fingers  and  toes  is  absent.  Hodgen  de- 
scribes a  foetal  skeleton  containing  sixty-five  fractures  which  he  thinks  were 
caused  by  muscular  action  during  uterine  life.  He  describes  also,  in  a  healthy 
child,  a  fracture  of  the  clavicle,  which  was  not  discovered  for  several  days  after 
birth ;  the  child  was  large  and  was  delivered  by  forceps. 

The  most  frequent  fractures  in  the  long  bones  are  those  of  the  clavicle, 
humerus,  and  femur.  Fracture  of  the  clavicle  near  its  acromial  end  is  occa- 
sionally complicated  by  severe  injury  to  the  brachial  plexus,  as  illustrated  in 
a  case  reported  by  Knight ;  permanent  injury  of  the  shoulder  with  paresis  fol- 
lowed. Fracture  of  the  clavicle  is  most  frequently  caused  by  forcible  extrac- 
tion of  the  shoulders. 

Fracture  of  the  humerus  most  frequently  occurs  in  the  delivery  of  the  after- 
coming  head  when  the  arms  become  extended  above  the  head.  Fracture  of 
the  femur  usually  results  from  difficult  version  and  extraction.  Fractures  of 
the  bones  of  the  leg,  of  the  ribs  and  sternum  are  rarely  met  with,  and  only  in 
cases  of  forcible  extraction  through  highly-contracted  pelves, 

Dislocations  of  the  foetal  skeleton  are  frequently  confused  with  fracture,  and 
are  caused  by  the  same  manipulations  which  give  rise  to  solutions  of  conti- 
nuity. Dislocation  and  separation  of  the  epiphyses  of  the  humerus  at  the  elbow- 
joint  have  been  not  infrequently  observed  after  manipulation. 

The  treatment  of  fractures  and  dislocations  of  the  trunk  and  extremities  is 
based  upon  the  principles  of  surgery  commonly  followed.  Difficulty  has  been 
experienced  in  maintaining  the  fragments  in  apposition  by  reason  of  restless- 
ness in  the  child,  and  the  necessity  to  move  it  frequently  when  it  nurses  and 
when  it  is  cleansed.  Fractured  clavicle  will  heal  without  deformity  with  a  very 
simple  retention  dressing  if  the  infant  be  kept  assiduously  upon  its  back. 
Fracture  of  the  humerus  and  of  the  femur  may  be  treated  to  advantage  by  some 
form  of  splint  material  which  can  be  dipped  in  hot  water,  moulded  to  the  child's 
limb,  and  retained  in  position  by  a  simple  roller  bandage.  Firm  and  unyield- 
ing dressings  must  be  avoided  in  these  cases,  as  the  danger  of  injury  to  the 
tissues  by  pressure  is  very  great.  Fractured  ribs  and  sternum  may  be  success- 
fully treated  by  a  broad  flannel  bandage  pinned  smoothly  about  the  chest. 
Dislocations  require  the  same  principles  of  treatment  which  should  be  followed 
in  managing  fractures. 

The  prognosis  in  fractures  of  the  foetus  is  usually  good.  As  most  of  them 
are  of  the  "  green-stick  "  variety,  a  favorable  result  without  deformity  is  the 
rule  rather  than  the  exception.  When  congenital  malformation  is  present,  the 
practitioner  should  be  guarded  in  his  prognosis.  He  may  remedy  webbed 
fingers  and  toes  by  dissecting  them  apart,  but  he  will  scarcely  hope  to  see  a 
congenitally  malformed  limb  become  perfectly  developed. 

Umbilical  Hemorrhage. 

If  the  umbilical  cord  be  tied  firmly  with  an  aseptic  ligature  after  its  pulsa- 
tions have  ceased,  if  the  stump  be  powdered  with  boracic  acid  or  salicylic  acid 
1  part  to  powdered  starch  3  or  5,  and  if  reasonable  care  be  exercised  to  protect 
it  from  violence,  haemorrhage  from  the  umbilicus  or  umbilical  inflammation 


86       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

rarely  occurs.  The  cord  may  be  best  protected  by  enclosing  it  in  a  small  mass 
of  antiseptic  cotton,  directing  the  extremity  of  the  stump  upward  and  to  the 
child's  right,  and  pinning  a  Hannel  binder  comfortably  tight  about  the  abdo- 
men. In  cases,  however,  where  syphilis,  haemophilia,  septic  infection,  and 
acute  fatty  degeneration,  with  haemoglobinuria,  are  present,  haemorrhage 
may  occur  when  the  cord  separates,  or  even  before  that  time.  This  complica- 
tion is  not  very  frequent,  Winckel  having  observed  it  but  once  in  5000  infants. 
Bouchut  quotes  Grandidier's  analysis  of  202  cases,  from  which  he  concludes 
that  the  hgemorrhage  begins  most  often  at  night,  and  often  accompanies  colic, 
vomiting,  somnolence,  and  jaundice,  with  ecchymoses  of  the  skin.  Bleeding 
occurs  rather  more  frequently  before  the  cord  is  entirely  separated,  and  usually 
between  the  fifth  and  ninth  days.  The  haemorrhage  takes  the  form  of  arterial 
oozing,  the  blood  often  failing  to  coagulate.  The  haemorrhage  may  persist 
from  one  hour  to  several  weeks.  The  mortality  from  umbilical  haemorrhage  is 
estimated  at  80  per  cent. 

The  treatment  is  frequently  futile.  A  needle,  armed  with  a  silk  ligature, 
may  be  passed  beneath  the  vessels  and  securely  tied  ;  two  surgical  pins  may 
be  passed  beneath  the  bleeding  tissue  at  right  angles  to  each  other,  and  the 
ligature  may  be  looped  around  the  pins.  Pressure  is  indicated  in  treating 
umbilical  haemorrhage ;  it  is  best  made  with  antiseptic  cotton  on  which  iodo- 
form has  been  freely  sprinkled. 

Umbilical  Polyp. 

The  umbilicus  may  fail  to  heal  perfectly,  and  abundant  granulations,  bleed- 
ing upon  touch,  and  polypoid  growths  may  develop;  they  are  best  treated  by 
the  application  of  nitrate  of  silver  or  other  suitable  escharotic. 

Umbilical  Hernia. 

A  protrusion  of  the  abdominal  contents  may  accompany  defective  closure  of 
the  umbilicus.  While  it  is  indicated  to  palliate  this  condition  by  suitable  dress- 
ings, yet  it  has  been  found  possible  to  secure  a  radical  cure  by  operation  very 
soon  after  birth.  Runge  describes  a  case  operated  upon  successfully  sixteen 
hours  after  birth.  In  the  majority  of  cases  a  cure  may  be  effected,  in  a  period 
varying  from  one  to  six  months,  by  the  application  of  an  umbilical  button. 
This  consists  of  a  hard-rubber  disk  convex  on  the  applied  surface,  which  is 
held  in  position  by  a  broad  band  of  surgeon's  adhesive  plaster. 

GaSTRO-INTESTINAL    H-S3MORRHAGE. 

This  complication  depends  upon  a  purpuric  condition,  and  manifests  itself 
most  frequently  from  the  fifteenth  to  twentieth  day  after  birth.  Kiwisch 
reports  cases  of  haemorrhage  from  the  intestinal  tract  following  the  normal 
birth  of  apparently  well-nourished  children.  The  first  symptoms  were  dis- 
charge of  blood  and  restlessness,  occurring  from  twelve  to  thirty  hours  after 
labor.  The  abdomen  became  dull  and  tumid,  the  patients  were  pallid,  and  in 
some  instances  vomited  blood ;  death  ensued  Avithin  forty-eight  hours. 

According  to  Grynfeltt,  gastro-intestinal  haemorrhages  usually  take  place 
during  the  first  three  days  after  birth  (Rilliet,  Silbermann,  Dusser),  though  in 
a  case  of  this  author's  it  occurred  on  the  fourth  and  fifth  days,  and  in  two 
instances,  seen  by  Rilliet,  the  children  were  fifteen  and  twenty  weeks  old. 
Sex  seems  to  play  no  special  predisposing  role,  but   the  influence  of  morbid 


INJURIES  AND    DISEASES    OF    THE   NEW-BORN.  87 

antecedents  in  the  parents  appears  to  be  a  factor  of  some  importance.  Pinard, 
Champetier,  Auvard,  and  others  have  noted  syphilis  in  the  progenitors,  but 
this  is  regarded  by  Grynfeltt  as  only  a  cause  acting  indirectly  in  deteriorating 
the  health  of  the  parents.  Haemophilia  has  certainly  been  proven  in  some 
instances. 

The  pathogeny  is  quite  as  obscure  as  the  etiology.  The  lesions  observed 
at  autopsies  are  the  most  variable.  Ulcerations  of  the  stomach  and  intestines 
have  been  found  ;  again,  only  a  simple  congestion  ;  while  other  cases  have  shown 
a  complete  absence  of  visible  lesion.  Grynfeltt  advances  a  theory  suggested  by 
observations  of  Billard,  and  confirmed  by  personal  studies  of  the  histology  of 
the  digestive  mucous  membranes  of  new-born  infants.  These  show  that  the 
vascular  supply  of  the  mucous  membrane  of  the  stomach  and  intestines  is 
exceedingly  rich  at  this  period  of  life.  Adding  to  this  state  of  physiological 
congestion  a  congestion  or  impeded  circulation  in  the  liver,  he  finds  it  easy 
to  ascribe  the  cause  of  such  heemorrhages  to  exaggerated  tension  in  the  portal 
area.  This  view,  he  believes,  is  supported  by  the  fact  that  these  haemor- 
rhages, at  first  sudden  and  profuse,  quickly  cease,  thus  resembling  a  true 
depleting  loss  of  blood. 

The  first  symptom  is  usually  the  haemorrhage  itself.  Blood  flows  from  the 
mouth  following  efforts  at  vomiting,  or  from  the  rectum,  more  or  less  mixed 
with  faeces  or  in  clots  ;  quite  often  both  phenomena  are  coincident,  haemate- 
mesis  being  usually  the  earlier.  When  one  alone  occurs,  hamatemesis  is  by  far 
the  more  frequent.  In  spite  of  the  gloomy  prognosis  evidenced  by  the  statistics 
of  Dusser  (43  deaths  in  78  collected  cases),  a  more  hopeful  view  must  be 
taken. 

In  treatment,  tannin  in  syrup  of  rhatany  oflFers  an  efficient  astringent 
potion.  One  and  a  half  to  two  and  a  half  grains  of  ergotin  in  mucilage  are 
employed  with   satisfaction  by  Widerhofer  of  Vienna. 

Icterus  Neonatorum. 

The  physiological  icterus  of  the  new-born  infant  appears  on  the  third  or 
fourth  day  of  life,  is  characterized  by  a  yellowish  pigmentation  of  the  face 
and  breast,  persists  for  about  a  week,  and  does  not  seem  to  disturb  the  patient's 
general  condition  at  all.  The  urine  is  dark  in  color,  containing  bile-stuff, 
while  the  stools  lack  the  color  usually  given  by  their  mixture  Avith  bile.  The 
cause  of  such  icterus  is  thought  by  Birch-Hirschfeld  to  be  swelling  of  Glisson's 
capsule,  commencing  at  the  umbilical  vein,  and  by  oedema  preventing  the  free 
discharge  of  bile  through  the  hepatic  vessels;  hence  the  jaundice  is  hepato- 
genic. Hofmeier  thinks  icterus  is  caused  by  the  enormous  number  of  red 
blood-corpuscles  which  are  formed  in  the  liver  and  hinder  the  production  and 
discharge  of  bile.  The  entrance  of  this  coloring  matter  into  the  blood  is 
furthered  by  catarrh  of  the  duodenum  and  congenital  stricture  of  the  ductus 
choledochus.  Halberstam  found  undissolved  bile-stuff  in  the  urine  of  children 
with  icterus,  and  the  epithelium  of  the  kidneys  infiltrated  with  the  same 
coloring  matter. 

The  harmless  character  of  this  jaundice  and  its  spontaneous  disappearance 
should  not  make  it  a  subject  of  anxiety  to  the  physician  or  parents;  it  some- 
times is  due  to  slight  changes  in  diet  or  any  temporary  disturbance  of  the 
child's  general  surroundings.  Beyond  the  regulation  of  the  bowels  by  the 
most  simple  laxatives,  no  treatment  should  be  employed  for  this  condition. 
Infective  jaundice  w^ill  be  considered  under  the  head  of  infections  which  attack 
the  foetus. 


88       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


The  Infections  attacking  the  New-born. 

The  recognition  of  bacteria,  ptomaines,  and  toxines  as  causes  of  disease  has 
served  to  explain  many  disorders  of  the  foetus  and  infant  at  birth  not  previ- 
ously understood.  Most  frequent  of  these  infections  are  those  by  the  micro- 
cocci of  gonorrhoea  and  the  streptococci  of  suppuration.  Gonorrhoea  in  the 
mother  affords  the  bestof  orrounds  for  fearing  wonorrhoeal  infection  in  the  new-born 
child.  The  most  usual  site  of  this  infection  is  the  conjunctiva,  and  ophthal- 
mia neonatorum  is  a  familiar  sequence  of  maternal  gonorrhoea.  The  treat- 
ment of  this  disorder  will  be  considered  in  another  section  of  this  book.  We 
are  interested,  however,  in  the  practical  prophylaxis  of  such  infection :  if  the 
practitioner  could  be  absolutely  positive  that  the  mother  had  never  been 
infected  by  the  gonococcus,  prophylaxis  would  be  entirely  unnecessary.  In 
hospital  patients,  however,  there  is  always  room  for  suspicion ;  and  in  private 
cases,  although  there  may  seem  no  adequate  reason  to  fear  such  a  complication, 
yet  its  appearance  will  often  surprise  and  disappoint  the  attending  physician. 
No  information  Avill  be  gained  in  this  matter  from  interrogating  the  patient : 
if  she  has  ever  been  infected,  her  husband  has  certainly  not  told  her  the  cause 
of  the  disorder,  and  her  physician  may  have  kept  her  in  like  ignorance. 
Furthermore,  in  women  who  have  never  been  infected  by  the  gonococcus  there 
occurs  at  the  latter  portion  of  pregnancy  a  vaginal  discharge  which  is  capable 
of  setting  up  a  mild  conjunctivitis  in  the  infant.  Hence  a  practical  rule  may 
be  followed  to  advantage,  that  where  a  vaginal  discharge  persists  during  the 
latter  portion  of  pregnancy  the  use  of  antiseptic  douches  is  certainly  indicated. 
These  douches  ma}^  be,  preferably,  creolin  or  bichloride  of  mercury :  the  first 
has  the  advantage  of  impairing  the  natural  condition  of  the  mucous  membrane 
of  the  vagina  less  than  does  the  mercurial ;  it  is  also  a  safer  substance  to  put 
in  the  hands  of  a  patient.  On  the  contrary,  its  odor  is  disagreeable  to  some, 
and  when  used  in  a  strono;  mixture  it  causes  considerable  irritation  and  burning. 
In  a  strength  of  one  teaspoonful  to  the  quart  the  resulting  mixture  is  seldom  so 
irritating  as  to  cause  discomfort.  The  quantity  used  should  be  not  less  than 
a  quart,  and  the  douche  should  be  preferably  taken  while  the  patient  is  in  the 
recumbent  posture.  The  douche-bag  should  hang  not  higher  than  three  feet 
above  the  patient's  body,  and  the  force  of  gravity  alone  should  be  employed  in 
giving  the  douche.  If  bichloride  of  mercury  be  chosen,  1 :  5000  is  sufficiently 
strong  for  such  use. 

In  patients  admitted  to  hospitals,  suffering  from  the  effects  of  previous 
gonorrhoea  or  having  acute  gonorrhoea,  the  treatment  must  be  more  radical ; 
here  a  preliminary  thorough  cleansing  of  the  vagina  should  be  made  with 
green  soap  and  creolin,  the  mixture  containing  2  per  cent,  of  the  creolin: 
following  this,  creolin  douches,  four  times  in  twenty-four  hours  for  the  ten 
days  preceding  labor,  will  be  found  of  advantage.  Should  the  mucous 
membrane  not  tolerate  such  frequent  douches,  the  vagina  may  be  tamponed 
with  iodoform  gauze  containing  50  per  cent,  of  iodoform,  and  the  number  of 
douches  be  reduced  one-half.  In  all  hospital  cases  a  preliminary  douche  of 
green  soap  and  creolin  may  be  used  to  advantage ;  in  private  practice  a  pre- 
liminary douche  of  bichloride,  1  :  5000,  may  also  be  employed  to  the  advantage 
of  mother  and  child. 

Aside  from  ophthalmia,  gonorrhoea  may  infect  the  infant  at  birth  upon 
other  mucous  membranes.  Rosinski  describes  the  residts  of  interesting  inves- 
tigations made  by  him  upon  gonorrhoea  occurring  in  the  mouths  of  new-born 
inft\nts.  The  lesions  caused  by  this  germ  in  the  mouth  develop  only  where 
the  pavement  epithelium  has  been  removed.     These  cells  are  especially  fragile 


Gonorrhoea  of  the  Mouth  in  the  Newborn    (RoslnsKi). 


INJURIES  AND   DISEASES    OF   THE  NEW-BOBN  89 

in  the  young  child,  and  hence  the  readiness  with  which  infection  occurs.  It  is 
interesting  to  note  that  in  gonorrhoea!  ophthalmia  it  is  very  rare  to  find  that 
the  lachrymal  sacs  become  involved ;  it  is  also  true  that  the  cylindrical  epi- 
thelium of  the  naso-pharynx  seems  also  to  resist  successfully  invasion  by  the 
gonococcus.  Clinical  observation  shows  that  these  cases  develop  usually 
between  the  fifth  and  tenth  day  of  life,  resulting  often  from  infection  from 
the  genital  canal  occurring  at  birth,  and  oftentimes  through  direct  infection 
at  the  hands  of  attendants.  This  is  especially  true  where  the  epithelium 
of  the  mouth  is  destroyed  through  efforts  at  cleansing.  These  cases  are 
remarkable  for  the  fact  that  they  affect  the  general  health  so  little ;  the 
children  nursing  well  and  seeming  free  from  pain.  The  lesions  are  yellowish 
plaques,  surrounded  by  a  border  of  pale-reddish  tissue,  in  which  the  process 
of  healing  usually  begins  upon  the  third  day  by  a  reaction  zone  of  deeper 
color.  The  epithelium  is  renewed  from  the  borders  of  the  plaque,  pus-cells 
being  thrown  off  as  the  healing  progresses.  Scar-tissue  is  never  developed 
in  these  cases.  The  accompanying  plate  gives  an  excellent  idea  of  the 
appearance  of  the  lesions.     (Plate  III.) 

The  treatment  of  gonorrhoea  affecting  the  mouth  of  the  new-born  con- 
sists in  careful  avoidance  of  injury  to  the  epithelium ;  the  finger  should  not 
be  inserted  into  the  mouth  of  an  infant  suffering  from  this  disorder :  the 
affected  surfaces  should  preferably  be  sprayed  with  a  solution  of  hydrogen 
peroxide  or  a  saturated  solution  of  boracic  acid.  Such  treatment  is  usually 
amply  sufficient  to  secure  the  recovery  of  the  patient.  The  infant's  general 
condition  often  requires  attention  in  these  cases,  and  its  food  and  hygiene  are 
matters  of  great  importance. 

General  Septic  Infection. 

Streptococci,  bacteria,  and  ptomaines  of  septic  infection  usually  find 
entrance  to  the  foetal  body  through  the  granulating  surfaces  upon  the  umbil- 
icus ;  the  result  is  arteritis  and  phlebitis  of  the  umbilical  vessels,  resulting  in 
the  formation  of  thrombi  and  the  infiltration  of  the  surrounding  tissues  with 
bacteria  and  ptomaines.  Both  umbilical  arteries  are  usually  involved,  the 
infection  extending  from  the  umbilicus  to  the  bladder.  The  umbilical  ring 
may  ulcerate,  or  may  have  healed  entirely  while  the  infection  has  proceeded 
within  the  abdomen.  According  to  Weber  and  Runge,  the  tissue  about  the 
arteries  is  usually  first  involved  ;  the  iliac  vessels  and  the  retroperitoneal  con- 
nective tissue  usually  escape ;  in  two-fifths  of  cases  Runge  found  pneumonia 
or  pleurisy  with  small  metastatic  abscesses.  Peritonitis  and  pysemic  metastases 
in  the  abdominal  viscera  and  the  joints  have  also  been  observed.  In  umbilical 
phlebitis  the  capsule  of  the  liver  and  the  liver  itself  become  involved.  Peri- 
carditis, pleuritis,  and  other  pysemic  complications  are  often  present.  The 
symptoms  of  such  infection  are  often  obscure.  The  umbilicus  may  become 
inflamed  shortly  after  birth ;  the  child  has  fever,  is  restless,  holds  its  legs  and 
thighs  flexed,  and  often  becomes  jaundiced.  Death  may  occur  in  convulsions, 
but  occasionally  recovery  ensues.  The  treatment  of  umbilical  septic  infection 
is  largely  prophylactic :  thorough  antisepsis  as  regards  the  physician,  nurse, 
and  external  genital  organs  of  the  patient,  a  suitable  and  cleanly  dressing  for 
the  umbilicus,  such  as  previously  given,  and  scrupulous  cleanliness  while  the 
cord  is  drying  and  becoming  separated,  render  umbilical  septic  infection  a 
rarity.  If  the  child  be  too  feeble  to  have  the  full  bath  for  the  first  month  of 
life,  it  is  comparatively  easy  to  allow  the  cord  to  remain  undisturbed.  Where, 
however,  the  child  is  bathed  daily  in  the  bath-tub,  such  of  the  cotton  as  may 


90       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

become  wet  should  be  carefully  removed,  the  cord  repowdered,  and  fresh  cot- 
ton applied. 

The  constitutional  treatment  of  an  infant  suffering  from  septic  infection 
through  the  umbilicus  consists  in  the  reduction  of  excessive  fever  by  judicious 
sponging  with  warm  or  cool  water,  and  the  free  administration  of  dilute  alcohol 
and  nourishing  food.  While  quinine,  if  it  can  be  taken,  is  a  useful  auxiliary, 
yet  alcohol  is  the  drug  of  most  importance  for  such  cases.  Infants  suffering 
from  severe  infections  often  bear  strychnia  as  a  stimulant  better  than  might  be 
expected  from  theoretical  considerations  only. 

Erysipelas. 

The  micrococcus  of  Fehleisen  may  obtain  an  entrance  at  the  umbilicus, 
and  erysipelatous  inflammation  of  the  subcutaneous  and  cutaneous  tissues  may 
result.  This  process  may  go  on  even  to  the  extent  of  gangrene  and  sloughing 
of  the  affected  parts.  Cases  of  mixed  infection  resembling  erysipelas  may 
develop,  complicated  by  diphtheria,  as  in  illustrative  cases  reported  by  J.  Lewis 
Smith  from  the  records  of  the  New  York  Infant  Asylum.  The  infection  may 
localize  itself  in  multiple  abscesses  beneath  the  skin,  or,  extending  to  the  peri- 
toneum, may  cause  death  from  acute  peritonitis. 

The  treatment  of  erysipelatous  infection  of  the  umbilicus  and  surrounding 
parts  consists  in  thorough  applications  locally  of  peroxide  of  hydrogen,  boracic 
acid,  or  thymol  solution,  1  :  1000.  Following  this,  equal  parts  of  iodoform  and 
boracic  acid  may  be  employed  freely.  When  pockets  of  pus  form,  they  should 
be  promptly  opened  with  a  knife  or  scissors  and  thoroughly  douched  with  an 
antiseptic.  The  child's  general  strength  must  be  assiduously  supported  by 
alcohol,  food,  and  strychnia  or  quinine.  As  a  stimulant  in  severe  prostra- 
tion, hypodermatic  injections  of  camphor  in  oil,  or  administration,  by  the 
mouth,  of  freshly-made  English  breakfast  tea,  with  rum,  will  be  found  of  ser- 
vice in  some  cases. 

Acute  Peritonitis  in  the  New-born. 

Acute  peritonitis  occasionally  arises  very  soon  after  birth  as  a  complication 
of  erysipelas  or  from  some  pathological  process  developing  in  the  intestine. 
The  communication  in  lymphatic  channels  between  the  intestine  and  the  peri- 
toneum seems  unusually  free  in  the  infant,  and  as  a  result  peritonitis  rapidly 
supervenes.  Cassell  describes  three  interesting  cases  of  this  sort.  Lorain, 
Quinquaud,  and  Silbermann  have  also  reported  illustrative  cases  of  this  dis- 
order. 

Tubercular  and  Typhoid  Infection. 

There  exists  certain  ground  for  belief  that  the  foetus  in  utero  may  become 
infected  by  tubercle  bacilli  and  also  by  the  bacilli  of  typhoid.  The  first 
few  days  after  birth  may  Avitness  acute  miliary  tuberculosis  or  the  development 
of  a  well-marked  typhoid  condition.  As  regards  the  former,  the  usual  clinical 
signs  of  acute  tuberculosis  will  be  present :  it  must  be  remembered,  however, 
that  the  infant  rarely  survives  acute  tuberculosis  long  enough  for  the  formation 
of  lung-cavities,  and  hence  physical  signs  will  often  be  lacking.  The  character 
of  the  fever,  the  rapid,  uninterrupted  course  of  the  disorder,  with  increased  dul- 
ness  over  the  thorax,  and  the  development  of  harsh  and  bronchial  breathing, 
will  usually  enable  the  physician  to  make  a  diagnosis. 


INJURIES  AND   DISEASES   OF   THE   NEW-BOBN.  91 

While  treatment  up  to  the  present  time  has  been  practically  unavailing, 
it  is  of  interest  to  note  the  experiments  of  Pinard  in  using  injections  of  the 
serum  of  dog's  blood  in  these  cases  ;  in  a  series  of  twenty-one  infants  so  treated 
he  believes  that  benefit  has  resulted,  the  remedy  seeming  to  act  as  a  powerful 
tonic  and  stimulant. 

The  intra-uterine  transmission  of  typhoid  infection  is  well  illustrated  by  a 
case  recorded  by  Giglio.  The  presence  of  the  typhoid  germ  was  demonstrated 
in  the  tissues  of  an  apparently  normal  foetus  and  placenta  born  forty-six  days 
after  the  beginning  of  typhoid  fever  in  the  mother. 

The  treatment  of  typhoid  in  the  new-born  is  practically  that  in  the  adult, 
reference  being  had  to  the  ease  with  which  the  infant  is  stimulated  or  de- 
pressed.    The  prognosis  in  such  cases  is  exceedingly  grave. 

Inspiration  Pneumonia. 

In  prolonged  labor,  complicated  by  a  septic  condition  of  the  mother's 
birth-canal,  premature  inspiratory  movements  on  the  part  of  the  foetus  may 
result  in  the  inspiration  of  septic  material :  lobular  septic  pneumonia  may 
result,  and,  occurring  soon  after  birth,  frequently  proves  rapidly  fatal.  Here, 
again,  the  efforts  of  the  physician  lie  in  prophylaxis,  in  delivering  the  patient 
promptly,  and  maintaining  so  far  as  possible  an  aseptic  condition  of  the  birth- 
canal  until  labor  shall  terminate. 

Tetanus. 

The  infant  may  become  infected  with  tetanus,  and  this  disorder  may  appear 
in  well-marked  type  from  the  sixth  to  the  ninth  day  after  birth.  The  tetanus 
bacillus  usually  finds  its  entrance  at  the  unhealed  umbilicus.  Brieger  has 
shown  the  specific  cause  of  this  disorder,  and  Beumer  and  Peiper  have  con- 
firmed by  clinical  observation  the  identity  of  trismus  and  tetanus  of  the  new- 
born with  inoculative  and  wound  tetanus.  The  mortality  among  infants  is 
exceedingly  large,  and  recovery  is  the  rare  exception.  Appearing  with  symp- 
toms of  restlessness,  night-terrors,  and  frequent  cries,  the  child  often  becomes 
nauseated,  has  slight  diarrhoea,  and  is  then  attacked  by  trismus.  This,  at 
first  intermittent,  finally  becomes  persistent,  and  develops  into  tetanic  contrac- 
tions of  the  entire  body.  Icterus  is  usually  present.  The  disorder  rarely  lasts 
more  than  three  or  four  days,  the  child  perishing  in  collapse  from  twelve  to 
twenty-four  hours  after  the  beginning  of  the  convulsions.  High  temperature 
is  usually  present  at  the  time  of  death.  On  post-mortem  examination  efiusion 
of  blood  and  serum  in  the  cerebral  tissues  is  frequently  found.  The  violence 
of  the  convulsions  may  give  rise  to  haemorrhages  into  the  muscular  interspaces 
or  into  the  tissues  of  the  mediastinum. 

In  treatment  hydrate  of  chloral  and  alcoholic  stimulants  give  most  pros- 
pects of  relief.  Holt  has  reported  a  case  which  recovered  under  the  free  use 
of  bromide  of  potassium.  A  specific  method  of  treatment  by  the  injection  of 
a  substance  similar  to  tuberculin  has  not,  so  far  as  we  know,  yet  been  employed 
in  this  disease.     There  would  certainly  seem  to  be  reasons  for  testing  its  value. 

Mastitis. 

Mastitis  in  the  new-born  infant  is  to  be  regarded  as  a  mild  septic  infection 
when  the  disorder  comes  to  the  point  of  suppuration  and  phlegmonous  inflam- 
mation. The  mammary  glands  of  new-born  children  frequently  become 
engorged  and  tender,  but  this  condition  subsides  if  the  glands  be  let  alone  and 


92       AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

protected  from  external  violence.  When,  however,  infection  occurs,  pus- 
formation  may  take  place  and  a  septic  mastitis  may  result.  Such  a  compli- 
cation, however,  is  exceedingly  rare  Avhere  antiseptic  precautions  are  habitually 
taken  in  the  treatment  of  labor  cases.  A  distinction  must  be  made  clinically 
between  simple  engorgement  of  the  breast  and  infection.  In  the  former  the 
child's  temperature  remains  but  little  disturbed,  its  appetite  is  unimpaired,  its 
rest  remains  practically  as  before.  If  the  glands  be  carefully  but  gently 
washed  with  soap  and  water  and  bathed  with  bichloride,  1 :  10,000,  a  thin  layer 
of  absorbent  cotton  jjut  over  them,  and  a  soft  flannel  bandage  pinned  snugly 
about  the  breast  and  supported  over  the  shoulders  by  shoulder-straps  or  some 
other  simple  device,  the  glands  may  remain  undisturbed  for  several  days  unless 
fever  or  restlessness  indicates  inflammation.  On  the  other  hand,  where  infec- 
tion is  present  and  pus  has  formed,  prompt  emptying  of  the  gland  by  incision, 
with  disinfection  of  the  cavity,  is  indicated. 

Infections  of  the  Blood. 

Profound  alterations  of  the  blood  and  nutritive  cellular  processes  in  the 
new-born,  the  probable  result  of  infection  at  birth,  have  been  described  under 
various  names  by  diff"erent  observers. 

Hecker  and  Von  Buhl  describe  a  disorder  of  infants  born  in  asphyxia 
characterized  by  cyanosis,  vomiting,  icterus,  profuse  parenchymatous  haemor- 
rhage, accompanied  by  acute  fatty  degeneration  of  visceral  epithelium  and 
heart-muscle.  Phosphorus-  and  arsenic-poisoning  were  excluded  in  diagnosis, 
and  the  malady  was  named  "acute  fatty  degeneration  of  the  new-born,"  or 
Buhl's  disease.  Its  pathology  is  not  perfectly  explained,  but  it  may  be  classed 
among  the  infective  disorders  resulting  in  the  extensive  disintegration  of  the 
blood. 

Acute  haemoglobinuria  of  the  new-born  was  first  clearly  described  by 
Winckel,  who  reported  twenty-three  cases  of  the  disorder.  It  is  characterized 
by  swelling  of  Peyer's  patches  and  the  mesenteric  glands,  blackish-red  staining 
of  the  pyramids  of  the  kidneys,  with  stripes  of  haemoglobin  coloring,  fatty 
degeneration  of  the  liver  and  other  viscera.  Haematogenic  icterus  is  present, 
the  haemoglobin  being  extensively  changed  into  bilirubin.  The  urine  is  dark 
brown-reddish  in  color,  contains  haemoglobin,  epithelium,  casts,  and  micro- 
cocci. Chemical  poisons  as  a  cause  were  excluded  in  diagnosis.  The  mothers 
showed  no  infection,  the  children  were  usually  well  developed.  The  mortality 
was  19  out  of  23.  The  cause  of  the  disorder  is  not  clearly  demonstrated.  It 
is  undoubtedly  an  infection  which  attacks  the  blood,  resulting  in  haemoglo- 
binaemia.  Prophylaxis  and  treatment,  beyond  the  faithful  emplo3"ment  of 
antiseptic  precautions,  are  practically  without  avail. 

Haematogenic  jaundice,  accompanied  with  multiple  oozing  of  blood,  has 
been  recently  described  in  an  interesting  paper  by  Partridge.  In  the  case 
reported  recovery  ensued.  In  1166  infants  born  at  the  Nursery  and  Child's 
Hospital,  New  York,  11  cases  of  haemorrhage  occurred,  with  a  mortality  of  75 
per  cent.  At  the  Sloan  Maternity  Hospital,  in  850  patients  there  were  14 
cases ;  mortality  over  60  per  cent.  No  intelligent  family  history  of  bleeding 
was  obtained. 

Somewhat  similar  to  these  cases  are  those  of  the  disorder  known  as 

Mel^na  Neonatorum. 

Infants  dying  with  profuse  haemorrhage  from  the  stomach  and  intestine  have 
revealed  an  ulcer  of  the  duodenum  as  a  cause.     In  explaining  these  phenomena 


INJURIES   AND    DISEASES    OF    THE   NEW-BOBN.  93 

Landau  assigns  as  a  cause  thrombosis  of  the  umbilical  vein,  resulting  in  em- 
bolism in  the  vessels  of  the  stomach  and  duodenum.  Persistence  of  the  ductus 
arteriosus  and  haemophilia  also  have  been  assigned  as  causes.  Kundrat  in  exam- 
ining Winckel's  case  found  excessive  secretion  of  the  gastric  juice,  which  had 
partly  digested  the  mucosa  of  the  intestine  and  occasioned  haemorrhage.  In 
other  cases  bloody  stools  and  vomiting  of  blood  persisted  for  several  days. 
Recovery  occasionally  ensues. 

The  prognosis  is  exceedingly  grave,  and  treatment  is  practically  unavail- 
ing. The  milder  preparations  of  iron  may  be  given  by  the  mouth,  and  hot  or 
cold  applied  to  the  surface  of  the  body  as  the  condition  of  the  child  indicates. 
An  abdominal  compress  may  also  be  useful. 

In  closing  this  consideration  of  the  infective  disorders  of  the  new-born  we 
must  again  emphasize  the  fact  that  while  we  are  not,  in  the  present  stage  of 
our  knowledge,  in  a  position  to  particularize  regarding  the  precise  nature  of 
the  infective  agent  and  its  mode  of  operation,  still,  the  fact  remains  reasonably 
proven  that  these  cases  result  from  some  direct  infection  occurring  just  before 
or  during  birth.  It  remains,  then,  the  positive  duty  of  the  practitioner  to  see 
to  it  that  rigid  asepsis — and,  better,  antisepsis — is  employed  regarding  his 
hands  and  instruments,  those  of  the  attendant,  and  also  the  external  organs  of 
the  patient.  Ehrendorfer,  writing  upon  this  subject,  draws  attention  to  the 
dangers  of  infection,  not  only  from  mother  to  child,  but  from  one  child  to  another 
in  hospital  wards.  The  practice  of  putting  a  number  of  children  in  the  same 
crib  is  objectionable,  as  is  the  custom  of  bathing  a  number  of  children  in  the 
same  bath-tub,  and,  still  worse,  of  using  the  same  towels  or  cloths  for  a  number 
of  baths.  From  the  moment  of  birth  each  infant  should  have  its  OAvn  toilet 
appliances,  be  they  of  the  simplest  description.  In  cleansing  the  child  absorb- 
ent material  which  can  be  thrown  away  and  not  used  a  second  time  is  prefer- 
able. Separate  vessels  for  bathing  the  child's  body  and  for  washing  the  head 
and  face  are  also  desirable.  In  this  way  septic  matter  from  the  umbilicus  is 
kept  away  from  the  mouth  and  eyes,  and  vice  versd.  Nurses  may  be  drilled 
to  advantage  in  these  niceties  in  the  care  of  infants,  which  are  not  simple 
matters  of  aesthetic  neatness,  but  are  founded  upon  pathological  facts. 


PART  II. 
THE   DIATHETIC  DISEASES. 


LITH^MIA. 

By  B.  K.  RACHFORD,  M.  D., 

Cincinnati. 


LiTH.TiMiA  {Xidoz,  stone ;  alfxa,  blood)  is  a  term  which  was  introduced 
by  Murchison  to  designate  a  group  of  symptoms  which  he  thought  to  be  due 
to  an  excess  of  uric  (lithic)  acid  in  the  blood.  Austin  Flint,  Sr.,  used  the 
term  uricremia  for  the  same  purpose.  Alexander  Haig  and  others  have 
written  largely  upon  the  subject  under  the  name  uricacidsemia.  A  number  of 
recent  writers  have  grouped  the  same  set  of  symptoms  under  the  title  lithuria. 
Concealed  gout  and  American  gout  have  also  been  very  largely  used  in 
naming  the  same  clinical  manifestations.  The  writer  has  made  a  number  of 
contributions  to  this  subject  under  the  title  lencomaine-poisoning.  All  of 
these  terms  have  found  their  way  into  medical  literature,  and  all  of  them  are 
more  or  less  inaccurate.  The  term  lithnemia  heads  this  chapter  not  because 
of  its  propriety,  but  rather  because  of  its  long  and  widespread  use  by  medical 
writers  in  describing  a  condition  Avhich  is  known  by  its  symptomatology 
rather  than  by  its  pathology.  We  know  that  lithic  acid  is  not  responsible 
for  all,  or  even  the  greater  portion,  of  the  symptoms  of  lithaemia.  This 
term  is  therefore  a  misnomer  and  conveys  a  false  idea  of  its  pathology.  Yet 
it  is  my  belief  that  the  time  for  rechristening  this  disease  must  aAvait  a  fuller 
knowledge  of  its  pathology  than  we  have  at  present.  Lithoemia  is  essentially 
an  auto-intoxication  resulting,  as  I  believe,  from  the  presence  of  an  excess  of 
the  alloxuric  bodies  in  the  body  media.  Uric  or  lithic  acid,  from  which  the 
disease  is  named,  is  one  of  these  bodies,  and  xanthin,  hypoxanthin,  hetero- 
xanthin,  and  paraxanthin  are  the  other  important  members  of  this  group. 
The  relative  importance  of  these  bodies  as  disease-producers  is  not  at  the 
present  time  clearly  made  out,  and  need  not  therefore  further  engage  our 
attention. 

Etiology. — Heredity  holds  first  place  among  the  etiological  factors  of 
lithremia.  In  fact,  one  may  say  that  this  disease  as  it  occurs  in  infants  and 
children  is  essentially  an  inheritance  from  lithnemic  ancestors. 

An  excess  of  jn'oteidfood  may  be  a  factor  in  developing  lithaemia.  It  is 
believed  that  the  alloxuric  bodies  have  their  origin  either  directly  or  indi- 
rectly from  the  proteid  food.  The  more  proteid  food,  therefore,  the  body 
is  called  upon  to  metabolize,  the  more  of  these  waste  products  will  be 
formed. 

Inactivity  will  predispose  to  lithgemia.     This  factor  is  especially  potent 

94 


LITH^MIA.  95 

when  associated  with  an  excessive  intake  of  proteid  food.  It  is  probable  that 
sedentary  habits  increase  the  liability  to  litbsemic  attacks  by  furnishing 
diminished  opportunities  for  the  oxidation  of  the  poisonous  alloxuric  bodies, 
since  it  is  a  recognized  fact  that  these  bodies,  however  they  may  be  formed, 
may,  under  favorable  conditions,  be  oxidized  into  non-toxic  uric  acid  and 
urea.  Active  exercise  in  the  open  air,  by  furnishing  the  most  favorable 
conditions  for  the  oxidation  of  these  bodies,  will  diminish  the  dangers  of 
auto-intoxication. 

JExcretion  of  the  Alloxuric  Bodies. — The  alloxuric  bodies  are  excreted  by 
the  kidneys,  the  skin,  and  the  intestinal  canal.  In  this  work  the  kidneys 
play  the  most  important  role.  These  bodies  are  removed  by  the  kidney  cells 
from  the  blood  into  the  urine.  Their  presence,  therefore,  in  great  excess  in 
the  urine  means  that  immediately  before  they  were  in  solution  in  excess  in 
the  blood.  Disease  of  the  kidneys  may  cause  an  abnormal  retention  of  these 
bodies  in  the  blood.  The  excretion  of  these  bodies  by  the  skin  is  of  especial 
importance  when  the  kidneys  fail  to  do  their  part  of  the  work.  The  un- 
doubted value  of  many  of  the  hot  springs  in  the  treatment  of  lithaemic  condi- 
tions depends  upon  the  fact  that  the  hot  alkaline  bath  promotes  the  cutaneous 
elimination  of  the  alloxuric  bodies.  In  the  hot  months  the  skin  is  more 
active  than  in  the  cold  months,  and  this  may  be  one  of  the  explanations  of 
the  comparative  infrequency  of  lithsemic  attacks  in  summer.  The  intestinal 
canal  is  a  most  important  channel  by  which  an  excess  of  the  alloxuric  bodies 
may  be  eliminated  from  the  blood  and  the  tissues.  In  practice  one  often 
finds  it  necessary  to  call  upon  the  intestinal  canal  to  assist  the  skin  and 
kidneys  in  the  excretion  of  these  bodies. 

Symptoms. — In  order  to  avoid  confusion  by  the  mingling  of  symptoms 
from  totally  different  causes,  I  shall  speak  first  of  the  symptoms  which  are 
thought  to  be  due  to  uric-acid  deposits  in  the  urinary  passages.  The  newly- 
born  lithgemic  infant  is  prone  to  eliminate  an  excess  of  urates  in  the  first 
days  of  life.  In  such  infants  uric-acid  crystals  may  be  precipitated  into  the 
tubules  of  the  pyramids  of  the  kidneys  and  cause  thereby  much  pain  and 
irritation.  These  uric-acid  infarctions  may  subsequently  be  washed  out  of 
the  tubules  and  serve  as  the  nuclei  of  urinary  calculi.  Jacobi  says  the  vast 
majority  of  renal  and  vesical  calculi  have  their  origin  in  this  way. 

Quite  recently  I  saw  an  infant  two  days  old.  It  was  crying  bitterly,  and 
seemed  to  be  in  great  pain  :  its  temperature  was  104°  F.,  and  had  been  nearly 
that  high  for  twenty-four  hours.  I  learned  that  this  infant  had  been  born 
of  lithsemic  parents,  and  that  it  had  passed  urine  but  once  since  birth.  The 
urine  passed  at  that  time  was  small  in  quantity  and  tinged  with  blood.  As 
treatment  it  was  given  a  warm  bath,  a  cathartic,  and  water  to  drink.  Two 
days  later  it  was  convalescent,  with  the  renal  secretion  established.  The 
urine  passed  by  this  infant  on  the  third  day  deposited  a  red  sand  of  urates 
on  the  diaper.  This  case  is  typical  of  a  class  of  cases  which  represent  the 
earliest  manifestations  of  infantile  lithsemia.  When  fever  and  long-continued 
paroxysms  of  crying  occur  in  newly-born  infants  coincident  with  the  passage 
of  urine  so  heavy  with  urates  as  to  deposit  a  red  sand  on  the  diaper,  one  is 
justified  in  making  the  diagnosis  of  this  special  uric-acid  type  of  lithsemia. 
These  lithsemic  infants  may,  as  they  grow  older,  continue  to  suffer  from 
attacks  of  painful  urination  accompanied  by  an  elevation  of  temperature  and 
irritation  of  the  external  genitalia.  The  paroxysms  of  crying  which  occur 
during  and  immediately  following  the  passage  of  urine  are  very  characteristic. 
In  the  interval  between  these  fits  of  crying  the  child  is  fretful,  and  grows 
more  so  as  the  time  approaches  when  it  can  no  longer  resist  the  inclination 


96      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

to  urinate.  The  urine  is  acid  and  contains  an  excess  of  urates  and  oxalates. 
In  some  patients  it  is  so  irritating  as  to  cause  a  vulvo-vaginitis  in  tlie  female 
infant  and  urethral  irritation  in  the  male.  The  clinical  picture  here  pre- 
sented is  by  no  means  peculiar  to  infants  and  childi'en.  In  adults  it  is  also 
common  to  find  frequent  and  painful  urination  associated  Avith  the  passage 
of  urine  small  in  (quantity,  high  in  specific  gravity,  and  heavy  with  urates. 

Nocturnal  incontinence  of  urine  in  children  may  be  a  litha?mic  symptom 
resulting  from  the  irritable  condition  of  the  urinary  passages  and  the  insta- 
bility of  the  spinal  nerve-centres  that  not  uncommonly  occurs  in  these  chil- 
dren. If  one  recognizes  the  fact  that  lithsemia  is  at  times  an  important 
factor  in  producing  incontinence  of  urine,  one  will  succeed  in  curing  cases 
of  incontinence  that  have  resisted  other  forms  of  treatment.  I  wish  to  note, 
however,  that  lithjiemia  does  not  rank  among  the  most  common  causes  of 
this  neurosis. 

True  arthritic  gout,  resulting  from  uratic  deposits  in  the  tissues  about  the 
joints,  is  very  rare  in  childhood,  and  moreover  does  not  come  within  the 
scope  of  this  paper. 

The  symptoms  and  treatment  of  urinary  gravel  are  elsewhere  described 
in  this  book. 

With  this  outline  of  the  role  that  uric  acid  plays  in  the  symptomatology 
of  lithaemia  we  may  pass  to  the  consideration  of  those  symptoms  of  lithasmia 
which  in  the  present  state  of  our  knowledge  cannot  be  attributed  to  uric 
acid.  The  writer  believes  that  these  symptoms  are  the  result  of  auto-intoxi- 
cation caused  in  part,  at  least,  by  the  alloxuric  bodies  other  than  uric  acid. 

G-astro-enteric  Symptoms. — The  gastro-enteric  symptoms  of  lithgemia  in 
infancy  and  childhood  are  little  understood,  and  they  are  of  vast  importance. 
The  history  of  the  following  cases,  which  are  extreme  examples  of  this  type 
of  lithiemia,  will  best  serve  to  emphasize  these  symptoms  : 

Case  A. — Male  infant,  eight  months  of  age ;  has  a  gouty  ancestry  on  both  sides.  This 
infant  has  had  since  he  was  two  months  old,  at  intervals  of  four  to  six  weeks,  the  most 
characteristic  lithaemic  attacks.  These  attacks  commence  with  nausea  and  vomiting, 
and  very  soon  the  infant  refuses,  and  the  stomach  rejects,  all  food.  The  nausea  and 
vomiting  continue  for  from  two  to  four  days,  and  during  this  time  nothing  is  retained 
by  the  stomach.  These  symptoms  are  accompanied  by  fever  and  by  very  rapid  breath- 
ing, which  is  not  explained  by  any  pulmonary  condition.  The  odor  of  the  breath  is 
sickening,  the  bowels  are  constipated,  and  toward  the  close  of  the  attack  the  baby  is 
prostrated  and  emaciated  to  an  alarming  degree.  Accompanying  and  immediately  fol- 
lowing these  attacks  the  stools  are  very  putrid  and  sometimes  oily  in  character.  These 
lithaemic  paroxysms  come  and  go  without  apparent  cause.  They  are  quite  independent 
of  the  wholesomeness  and  digestibility  of  the  food,  and  the  duration  of  the  attack  is  but 
slightly  influenced  by  medication. 

Case  B. — Age  four  years,  a  brother  of  infant  A  ;  has  been  having  very  similar  Tithaimic 
attacks  since  he  was  an  infant  a  few  months  old.  His  attacks  were  formerly  character- 
ized by  obstinate  constipation,  with  fever,  nausea,  vomiting,  and  rapid  breathing.  The 
nausea  and  vomiting  would  continue  for  three  or  four  days,  and  would  then  disappear 
as  suddenly  as  they  came,  leaving  the  patient  to  slowly  convalesce  during  the  next  few 
days.  These  attacks  came  and  went  without  apparent  cause.  The  mother  soon  learned 
to  expect  them  every  six  or  eight  weeks,  and  also  learned  that  they  were  self-limited. 
The  point  of  special  interest  in  this  boy's  case  is  that  recently  these  attacks  have  changed 
in  character.  At  the  present  time  vomiting  is  no  longer  a  prominent  symptom.  They 
are  now  characterized  by  headache  with  nausea,  and  followed  by  a  more  or  less  pro- 
longed narcotism,  during  which  the  child  falls  into  a  deep  sleep  from  which  he  awakens 
somewhat  improved.  In  brief,  one  may  say  that  the  gastro-intestinal  paroxysms  of  his 
infancy  are  being  transformed  into  true  migraine.  This  substitution  of  one  form  of 
lithsemic  paroxysm  for  another  is  quite  characteristic  of  the  disease. 

The  disease  may  manifest  itself  in  young  infants  by  attacks  of  gastric 
pain,   associated   with   rapid  breathing,   nausea,   vomiting,   and  fever.     The 


LITH^MIA.  97 

gastric  paroxysms  may  be  so  severe  that  all  food  is  rejected  for  a  period 
of  from  one  to  five  days.  The  temperature  may  reach  104°  or  105°  F.,  but 
sometimes  in  the  most  severe  cases  the  fever  ranges  between  normal  and 
102°  F.  In  these  attacks  the  patient  may  be  prostrated  to  the  last  degree, 
occasionally  having  a  subnormal  temperature.  Toward  the  close  of  these 
acute  attacks  the  infant  or  child  may  be  much  emaciated. 

Occasionally  these  lith^emic  paroxysms  are  ushered  in  by  convulsions, 
Avhich  may  recur  with  such  regularity  as  to  become  quite  characteristic  symp- 
toms of  such  attacks.  These  gastric  paroxysms  are  self-limited.  In  dura- 
tion and  severity  they  are  influenced  but  slightly  by  medical  treatment.  The 
nausea  and  vomiting  go  almost  as  quickly  as  they  came,  but  there  is  left 
more  or  less  abdominal  tenderness  and  gastro-intestinal  irritation,  from 
which  the  infant  or  child  slowly  convalesces.  The  stools  following  these 
attacks  are  putrid,  and  in  young  infants  are  sometimes  oily  in  character. 
The  interval  between  the  attacks  may  be  as  short  as  one  week,  or  months  may 
intervene.  In  the  less  severe  forms  of  lith^mia  the  infant  or  child  may  be 
quite  well  during  this  interval,  but.  unfortunately,  this  is  not  always  so. 
Some  of  these  lithaemic  children  remain  pale  and  frail-looking  at  all  times. 
They  are  peevish  and  hard  to  please ;  they  are  as  relentless  as  they  are 
exacting  in  their  demands.  Lithremic  infants  and  children  are  mentally  pre- 
cocious, and  Avhen  ill  and  peevish  between  the  acute  attacks  they  exercise  this 
precocity  in  devising  ways  and  means  to  secure  the  constant  attention  of  all 
around  them. 

From  the  gastro-enteric  type  of  lithsmia  above  described  there  are  many 
variations.  In  children  these  attacks  may  occur,  as  they  commonly  do  in 
adults,  with  little  or  no  elevation  of  temperature.  They  may  or  may  not  be 
accompanied  by  convulsions,  headache,  gastric  pain,  or  dyspnoea.  The  dys- 
pnoea when  it  does  occur  is  an  interesting  symptom,  since  it  is  not  due  to 
pulmonary  causes,  but  is,  like  all  the  other  symptoms,  toxic  in  origin  and  to 
be  classed  as  a  nervous  symptom.  In  rare  instances  vomiting  of  blood  may 
occur  both  in  the  child  and  the  adult,  but  this  symptom  does  not  change  the 
prognosis  or  delay  the  return  of  the  digestive  organs  to  their  normal  condi- 
tion. It  is  of  importance  in  that  such  a  lithjemic  attack  might  be  mistaken 
for  gastric  ulcer. 

In  infancy,  childhood,  and  adult  life  a  chronic  intestinal  fermentation 
may  be  dependent  upon  a  lithsemic  condition,  but  in  these  cases  the  symp- 
toms which  are  always  present  as  a  result  of  chronic  intestinal  fermentation 
are  at  times  aggravated  into  more  acute  attacks  of  gastro-intestinal  disturb- 
ance.  These  acute  gastro-intestinal  attacks  recur  without  apparent  cause 
and  at  more  or  less  regular  intervals,  in  that  way  breaking  in  upon  the 
milder  gastro-enteric  symptoms,  which  are  constantly  present.  This  type 
of  lithsemia  is,  in  the  adult,  commonly  associated  with  great  mental  depres- 
sion. It  may  also  here  be  noted  that  the  pain  from  these  gastric  attacks  is 
not  uncommonly  so  severe  in  the  adult  as  to  demand  for  its  relief  the  hypo- 
dermic use  of  morphine.  The  lith^mic  attacks  of  infancy  and  childhood  are, 
fortunately,  not  so  painful  as  they  may  be  in  later  life.  The  gastro-enteric 
symptoms  of  lithgemia  at  all  ages  may  vary  in  severity  from  a  slight  nervous 
dyspepsia  to  an  attack  of  pain  and  vomiting  so  severe  as  not  only  to  strike 
down,  but  even  to  endanger  the  life  of,  the  patient. 

Nervous  Symptoms. — Nervousness  in  a  great  variety  of  manifestations  is 
to  be  observed  in  lithc^mic  individuals.  It  might  almost  be  said  that  the  entire 
symptomatology  of  lithremia  at  all  ages  may  be  directly  or  indirectly  referred 
to  the  nervous   svstem.      Infants   and   children  with   strong  inborn  lithfemic 


98      AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tendencies  have  very  unstable  nervous  systems.  The  increased  reflex  excita- 
bility of  these  children  predisposes  them  to  general  nervous  irritability. 
They  are  commonly  quick-witted,  bright-faced,  small  and  slender  of  stature, 
and  flit  about  with  quick  and  nervous  movement.  But  lithgemic,  unlike 
tuberculous,  precocity  is  not,  as  a  rule,  coupled  wnth  physical  inferiority ; 
neither  is  lithnemic  precocity  so  fitful,  so  asymmetrical,  and  so  short-lived  as 
the  tuberculous.  Lithtemic  children,  in  fact,  are,  under  proper  restraint,  capa- 
ble of  the  highest  intellectual  development  in  after-life. 

Eclampsia  may  be  a  symptom  of  litluemia.  In  this  connection  the  fol- 
loAving  abstract  of  a  case  reported  by  Irving  Snow  to  the  American  Pediatric 
Society  in  1893  is  of  interest.  This  case  was  reported  under  the  title  "  Gas- 
tric Neurosis  in  Childhood,"  and  the  clinical  history  of  this  child  conforms 
in  almost  every  particular  to  the  gastro-intestinal  form  of  lithsemia  above 
described.  The  lith?emic  attacks  from  Avhich  this  child  suff"ered  commenced 
when  it  Avas  nineteen  months  old.  The  most  characteristic  symptom  of 
these  attacks  was  the  initial  convulsion.  This  was  followed  by  from  three  to 
five  days  of  fever  and  vomiting,  and  then  rapid  convalescence  supervened. 
These  spells  Avere  periodic ;  they  came  and  went  without  apparent  cause  at 
intervals  of  a  few  weeks.  Convulsions  continued  to  mark  the  onset  of  the 
attacks  until  the  child  was  four  years  old,  when  the  convulsions  ceased,  but 
otherwise  the  attacks  Avere  unchanged,  except  that  they  w^ere  more  frequent 
and  possibly  more  severe.  After  the  cessation  of  the  convulsions  the  attacks 
were  characterized  by  "vomiting,  fever,  hypersecretion,  and  irritability  of 
the  stomach,  Avhich  A\ere  independent  of  dietetic  errors  or  of  organic  disease." 
FolloAving  the  report  of  this  case,  similar  cases  w'ere  reported  by  Holt, 
Christopher,  Rotch,  Seibert,  Forchheimer,  and  Cailld,  and  the  opinion  Avas  a 
common  one  that  these  cases  Avere  very  frequently  observed  in  practice,  but 
that  their  etiology  Avas  obscure  and  their  classification  uncertain.  I  have 
here  introduced  the  abstract  of  this  case  and  the  discussion  Avhich  folloAved 
for  the  purpose  of  emphasizing  the  fact  that  eclampsia  is  not  uncommonly 
associated  Avith  other  Avell-marked  lith?emic  symptoms.  I  desire  to  emphasize 
this  clinical  relationship,  since  my  laboratory  experiments  have  demonstrated 
that  eclampsia  may  be  a  symptom  of  lithremia.  The  fact  of  greatest  import- 
ance pertaining  to  lith?emic  eclampsia  is  that  these  convulsions  may  continue 
to  recur  till  finally  Ave  may  have  established  the  type  of  epilepsy  Avhich  has 
been  described  as  migrainous  epilepsy. 

Migraine  is  one  of  the  most  common,  as  well  as  one  of  the  most  charac- 
teristic, symptoms  of  lithnemia  in  adult  life,  and  it  is  but  slightly  less  im- 
portant as  a  manifestation  of  this  condition  in  childhood.  These  paroxysmal 
and  commonly  unilateral  headaches  occur  at  more  or  less  regular  intervals 
Avithout  apparent  cause;  they  are  sometimes  associated  Avith  nausea,  vomit- 
ing, and  gastric  pain,  and  not  infrequently  with  disorders  of  vision.  They 
are  self-limited,  and,  as  a  rule,  end  in  narcotism,  Avhich  produces  a  sleep  from 
Avhich  the  patient  aAvakens  convalescent  from  the  attack.  Migraine  is  quite 
common  in  late  childhood,  and  may  occur  in  very  young  children.  These 
lithaemic  headaches  may  present  tAvo  distinct  clinical  types:  one  that  is  asso- 
ciated Avith  nausea  and  vomiting,  and  commonly  called ''sick  headache;" 
and  the  other,  in  which  there  is  not  the  slightest  trace  of  these  symptoms, 
may  be  designated  as  migrainous  neuralgia.  These  clinical  types  of  migraine 
are  important  from  a  therapeutic  standpoint,  since  they  do  not  yield  alike  to 
the  same  line  of  treatment. 

In  concluding  the  nervous  symptoms  of  lithaemia  it  may  be  broadly  stated 
that  headache,  gastric  pain,  nausea,  vomiting,  eclampsia,  and  rapid  breath- 


LITH^MIA.  99 

ing  (asthma)  are  lithsemic  symptoms  which  may  occur  in  paroxysms,  and 
which  may  be  commingled  in  varying  degrees  of  intensity  to  make  the  clinical 
picture  of  an  individual  attack. 

Eczema  is  one  of  the  most  common  of  lith?emic  manifestations  in  infants. 
and  children.  Special  note  should  be  made  of  the  importance  of  this  symp- 
tom, since  the  successful  treatment  of  this  form  of  eczema  depends  upon  the 
recognition  and  treatment  of  the  lithsemic  element.  Lithsemic  eczema  may 
occur  in  well-nourished  children  with  a  family  history  of  lithgemia,  and  is  to 
be  carefully  diiferentiated  from  tuberculous  eczema,  since  the  two  types 
require   radically  different  constitutional  treatment. 

Urine  in  Lithcemia. — The  urine  excreted  during  a  lithgemic  paroxysm  is, 
as  a  rule,  scant  and  unusually  acid  in  reaction.  It  is  highly  colored,  and 
the  specific  gravity  is  generally  considerably  increased :  on  standing  it 
deposits  a  red  sand  of  urates.  In  the  urines  passed  immediately  following 
lithaemic  headache,  lithjemic  eclampsia,  and  certain  other  of  the  more  severe 
forms  of  lithamia  the  poisonous  xanthin  bodies,  paraxanthin  and  hetero- 
xanthin,  may  be  found  in  enormous  excess  of  the  normal  minute  quantities 
of  these  substances  present  in  the  urine  of  non-lithgemic  individuals.  Special 
note  should  be  made  of  the  fact  that  albumin  may  occur  in  the  urine  during, 
and  for  some  days  after,  a  lithgemic  attack,  and  then  entirely  disappear.  This 
recurrent  and  transient  albuminuria  is  not  a  very  common  symptom  of  lith- 
Eemia,  but  when  it  does  occur  it  is  a  very  characteristic  and  significant  one. 
It  is,  in  fact,  a  danger  signal,  which  being  interpreted  means  that  most  care- 
ful treatment  must  be  begun  and  continued  if  the  kidney  is  to  be  saved  from 
irreparable  damage. 

Treatment. — The  dietetic  treatment  of  lithaemia  is  of  the  first  importance 
in  infancy,  as  it  is  at  all  periods  of  life.  Mother's  milk  is  an  ideal  food  for 
lithsemic  infants,  but  when  it  becomes  necessary  to  supplement  this  food  it  is 
best  to  do  so  with  cow's  milk  to  which  cereals  have  been  added.  I  have 
been  much  impressed  with  the  importance  of  adding  barley-  or  rice-water  to 
cow's  milk  as  a  food  for  these  children.  Jacobi  for  many  years  has  enthusi- 
astically advised  that  cow's  milk  as  a  food  for  infants  should  always  be  mixed 
with  cereals,  and  it  is  my  experience  that  this  is  of  special  importance  to 
lithgemic  infants.  Beef-juice  and  meat  soups  and  teas  are  at  all  times  con- 
traindicated.  When  the  lithsemic  infant  becomes  a  child,  the  milk  and 
cereals,  including  bread,  should  continue  to  occupy  the  most  important  place 
upon  his  bill  of  fe,re.  Milk  and  cereals  are,  in  fact,  ideal  foods  for  lithsemics 
of  all  ages.  As  the  child  develops,  it  becomes  necessary  to  add  eggs,  fish, 
and  poultry  to  his  diet.  These  foods  are  very  much  to  be  preferred  to 
butcher's  meat  as  a  means  of  furnishing  proteid  food  to  the  rapidly  develop- 
ing lithaemic  child.  Butcher's  meat  may,  however,  be  allowed  in  small 
quantities  once  a  day  to  lith^mic  children  who  lead  an  active  out-door  life. 
In  advising  as  to  the  proscribed  and  prescribed  proteid  foods  for  lithgemic 
children  it  is  well  to  keep  in  mind  that  the  following  foods  are  to  be  recom- 
mended in  the  order  named :  Milk,  eggs,  fish,  oysters,  poultry,  game,  and 
butcher's  meat.  At  the  beginning  of  this  list  we  have  the  best,  and  at  the 
end  the  worst,  foods  for  lith?emics  of  all  ages.  Fresh  fruits  and  fresh  vege- 
tables should  enter  largely  into  the  diet  of  all  lithfemic  children,  and  these 
foods,  together  Avith  milk,  eggs,  and  cereals,  should  constitute  the  almost  exclu- 
sive diet  until  they  are  old  enough  to  live  a  very  active  out-door  life.  Then, 
as  above  indicated,  fish,  poultry,  and  in  small  quantities  butcher's  meat,  may 
be  added.  In  the  treatment  of  adults  I  advise  that  they  eat  moderately  of 
simple  food  and  abstain  absolutely  from  wine  and  malt  liquors.     In  this  bit  of 


100   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

advice  we  have  a  condensed  statement  of  the  dietetic  management  of  lithae- 
mia.  Over-eating  is  a  factor  in  its  cause,  and  under-eating  is  a  factor  in  its 
cure.  Lithiemics  for  this  reason  should  be  advised  against  taking  an  excess 
of  food  of  any  kind.  Meats  may  be  taken  only  in  such  quantities  as  are 
necessary  to  supply  the  proteid  waste  and  repair  of  the  body,  but  it  will  be 
found  that  most  lithamics  take  meat  largely  in  excess  of  this  quantity.  It 
will  therefore  be  necessary  to  place  restrictions  on  the  quantity  of  meat 
taken,  and  substitute  poultry,  game,  fish,  oysters,  eggs,  as  above  directed. 
No  harm,  however,  can  come  to  lithaemics  leading  an  active  life  from  the 
moderate  use  of  these  simple  proteid  foods.  The  only  care  necessary  is 
to  avoid  an  excess  of  these  foods  and  to  see  that  they  are  prepared  in  a  sim- 
ple and  digestible  form.  Fries  and  salads  are  objectionable,  and  fresh  pork, 
lobsters,  and  crabs  are  not  to  be  commended.  Sweets,  such  as  candies, 
pastries,  and  preserves,  are  to  be  used  sparingly  if  at  all.  The  knowledge 
that  sweets  are  injurious  to  lithremics  is  a  bit  of  information,  born  of  clinical 
experience,  upon  Avhich  almost  all  writers  are  agreed.  Sweets  are  therefore 
to  be  restricted,  even  though  we  cannot  trace  the  connection  between  this 
class  of  foods  and  the  nitrogenous  poisons  which  are  thought  to  be  the  cause 
of  the  symptoms  of  lithgemia.  Milk,  cereals,  fresh  fruit,  and  fresh  vegetables 
should  continue  to  be  the  most  important  foods  of  lithamics  throughout  life. 

Exercise  in  the  open  air  is  scarcely  less  important  than  diet  to  lithwmic 
children.  They  should,  therefore,  be  encouraged  in  all  kinds  of  out-door 
athletic  sports.  It  will  be  found  that  many  of  these  lithfemic  children  re- 
quire a  great  deal  of  urging  and  commanding  in  order  to  have  them  take  the 
proper  amount  of  exercise  in  the  open  air.  It  is  a  common  observation  that 
lithjTemic  children  are  averse  to  out-door  exercise  and  very  fond  of  in-door 
intellectual  pursuits.  The  out-of-school  companions  of  lithsemic  children 
should  be  bicycles,  skates,  and  tennis  racquets  instead  of  books.  Wholesome 
exercise  in  the  open  air  is  necessary  to  the  pro])er  physical  and  intellectual 
development  of  any  child,  but  lack  of  exercise  is  especially  baneful  to  one  of 
inborn  lithaemic  tendencies.  Exercise  promotes  the  nitrogenous  metabolism  ; 
it  furnishes  the  conditions  for  the  more  complete  oxidation  of  the  alloxuric 
bodies  into  harmless  nitrogenous  extractives.  The  air  in  which  the  exercise 
is  taken  should  be  as  pure  as  possible.  City  children  of  this  type  should 
have  two  or  three  months  of  active  out-door  life  in  the  country  every  year. 
They  may  be  sent  to  the  seashore,  the  mountains,  or  a  neighboring  farm 
with  almost  equal  advantage.  Fothergill  believed  that  a  certain  amount  of 
pure  country  air  was  absolutely  necessary  to  the  satisfactory  development  of 
lithogmic  children. 

Before  beginning  the  medical  treatment  of  lith?emia  one  should  make  a 
careful  search  for  such  reflex  factors  as  may  possibly  contribute  toward  pre- 
cipitating lithjemic  paroxysms.  If  eye-strain  exists,  it  should  be  corrected. 
If  pelvic  or  rectal  disease  be  present,  it  should  be  treated.  In  short,  all 
reflex  factors  should,  if  possible,  be  removed  before  other  treatment  is  com- 
menced. While  I  am  convinced  that  the  reflex  factors  have  had  undue 
prominence  given  them  in  the  study  and  treatment  of  lith?emic  paroxysms, 
yet  I  am  not  pessimistic  enough  to  believe  that  they  should  be  disregarded 
in  the  treatment  of  these  conditions.  Pelvic  disease,  I  think,  especially  de- 
mands treatment  when  it  occurs  in  cases  where  the  lithaemic  paroxysms  coin- 
cide with  the  menstrual  period.  The  failure  of  medicinal  and  dietetic  treat- 
ment to  cure  certain  lithsemic  paroxysms  may  sometimes  be  due  to  the  fact 
that  there  is  present  some  eye,  preputial,  or  pelvic  disease  which  continues 
to  act  as  a  potent  reflex  factor  in  calling  forth  these  paroxysms. 


LITH^MIA.  101 

The  medicinal  treatment  of  lithaemia  should  aim  to  cure  constipation  and 
to  favor  the  elimination  and  promote  the  oxidation  of  the  alloxuric  bodies 
which  are  believed  to  be  the  materiel  morhi  of  this  affection.  In  infants  and 
children  it  may  advantageously  be  begun  with  small  doses  of  calomel  and 
soda  repeated  at  short  intervals  until  catharsis  begins.  After  a  day  or  two 
of  rest  from  medication  our  little  patients  may  be  given  some  form  of  ellmi- 
native  treatment.  Volumes  have  been  written  on  the  drugs  which  are  given 
for  the  purpose  of  eliminating  the  poisons  of  lithaemia,  and  there  always  has 
been,  and  possibly  will  be  for  some  time  to  come,  much  confusion  as  to  their 
comparative  value.  It  is  my  belief  that  the  salts  of  salicylic  acid  are  the  most 
valuable  eliminative  medicines  we  have.  After  the  preliminary  calomel  course 
it  is  my  custom  to  order  some  salicylate,  the  one  selected  depending  upon  the 
age  of  the  child  and  the  nature  of  the  symptoms.  Salol  is  especially  useful.  I 
have  seen  lithsemic  infants  suffering  from  chronic  intestinal  fermentation  with 
gastric  crises  very  much  benefited  by  one  grain  of  this  drug  after  each  nursing. 
Other  antiseptics  will  not  accomplish  the  same  result,  and  it  is  not,  therefore, 
simply  a  question  of  intestinal  antiseptics.  The  salol  in  these  cases  must 
be  continued  for  weeks  or  months  in  doses  to  suit  the  age  of  the  child.  If  the 
lithaemic  manifestation  be  an  eczema,  salol  is  equally  advantageous;  in  such 
cases  I  also  commonly  give  a  few  grains  of  phosphate  of  sodium  or  benzoate 
of  lithium  dissolved  in  each  portion  of  food.  An  infant  two  years  of  age 
may  be  given  in  this  way  twenty  grains  of  the  phosphate  of  sodium  and  three 
grains  of  the  benzoate  of  lithium  in  twenty-four  hours.  In  a  word,  salol, 
phosphate  of  sodium,  and  benzoate  of  lithium  are  the  medicines  usually  relied 
upon  in  the  treatment  of  infantile  lithaemia,  and  great  good  can  be  accom- 
plished by  their  intelligent  use  in  connection  with  such  dietetic,  hygienic,  or 
local  treatment  as  the  special  manifestations  suggest.  Should  the  phosphate 
of  sodium  fail  to  regulate  the  bowels  (almost  all  of  these  cases  are  constipated), 
it  becomes  absolutely  necessary  to  supplement  this  treatment  with  a  laxative 
which  will  evacuate  the  upper  intestine.  Enemas  and  suppositories  may  be 
used  as  assistants  to  other  laxatives,  but  they  are  not  to  be  relied  upon  exclu- 
sively. I  wish  here  to  especially  insist  that  this  laxative  treatment  is  as 
absolutely  necessary  in  the  lithaemia  of  infants  and  children  as  it  is  in  adults. 
Salicylate  of  sodium  may  be  advantageously  substituted  for  salol  in  children 
over  five  or  six  years  of  age.  The  salicylate  of  sodium  derived  from  winter- 
green  is  preferable,  because  it  is  more  palatable  and  less  irritating  to  the  gastric 
mucous  membrane.  It  should,  if  possible,  be  given  in  a  little  Seltzer  water, 
which  may  for  convenience  be  obtained  in  siphon.  The  siphon  of  Seltzer 
should  be  kept  in  a  cool  place,  and  the  water  may  be  drawn  into  a  glass  con- 
taining the  dose  of  salicylate.  In  this  way  it  is  possible  to  give  the  drug 
for  an  indefinite  time  without  disgusting  the  palate  or  irritating  the  stomach. 

While  the  salicylates  are  our  best  remedies  in  all  forms  of  lithaemia,  the 
salts  of  lithium  are  also  of  value  in  certain  manifestations  of  the  disease.  The 
natural  lithia  waters  may  be  used,  and  it  is  much  in  their  favor  that  these 
waters  are  tasteless,  and  therefore  readily  taken  by  infants  and  children. 
Much  of  their  efficacy,  however,  is  due  to  the  water  itself  rather  than  to  the 
lithia  it  contains.  Many  lithaemic  patients  drink  little,  and  will  be  greatly 
benefited  by  simply  increasing  the  quantity  of  liquid  taken  in  twenty-four 
hours.  Mention  has  previously  been  made  of  the  importance  of  giving 
newly-born  infants  water  to  drink,  since  it  is  often  needed  to  dissolve  and 
thereby  favor  the  excretion  of  urates  that  might  otherwise  irritate  the 
inflamed  urinary  passages.  For  the  same  reasons  lithaemic  patients  of  all 
ages   are  benefited  by  drinking   water,   and  much  of  the  benefit  derived 


102   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

from  drinking  sulphur  and  other  waters  at  the  springs  comes  from  the  large 
quantity  of  liquid  taken,  rather  than  the  contained  medicinal  agent.  Yet 
in  giving  full  credit  to  water  as  a  remedy  one  must  not  overlook  the  fact 
that  many  natural  Avaters  contain  salts — lithia,  for  example — that  are  of  real 
value  in  the  treatment  of  lithsemia.  Of  the  lithia  salts,  the  benzoate  and  citrate 
are  much  to  be  preferred,  and  I  would  select  the  benzoate,  as  it  gives  the  best 
results.  For  infants  the  dose  is  gr.  ss-j  three  times  a  day  dissolved  in  milk ; 
to  older  children  it  may  be  given  in  tablet  form  or  dissolved  in  water.  The 
citrate  of  lithium  is  somewhat  less  efficient,  but  more  palatable,  than  the 
benzoate. 

The  soda  salts  are  of  great  value  in  the  treatment  of  lithtemia,  and  the 
mineral  waters  which  are  composed  largely  of  these  salts — such,  for  example, 
as  Carlsbad — have  a  well-deserved  reputation.  The  following  prescription 
has  long  been  a  favorite  with  me  for  older  children  and  adults: 

I|<.   Sodii  salicylatis  (from  wintergreen)      .    .    .  sij  ; 

Sodii  phosphat.,  dry Hiv  ; 

Sodii  sulphat.,  dry siss. — M. 

Sig.  A  teaspoonful,  more  or  less,  in  a  small  glass  of  Seltzer  water 
before  breakfast  every  morning  or  every  second  morning. 

It  is  important  that  dry  salts  be  used  in  this  prescription.  The  dose  is 
to  be  regulated  by  the  cathartic  eifect.  Violent  daily  catharsis  is  not  to  be 
desired,  but  a  decided  laxative  eifect  must  be  produced.  In  connection  with 
this  treatment  I  commonly  use  one  of  the  following  prescriptions : 

First :  A  one-grain  salol-coated  pill  of  permanganate  of  potash  (Upjohn), 
which  is  to  be  given  directly  after  each  meal  to  all  lithgemic  patients  having 
pronounced  gastro-intestinal  symptoms.  (Sick  headache  and  the  gastro- 
enteric types  of  lithoemia  belong  to  this  class.) 

Second :  A  capsule  containing  from  two  and  a  half  to  five  grains  of  salol 
and  from  one-twelfth  to  one-quarter  grain  of  cannabis  Indica,  which  is  to  be 
given  after  each  meal  to  all  patients  in  whom  the  lithsemic  paroxysms  are 
not  associated  Avith  gastro-enteric  symptoms.  (Migrainous  neuralgia  and 
lithaemic  epilepsy  belong  to  this  class.) 

These  prescriptions  are  to  be  used  in  connection  with  the  soda  salts,  and 
are  especially  adapted  for  the  treatment  of  lithtemia  in  late  childhood  and 
adult  life.  They  are  not  suited  to  young  children  or  to  frail  and  wasted 
lithgemics  of  any  age. 

Dilute  nitro-muriatic  acid  and  colchicum  have  long  held  a  place  among 
medicines  Avhich  are  of  value  in  the  treatment  of  lithsemia.  Both  may  be 
given  to  older  children  and  adults,  but  are  not  to  be  employed  in  infants  and 
young  children.  The  dilute  nitro-muriatic  acid  in  five-drop  doses,  well 
diluted,  before  meals,  is  a  valuable  remedy  in  the  treatment  of  lithaemic 
headaches  in  older  children.  The  wine  of  colchicum  in  five-  to  eight-drop 
doses  may  be  tried  for  the  relief  of  painful  lithoemic  paroxysms  of  any  kind. 

For  stout  and  vigorous  patients  the  natural  waters  are  of  great  value, 
especially  those  of  the  thermo-alkaline  springs  of  Virginia  and  Arkansas 
and  waters  of  the  Carlsbad  type.  The  Bedford  Springs  of  Pennsylvania, 
the  Crab  Orchard  Springs  of  Kentucky,  the  St.  Clair  and  Mount  Clemens 
Springs  of  Michigan,  the  Saratoga  Springs  of  New  York,  and  the  West  Baden 
and  French  Lick  Springs  of  Indiana  may  also  be  recommended. 


HEREDITARY  SYPHILIS. 

By  henry  DWIGHT  CHAPIN,  M.  D., 

New  York. 


No  period  of  life  is  exempt  from  syphilis,  which  has  been  aptly  styled 
"the  least  venereal  of  the  venereal  diseases."  It  is  a  chronic  infectious  pro- 
cess, doubtless  of  microbic  origin,  the  ravages  of  which  are  modified  by  age, 
conditions  of  body,  and  environment.  The  micro-organism  most  commonly 
associated  with  syphilis  as  a  probable  causative  agent  has  been  found  by  Lust- 
garten  within  the  cellular  protoplasm  of  syphilitic  products.  He  describes  it 
as  a  bacillus  from  three  to  seven  micro-millimetres  in  length,  with  often  a 
slightly  wavy  shape.  Unfortunately,  pure  cultures  have  not  been  made  of 
this  bacillus,  and  the  fact  that  the  lower  animals  do  not  contract  syphilis  pre- 
vents the  possibility  of  proof  by  inoculation. 

Syphilis  in  early  life  may  be  either  hereditary  or  acquired.  It  is  not  neces- 
sary to  consider  acquired  syphilis  at  length  in  a  work  devoted  to  diseases  of 
children,  as  it  presents  no  essential  differences  from  the  same  affection  in  adult 
life.  It  may  be  well  to  bear  in  mind,  however,  that  syphilis  detected  in  infancy 
is  not  necessarily  inherited,  but  may  be  acquired.  A  primary  sore  upon  the 
genital  tract  of  the  mother  may  infect  the  infant  during  birth,  though  the 
possibility  of  this  has  been  denied.  The  nurse  or  attendant  may  have  a 
primary  lesion  upon  breast  or  lips.  Much  more  common  will  be  infection 
from  some  secondary  lesion,  especially  a  mucous  patch  upon  the  mouth  or  lips. 
There  are  many  ways  in  which  the  blood  or  infective  secretions  of  a  syphilitic 
patient  may  come  in  contact  with  a  solution  of  continuity  in  the  skin  or  mucous 
membranes  of  an  infant  or  child.  In  such  a  case  a  chancre  will  appear  at  the 
point  of  contact,  followed  in  due  time  by  the  after-lesions  of  the  disease.  There 
are  certain  peculiarities  in  the  effect  of  the  syphilitic  virus  upon  young  proto- 
plasm which  will  be  noted  under  the  Morbid  Anatomy. 

The  subject  will  be  here  considered  under  the  two  heads  of  hereditary 
syphilis  in  infancy,  and  the  taint  as  it  is  seen  in  childhood  or  when  appar- 
ently delayed. 

Hereditary  Syphilis  in  Infancy. 

The  disease  may  be  acquired  from  the  father  or  mother,  or  from  both 
parents,  the  poison  being  lodged  in  the  spermatozoa  of  the  male  or  the  ovum 
of  the  female. 

Paternal  Influence. — While  it  has  been  denied  by  some  observers  that 
the  father  alone  can  transmit  syphilis,  the  consensus  of  opinion  is  in  favor  of 
the  possibility  of  such  transmission,  which  can  and  does  take  place.  The 
chances  of  this  transmission  depend  upon  certain  factors,  such  as  the  stage  of 
the  disease  and  the  degree  of  its  intensity,  as  well  as  the  thoroughness  with 
which  treatment  has  been  followed.     Without  mercurial  treatment  the  sperma- 

103 


104    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tozoa  can  usually  transmit  the  syphilitic  poison  during  the  first  year  after  pri- 
mary infection,  and  there  is  great  danger  to  the  foetus  from  syphilitic  contagion 
up  to  the  fourth  year.  The  longer  the  duration  of  the  disease,  the  less  will  be 
the  danger  to  the  offspring,  owing  to  the  periods  of  latency  observed  during  its 
later  stages.  If  the  father  be  subjected  to  early  and  thorough  treatment,  the 
probability  of  transmission  of  the  disease  will  be  much  lessened,  and  such  a 
possibility  soon  becomes  lost  with  a  reasonable  laj)se  of  time.  If  the  father 
infect  the  mother,  as  frequently  happens,  there  will  be  a  double  syphilization 
of  the  offspring,  which  will  probably  be  stillborn  or  soon  succumb  to  an  aggra- 
vated form  of  the  disease.^ 

Maternal  Influence. — The  influence  of  the  mother  upon  the  growth  and 
development  of  the  foetus  contained  within  her  uterus  is  obviously  very  great, 
and  hence  when  she  is  suffering  from  constitutional  syphilis  the  disease  is 
transmitted  in  an  active  stage  to  her  child.  The  degree  of  such  transmission 
depends,  as  noted  above  in  the  case  of  the  father,  upon  the  stage  and  severity 
of  the  disease  and  the  nature  of  the  treatment  employed.  During  periods  of 
latency  the  mother  may  bear  healthy  children,  followed  by  abortions  or  syphi- 
litic infants  caused  by  renewed  manifestations  of  the  disease.  It  has  been  con- 
sidered that  the  power  of  transmission  is  practically  lost  at  the  end  of  six 
years.  As  a  general  rule,  it  can  be  stated  that  the  chances  of  infection  of  the 
foetus  and  the  severity  of  the  type,  if  infected,  are  in  direct  proportion  to  the 
activity  of  the  syphilis  in  either  or  both  parents.  It  has  been  said  that  if  the 
mother  contract  syphilis  before  the  eighth  month  of  utero-gestation,  she  may 
transmit  the  disease  to  the  foetus,  although  healthy  at  the  time  of  conception. 
Dr.  Taylor,  on  the  contrary,  denies  tliat  the  syphilis  of  the  mother,  acquired 
during  pregnancy,  can  be  conveyed  to  the  foetus  through  the  utero-placental 
circulation,  as  the  disease  is  only  communicated  either  by  the  sperm-cells  or  by 
the  ovule  diseased  at  the  time  of  conception.  One  of  the  peculiar  phenomena 
seen  in  connection  with  infants  who  are  born  syphilitic  is  that  the  mother  may 
apparently  be  free  from  any  taint  of  the  disease.  It  has  been  a  subject  of 
much  dispute  whether  these  are  instances  of  latent  syphilis  or  whether  the 
women  are  really  healthy.  Whatever  the  cause,  these  cases  show  immunity  in 
contracting  syphilis. 

In  1837,  Colles  wrote  that  "  a  new-born  child  affected  with  inherited  syphi- 
lis, even  although  it  may  have  symptoms  in  the  mouth,  never  causes  ulceration 
of  the  breast  which  it  sucks  if  it  be  the  mother  who  suckles  it,  although  con- 
tinuing capable  of  infecting  a  strange  nurse."  The  substantial  truth  of  this 
dictum  has  not  been  seriously  questioned  during  the  many  years  that  have 
elapsed  since  its  enunciation,  although  varying  explanations  have  been  offered. 
Fournier  states  that  the  inoculation  experiments  of  Caspari  and  Neumann  have 
proved  conclusively  that  the  apparent  immunity  of  the  mother,  who  has  borne 
a  child  syphilitic  by  its  father,  against  the  contraction  of  the  disease  from  her 
offspring,  is  due  to  the  fact  that  she  has  already  been  infected  by  syphilis  dur- 
ing the  intra-uterine  period  of  the  child's  life.  Thus,  conceptional  syphilis  is 
to  be  classed  with  the  hereditary  form  of  the  disease,  since  there  is  here  no  pri- 
mary lesion.  This  form  of  conceptional  syphilis  may  remain  latent  for  years. 
Diday  advances  as  an  explanation  of  Colles'  law  the  idea  that  all  infectious  dis- 
eases may  certainly  be  mitigated  to  the  point  of  absolute  protection  by  the 
methodically  repeated  inoculation  of  their  essential  cause  (microbic)  or  of  its 
products  (toxic  ptomaines,  etc.).  Bouchard  considers  that  while  the  foetus 
retains  the  supposed  pathogenic  agent  itself,  the  products  dissolved  in  the 
blood  find  their  way  to  the  tissues  of  the  mother  and  set  up  a  nutritive  change, 
^  Dr.  F.  E.  Sturgis  strongly  denies  the  paternal  transmission  of  syphilis. 


HEREDITARY  SYPHILI8.  105 

resulting  in  what  he  calls  a  "bactericidal  condition,"  which  renders  difficult  or 
impossible  the  development  of  the  infectious  agent  when  introduced  by  later 
inoculation,  as  from  the  lips  of  her  child.  The  doctrine  of  syphilis  being  con- 
tracted by  conception,  sometimes  called  "choc  en  retour,"  although  having 
wide  acceptance,  is  not  acknowledged  by  all.  Kassowitz  believes  that  the 
women  who  appear  healthy  and  remain  so,  even  after  giving  birth  to  syphilitic 
children,  are  really  free  from  specific  taint. 

Syphilis  of  the  Placexta. — Dr.  Frankel  in  1873  published  a  paper  in 
which  he  affirmed  the  existence  of  three  forms  of  involvement  of  the  placenta 
by  syphilis — i.  e.,  endometritis  decidualis,  endometritis  placentaris,  and  disease 
of  the  villous  portion  of  the  foetal  placenta.  This  conclusion  was  based  upon 
an  examination  of  over  one  hundred  placentae.  Zilles  in  1885  published  the 
results  of  a  study  of  three  hundred  placentge  derived  from  Prof.  Saxinger's 
obstetrical  clinic.  He  finds  that  placental  syphilis  can  often  be  diagnosed 
microscopically,  and  that  it  oftenest  happens  in  connection  with  foetal  syphilis. 
The  maternal  portion  of  the  placenta  or  the  foetal  part  only  may  be  affected, 
while,  again,  the  whole  of  the  placenta  may  be  involved  in  the  disease.  Syphi- 
lis is  one  of  the  recognized  causes  of  hydramnios. 

Morbid  Anatomy. — The  lesions  of  syphilis,  while  always  essentially  the 
same,  Avill  nevertheless  be  modified  by  age.  Young  protoplasm  is  active,  and 
usually  exhibits  a  marked  reaction  to  irritative  processes,  so  that  the  tissues 
are  apt  to  be  extensively  involved  in  hereditary  syphilis.  The  lesions  may  be 
broadly  divided  into  those  involving  the  skin  and  mucous  membranes,  the  vis- 
cera, and  the  bones. 

Skin"  and  Mucous  Membranes. — The  skin  may  be  affected  by  erythema, 
maculo-papules,  or  papules.  A  vesicular  and  pustular  eruption  may  occasion- 
ally be  seen.  Blebs  or  buUse  often  appear  at  birth  in  a  severe  type  of  the 
disease.  Crops  of  boils,  with  well-defined,  coppery-red  bases,  are  apt  to  be 
symmetrically  arranged  when  many  are  present,  or  asymmetrically  distributed 
if  only  a  few  are  seen.  The  distribution  and  course  of  the  various  eruptions 
will  be  noted  more  at  length  under  Symptoms.  In  general,  they  develop 
quickly  and  spread  over  extensive  areas  of  surface  on  account  of  the  character 
of  infant  protoplasm,  noted  above,  as  well  as  from  the  activity  of  the  circula- 
tion in  the  skin. 

The  lesions  of  the  mucous  membranes  may  be  in  the  form  of  catarrhal  pro- 
cesses, of  mucous  patches,  or  of  superficial  or  deep  ulcerations.  Any  or  all  of 
these  lesions  may  involve  any  part  of  the  alimentary  tract  or  of  the  respiratoiy 
tract.  They  are  seen  most  commonly,  however,  in  the  upper  part  of  these 
areas,  in  some  part  of  the  mouth  or  fauces  in  the  former  case,  and  in  the  nose 
and  larynx  in  the  latter.  Still,  they  may  likewise  occasionally  involve  the 
intestine  or  trachea  and  bronchial  tubes. 

Visceral  Lesions. — The  viscera  are  apt  to  be  more  extensively  involved 
in  hereditary  than  in  acquired  syphilis,  the  lesion  being  in  the  form  of  an  inter- 
stitial hyperplasia  more  or  less  diffuse.  Circumscribed  gummy  infiltrations 
are  not  so  frequent.  The  growth  of  interstitial  connective  tissue,  which  grad- 
ually contracts,  thereby  partially  obliterating  the  parenchyma  of  the  organ,  may 
involve  the  lungs,  spleen,  liver,  pancreas,  and  testicle. 

Lungs. — Usually  a  portion  of  a  lobe,  but  occasionally  a  whole  lobe,  may 
present  a  diffuse  fibroid  infiltration.  The  part  involved  is  grayish-white  in 
color  and  tough  in  consistency,  and  surrounded  by  an  inflamed  pleura.  Under 
the  microscope  there  is  seen  to  be  thickening  of  the  septa  and  compression  of 
the  alveoli  by  fibrous  tissue,  which  is  quite  vascular.  Occasionally  a  few 
rounded  masses  about  the  size  of  a  hickory-nut  may  be  noted.     These  gum- 


106  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

mata  may  break  down  in  the  centre  into  puriform  matter,  but  they  are  not  apt 
to  exist  in  the  same  subject  that  the  diffuse  interstitial  inflammation  attacks. 

iSplee)!. — The  spleen  is  generally  more  or  less  enlarged  from  a  diffuse  inter- 
stitial hyperplasia.  There  usually  coexists  a  thickening  of  the  capsule.  Accord- 
ing to  Dr.  Gee,  the  severer  the  grade  of  syphilis  the  greater  will  be  the  hyper- 
trophy of  the  spleen.  This  enlargement  may  remain  persistent  for  a  long  time 
after  other  symptoms  have  disappeared. 

Liver. — The  liver,  which  is  not  infrequently  affected,  is  hardened  and 
enlarged  from  a  diffused  sclerosis.  Occasionally  the  affection  may  be  circum- 
scribed. The  hepatic  cells  are  compressed  and  the  capillary  blood-vessels 
partly  obliterated  by  the  pressure.  As  in  cirrhosis  in  the  adult,  section  of  the 
liver  is  accompanied  by  creaking,  and  the  cut  surface  presents  a  yellowish  area, 
interwoven  with  whitish  opaque  streaks  of  fibro-plastic  matter.  The  capsule 
of  Glisson  may  be  thickened  upon  the  surface  of  the  liver,  and  there  may  be 
local  peritonitis.  Gummata,  in  the  form  of  small,  circumscribed  nodules,  may 
be  found  in  the  tissue  of  the  liver.  They  may  be  seen  in  association  with  cir- 
rhosis.    These  nodules  are  yellowish,  with  a  tendency  to  soften  in  the  centre. 

Pancreas. — Birch- Hirschfeld  has  called  attention  to  the  fact  that  there  may 
be  hyperplasia  of  the  connective  tissue  of  the  pancreas,  which  on  section  pre- 
sents the  same  fibroid  appearance  seen  in  the  liver  and  other  visceral  organs 
thus  affected.  He  found  in  a  few  cases  the  head  of  the  organ  more  involved 
than  the  remaining  part  of  the  gland. 

Testicles. — An  interstitial  orchitis  may  affect  one  or  both  testicles,  produ- 
cing hardening  and  slight  enlargement  of  the  glands.  The  hyperplasia  may 
be  uniformly  distributed  through  the  organ,  or  the  latter  may  be  irregularly 
involved.  The  epididymis  is  not  usually  affected.  Atrophy  of  the  seminal 
ducts  may  ensue.  Sufficient  change  in  the  testicle  to  be  detected  clinically  is 
not  often  seen  in  hereditary  syphilis. 

Kidneys. — Parrot  has  found  small  tumors,  produced  by  infiltrations  of  round 
cells  into  the  connective-tissue  stroma,  which  compress  the  tubules,  and  thus 
cause  a  colloid  degeneration  of  the  contained  epithelium.  If  this  process  is 
extensive,  it  Avill  eventuate  in  a  general  atrophy  of  the  kidney.  General 
nephritis  may  be  seen  in  hereditary  syphilis,  but  it  is  difficult  to  say  whether 
the  latter  is  more  than  a  predisposing  cause  of  the  former  condition. 

Heart. — Gummata  may  be  found  in  the  heart.  Dr.  Coupland  has  reported 
a  case  where  the  walls  of  this  organ  Avere  thickened  and  hardened. 

Bone  Lesions. — Waldemeyer,  Kbbner,  Parrot,  and  R.  W.  Taylor  have 
shown  that  various  bony  lesions  are  quite  common  in  hereditary  syphilis. 
Many  of  these  lesions,  that  were  formerly  referred  to  rickets  or  scrofula,  are 
now  recognized  as  syphilitic.  There  are  two  principal  ways  in  which  the  spe- 
cific poison  affects  the  bones  in  early  life.  In  one  instance  the  brunt  of  the 
disease  and  morbid  change  takes  place  at  the  junction  of  the  shaft  with  the 
epiphysis  ;  in  the  other,  the  periosteum  covering  the  long  bones  is  principally 
affected.     Both  of  these  varieties  involve  principally  the  long  bones. 

Osteo-chondritis. — This  inflammatory  process  is  induced  only  by  syphilis, 
and  may  be  the  sole  manifestation  of  the  taint.  The  lesion  starts  in  the  car- 
tilage joining  the  epiphysis  with  the  diaphysis,  where  normal  groAvth  in  length 
of  the  bones  takes  place ;  hence  deformity  of  the  bone,  due  to  a  crippling  of 
its  proper  development,  may  ensue.  The  lesion  most  commonly  affects  the 
bones  of  the  forearm,  leg,  arm,  and  thigh,  although  other  bones  may  be 
involved,  such  as  the  metacarpal  and  metatarsal  bones,  the  clavicle,  sternum, 
and  ribs. 

The  number  of  the  bones  affected  appears  to  depend,  to  a  certain  extent, 


HEBEDITABY  SYPHILIS.  107 

upon  the  severity  of  the  general  poisoning.  It  has  been  found  in  stillborn 
infants  that  most  of  the  long  bones  may  be  thus  affected,  and  in  those  born 
living,  if  the  bone  lesion  is  multiple,  recovery  is  uncommon.  The  cartilage 
affected  first  becomes  thickened  and  soft  from  proliferation  of  cartilage-cells, 
and  there  is  at  the  same  time  lessening  of  the  intercellular  substance.  This 
may  be  felt  as  a  sort  of  collar-like  swelling  at  the  end  of  the  bone  affected. 
The  swelling  may  be  visible  if  the  child  is  not  too  fat.  If,  as  occasionally 
happens,  one  portion  or  side  of  the  cartilage  only  is  involved,  the  swelling  will 
be  felt  not  to  completely  encircle  the  bone,  but  as  a  circumscribed  nodule. 
The  disease  is  apt  to  be  symmetrical  and  involve  the  distal  oftener  than  the 
proximal  ends  of  the  bones.  There  is  little  change  in  the  integument  or  sur- 
rounding tissues  in  many  cases,  as  the  disease  is  not  apt  to  extend  farther  than 
the  bone.  In  such  a  case  the  swelling  may  remain  for  a  long  time,  accom- 
panied by  little  pain  or  disability.  It  may  originally  develop  slowly  or  quickly, 
and  its  disappearance  will  usually  promptly  follow  a  proper  mercurial  treatment. 
In  some  cases,  however,  degenerative  changes  may  ensue,  with  a  breaking 
down  of  some  part  of  the  SAvelling.  If  the  morbid  process  continues,  there 
will  be  softening,  soon  followed  by  ulceration  of  the  skin.  If  suppuration 
keeps  up,  the  cartilage  will  be  destroyed  and  the  epiphysis  completely  sepa- 
rated from  the  diaphysis.  Even  in  these  cases  the  joint  is  not  apt  to  be 
involved,  although  cases  of  subacute  synovitis,  and  even  pus  in  the  joint,  have 
been  reported.  If  the  ulceration  is  extensive,  the  epiphysis,  when  completely 
separated,  may  be  extruded.  When  there  is  destruction  of  the  cartilage  and 
epiphysis,  there  will  of  course  ensue  arrest  of  growth  and  consequent  deformity 
in  the  limb.  Parrot  has  described  cases  in  which  the  skin  remains  unbroken 
after  separation  of  the  epiphysis,  inducing  a  condition  of  paralysis  in  the 
affected  part.  Dr.  Taylor  describes  cases  in  Avhich,  the  intervening  cartilage 
having  been  destroyed,  the  epiphysis  is  united  to  the  shaft  only  by  fibres  of 
periosteum.  This  membrane  may  become  much  thickened,  and  form  a  more 
or  less  complete  cylinder,  uniting  the  two  fragments  Avith  considerable  firm- 
ness. Bony  spiculse  shoot  from  its  inner  surface  between  the  two  osseous  sur- 
faces, and  thus  eventually  bony  union  is  secured.  The  swollen  periosteum 
may  gradually  resume  a  moi^e  nearly  normal  thickness. 

Osteo-chondritis  develops  early  in  life,  usually  within  the  first  month.  The 
lesion  may,  however,  occur  later,  when  it  is  not  apt  to  become  multiple,  and 
may  be  unsymmetrical  in  distribution.  The  question  as  to  whether  certain 
epiphyseal  swellings  may  be  due  to  syphilis  or  rickets  will  possibly  arise. 
Other  lesions  of  these  two  diseases  will  have  to  be  sought  after  in  order  to  aid 
in  making  a  correct  diagnosis.  Such  swellings  are  pretty  surely  syphilitic  if 
they  occur  during  the  first  six  months  of  life,  and  at  all  times  are  relieved  by 
mercurial  treatment.  Again,  the  epiphyseal  swellings  of  rickets  are  ahvays 
symmetrical,  while  those  of  syphilis  may  be  unilateral. 

Periostitis. — This  form  of  lesion  occurs  later  in  hereditary  syphilis,  usually 
after  the  child  has  begun  to  walk.  It  attacks  by  preference  the  femur,  tibia, 
and  bones  of  the  forearm,  occurring  usually  from  the  second  to  the  fourth  or 
fifth  year.  There  is  more  or  less  enlargement  of  the  affected  bone.  At  an 
early  stage  of  the  disease  the  bones  are  attacked  symmetrically,  but  later  cir- 
cumscribed nodes  may  be  placed  unilaterally. 

Dactylitis. — The  phalanges  and  the  metacarpal  and  metatarsal  bones  may 
be  enlarged  to  several  times  their  natural  size.  After  an  interval  of  time  the 
skin  may  become  inflamed  and  break  down  from  the  formation  of  an  abscess. 
The  proximal  phalanges  are  more  apt  to  be  attacked  than  the  distal,  and  sev- 
eral bones  of  each  hand  may  be  affected.     There  is  not  much  destruction  of 


108  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDBEN. 


bone,  even  in  severe  cases,  and,  although  the  disease  tends  to  run  a  slow  course, 
it  is  always  influenced  favorably  by  treatment.  Dactylitis  is  apt  to  occur  in  very 
young  subjects,  when  it  takes  the  form  of  a  gummatous  infiltration.   (Fig.  1). 


Fig.  1. 


Syphilitic  Dactylitis. 

Craniotahes. — The  local  thinning  of  portions  of  the  cranial  bones  was 
formerly  attributed  exclusively  to  rickets,  but  is  now  known  to  ensue  as  Avell 
in  the  malnutrition  accompanying  syphilis.  As  it  is  due  to  pressure  of  the 
thin  skull  between  the  brain  and  pilloAv,  it  is  especially  apt  to  involve  the 
occipital  bone.  Carpenter  considers  that  both  craniotabes  and  Parrot's  nodes 
are  often  syphilitic  manifestations,  although  they  are  more  frequently  regarded 
as  evidences  of  rickets :  74  per  cent,  of  cases  of  craniotabes  are  syphilitic, 
according  to  this  author. 

Symptoms. — The  symptoms  of  hereditary  syphilis  vary  widely  according 
to  the  extent  of  the  poison.  When  the  virus  is  concentrated,  as  in  cases  where 
both  parents  are  syphilitic,  the  foetus  Avill  be  attacked  by  the  disease  in  the 
uterus,  and,  as  a  result,  we  shall  have  abortion  more  or  less  early  in  the  preg- 
nancy. As  the  disease  abates  in  one  or  both  parents  the  pregnancies  will 
be  longer  in  duration,  until  finally  apparently  healthy  infants  may  be  born. 

In  some  cases  the  infant  will  present  marked  evidences  of  syphilis  at 
birth  ;  often,  however,  the  onset  is  delayed  until  later,  and  at  birth  there 
may  be  absolutely  no  manifestation  of  the  disease.  In  158  cases  analyzed  by 
Diday  the  first  manifestation  of  symptoms  occurred  in  86  cases  before  the 
completion  of  one  month  ;  in  45  before  the  completion  of  two  months  ;  and 
in  15  before  the  completion  of  three  months  after  birth.  The  remaining  12 
cases  showed  the  symptoms  in  intervals  varying  from  four  months  to  two 
years. 

The  earlier  the  disease  manifests  itself  after  birth,  the  graver  will  be  the 
nature  of  the  attack.     Very  early  syphilis  is  usually  accompanied  by  emacia- 


HEREDITARY  SYPHILIS.  109 

tion,  eruptions  of  bullae,  particularly  upon  the  palms  of  the  hands  and  soles  of 
the  feet,  and  an  extreme  degree  of  coryza,  cracked  and  ulcerated  lips,  and  evi- 
dences of  visceral  and  bony  disease.  In  the  older  cases  there  may  be  no 
interference  with  nutrition,  and  possibly  one  or  two  mucous  patches  may  be 
the  only  active  manifestation  of  the  disease.  In  studying  the  symptoms  it 
may  be  well  to  consider  the  disease  as  it  shows  itself  in  diiferent  structures  and 
areas  of  the  body. 

Skin. — One  of  the  early  symptoms  appearing  upon  the  skin  will  be  the 
eruption  of  small  round  pink  spots,  disappearing  on  pressure,  and  usually 
appearing  first  on  the  lower  portion  of  the  abdomen.  It  may  spread  from  this 
location  and  finally  involve  the  whole  body.  Pigmentation  of  these  spots  may 
ensue,  and  they  may  present  a  dark-red,  coppery  discoloration.  This  latter 
change  may  be  considered  as  having  a  diagnostic  value.  In  hereditary  syph- 
ilis the  rashes  often  develop  rapidly,  and  are  apt  to  be  less  symmetrical  than 
those  seen  in  adults.  They  are  likewise  polymorphous,  as  several  different 
forms  of  syphilide  may  be  exhibited  at  the  same  time  in  a  given  case.  A  pap- 
ular syphilide  may  be  seen  in  the  form  of  small  or  large  flat  papules,  symmetri- 
cally distributed  over  the  surface.  These  papules  are  not  so  apt  to  group  them- 
selves into  lines  and  circles  as  in  older  subjects  with  syphilis.  They  are  not 
so  solid  and  deeply  infiltrated  as  in  the  adult.  Upon  the  palms  and  soles  these 
papules  may  be  very  abundant  and  fuse  together,  presenting  a  thickened,  dull- 
red  surface.  The  vesicular  syphilide  is  not  common,  and  when  seen  is  apt  to 
be  in  very  severe  cases.  The  vesicles  may  be  associated  with  pustules,  and 
appear  in  closely-arranged  groups  about  the  mouth  or  chin  or  various  other 
parts  of  the  body,  especially  the  nates  and  hypogastrium.  Pustules  may  form, 
especially  on  the  face,  buttocks,  and  thighs.  The  ulceration  is  deeper  and  the 
crusts  darker  in  color  than  in  impetiginous  eczema.  Pemphigus  likewise 
appears  in  the  severe  forms  of  the  disease.  It  most  frequently  attacks  the 
palms  of  the  hands  and  soles  of  the  feet ;  it  may  have  a  copper-colored  areola 
and  develop  rapidly.  Crops  of  indolent  boils,  symmetrically  distributed  and 
of  a  copper- red  color,  may  appear  in  connection  with  other  eruptions.  They  are 
more  apt  to  be  seen  in  badly-nourished  infants.  In  some  cases  the  only  appear- 
ance of  syphilis  upon  the  skin  will  be  a  smoky  discoloration,  seen  most  dis- 
tinctly in  the  prominent  parts  of  the  face,  such  as  the  eyebrows,  cheek-bones, 
and  bridge  of  the  nose.  The  nutrition  of  the  skin  is  much  affected  in  cases 
where  the  cachexia  is  marked  ;  it  hangs  in  dry,  loose  folds,  having  an  unhealthy, 
earthy  appearance. 

Mucous  Memhrmies. — The  mucous  membranes,  as  well  as  the  skin,  present 
the  earliest  manifestations  of  the  disease.  One  of  the  most  typical  lesions  is 
the  coryza,  which  may  be  the  first  symptom  noted.  First,  there  may  be  a 
serous  discharge  which  attracts  little  notice ;  this,  however,  gradually  becomes 
worse,  and  the  nasal  secretion  takes  on  a  purulent  or  even  a  bloody  character, 
and  may  be  sufficiently  irritating  to  cause  excoriations  of  the  upper  lip.  The 
mucous  membrane  itself  becomes  thickened,  and  the  inspissated  secretion  soon 
dries,  forming  crusts,  which  may  completely  block  up  the  passage  through  the 
nostrils  and  seriously  interfere  with  nursing.  The  secretion  may  likewise  be 
ofi"ensive.  In  severe  cases,  particularly  where  cleanliness  is  not  practised  and 
the  decomposing  secretions  are  allowed  to  remain  in  the  nostril,  there  may  fol- 
low ulceration  of  the  mucous  membrane,  and  possibly  even  necrosis  of  the 
adjacent  bony  parts.  There  is  apt  to  be  a  flattening  of  the  bridge  of  the 
nose,  probably,  to  a  certain  extent,  due  to  the  interference  with  normal  respi- 
ration. The  inflammation  may  spread  to  the  pharynx  and  larynx,  although 
its  action  is  likely  to  be  limited  to  the  Schneiderian  membrane. 


no  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Mucous  patches  will  be  seen  in  most  cases  of  hereditary  syphilis,  and, 
although  they  appear  most  constantly  on  the  mucous  membranes,  they  may 
be  present  upon  the  skin,  particularly  at  its  junction  with  the  mucous 
membranes,  or  upon  those  parts  which  are  thin  and  exposed  to  various 
secretions.  They  may  occasionally  be  seen  on  any  part  of  the  cutaneous 
surface  of  the  body.  They  are  oftenest  seen  in  the  mouth,  about  the  nose, 
upon  the  scrotum,  vulva,  labial  commissures,  and  occasionally  at  the  umbil- 
icus. In  the  mouth  the  most  frequent  situations  are  upon  the  angles  of 
the  lips,  inside  of  the  cheeks,  the  pillars  of  the  fauces,  the  tonsils,  and  the 
sides  and  dorsum  of  the  tongue.  They  consist,  in  the  early  stage,  of  a  slightly 
raised  segment  of  mucous  membrane,  presenting  a  whitish  surface  and  red 
margins.  This  may  soon  ulcerate.  When  the  mucous  patches  appear  at  the 
angles  of  the  mouth,  deep  fissures  will  often  form  at  the  corners  of  the  lips, 
extending  sometimes  well  out  into  the  cheek.  These  fissures  are  sometimes 
called  rhagades,  and  are  diagnostic.  The  secretions  on  these  mucous  patches 
are  very  infective.  When  mucous  patches  appear  on  the  cutaneous  surface, 
they  are  slightly  raised,  with  a  macerated  appearance,  and  frequently  seamed 
with  erosions  or  cracks.  In  the  late  stages  of  hereditary  syphilis  mucous 
patches -are  not  so  numerous  as  in  the  earlier  stages  of  the  disease,  but  they 
frequently  recur  after  the  child  is  apparently  restored  to  health. 

Disturhanee  of  JVutrition. — The  extent  to  which  the  general  nutrition  of 
the  infant  is  disturbed  Avill  depend  upon  the  severity  of  the  attack.  In  grave 
cases  there  is  atrophy  of  all  the  structures  of  the  body,  the  infant  presenting 
a  weazen  appearance,  with  a  countenance  resembling  that  of  an  old  man. 
These  cases  are  almost  invariably  fatal,  and  are  caused  by  the  blighting 
influence  of  the  virus.  In  many  cases,  however,  a  failure  of  nutrition  will 
ensue  gradually,  consecutive  to  gastro-intestinal  disturbance.  This  may  be 
due  to  actual  specific  disease  of  the  liver,  stomach,  or  intestines,  or  it  may  be 
due  to  indigestion  and  malassimilation  only  indirectly  caused  by  feebleness 
from  the  cachexia.  In  bottle-fed  babies  digestive  disturbances  are  marked 
and  severe,  infants  upon  the  breast  being  much  less  liable  to  suffer.  In  some 
cases  the  infant  will  present  very  slight  disturbance  of  the  general  nutrition, 
being  plump  and  well-nourished  throughout  the  course  of  the  disease,  which 
may  be  only  manifested  by  mucous  patches  or  mild  evidences  of  the  infection. 

Co7idition  of  tlie  Blood. — A  condition  of  profound  angemia  is  frequently 
seen,  particularly  in  severe  cases.  Johann  Loos  states  that  hereditary  syphilis 
is  always  associated  with  an  antemia  which  under  some  conditions  may  reach  an 
extreme  degree  of  intensity.  This  anaemia  is  characterized  by  a  diminution  in 
the  number  of  the  red  blood-corpuscles,  by  quite  a  marked  alteration  in  these 
corpuscles,  the  appearance  of  megalocytes  and  microcytes,  and  by  the  appear- 
ance of  nucleated  erythrocytes,  sometimes  in  quite  notable  quantity.  It  is 
always  characterized  by  the  constant  existence  of  leucocytosis,  which  may 
often  become  extreme,  and  by  the  appearance  of  myelo-plaques  in  the  blood. 
This  an?emia  is  a  very  important  and  significant  symptom  of  the  disease,  and 
may  directly  occasion  a  fiital  issue.  He  further  states  that  there  are  only  two 
diseases  common  to  childhood  in  which  the  lesions  of  the  blood  suggest  the 
changes  just  described,  and  these  are  splenic  anaemia  and  severe  forms  of 
rachitis. 

A  form  of  syphilis  haemorrhagica  neonatorum  has  been  described  by 
Bumstead  and  Taylor.  There  may  be  simply  a  limited  subcutaneous  effusion, 
or  the  mucous  membranes  may  be  the  seat  of  the  haemorrhage.  Haemorrhage 
at  the  umbilicus  shortly  after  birth  may  be  due  to  this  cause. 

Crlandular  Enlargements. — General  adenopathy  is  not  seen  in  the  hereditary 


HEREDITARY  SYPHILIS.  Ill 

form  of  syphilis.  There  may  be  enlargement  of  the  chains  of  cervical  glands 
consecutive  to  lesions  in  the  adjacent  mucous  membranes,  and  occasionally 
there  may  be  an  affection  of  the  inguinal,  axillary,  or  cervico-maxillary 
glands  -R-ithout  any  deeper  lesions  being  noted  to  account  for  their  existence 
by  septic  absorption.  The  glands  are  hard,  moving  without  pain  in  the  areolar 
tissue  under  pressure  by  the  finger.  Some  writers  consider  that  enlargement 
of  the  epitrochlear  glands  is  pathognomonic  of  congenital  syphilis,  but  well- 
marked  cases  occasionally  fail  to   show  this    sign  upon  careful  examination. 

Bony  Organs. — The  frequency  with  which  the  bones  are  involved  in 
hereditary  syphilis  has  been  noted  in  the  morbid  anatomy  of  the  disease.  In 
every  case  the  long  bones  should  be  carefully  examined  for  enlargement  and 
thickening  at  the  epiphyseal  and  distal  ends.  In  cases  where  suppuration  has 
taken  place  the  epiphysis  may  be  separated  from  the  shaft,  and  crepitation 
will  then  be  found  upon  careful  handling.  The  joint  itself  may  occasionally 
be  involved  in  the  inflammation,  showing  the  well-known  symptoms  of  arthritis. 
AVhere  the  bones  are  much  aifected  there  will  be  some  disability  of  the  limb, 
possibly  extending  to  complete  paralysis.  Immobility  in  such  a  case  is  with- 
out doubt  due  to  the  affection  of  the  bones. 

Dactylitis. — In  the  early  period  of  the  disease  an  enlargement  of  the 
phalanges  is  frequently  seen,  and  occasionally  also  of  the  metatarsal  and 
metacarpal  bones.  The  proximal  phalanx  is  moi-e  frequently  attacked  than  the 
distal :  the  affe«tion  may  spread  to  all  of  the  phalanges,  but  is  more  apt  to 
involve  only  one.  which  may  be  enlarged  to  double  its  normal  size.  This 
enlaro-ement  is  the  result  of  specific  inflammation  of  the  bone  and  periosteum, 
and  runs  a  slow  course  unless  modified  by  specific  treatment.  There  is  not 
apt  to  be  much  involvement  of  the  soft  parts ;  the  integument  will  be  reddish 
and  inflamed,  but  there  is  little  tendency  to  suppuration  and  ulceration.  These 
swellings  usually  present  a  fusiform  shape,  with  a  hard,  firm  sensation  to  the  touch. 

Teeth. — The  appearance  of  the  deciduous  teeth  is  delayed  in  hereditary 
syphilis,  as  in  rachitis.  The  first  teeth  may  not  appear  until  the  tenth  or 
twelfth  month,  or  even  later.  These  teeth  are  poorly  developed  and  apt  to 
undergo  early  decay.  There  is  usually  a  similar  delay  in  the  appearance  of 
the  second  teeth,  which  present  more  pathognomonic  changes,  which  will  be 
noted  in  connection  with  late  hereditary  syphilis. 

Xervous  JDisturbances. — Lesions  of  the.  nerve-centres  do  not  often  appear 
in  hereditary  syphilis ;  there  may  be,  however,  an  occasional  palsy  due  to  a 
peripheral  cause.  One  form  in  connection  with  bony  lesions  has  already  been 
mentioned.  There  may  be  contractures  and  paresis,  however,  where  no  bony 
lesion  can  be  noted.  Henoch  questions  whether  such  affections  may  not  be 
myopathic  in  their  origin  and  independent  of  the  nervous  system. 

The  following  case  coming  under  my  observation  illustrates  a  case  of 
paralysis  evidently  caused  by  interstitial  syphilitic  myositis:  An  infant  four 
weeks  old.  whose  mother  presented  syphilitic  lesions,  was  born  healthy  at  full 
term.  When  seven  davs  old  it  was  noticed  that  the  right  leg  was  drawn  up 
and  apparently  did  not"^  move ;  also  the  right  arm.  There  was  complete  loss 
of  power  in  these  members  ;  there  was  wrist-drop,  and  a  loss  of  faradic  and 
galvanic  irritability  in  the  extensors  of  the  left  wrist.  The  muscles  affected 
were  rather  hard  and  painful  to  the  touch.  .  There  was  an  enlargement  at 
the  epiphyseal  end  of  the  left  humerus.  The  paralysis  completely  disappeared 
in  about  two  months  under  specific  treatment. 

Dr.  Eustace  Smith  states  that  a  form  of  real  paralysis  has  been  occasionally 
seen  affecting  the  branches  of  the  brachial  plexus,  causing  more  or  less  com- 
plete loss  of  power  in  the  arm. 


112  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Onychia. — Two  kinds  of  onychia  are  noted  in  hereditary  syphilis — the 
ulcerative  and  the  nutritive.  In  the  ulcerative  form  the  pustule  appears  at 
the  margin  of  the  nail,  which  soon  breaks  down,  leaving  a  sloughy  surface, 
which  may  destroy  the  matrix.  The  surrounding  skin  presents  a  coppery 
discoloration.  In  the  nutritive  form,  which  is  apt  to  appear  later,  the  ulcer 
has  a  sloughy  base,  and  presents  a  swelling  around  the  periphery  of  the  nail, 
which  becomes  thickened  and  brittle.  Swelling  and  deformity  of  the  phalanx 
may  ensue.  In  a  case  recentl}'^  observed,  a  child  of  two  years,  whose  father 
had  a  specific  history,  presented  immense  bulbous  masses  upon  the  extremities 
of  the  thumb  and  middle  finger  of  the  right  hand  and  the  thumb  and  fore 
finger  of  the  left  hand.  These  were  granular,  warty  masses  about  the  size  of 
hickory-nuts,  Avith  the  nail  protruding  backAvard.  When  the  infant  was  eight 
months  old  it  appealed  healthy,  except  that  the  finger-nails  now  involved  Avere 
like  claAvs  and  were  reddened  as  if  scalded.  The  trouble  had  continued  until 
the  nutritive  changes  produced  the  enlarged  mass  here  noted.  There  had 
been  a  history  of  "snuffles,"  abscesses  on  the  buttocks,  sore  lips  and  gums, 
but  at  the  time  of  the  examination  the  only  other  manifestation  of  the  disease 
was  a  large  mucous  patch  in  front  of  the  scrotum.  In  the  nutritive  form  of 
onychia  the  hyperaemia  of  the  matrix  and  the  deformity  of  the  phalanx,  if  not 
extreme,  may  disappear  under  specific  treatment. 

Iritis. — This  is  an  exceedingly  rare  affection  in  hereditary  syphilis,  but 
cases  have  been  reported  by  Mr.  Hutchinson  in  infants  varying  in  age  from 
six  Aveeks  to  sixteen  months.  It  does  not  diff"er  from  the  same  manifestation 
in  adults. 

Alopecia. — There  may  be  loss  of  hair  in  the  scalp,  eyebroAvs,  or  eyelashes. 
The  last  form  is  the  most  pathognomonic,  as  there  may  be  a  deficiency  in  the 
nourishment  of  the  hair  of  the  scalp  in  rickets  or  any  condition  of  cachexia 
in  infants. 

General  Irritability. — Syphilitic  infants  are  very  fretful,  and  the  cry  is  of 
a  peculiar  high-pitched  character.  This  fretfulness  is  particularly  apt  to  be 
present  at  night,  at  Avhich  time  the  child  is  extremely  Avakeful.  In  this,  how- 
ever, it  does  not  difter  much  from  rickets. 

Diagnosis. — A  difiiculty  in  the  diagnosis  of  hereditary  syphilis  may 
obtain  Avhere  typical  lesions  are  not  well  marked,  or  where  it  is  a  question 
betAveen  syphilis  and  scrofulous  or  tubercular  lesions.  In  cases  of  marasmus, 
if  there  is  no  history  of  chronic  indigestion,  particularly  if  the  infiint  have 
been  fed  at  the  breast,  there  is  strong  suspicion  of  syphilis.  A  careful 
examination  for  mucous  patches  will  often  throAv  light  on  such  a  case. 
Chronic  coryza  is  likeAvise  a  valuable  sign  in  diagnosis. 

The  following  points  of  distinction  between  syphilitic  and  scrofulous  lesions 
of  the  skin  have  been  given  by  Dr.  P.  A.  Morrow  :  (1)  Syphilitic  lesions  are 
general  in  their  distribution ;  they  may  occur  upon  any  region  of  the  body. 
Scrofulous  lesions  are  more  limited  in  their  localization  ;  they  have  a  special 
predilection  for  the  neck  or  regions  rich  in  lymphatic  glands.  (2)  Syphilitic 
lesions  are  ambulatory  and  changing ;  they  disappear  and  reappear  elscAvhere. 
Scrofulous  lesions  are  fixed  and  permanent.  (3)  The  color  of  syphilitic 
lesions  is  reddish-brown  or  "lean-ham"  tint.  The  color  of  scrofulous  lesions 
is  brighter  and  more  violaceous  in  hue.  (4)  Syphilis  is  distinct  from  scrofula 
in  its  objective  appearances  and  mode  of  evolution.  In  the  initial  stage  the 
syphilitic  neoplasms  are  firm  and  hard ;  the  scrofulous  infiltrations  ai'e  softer 
and  more  compressible.  In  the  ulcerative  stage  the  differences  are  more 
pronounced  ;  the  ulcers  of  syphilis  are  cleaner  cut,  regular  in  contour,  Avith 
perpendicular,    firmly-infiltrated    borders    encircled    by  a   pigmented   areola ; 


HEBEDITABY  SYPHILIS,  113 

scrofulous  ulcers  are  irregular,  with  soft,  undermined  borders ;  they  are 
painless,  bleed  easily,  and  show  slight  tendency  to  spread.  (5)  The  crusts  of 
syphilis  are  bulkier,  thicker,  with  a  tendency  to  accumulate  in  layers,  and 
darker  in  color ;  the  cicatrices  are  smooth  and  remain  long  surrounded  by  a 
pigmented'  areola.  The  crusts  of  scrofula  are  softer,  more  adherent;  the 
cicatrices  are  elevated,  irregular,  bridled ;  they  retain  their  violaceous  color 
for  a  long  time.  (6)  The  course  of  a  syphilitic  ulcer,  though  sluggish  and 
chronic,  is  much  more  rapid  than  that  of  scrofula.  (7)  Absence  of  pain  and 
local  reaction  characterize  both  syphilitic  and  scrofulous  ulcers ;  they  are 
essentially  lesions  without  symptoms. 

In  connection  with  the  bony  lesions  it  is  important  to  diagnose  between 
syphilis  and  tubercular  and  rachitic  affections.  The  following  points  in  diagnosis 
between  syphilis  and  tuberculosis  are  given  by  Dr.  Morrow :  (1)  Syphilis  ex- 
hibits a  marked  predilection  for  the  long  bones ;  its  habitual  localization  is  in 
the  diaphysis,  and  almost  always  at  its  terminal  extremity.  Tuberculosis  is 
almost  exclusively  situated  in  the  epiphyses,  rarely  affecting  the  shaft.  (2)  In 
syphilis  there  is  a  marked  enlargement  of  the  bone  by  more  or  less  volumin- 
ous osseous  tumors  or  hyperostoses,  with  little  or  no  involvement  of  the  soft  parts ; 
and  in  tuberculosis  the  tumefaction  is  due  less  to  increase  in  the  size  of  the 
bone  than  to  oedematous  infiltration  of  the  soft  structures.  (3)  In  syphilis 
there  is  little  tendency  to  suppuration  and  necrosis  ;  in  tuberculosis  the  pyogenic 
tendency  is  marked.  (4)  In  syphilis  osteocopic  pains,  with  tendency  to  noc- 
turnal exacerbation,  are  a  pronounced  feature  ;  in  tuberculosis  the  pain  is  dull 
and  heavy,  not  aggravated  at  night ;  sometimes  there  is  entire  absence  of  acute 
painful  symptoms.  (5)  The  osseous  lesions  of  syphilis  rarely  react  upon  the 
general  system,  while  those  of  tuberculosis  often  determine  a  marked  impair- 
ment of  the  general  health,  grave  complications,  hectic  fever,  cachexia,  etc. 

In  syphilitic  dactylitis  there  is  little  involvement  of  the  soft  parts,  the 
swelling  being  caused  by  the  enlargement  in  the  size  of  the  bone.  In  tuber- 
cular dactylitis  the  swelling  is  due  more  to  an  oedematous  infiltrated  condition  of 
the  soft  tissues  than  to  enlai'gement  of  the  bone.  In  the  latter  cases  breaking 
down  of  the  tissues  and  ulceration  are  more  apt  to  ensue. 

The  diagnosis  between  syphilis  and  rickety  bone-lesions  may  be  of  great 
importance.  Epiphyseal  swellings  occurring  under  six  months  are  very  apt  to 
be  syphilitic.  In  syphilis  the  epiphyseal  swelling  may  be  unilateral,  but  it  is 
always  symmetrical  in  rachitis.  In  doubtful  cases  the  SAvelling  must  be  sub- 
jected to  specific  treatment.  It  is  well  to  remember,  however,  that  rickets  and 
syphilis  may  coexist  in  the  same  case.  There  is  almost  invariably  enlargement 
at  the  costo-chondral  articulations  in  all  cases  of  rickets,  which  is  absent  in 
syphilis. 

Prognosis. — ^According  to  KassoAvitz,  one-third  of  all  syphilitic  children 
die  before  their  birth,  and  among  those  who  are  born  34  per  cent,  die  in  the 
first  six  months  of  life.  Fournier  places  the  mortality,  when  derived  from  the 
father  alone,  at  28  per  cent.  ;  from  the  mother  alone,  60  per  cent.  ;  when  from 
both  parents,  Qd>^  per  cent.  The  earlier  the  symptoms  appear  after  birth, 
the  severer  will  be  the  type  of  the  disease  and  the  worse  the  prognosis.  Involve- 
ment of  the  bones  and  viscera  means  a  severe  type  of  the  disease.  Infants 
fed  upon  the  breast  will  have  a  much  better  chance  than  those  artificially  fed. 
In  bottle-fed  infants,  particularly  when  the  disease  appears  early,  the  prognosis 
is  almost  always  fatal  ;  it  is  invariably  so  in  hospitals  and  lying-in  institutions. 
Any  interference  Avith  digestion  and  assimilation,  no  matter  from  what  cause, 
will  necessitate  a  guarded  prosrnosis.  If  the  corvza  is  extreme  and  breathing 
much  disturbed,  the  prognosis  must  be  altered  in  proportion  to  the  amount  oi 

8 


114  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

such  disturbance,  which  interferes  with  rest  and  the  taking  of  food.  If  the 
digestion  remains  good,  and  particularly  when  the  manifestations  of  the  disease 
are  not  severe,  complete  recovery  takes  place,  and  the  infant  may  grow  up 
healthy  and  strong. 

Late  Hereditary  Syphilis. 

In  some  cases  of  hereditary  syphilis  the  manifestations  of  the  disease  during 
infancy  may  be  exceedingly  mild,  and,  in  fact,  overlooked.  It  is  possible  in 
such  a  case  that  the  poison  may  show  itself  in  various  ways  during  the  period 
of  childhood.  "  Syphilis  tarda  "  is  a  term  applied  to  those  cases  in  which  the 
first  manifestations  of  hereditary  syphilis  appear  in  childhood.  The  existence 
of  such  a  condition  without  any  earlier  evidence  of  the  disease  has  been  dis- 
puted. It  is  analogous  to  the  discussion  as  to  whether  syphilis  in  the  adult 
may  present  late  secondary  or  tertiary  symptoms  without  being  preceded  by 
earlier  lesions. 

Late  hereditary  syphilis  may  manifest  itself  either  in  certain  active  lesions 
plainly  to  be  attributed  to  this  condition,  or  by  certain  developmental  defects 
that  may  easily  be  confused  with  scrofula,  tuberculosis,  or  rickets.  It  may  be 
well  for  us  to  note  some  of  the  more  characteristic  lesions. 

Bone  Affections. — One  of  the  commonest  manifestations  is  a  periostitis 
involving  various  long  bones,  especially  the  tibia,  the  ulna,  the  radius,  and 
the  humerus.  Accompanying  this  periostitis  there  may  be  considerable  thick- 
ening upon  the  surface  of  the  bone,  sufficient  to  induce  a  change  in  its  form. 
The  lesion  may  be  multiple  and  symmetrical,  although  occasionally  unilateral. 
It  is  attended  often  with  little  discomfort  aside  from  occasional  nocturnal 
pains.  The  nasal  bones  may  be  aifected,  producing  much  deformity  by  destruc- 
tion of  the  bony  arch  of  the  nose.  In  many  cases  not  so  severe  there  is  marked 
flattening  of  the  bridge  of  the  nose  and  a  wide  separation  of  the  eyes.  The 
frontal  bone  is  apt  to  be  large  and  flat,  with  prominences  somcAvhat  exagger- 
ated. There  is  also  usually  a  very  high  palate  arch.  Dactylitis  may  be 
seen  in  this  late  stage  of  the  disease,  and  sluggish  swellings  of  the  meta- 
carpal and  metatarsal  bones.  The  secondary  teeth  are  aff'ected  in  a  way 
that  has  been  considered  pathognomonic.  As  is  well  known,  Mr.  Jonathan 
Hutchinson  first  called  attention  to  this  condition.  The  principal  change  is 
noted  in  the  two  superior  middle  incisors,  which  are  small,  peg-shaped,  and 
placed  at  such  an  angle  that  the  cutting  borders,  if  continued,  would  meet. 
They  may  occasionally  be  deflected  outward,  as  in  the  accompanying  illustration. 
(Plate  IV.)  The  cause  of  this  maldevelopment  has  been  explained  by  Four- 
nier  as  due  to  defective  growth  within  the  alveolus,  while  Hutchinson  refers 
it  rather  to  an  early  stomatitis  or  an  alveolar  periostitis  often  present  during 
infancy.  The  incisors  are  apt  to  be  notched  at  the  lower  edge,  as  is  well 
shown  in  the  plate,  which  is  taken  from  a  case  under  the  care  of  Dr. 
Stowell.  The  enamel  is  usually  eaten  away  in  this  portion  of  the  teeth. 
Dr.  John  N.  Mackenzie  has  called  attention  to  ulceration  of  the  palate,  which 
is  apt  to  take  place  in  the  centre,  and  be  followed  by  caries  or  necrosis  of  the 
bone.  There  may  be  simultaneous  or  consecutive  deep  ulceration  of  the  palate, 
pharynx,  and  naso-pharynx  at  any  time  previous  to  the  age  of  puberty.  Large 
and  indolent  mucous  patches  may  be  present  upon  the  cheek,  tongue,  gums, 
and  especially  about  the  corners  of  the  mouth.  The  ulceration  about  the  lips 
may  leave  long  scars,  particularly  to  be  seen  at  the  commissures  of  the  lips. 
This  is  most  beautifully  shoAvn  in  the  accompanying  illustration  of  Dr.  Sto- 
well's  case.     (Plate  V.) 


< 


HEREDITARY  SYPHILIS.  115 

Kidneys. — Fournier  considers  that  chronic  degenerative  changes  may  take 
place  in  the  kidneys,  usually  in  the  form  of  a  parenchymatous  nephritis  and 
amyloid  degeneration. 

Interstitial  Keratitis. — There  is  frequently  noticed  an  opacity  of  the  cornea 
without  much  congestion  of  the  conjunctiva.  The  opaque  areas  may,  in  severe 
cases,  coalesce,  and  cover  the  whole  cornea.  Although  primarily  attackino^ 
one  eye,  it  soon  involves  the  other.  There  may  coexist  an  iritis,  presenting 
symptoms  which  are  indolent  in  character  without  the  severe  pain  and  photo- 
phobia so  often  seen  in  many  cases  of  iritis.  It  may  be  difficult  to  recognize 
the  existence  of  iritis  when  the  cornea  is  opaque  from  the  presence  of  abun- 
dant interstitial  keratitis.  Deeper-seated  troubles,  such  as  choroiditis  and  reti- 
nitis, may  occasionally  occur. 

The  G-enitalia. — Occasionally  a  painless  enlargement  of  one  or  both  testi- 
cles may  be  noticed,  accompanied  by  a  slight  degree  of  hydrocele.  This  con- 
dition may  sometimes  involve  the  epididymis  and  the  cord.  "When  the  testicle 
is  thus  involved,  there  are  apt  to  be  syphilitic  lesions  in  other  parts  of  the 
body,  which  will  aid  in  diagnosis.  In  many  cases  all  the  evidence  of  syphilitic 
taint  in  childhood  will  be  seen  in  arrested  and  perverted  development.  Such 
a  child  exhibits  in  its  growth  much  retardation  of  development  in  comparison 
with  other  children  of  the  same  age.  This  may  be  particularly  seen  in  the 
genital  organs,  the  testicles  at  puberty  being  the  size  seen  in  very  early  child- 
hood, and  in  girls  an  absence  of  mammary  development,  delayed  menstruation, 
and  a  non-appearance  of  hairs  on  the  genital  and  axillary  regions.  Fournier 
has  given  the  name  "•  infantilism  "  to  this  defective  physical  and  mental  devel- 
opment.     Such  cases  not  infrequently  develop  epilepsy. 

The  Treatment  of  Syphilis. 

The  dictum  of  Dr.  Holmes  that  the  proper  treatment  of  some  diseases 
should  be  begun  one  hundred  years  before  birth  may  be  modified,  in  syphilis, 
to  a  treatment  existinor  several  months  before  birth.  There  is  no  doubt  that 
parents  who  exhibit  any  specific  symptoms  or  who  have  had  syphilitic  children 
should  be  subjected  to  constant  specific  treatment  and  oversight.  Such  treat- 
ment may  avoid  miscarriage,  and  possibly  prevent  the  development  of  syphilitic 
disease  in  the  infant.  The  treatment  of  the  syphilitic  infant  resolves  itself 
into  specific  medication  directed  to  the  actual  poison  of  the  disease  and  to 
means  aimed  to  prevent  the  collateral  loss  of  nutrition  which  is  so  common  and 
so  grave  in  these  cases.  Mercurial  treatment  may  be  applied  by  external  or 
internal  medication.  The  former  is  particularly  adapted  to  cases  where  infan- 
tile diarrhoea  and  indigestion  may,  to  a  certain  extent,  contraindicate  the  inter- 
nal use  of  mercury.  Daily  inunctions  of  mercurial  ointment  mixed  with  from 
four  to  eight  times  its  quantity  of  vaseline  or  rose  ointment  are  efficacious.  It 
may  be  rubbed  on  the  inside  of  the  thighs  or  in  the  axillae,  using  a  portion 
about  the  size  of  a  small  hickory-nut.  Or  the  ointment  may  be  applied  on  a 
flannel  roller  and  bandaged  about  the  child  once  a  day.  Before  applying  the 
ointment  in  this  way  the  skin  must  be  cleansed  thoroughly  with  soap  and  tepid 
water.  A  little  more  cleanly  method  of  local  medication  consists  in  applying 
five  drops  of  a  10  per  cent,  solution  of  the  oleate  of  mercury  three  times  daily. 
It  is  certain  that  under  external  applications  the  specific  lesions  will  frequently 
disappear. 

It  is  probable,  however,  that  it  will  be  found,  as  a  rule,  more  satisfactory  to 
employ  internal  medication.  Mercury  with  chalk  is  one  of  the  best  prepara- 
tions, in  doses  of  one-fourth  of  a  grain  to  one  or  two  grains  twice  a  day.     Dr. 


116  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Jacobi  prefei's  calomel,  on  account  of  the  rapidity  of  its  action,  in  doses  of  from 
■^  to  ^  grain  three  times  a  day.  Bichloride  of  mercury  has  many  adherents. 
The  liquor  of  Tan  Swieten  is  the  form  recommended  by  Parrot  for  internal 
administration.     The  formula  is  as  follows  : 

^.  Bichloride  of  mercury 1  part. 

"Water 950  parts. 

Rectified  spirits 100  parts. 

Sig.  5  to  20  drops  in  milk  three  times  a  day. 

The  bichloride  of  mercury  may  be  given  in  simple  watery  solution,  which 
may  be  combined  with  milk,  and  hence  readily  taken  by  the  infant.  The  dose 
varies  from  .5-^  to  -glQ  of  a  grain,  according  to  the  age  and  condition  of  the 
infant.  If  intestinal  irritation  be  caused  by  the  drug,  a  mixture  of  wine  of 
pepsin  and  elixir  of  bismuth  may  be  used  as  a  menstruum. 

An  important  element  in  the  management  of  these  cases  will  be  the  local 
treatment,  applied  to  mucous  patches,  excoriations,  and  especially  to  the  coryza. 
Ulcerations  and  destructive  processes  in  the  nose  may  be  largely  avoided  by 
keeping  the  nasal  passages  clean  by  tepid  water  or  bland  oil.  A  2  per  cent, 
solution  of  the  oleute  of  mercury  will  be  efficacious  in  the  nose.  Mucous 
patches  or  condylomata  should  be  kept  clean,  and  may  be  dusted  with  calomel 
and  bismuth.  Nitrate  of  silver  may  be  applied  to  patches  appearing  in  the 
mouth  that  are  intractable  to  internal  treatment. 

Where  the  bones  are  involved  and  evidence  of  gumma  in  any  portion  of  the 
body  is  present,  iodide  of  potash  should  be  employed.  In  the  visceral  lesions 
this  remedy  likewise  acts  well:  and  if  the  indications  arise,  mixed  treatment, 
by  combining  the  biniodide  of  mercury  with  iodide  of  potassium,  may  be  em- 
ployed. The  iodide  of  potassium  is  most  efficacious,  although  the  iodide  of 
sodium  may  be  administered  with  good  results.  The  dose  should  be  moderate, 
not  averaging  more  than  a  few  grains. 

The  general  care  of  the  nutrition  of  the  syphilitic  infant  is  most  important. 
The  chances  for  maintaining  good  nutrition  are  much  improved  by  keeping  the 
baby  on  its  mother's  breast.  If  the  mother  is  unable  to  entirely  supply  the 
infant  with  nourishment,  the  bottle  may  be  employed,  but  never  to  the  com- 
plete exclusion  of  the  breast.  The  well-known  fact  that  an  infant  cannot  infect 
the  mother,  although  the  latter  shows  no  evidences  of  syphilis,  justifies  us  in 
insisting  upon  her  nursing  her  own  infant.  The  employment  of  a  healthy  wet- 
nurse,  although  of  advantage  to  the  infant,  is  not  justifiable,  as  the  former  will 
almost  surely  be  infected  by  the  latter.  After  nursing,  the  nipple  should 
always  be  carefully  cleansed,  as  well  as  the  infant's  mouth,  by  the  use  of  some 
bland  disinfectant  solution.  In  cases  in  which  the  infant  is  deprived  of  the 
breast  the  most  scrupulous  care  and  cleanliness  must  be  exercised  in  artificial 
feeding.  A  mild  form  of  indigestion  will  severely  handicap  the  syphilitic  infimt, 
and  may  eventuate  in  its  death.  General  tonic  treatment  and  stimulation  may 
be  employed  in  connection  with  specific  treatment. 

The  treatment  of  the  later  forms  of  syphilis  will  depend  upon  the  activity 
of  the  morbid  process.  Mercury  should  always  be  exhibited  in  some  form 
when  there  is  any  evidence  of  active  syphilitic  disease.  It  has  been  proven 
that  small  and  proper  doses  of  mercury  are  tonic  in  syphilis,  and  actually 
relieve  the  hydmemia  and  defective  nutrition  so  often  seen  in  this  disease.  If 
there  is  no  evidence  of  an  active  syphilitic  process,  the  treatment  will  resolve 
itself  into  improving  the  nutrition  of  the  child  in  every  way.  Good  food, 
tonics,  iron,  cod-liver  oil,  change  of  air  when  possible,  are  all  of  value  in  aiding 
healthy  growth  and  development  in  these  retarded  cases. 


PART  III. 
THE   INFECTIOUS   DISEASES. 


MEASLES. 

By  LOUIS  STARE,  M.  D., 

PHIIiADELPHIA. 


Rubeola  is  an  acute,  infectious  disease,  characterized  by  coryza  and 
other  catarrhal  symptoms,  by  continued  fever,  and  by  an  eruption  of  slightly 
elevated,  crimson  papules  upon  the  face  and  body,  followed  by  furfuraceous 
desquamation. 

It  is  perhaps  the  commonest  of  the  infectious  diseases  of  childhood,  and 
very  few  individuals  arrive  at  adult  age  without  having  suffered  from  an 
attack.  One  attack  usually  protects  against  a  second,  though  instances  in 
which  there  have  been  two,  or  even  three,  attacks  are  not  rare. 

In  large  cities  scattered  cases  of  measles  may  be  encountered  at  almost 
any  time,  but  at  certain  recurring  intervals,  varying  from  eighteen  months  to 
two  years,  the  disorder  becomes  epidemic.  These  epidemics  are  alike  in  the 
fact  that  young  children,  being  unprotected  by  a  previous  attack,  uniformly 
suffer  most ;  unlike,  in  the  extent  of  their  prevalence,  in  fatality,  and  in  the 
accentuation  of  particular  symptoms.  In  isolated  localities,  having  infrequent 
communication  with  large  centres  of  population,  and  where  measles  has  pre- 
vailed only  at  long  intervals,  the  disease  when  it  does  arise  finds  a  greater  num- 
ber of  victims,  attacks  a  larger  proportion  of  adults,  and  is  more  fatal.  When 
introduced  to  a  virgin  soil  the  virulence  is  extreme.  As  an  instance  of  this 
the  four  months'  epidemic  of  1875  in  the  Fiji  Islands  may  be  cited :  during  it 
40,000  natives  died  out  of  a  population  of  150,000 — upward  of  1  to  every  4 
souls.  By  contrast,  the  mortality  in  London  in  1886 — an  average  year — was 
1  to  each  2000  of  the  population. 

Etiology. — The  prime  cause  of  the  disease  is  a  specific  poison,  the  nature 
of  which  has  not  been  determined,  though  A.  Ransome  and  Braidworth  and 
Vacher  have  discovered,  in  the  breath  and  secretions  of  measles  patients, 
certain  peculiar  organisms  identical  with  those  to  be  described  as  existing 
in  the  skin,  the  lungs,  and  the  liver.  It  is  certain,  however,  that  the  poison 
spreads  by  contagion,  and  most  probable  that,  whether  or  no  these  micro-organ- 
isms carry  it,  it  is  given  off  in  the  breath  and  secretions.  The  contagion  is 
usually  conveyed  directly  from  the  sick  to  the  well,  and  is  so  virulent  that 
when  once  introduced  to  a  dwelling  or  hospital  ward  its  spread  is  rarely 
stopped  until  all  unprotected  inmates  suffer.  It  may  be  carried  from  place  to 
place  by  fomites,  but  simple  airing  of  the  clothing  is  usually  sufficient  to  dis- 
infect it.  When  such  instances  of  infection  occur  close  connection  is  shown, 
the  medium  being  a  child  or  nurse  coming  directly  from  an  infected  house. 
Experimentally,  the  disease  has  been  propagated  by  inoculation  with  the 
blood,  the  nasal  and  bronchial  mucus,  and  the  tears  of  a  patient,  and   also 

117 


118   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

with  the  serum  taken  from  the  vesicles  which  occasionally  accompany  the 
eruption.  Infection  begins  in  the  incubative  stage,  is  most  active  during  the 
pre-eruptive  period  of  corjza  and  fever,  continues  throughout  the  eruption, 
and  thereafter  rapidly  subsides,  to  disappear  at  the  end  of  the  third  week. 

No  age  of  infancy  or  childhood  is  exempt  from  measles.  It  may  occur 
in  sucklings  a  few  weeks  old,  but  is  uncommon  during  the  first  six  months 
of  life.  The  period  of  greatest  susceptibility  is  between  the  second  and  sixth 
years. 

According  to  some  authorities,  males  are  more  prone  to  be  attacked  than 
females,  but  the  disproportion  between  the  two  sexes  is  insignificant.  Season, 
too,  seems  to  have  little  influence  in  furthering  the  onset  of  the  disease.  If 
there  be  any  difi"erence,  it  is  in  favor  of  the  damp,  changeable,  depressing 
weather  of  March,  April,  and  early  May.  In  the  Children's  Hospital  of 
Philadelphia,  for  example,  scarcely  a  year  passes  in  which  there  is  not  a  more 
or  less  extended  epidemic  during  these  months.  Apart  from  unknown  atmo- 
spheric causes,  the  explanation  may  be  found  in  the  fiict  that  at  this  season 
children  are  below  par,  or  impaired  in  health  by  the  disorders  and  confine- 
ment incident  to  the  winter  months,  and  therefore  less  able  to  resist  the 
contagion  which  is  always  latent  in  large  cities. 

Pathology. — When  death  comes  early  in  the  course  of  the  disease  from 
the  force  of  the  poison  itself,  an  autopsy  reveals  hypostatic  congestion  of  the 
lungs,  hyper?emia  of  the  mucous  membranes,  and  congestion  of  the  organs 
generally,  with  extravasation  into  their  substance,  and  softening.  The  blood 
is  fluid,  dark-colored,  and  deficient  in  fibrin. 

During  an  epidemic  at  the  Philadelphia  Hospital,  Drs.  Keating  and 
Formad  detected  large  numbers  of  microbes  in  the  liquor  sanguinis  and  white 
corpuscles  of  blood  taken  from  malignant  cases,  and  the  author  has  since 
made  the  same  observation.  Quite  recently,  too,  a  bacillus  has  been  discovered 
in  the  urine  of  rubeolous  patients.  What  relation  these  organisms  bear  to 
the  disease  cannot  yet  be  definitely  asserted.  In  sections  of  skin  made  on 
the  sixth  day  of  the  eruption  Braidworth  and  Vacher  found  swelling  of  the 
chorium  and  thickening  of  the  rete  Malpighii,  due  to  great  proliferation  of 
cells  which  extended  along  the  hair  and  sweat-ducts  into  the  glands.  Spark- 
ling, colorless,  spheroidal,  and  elongated  bodies  were  also  present  in  the  true 
skin  next  to  the  rete,  in  the  lungs,  and  in  the  liver.  In  each  situation  these 
bodies  were  mixed  with  others,  spindle-shaped,  staff'-shaped,  and  canoe-shaped ; 
all  appeai'ed  to  be  albuminoid  in  character. 

Other  morbid  appearances  vary  with  the  complications  upon  which  death  so 
frequently  depends.  The  most  common  lesions  are  those  of  diff"use  broncho- 
pneumonia and  of  structural  alterations  of  the  mucous  membrane  of  the 
gastro- intestinal  tract,  either  catarrhal  inflammation,  follicular  entero-colitis, 
ulcerative  inflammation,  especially  of  the  colon,  or  softening.  Less  frequent 
are  caseation  of  the  bronchial  glands,  miliary  tuberculosis  of  the  lungs, 
pulmonary  collapse,  membranous  laryngitis,  diphtheria  of  the  pharynx,  and 
effusions  into  the  pleur?e  and  other  serous  cavities. 

Incubation. — The  interval  between  the  actual  introduction  of  the  poison 
and  the  appearance  of  the  first  symptoms  of  illness  has  been  quite  accu- 
rately determined — first,  by  experiment,  measles  having  been  introduced  by 
inoculation  in  Edinburgh,  Italy,  and  Germany  ;  second,  by  the  careful  study 
of  outbreaks  in  virgin  soil,  such  as  that  in  the  Faroe  Islands,  by  Panum  ; 
and  third,  by  ordinary  clinical  observation.  From  all  these  sources  the  period 
may  be  fixed  at  from  ten  to  twelve  days. 

Adults  and  older  children  may  complain  of  distaste  for  food,  slight  head- 


MEASLES. 


119 


ache,  and  lassitude  for  several  days  before  the  actual  beginning  of  the  disease, 
but  younger  children  appear  to  be  perfectly  Tvell,  and  practically  there  are 
no  symptoms  during  incubation. 

Symptoms. — The  course  of  rubeola  may  be  divided  into  several  stages. 

Prodromal  Stage. — This  lasts  about  four  days,  and  is  characterized  by  the 
following  group  of  symptoms :  lassitude,  irritability,  at  times  chilliness,  pain 
in  the  back  and  limbs,  headache,  loss  of  appetite,  thirst  and  other  indications 
of  gastro-intestinal  disturbance,  and,  more  important,  fever,  with  the  various 
signs  of  catarrhal  irritation  of  the  mucous  membrane  of  the  eyes,  nose,  fauces, 
and  larvnx.  The  chilliness  is  not  marked,  rarelv  amounting  to  more  than  a 
disposition  on  the  part  of  the  patient  to  keep  near  a  fire  or  a  desire  for  more 
clothing,  and  a  degree  of  coolness  in  the  extremities  appreciable  to  the  nurse's 
hand.  The  same  may  be  said  of  pain  in  the  back  and  limbs,  its  presence  in 
older  children  being  established  only  by  close  questioning,  and  in  younger  by 
their  showing  indications  of  suffering  when  moved. 

Pyrexia  is  uniformly  present.  It  may  be  postponed  until  the  second  day 
of  the  prodromal  stage,  but  usually  begins  on  the  first.  The  fever  is  contin- 
ued in  type,  the  ascent  of  temperature  being  marked  by  evening  exacerbations 

Fig.  1. 


104° 

103° 

102° 

101° 

100° 

99° 

98° 

97° 

Days  ofDi* 

JhUte. 

Bitp. 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

ME 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

A 

1 

\ 

\ 

i 

\ 

1 

^ 

I 

J 

r 

1 

1 

\ 

/ 

1 

\ 

'^ 

\ 

A 

P 

L 

\   1 

J 

■ 

Y 

L 

<* 

J 

/ 

Sl 

^ 

^ 

"^ 

"/ 

V 

A 

A 

r 

\ 

f 

I  , 

■- 

\ 

Y 

. 

1 

2 

8 

4 

5 

6 

7 

8 

» 

10 

11 

12 

,.'■ 

u 

^:'^;o.^ 

'■■y 

e-^ 

i^^oo 

"';.» 

^■^ 

>'°,o' 

,0     .' 

^A^ 

;'°;o' 

,ot.-' 

.''■'■ 

,-'' 

^■^ 

J^i^ 

t4 

^■■■n* 

'\^ 

■^^^ 

^-i^ 

t<^ 

■tK^ 

'^-  i"* 

^^■ 

Chart  of  Temperature  in  Measles,  showing  Pre-eruptive  Rise. 

This  chart  was  taken  from  a  negro  bov  set.  eight  vears,  a  patient  at  the  Children's  Hospital,  Philadelphia. 
The  attack  of  measles  began  on  the  day  marked  i ;  the  eruption  was  detected  on  that  marked  5,  and  was  at 
its  height  on  5  and  6. 

(about  2°)  and  morning  remissions  (about  1°),  which  show  a  tendency  to  become 
less  decided  and  shorter  as  the  day  of  eruption  is  approached.  Sometimes  there 
is  a  marked  remission  or  complete  intermission  on  the  second  or  third  day,  after 
which  the  temperature  curve  pursues  the  ordinary  course.     (See  Figs.  1  and  2.) 


120   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILD  REX. 

With  the  rise  in  temperature  the  pulse  becomes  increased  in  frequency, 
force,  and  volume,  though  it  is  rarely  as  frequent  as  in  scarlet  fever.  The 
skin,  while  moist,  feels  hot ;  complaints  are  made  of  frontal  headache ;  and 
the  child,  at  first  irritable  and  restless,  gradually  passes  into  a  condition  of 
quiet  and  drowsiness,  when  it  is  said  to  ''sleep  for  the  measles." 

The  pathognomonic  catarrhal  symptoms  begin  with,  or  even  precede,  the 
pvrexia.  These  are  inflammation  and  redness  of  the  conjunctivne — the  pal- 
pebral portions  especially — injection  of  the  whites  of  the  eyes,  photophobia, 
lachrymation,  stuffing  of  the  nose,  sneezing,  and  an  abundant  discharge  of 
muco'-purulent  fluid  from  the  anterior  nares.  The  secretions  from  the  eyes 
and  nose  are  irritating  and  excoriate  the  skin  over  which  they  flow ;  the  red- 
ness thus  produced,  with  the  injection  of  the  eyeballs,  the  swelling  of  the  lids 
and  face  generally,  make  up  a  heavy,  almost  characteristic,  physiognomy. 

Cough  is  usually  present  from  the  first  day.  Slight  and  infrequent  in  the 
beginning,  it  gradually  increases,  until  on  the  third  or  fourth  day  it  assumes  a 
peculiar  character.  It  is  laryngeal,  hard,  dry,  rather  hoarse,  and  occurs  in 
short  paroxysms.  Expectoration,  when  present,  is  slight  and  consists  of  clear, 
viscid  mucus.     The  voice  is  hoarse. 

The  tongue  is  covered  with  a  light  white  coating ;  the  tonsils  are  moder- 
ately enlarged ;  the  mucous  membrane  of  the  soft  palate,  fauces,  and  pharynx 
is  uniformlv  swollen  and  reddened,  and  from  twelve  to  twenty-four  hours  before 
the  close  of  the  prodromal  period  often  becomes  maculated  Avith  darker  red, 
slightlv-elevated  spots  closely  resembling  those  of  the  cutaneous  eruption ; 
the  latter  appearance  is  most  noticeable  upon,  and  may  be  confined  to,  the 
soft  palate. 

Koplik  recently  called  attention  to  a  peculiar  eruption  upon  the  buccal 
and  labial  mucous  membrane  which  he  claims  to  be  pathognomonic  of 
measles.  This  eruption  appears  on  the  first  day  of  invasion  as  a  variable 
number  of  "small,  irregular  spots  of  a  bright-red  color,"  each  having  in  its 
centre  a  "bluish-white  speck."  As  the  skin-rash  appears  the  eruption  on 
the  mucous  membrane  grows  diff'use.  and  when  the  former  is  at  the  efflores- 
cence the  latter  has  but  the  characters  of  a  discrete  spotting,  and  has  become 
a  diifuse  redness  with  innumerable  bluish-white  maculte  scattered  over  its  sur- 
face. This  svmptom  must  not  be  confounded  with  the  pharyngeal  eruption 
alreadv  mentioned,  and,  if  as  constantly  present  as  Koplik  asserts,  will  prove 
of  great  diagnostic  value  in  the  early  stage  of  the  disease. 

Moderate  enlargement  of  the  glands  behind  the  angle  of  the  jaw  is  an  ordi- 
nary feature,  and  the  same  condition  of  the  cervical  lymphatics  may  sometimes 
be  observed. 

There  are  anorexia,  thirst,  slight  difficulty  in  deglutition,  sometimes  vomit- 
ing, and  at  first  constipation,  later  diarrhoea. 

Of  nervous  manifestations,  irritability  and  drowsiness  have  been  already 
mentioned.  The  latter  symptom  is  often  very  marked,  the  child  sleeping  for 
the  greater  part  of  one  or  even  two  days  before  the  rash  appears,  waking  only 
to  ask  for  drink  or  to  have  its  urgent  wants  attended  to,  and  then  drowsing 
off"  awain.  There  is  no  danger  in  this  condition,  unless  it  be  associated  with 
indications  of  cerebral  disease  or  deepen  into  coma  or  alternate  with  decided 
delirium.  Restlessness  with  mild  delirium  at  night  may  take  the  place  of 
drowsiness,  and,  in  exceptional  cases,  convulsions  occur. 

Eruptive  Stage. — The  eruption  usually  appears  in  the  evening  of  the 
fourth  day.  For  a  few  hours  immediately  preceding  its  outbreak  the  nervous 
symptoms  are  increased,  or,  if  absent  before,  are  developed,  and  it  is  at  this 
time  that  convulsions  are  most  liable  to  take  place.     The  rash  shows  itself  first 


MEASLES. 


121 


on  the  skm  immediately  behind,  benea.th,  and  in  front  of  the  ears ;  thence  it 
spreads  to  the  rest  of  the  face,  the  neck,  the  trunk,  and  the  limbs,  completing 
Its  extension  over  the  entire  body  in  from  twenty-four  to  forty-eight  hours.  It 
begins  in  the  form  of  distinct  maculae,  more  or  less  deep  crimson  in  color, 
rounded  in  shape,  with  irregular  edges,  and  varying  from  half  a  line  to  three 
lines  m  diameter.  These  soon  develop  into  slightly  elevated  papules  with  hard, 
flat  summits,  which  feel  firm  to  the  touch  and  temporarily  lose  their  color  under 
pressure.  Isolated  and  few  in  number  in  the  beginning,  the  papules  rapidly 
become  more  abundant,  and  show  a  tendency  to  arrange  themselves  into  irreg- 
ular clusters,  the  unafi'ected  portions  of  the  skin  preserving  the  normal  appear- 
ance.    The  intensity  of  the  eruption  varies  greatly ;  sometimes  the  papules  are 

Fig.  2. 


F 

105° 
104° 

103° 
102° 
101° 

100° 
99° 
98° 

97^ 

DayaofDii. 

Fulse. 

^ 

£ 

M 

E 

i^ 

E 

M 

E' 

M^ 

E 

^ 

E 

M 

E 

M 

E 

M 

E 

M 

E 

^ 

E 

^ 

■ 

A 

^ 

' 

1 

■ 

\ 

1 

^ 

1 

I 

j 

1 

1 

11 

/ 1 

/  1 

I 

j 

V 

1 

1 

\| 

A 

y 

- 

/* 

V 

V 

U 

\ 

^ 

V 

' 

\ 

sj 

i 

\, 

■■ 

- 

, 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

f-^ 

££ 

^^ 

<^^ 

^ 

f^ 

&£ 

^^ 

P^^ 

:?AoO 

.■-'■' 

Chart  of  Temperature  and  Pulse  in  Measles. 

quite  scattered  and  the  few  clusters  are  separated  by  large  areas  of  healthy  skin  ; 
at  others  they  are  so  numerous  and  coalesce  so  closely  that  extended  portions 
of  the  surface  assume  a  dark-red  tint.  This  coalescing  is  most  frequently 
observed  on  the  face,  on  the  neck  and  back,  and  near  the  flexures  of  the  joints. 
Occasionally,  in  very  severe  cases,  minute  vesicles  form  on  the  summits  of  the 
papules.  After  full  development  the  rash  shows  little  change  for  one  or  two 
days.  It  then  begins  to  fade  in  the  order  of  its  appearance,  assuming  a  lighter 
or  yellowish-red  color,  and  in  a  day  or  two  later  disappears,  leaving  only  faint 
reddish  stains  which  mottle  the  skin  for  several  days  longer.  The  subsidence 
of  the  rash  is  followed  by  desquamation,  the  epithelium  falling  in  very  fine 
bran-like  scales.  This  process  is  most  noticeable  on  the  face,  but  even  in  this 
position  may  readily  escape  observation. 

The  rash  may  vary  in  other  characters  as  well  as  in  its  intensity.     Some- 


122    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

times  the  papules  on  their  first  appearance  are  hard  and  prominent,  resembling 
closely  those  of  variola.  Again,  their  crimson  color  may  not  entirely  disap- 
pear on  pressure — a  condition  due  to  great  hypersemia  of  the  skin.  Finally, 
the  eruption  may  steadily  grow  darker  until  a  deep-purple  color  is  acquired  ; 
this  is  also  due  to  intense  hypersemia  with  rupture  of  distended  cutaneous 
capillaries.  Such  a  rash  does  not  disappear  on  pressure :  it  remains  at  its 
height  much  longer  than  the  ordinary  eruption,  and  is  slow  in  fading. 

The  fever  does  not  abate  on  the  appearance  of  the  eruption ;  on  the  con- 
trary, it  often  attains  a  higher  marking  (103°-105°  F.  in  the  axilla)  on  the 
first  and  second  day  ;  after  that,  as  the  rash  fades,  it  rapidly  falls  to  the 
normal  line. 

The  preceding  chart  (Fig.  2)  presents  a  fair  picture  of  the  temperature 
curve  of  measles  of  average  severity.  The  patient  who  furnished  the  record 
was  a  boy  five  years  old,  an  inmate  of  the  Children's  Hospital,  Philadelphia, 
Having  been  directly  exposed  to  contagion,  the  symptoms  of  coryza  were 
noticed  on  the  day  marked  1 :  the  eruption  appeared  on  the  evening  of  that 
marked  4,  and  was  at  its  height  on  5  and  6.  Afterward  the  eruption  rapidly 
faded,  and  with  it  the  temperature  fell  almost  to  the  normal  line  on  8,  though 
complete  lysis  was  delayed  for  forty-eight  hours  by  a  trifling  secondary  laryn- 
geal catarrh. 

The  pulse  increases  in  frequency  as  the  temperature  rises,  and  follows  its 
curve  moderately  closely.  The  maximum  ratio  is  usually  about  120  beats  per 
minute,  though  it  occasionally  rises  higher,  as  in  the  case  just  referred  to. 

During  the  acme  of  the  eruption  and  pyrexia  the  catarrhal  symptoms 
become  more  severe.  The  conjunctivae  are  red,  the  eyelids  are  much  swollen, 
photophobia  is  extreme,  and  there  is  a  copious  flow  of  irritating  tears ;  the 
nasal  passages  are  dry  and  encrusted,  or  there  is  a  free  discharge  of  acrid 
mucus,  and  crusts  of  dried  blood  may  often  be  seen  about  the  nostrils,  for 
epistaxis  is  common.  The  upper  lip  is  tumid  and  excoriated,  the  cheeks  are 
swollen  and  deeply  reddened,  and  the  characteristic  physiognomy,  already 
mentioned  as  existing  in  the  prodromal  stage,  is  more  strikingly  marked.  The 
tongue  is  usually  moist,  with  a  thick,  yellowish-white  central  coating  and 
red  tip  and  edges;  the  soft  palate,  tonsils,  and  pharynx  are  red ;  and  the 
throat  feels  sore.  Thirst  and  anorexia  continue  ;  there  may  be  some  tunie- 
faction  and  tenderness  of  the  abdomen  ;  moderate  diarrhoea  is  the  rule ;  and 
in  some  cases  there  are  violent  vomiting  and  purging.  The  respiratory 
movements  are  somewhat  quickened :  the  voice  is  husky,  the  cough  is  parox- 
ysmal, dry,  hoarse,  and  troublesome,  and  attacks  of  spasmodic  croup  are  apt 
to  occur.  Physical  examination  of  the  chest  reveals  the  signs  of  catarrh  of  the 
larger  bronchial  tubes,  and  as  a  rule — especially  in  scrofulous  children — of 
enlargement  of  the  bronchial  glands.  The  probability  of  a  similar  enlarge- 
ment of  the  glands  at  the  angles  of  the  jaw  and  sides  of  the  neck  must  also 
be  remembered.  The  urine  is  scanty,  dark  yellow  in  color,  with  abundant 
urates,  and,  while  the  temperature  remains  elevated,  may  contain  a  trace  of 
albumin.  Prostration  of  the  general  strength  is  not  decided  in  the  majority 
of  cases. 

Stage  of  Decline. — So  soon  as  the  rash  begins  to  fade — fourth  day  of 
eruption,  eighth  of  disease — the  other  symptoms  rapidly  abate.  The  pulse 
loses  its  rapidity,  though  it  is  somewhat  weaker  than  normal ;  the  temperature 
steadily  falls,  often  with  considerable  sweating  ;  the  coryzal  symptoms  subside ; 
the  voice  becomes  less  hoarse  ;  the  cough  grows  looser  and  less  frequent ;  and, 
if  the  child  be  old  enough,  nummular  masses  of  muco-purulent  matter  are 
freely    expectorated.     The  tongue  cleans  off;  appetite  returns;  there    is    no 


MI]ASLES.  123 

longer  thirst,  irritability,  or  restlessness ;  the  bowels  return  to  their  normal 
condition,   and  ordinary  health  is  soon   regained. 

Modified  Forms. — Measles  without  eruption  and  measles  without  catarrh 
have  been  described  by  different  authorities.  In  regard  to  the  first  modification, 
it  is  difiicult  to  doubt  the  records  of  certain  isolated  cases  that  have  occurred 
during  epidemics  of  the  disease,  though  the  author  has  never  met  with  any 
examples.  On  the  other  hand,  cases  reported  as  "rubeola  sine  catarrho" 
must  be  classed  under  rubella  rather  than  modified  rubeola. 

There  is,  however,  a  form  of  measles  which  is  distinguished  from  its  outset 
by  typhoid  symptoms,  and  is  very  fatal.  Malignant,  ataxic,  or  black  measles, 
as  this  variety  is  called,  may  occur  as  an  epidemic  or  sporadic  afi'ection,  but  it 
is  usually  the  former.  There  is  great  prostration  ;  the  patient  is  dull  and  stupid  ; 
the  pulse  is  small,  feeble,  and  frequent ;  the  respiratory  movements  are  diffi- 
cult and  rapid;  the  rectal  temperature  is  high,  often  reaching  107°  or  108° 
F.,  while  the  hands  and  feet  feel  cold ;  the  tongue  is  dry,  brown,  and  thickly 
coated ;  epistaxis  is  often  obstinate,  and  hsematuria  may  occur.  The  rash 
appears  slowly,  imperfectly,  and  irregularly,  assumes  a  livid,  purplish,  or 
blackish  hue,  and  may  quickly  retrocede  ;  at  the  same  time,  the  skin  is 
thickly  mottled  with  petechise.  The  attack  progressing,  the  pulse  becomes 
so  rapid  that  it  can  scarcely  be  counted;  there  is  muscular  tremor  with 
muttering  delirium,  and  life  terminates  in  coma  or  convulsions.  After  death 
ecchymoses  may  be  found  in  the  viscera. 

Coraplications. — The  conditions  which  disturb  the  regular  course  and 
threaten  the  ordinarily  favorable  result  of  measles  are  mainly  furnished  by  an 
undue  development  of  certain  of  the  usual  or  unusual  features — an  exaggera- 
tion determined  either  by  the  nature  of  the  special  epidemic  or  by  certain 
constitutional  peculiarities  of  the  individual  aflFected.  These  complications 
may  be  described  in  the  order   of  their  frequency   and  importance. 

Bronchial  catarrh  may  spread  from  its  ordinary  position,  the  larger  tubes, 
to  those  of  smaller  calibre,  and  become  a  grave  complication.  The  extension 
is  most  common  in  infants  under  one  year,  and  in  them  usually  proves  fatal 
through  collapse  of  the  lung — a  condition  readily  produced  at  this  early  age. 
The  indicative  symptoms  are  dyspnoea  and  rapid  breathing,  lividity  of  the 
face  and  extremities,  a  haggard  and  anxious  expression  of  the  countenance, 
and  the  detection,  on  auscultation,  of  fine  subcrepitant  rales  distributed 
throughout  both  lungs. 

After  the  age  of  twelve  months  catarrhal  pneumonia  is  more  frequent  than 
extended  bronchitis.  It  is,  in  fact,  the  most  common  complication  of  the  dis- 
ease, and  may  occur  at  any  time  during  its  course.  When  it  arises  early,  the 
eruption  is  often  delayed,  or,  if  already  present,  may  retrocede,  and  there  is  con- 
siderable aggravation  of  the  general  symptoms.  If  later — at  about  the  time  of 
the  disappearance  of  the  rash,  for  example — the  temperature,  instead  of  falling, 
remains  high,  ranging  in  the  neighborhood  of  102°  F. :  in  place  of  the  usual 
general  improvement,  there  are  greater  weakness  and  more  manifest  illness  ; 
the  patient  is  listless  and  takes  little  interest  in  his  toys  or  in  what  is  going  on 
about  him  ;  there  is  increased  thirst  and  anorexia ;  the  face  is  pinched  and 
distressed-looking ;  the  lips  are  livid,  and  the  alse  nasi  move  to  and  fro  v/ith 
the  breathing,  which  is  labored  and  quickened.  On  physical  examination  of 
the  chest  the  ordinary  signs  of  broncho-pneumonia  can  be  detected.  This  compli- 
eation  varies  greatly  in  degree  of  severity.  It  often  runs  a  prolonged,  subacute 
course,  and  may  terminate  in  complete  recovery,  in  death,  or,  becoming 
chronic,  may  merge  into  one  of  the  varieties  of  pulmonary  phthisis. 

Intestinal  catarrh,   which  is  usually   productive  of  nothing  more  than   a 


124    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

trifling,  readily-controlled  diarrhoea,  may  be  aggravated  into  an  entero-colitis, 
or  even  an  ulcerative  inflammation  of  the  mucous  membrane  of  the  colon. 
These  complications  are  excited  by  improper  food,  by  injudicious  use  of  purga- 
tive medicines,  and  by  careless  exposure  to  cold  and  dampness.  They  some- 
times appear  during  the  initial  stage,  but  are  usually  developed  later  in  the 
disease.  The  symptoms  are  tumidity  and  tenderness  of  the  abdomen,  colic, 
tenesmus,  and  more  or  less  frequent  purgation,  the  evacuations  being  green  in 
color  and  containing  glairy  or  bloody  mucus.  The  regular  course  of  the 
disease  is  little  affected,  though  in  nervous,  sensitive  children  the  intestinal 
lesions  may  maintain  a  temperature  of  104°  or  105°  F.  for  several  days  after 
the  subsidence  of  the  rash.  In  such  cases  convalescence  is  prolonged,  though 
the  ultimate  outlook  is  favorable  unless  catarrhal  pneumonia  coexists  ;  then  the 
danger  inherent  to  the  latter  condition  is  greatly  increased. 

Laryngitis  often  complicates  measles.  It  is  most  likely  to  occur  during 
the  decline  of  the  eruption.  Ordinarily  the  spasmodic  form — false  croup — is 
assumed,  with  symptoms  that  are  alarming  to  the  uninitiated,  but  really  devoid 
of  actual  danger  and  without  effect  upon  the  regular  course  of  the  disease. 
Sometimes,  on  the  contrary,  a  pseudo-membranous  exudation  forms  in  the 
larynx,  and  the  case  at  once  becomes  extremely  grave.  The  symptoms  are  the 
same  as  in  idiopathic  cases.  Thickening,  softening,  and  ulceration  of  the 
mucous  membrane  occasionally  occur,  and  Rilliet  and  Barthez  record  a  case 
in  which  suppuration  about  the  larynx  followed  an  attack  of  measles. 

Convulsions  happening  during  the  eruptive  stage  are  of  grave  import ; 
preceding  it,  they  are  seldom  serious. 

Epistaxis,  when  it  becomes  profuse  and  exhausting,  always  tends  to  post- 
pone the  restoration  to  health,  and  may  determine  death  in  weak  subjects  or 
when  the  disorder  is  severe  and  ataxic  in  type. 

Ophthalmia  and  otitis  are  infrequent  complications,  and  are  almost  entirely 
limited  to  patients  having  tuberculous  tendencies.  Both  yield  sluggishly  to 
treatment,  and  otitis  may  prove  fatal  by  an  extension  of  the  inflammatory 
process  to  the  membranes  of  the   brain. 

Paralysis  should  be  mentioned  as  a  rare  accident  that  may  be  associated 
wuth  measles.     Drs.  Barlow  and  Ormerod  have  recorded  cases  in  point. 

Sequelae. — Many  of  the  conditions  referred  to  as  complications  may  also 
occur  as  sequels  of  the  disease.  Thus  catarrhal  pneumonia,  laryngitis,  and  bron- 
chitis in  chronic  form,  and  chronic  gastro-intestinal  catarrh  are  frequent  results. 
Enlargement  of  the  bronchial  glands  is  another  common  sequence,  and  acute 
tuberculosis  so  often  follows  that  the  physician  must  suspect  its  development 
whenever  a  patient  remains  feeble  and  feverish  after  an  attack  of  measles.  In 
children  having  a  tuberculous  diathesis  the  disease  is  very  prone  to  light  up 
any  or  all  of  the  troubles  which  are  characteristic  of  their  constitutional  taint. 
Other  less  common  sequelne  are  "marasmus,"  or  a  condition  of  general  wast- 
ing and  debility  ;  diseases  of  the  eyes  and  ears  ;  ulcerative  stomatitis,  with 
necrosis  of  the  jaw;  gangrene  of  the  cheek  and  vulva;  necrosis  of  the  nasal 
cartilages ;   and,  rarest  of  all,  renal  disease. 

Whooping-cough  is  generally  supposed  to  bear  an  intimate  relation  to 
measles.  Epidemics  of  the  two  diseases  undoubtedly  often  follow  close  upon 
each  other  without  any  uniformity  of  precedence.  What  the  actual  connec- 
tion may  be  is  uncertain,  but  it  is  probable  that  the  presence  of  one  exanthem 
merely  lessens  the  resistance  which  a  healthy  body  manifests  to  the  infective 
power  of  the  other. 

Diagnosis. — The  distinguishing  features  of  rubeola  are  the  long  prodromal 
stage  with  its  marked  catarrhal  symptoms  ;  the  course  of  the  fever-curve,  espe- 


MEASLE8.  125 

cially  the  continuance  of  high  temperature  for  two  days  after  the  appearance 
of  the  eruption  ;  and  the  peculiaritiies  of  the  rash.  It  should  be  remembered, 
however,  that  the  rash,  though  quite  characteristic  in  typical  cases,  is  more  apt 
to  be  misleading,  through  its  variations,  than  any  of  the  other  pathognomonic 
signs ;  and  it  may  be  said  of  measles,  as  indeed  of  all  other  exanthemata,  that 
a  diagnosis  must  never  be  based  exclusively  upon  the  eruption. 

In  the  initial  stage  it  is  often  difficult  to  differentiate  between  measles  and 
an  ordinary  acute  catarrh — a  "severe  cold."  The  coryzal  symptoms  are 
identical :  hoarseness  and  cough  are  present  in  both,  and  both  are  attended  by 
fever.  If  such  symptoms  are  developed  at  a  time  when  measles  is  epidemic, 
the  probabilities  are  strongly  in  favor  of  an  attack  of  the  disease.  On  the 
other  hand,  if  the  history  of  exposure  to  contagion  is  uncertain,  it  is  best  to 
withhold  a  decided  opinion  and  wait  for  the  appearance  of  the  rash,  which,  it 
is  well  to  recollect,  shows  upon  the  soft  palate  from  twenty-four  to  forty-eight 
hours  before  it  can  be  detected  upon  the  skin.  In  this  connection  the  buccal 
eruption  described  by  Koplik,  and  already  mentioned,  may  be  of  great 
assistance  in  establishing  an  opinion.  It  may  be  stated  here  that  this 
element  of  uncertainty  in  the  early  diagnosis  is  much  to  blame  for  the  ready 
and  wide  extension  of  the  disease ;  for,  while  contagion  is  freely  given  off"  by 
patients  in  the  catarrhal  stage,  isolation  is  rarely  practised  until  all  doubt  as  to 
the  nature  of  the  attack  is  cleared  up  by  the  eruption. 

Sore  throat,  which  is  sometimes  present,  combined  with  fever,  may  suggest 
scarlatina,  but  the  latter  disease  has  a  sudden  onset,  with  vomiting,  rapid  and 
extreme  elevation  of  temperature,  and  very  frequent  pulse,  and  without  catar- 
rhal symptoms ;  further,  the  characteristic  eruption  appears  not  later  than 
twenty-four  hours  from  the  commencement  of  the  attack. 

In  the  eruptive  stage,  when  the  color  and  grouping  of  the  papules  are 
typical,  and  the  fever,  coryza  and  cough  marked,  there  is  little  room  for  error. 

When  the  rash  appears  in  hard,  isolated  papules,  variola  may  be  suspected, 
a  mistake  not  uncommonly  made.  In  small-pox,  however,  the  pre-eruptive 
stage  is  characterized  by  obstinate  vomiting  and  severe  pain  in  the  back. 
When  the  eruption  appears,  the  temperature  abruptly  falls  and  the  active 
symptoms  abate ;  the  papules  themselves  are  harder  than  ever  noticed  in 
measles,  feeling  like  pellets  of  shot  under  the  skin,  and  by  the  second  day 
those  first  appearing  on  the  face  are  changed  into  vesicles. 

There  is  more  difficulty  in  distinguishing  the  rubeolous  eruption  from  the 
rash  of  rubella  than  from  that  of  any  other  of  the  exanthemata.  The  points 
of  distinction  are  the  short,  often  featureless,  prodromal  stage  of  rubella,  the 
comparative  absence  of  catarrhal  symptoms,  and  the  fact  that  the  papules  are 
smaller  and  lighter  in  color,  appear  almost  •  simultaneously  on  the  face,  the 
wrists,  and  the  ankles,  and  thence  extend  over  the  body,  showing  no  tendency 
to  irregular  grouping. 

Various  skin  eruptions,  notably  the  early  stages  of  acute  and  general  eczema 
and  syphilitic  roseola,  resemble  the  rash  of  measles,  but  the  diff"erences  in  clin- 
ical history  and  the  entire  absence  of  general  symptoms  render  the  distinc- 
tion easy. 

Prognosis. — Generally  speaking,  the  percentage  of  fatality  in  rubeola  is 
small.  Nevertheless,  in  individual  cases  the  prognosis  depends  upon  the  type 
of  the  epidemic,  the  age  and  previous  condition  of  health  of  the  patient,  the 
nature  of  the  hygienic  surroundings,  and  the  character  aud  severity  of  the 
complications. 

An  attack,  of  whatever  severity  short  of  malignancy,  occurring  in  a  pre- 
viously healthy  child  over  the  age  of  two  years,  who  is  surrounded  by  the  usual 


126    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

comforts  of  life  and  treated  with  ordinary  skill,  should  almost  invariably  ter- 
minate in  recovery ;  and  in  such  cases  even  the  onset  of  so  serious  a  compli- 
cation as  catarrhal  pneumonia  is  rarely  fatal.  Quite  the  reverse  is  true  when 
the  disease  attacks  children  who  are  constitutionally  feeble  or  debilitated  by 
some  antecedent  acute  disease,  who  are  suffering  from  rickets  or  suppurative 
bone  disease,  who  have  chronic  pulmonary  lesions,  who  are  subjects  of  the 
tuberculous  diathesis,  and  who  live  in  crowded  and  filthy  houses  or  unhealthy 
localities.  These  patients,  when  they  survive  the  force  of  the  disease  itself, 
are  often  carried  away  by  one  of  the  complications  or  sequelae,  to  the  devel- 
opment of  which  they  are  very  prone. 

In  children  under  two  years  of  age  measles  is  more  serious,  and  the  younger 
the  infant  the  greater  is  the  danger  of  an  unftivorable  termination.  Here  death 
is  due  to  the  readiness  with  which  bronchial  catarrh  extends  to  the  finer  tubes, 
producing  catarrhal  pneumonia  or  pulmonary  collapse — a  tendency  inherent  to 
every  catarrh  in  the  very  young,  but  most  marked  in  that  attending  measles, 
and  very  apt  to  be  exhibited  in  weakly  or  rachitic  infants. 

The  gravity  of  the  different  complications  and  the  fatality  of  epidemics 
of  malignant  type  have  already  been  referred  to.  In  ordinary  epidemics  the 
prognosis  becomes  unfavorable  under  the  following  conditions :  When  the 
prodromal  stage  is  more  prolonged  than  usual  and  attended  by  violent 
symptoms  of  any  kind,  as  great  jactitation,  irritability,  dyspnoea,  stupor,  and 
coma  or  convulsions  ;  when  the  eruption  is  irregular  in  development  or  course ; 
when  the  pyrexia  continues  after  the  subsidence  of  the  rash  ;  when  in  the  later 
stages  of  the  disease  the  face  remains  deeply  flushed  or  grows  pale ;  when 
cough,  dyspnoea,  or  diarrhoea  persist,  and  when  the  child  is  left  weak,  languid, 
dispirited,  or  irritable. 

Dr.  Ellis  places  the  mortality  of  measles  at  1  in  15  cases.  My  own  experi- 
ence has  been  much  more  fortunate.  In  private  practice  all  of  my  cases  have 
recovered  save  one,  and  that,  an  infant  of  nine  months,  died  of  meningitis 
directly  due  to  the  active  lighting  up.  by  the  measles,  of  a  long-standing  disease 
of  the  middle  ear.  Even  in  my  hospital  wards  the  mortality  has  been  less 
than  that  ojiven  bv  the  author  quoted,  and  the  deaths,  while  occasionally  due 
to  the  force  of  the  poison  on  enfeebled  bodies,  have  mainly  occurred  in  patients 
previously  affected  with  spinal  caries  or  suppurating  joints  or  having  badly 
deformed  rachitic  chests. 

Before  leaving  this  division  of  the  subject  some  attention  should  be  given 
to  the  question  of  the  liability  of  the  return  of  measles.  The  fact  is,  that, 
next  to  typhoid  fever,  measles  is  the  most  liable  of  all  the  exanthemata  to 
return.  A  number  of  cases  are  on  record  in  which  patients  have  had  a  second 
attack  after  a  short  interval,  and  sometimes  so  soon  after  the  first  as  to  consti- 
tute a  true  relapse,  both  attacks  running  their  course  within  a  period  of  four 
or  five  weeks. 

Treatment. — Attention  must  be  directed  first  to  the  hygienic  manage- 
ment of  the  disease,  as  this  is  of  vast  importance  in  all  cases,  and  in  those  of 
ordinary  severity  sufiices,  with  a  very  little  aid  from  simple  drugs,  to  ensure 
a  favorable  ending. 

As  early  as  the  nature  of  the  attack  can  be  decided  upon  the  patient 
must  be  put  to  bed,  and  confined  there  until  not  only  the  rash  itself,  but  all 
traces  of  the  remaining  yellowish-red  stains,  have  disappeared — about  the 
eighth  or  tenth  day  of  the  disease.  Youngr  infants,  with  whom  it  is  difficult 
to  enforce  complete  rest  in  bed,  must,  when  taken  up,  be  held  upon  the  nurse's 
lap  and  be  properly  protected  by  some  light  wrap.  If  it  be  possible  to  have  two 
cots,  one  for  day  and  the  other  for  night  use,  the  patient's  comfort  is  greatly 


MEASLES.  127 

increased.  Care  must  be  taken  to  provide  only  sufficient  bed-covering  to 
maintain  warmth ;  the  mattress  should  be  of  hair,  and,  when  only  one  bed 
is  at  command,  the  sheets  ought  to  be  changed  at  least  once  each  day,  though 
accidental  soiling  may  render  more  frequent  renewal  necessary.  A  large,  airy, 
and,  if  possible,  isolated  chamber  is  to  be  selected  for  the  sick-room,  and  an 
open  fireplace  for  wood  or  coal  is  the  best  method  of  heating,  at  the  same  time 
securing  free  ventilation  without  draughts.  When  heat  is  supplied  from  a 
furnace,  change  of  air  must  be  effected  by  a  window  or  door,  the  patient 
being  protected  from  chilling  currents  by  a  carefully  placed  screen.  The 
proper  temperature  is  Qb°  to  68°  F.  During  the  continuance  of  photophobia 
and  conjunctival  irritation  the  room  must  be  moderately  darkened,  and  it  is 
always  well  to  see  that  the  bed  is  so  placed  that  the  patient's  face  will  not 
be  turned  directly  toward  a  window.  All  superfluous  hangings  and  furniture 
should  be  dispensed  with,  though  it  is  unnecessary  to  strip  the  apartment  so 
completely  as  in  case  of  scarlet  fever. 

After  the  child  is  well  enough  to  leave  his  bed  he  should  be  kept  in 
the  sick-room  for  three  or  four  days ;  then,  so  far  as  his  own  safety  is 
concerned,  he  may  be  allowed  the  range  of  the  house,  but  not  permitted  to 
go  out  doors  for  a  week  longer,  and  then  only  in  favorable  weather.  If,  however, 
there  are  other  susceptible  subjects  in  the  house,  and  the  question  is  one  of 
isolation,  he  must  not  quit  his  chamber  until  the  end  of  the  third  week  from 
the  beginning  of  the  attack. 

The  diet  requires  careful  regulation.  Nursing  infants  must  be  fed,  during 
the  febrile  stage  of  the  disease,  at  somewhat  shorter  intervals  than  in  health, 
but  if,  on  account  of  increased  thirst,  they  suck  very  greedily,  the  time  of 
lying  at  the  breast  must  be  curtailed,  the  object  being  to  secure  sufficient 
nourishment  without  at  any  time  overloading  the  alimentary  canal  and  over- 
working the  digestive  powers,  which  are  enfeebled  by  the  catarrhal  condition 
of  the  mucous  membrane.  With  bottle-fed  babies  it  is  even  more  essential  to 
carefully  regulate  the  axlministration  and  preparation  of  the  artificial  food. 
For  example,  a  child  of  nine  months,  who  in  health  would  be  fed  five  times 
daily  and  take  in  all  about  forty  fluidounces  of  appropriately  strong  food,  must 
during  measles  be  placed  nearly  on  the  plane  of  a  child  six  months  old,  the 
feedings  being  increased  to  six  or  eight  a  day,  the  total  quantity  reduced 
to  thirty  or  thirty-four  fluidounces,  and  the  strength  proportionally  lessened. 
For  the  purpose  of  dilution  lime-water  or  barley-water  may  be  employed 
with  advantage,  on  account  of  its  power  of  preventing  rapid  coagulation  and 
the  formation  of  large,  tough   curds  in  the  stomach. 

Should  ordinary  milk  mixtures  disagree,  it  is  well  to  resort  to  Pasteuriza- 
tion or  partial  precligestion,  and  if  it  be  impossible  for  the  infant  to  retain  any 
form  of  milk  food,  as  is  sometimes  the  case,  raw  beef  juice  in  doses  of  two 
teaspoonfuls  every  two  hours,  or  veal  broth  and  barley-water  may  be  resorted 
to  as  temporary  substitutes. 

Patients  who  are  old  enough  to  take  a  mixed  diet  when  well  should  at  once 
be  placed  upon  liquid  food. 

To  relieve  thirst,  pure  water,  carbonic-acid  water,  and  Vichy  are  prefer- 
able to  any  of  the  old-fashioned  sweetened  or  acidulated  drinks.  They  are  to 
be  given  cool  (not  iced),  and  in  moderate  quantities  at  short  intervals.  In 
administering  drink  a  good  plan  is  to  use  a  small  glass — holding  a  fluidounce, 
for  example ;  to  drain  this  gives  the  child  more  satisfaction  than  the  same 
draught  from  a  larger  vessel  which  he  is  not  allowed  to  empty,  and  there  is 
much  less  danger  of  an  excessive  quantity  being  taken. 

With  the  decline  of  the  temperature  and  the  abatement  of  symptoms  denot- 


128     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ing  gastro-intestinal  disturbance,  additions  may  gradually  be  made  to  the  diet 
until  the  full  feeding  of  health  is  resumed. 

...  m 

Due  attention  must  be  paid  to  keeping  the  patient's  person  clean.  To 
this  end  the  face,  hands,  portions  of  the  body  liable  to  become  soiled,  and 
even  the  whole  surface,  should  be  sponged  with  tepid  water  every  morning, 
each  part  being  washed  and  dried  separately,  so  as  to  avoid  exposure  and 
chilling. 

\Vhen  the  patient  is  well  enough  to  go  into  the  open  air,  it  is  essential  to 
see  that  he  is  properly  dressed  with  warm  woollen  under-clothing ;  morning 
spongings  with  salt  water  may  also  be  ordered  now,  and  complete  restoration 
to  health  will  be  greatly  hastened  by  a  change  of  air.  So  the  atmosphere  be 
dry  and  bracing,  it  makes  little  difference,  in  ordinary  cases,  whether  the  resort 
selected  be  at  the  sea-coast  or  inland,  though  the  former  is  to  be  preferred  when 
the  disease  leaves  the  subject  with  marked  glandular  enlargements  or  develops 
other  manifestations  of  the  tuberculous  diathesis. 

The  medicinal  treatment  of  ordinary  cases  of  measles  is  very  simple. 
Early  in  the  attack,  while  the  temperature  is  elevated  and  the  cough  hoarse, 
citrate  of  potassium  is  useful  as  a  febrifuge  and  relaxing  expectorant.  To  a 
child  six  years  old  from  one  to  two  fluidrachms  of  liquor  potassii  citratis 
should  be  given  every  two  hours,  and  to  this  may  be  added  20  drops  of  pare- 
goric and  5  or  10  drops  of  syrup  of  ipecacuanha  if  the  cough  becomes  very 
troublesome  and  croupy — a  tendency  often  exhibited  during  the  first  two  or 
three  nights  of  the  attack.  Later,  as  the  cough  grows  loose,  a  stimulating 
expectorant  should  be  substituted.  The  best  of  this  class  of  drugs  is  chloride 
of  ammonium,  which  must  be  given  in  solution  and  in  doses  of  1  to  2  grains 
every  second  hour.  As  convalescence  approaches  the  expectorant  may  be 
gradually  discontinued,  and  1  grain  of  quinine  may  be  given  three  times  daily, 
either  in  solution  or  in  chocolate  tablets ;  sometimes,  too,  there  is  sufficient 
debility  to  Avarrant  the  administration  of  moderate  doses  of  whiskey.  Finally, 
a  course  of  iron  or  of  cod-liver  oil — in  tuberculous  cases — is  often  necessary. 
•  While  pursuing  these  general  measures  the  eyes  need  careful  attention. 
Four  times  daily  the  lids  should  be  washed  with  water  as  hot  as  can  be  borne, 
and  afterward  a  few  drops  of  a  solution  of  borax  (gr.  v  to  f^j)  gently  applied 
to  the  conjunctivae.  In  case  of  great  photophobia  and  conjunctival  irritation 
a  weak  solution  of  cocaine  (gr.  j  to  f^ss)  may  be  dropped  into  the  eye  twice 
daily.  It  is  well  also  to  spray  the  nares  and  pharynx  at  frequent  intervals 
with  Dobell's  solution  or  Listerine  diluted  with  water  (1  part  to  6),  or,  if  the 
patient  be  old  enough,  the  throat  may  be  gargled  every  three  hours  with  one 
teaspoonful  of  chlorate  of  potassium  dissolved  in  4  fluidounces  each  of  claret 
and  water.  Mild  counter-irritation  of  the  skin  of  the  throat  is  often  of  serv- 
ice in  relieving  pain  and  hoarseness ;  for  this  purpose  a  combination  of  tur- 
pentine and  olive  oil  (1  part  to  2  or  3)  may  be  employed  several  times  in 
the  twenty-four  hours. 

Malignant  measles  demands  a  stimulant  and  tonic  treatment.  Whiskey  or 
brandy  in  properly  proportioned  quantities  must  be  added  to  the  milk,  or 
brandy-and-egg  mixture  may  be  employed,  and  raw  beef  juice  and  concen- 
trated meat  broth  must  form  an  element  in  the  diet.  Of  drugs,  quinine, 
carbonate  of  ammonium,  and  digitalis  are  called  for,  and  must  be  used  in 
sufficient  doses  to  meet  the  urgency  of  the  indications.  In  this  form  mustard 
baths  and  hot  packs  are  of  great  service.  For  the  mustard  bath,  which  is 
more  suitable  for  children  under  three  years  of  age,  the  water  should  be  at  a 
temperature  of  100°,  and  contain  about  one  tablespoonful  of  mustard  to  the 
gallon  ;  the  patient  is  immersed  up  to  the  neck  for  three  minutes,  then  quickly 


MEASLES.  129 

dried  and  placed  in  bed  between  blankets  or  wrapped  in  a  blanket  and  dried 
later.  The  bath  may  be  repeated  in  two  hours  if  necessary.  In  hot  packing 
the  child  is  placed  between  blankets,  and  then  a  blanket  wrung  out  as  dry  as 
possible,  after  being  wet  with  hot  water  or  mustard  and  water  (two  teaspoonfuls 
to  the  gallon),  is  quickly  wrapped  about  the  body,  care  being  taken  lest  it  be 
too  hot ;  it  may  be  renewed  in  half  an  hour. 

At  times  one  or  more  of  the  symptoms  of  the  disease  may  be  so  modified 
or  exaggerated  as  to  require  special  treatment. 

Headache,  when  violent,  is  usually  attended  by  constipation,  and  can  be 
relieved  by  unloading  the  bowels  and  by  putting  the  feet  in  hot  mustard- 
water  (one  tablespoonful  to  the  bath)  or  applying  a  mustard  plaster  (  1  part  to 
4  or  6  of  flour)  to  the  nape  of  the  neck.  For  the  purpose  of  evacuating  the 
bowels  enemata  or  glycerin  suppositories  should  first  be  tried,  and  if  these 
fail,  a  mild  laxative,  as  calomel  in  broken  doses  or  milk  of  magnesia  with 
aromatic  syrup  of  rhubarb,  may  be  administered.  Active  purgatives  should 
never  be  employed,  on  account  of  the  decided  diarrhoeal  tendency  of  the 
disease.  Should  these  measures  fail  to  relieve  the  headache,  resort  must  be 
had  to  bromide  of  potassium  or  elixir  of  the  valerianate  of  ammonium. 

Moderate  looseness  of  the  bowels  need  not  be  interfered  with,  but  if  the 
purging  be  sufficiently  violent  and  continuous  to  threaten  the  strength  of  the 
patient,  a  combination  of  rhubarb,  bismuth,  and  chalk  mixture  may  be 
prescribed,  or,  if  the  evacuations  be  very  watery,  it  may  be  necessary  to  use 
a  more  powerful  astringent,  as  oxide  of  zinc  in  doses  of  gr.  \-^  every  three 
or  four  hours. 

Distressing  vomiting  is  best  treated  by  causing  the  patient  to  drink  tepid 
water,  and,  when  the  stomach  has  been  relieved  of  altered  food  and  irritating 
secretions,  applying  weak  mustard  plasters  to  the  epigastrium.  In  this  condi- 
tion, however,  it  is  most  important  to  pay  careful  attention  to  the  feeding. 

When  the  eruption  is  delayed,  appears  irregularly,  or  retrocedes,  it  must 
be  remembered  that  the  condition  depends  upon  some  complication — broncho- 
pneumonia, for  example — and  that  the  true  mode  of  relief  is  to  relieve  the 
internal  inflammation  which  is  the  cause  of  the  difficulty :  hot  mustard  foot- 
baths or  full  baths,  hot  packs,  mustard  sinapisms,  and  stimulants  are  required. 
Liquor  ammonii  acetatis  is  a  useful  preparation  in  these  cases ;  it  may  be 
given  in  doses  of  one  to  two  teaspoonfuls  every  two  hours.  When  the  rash 
itches  or  burns,  frequent  applications  of  fresh  lard  or  vaseline  will  afi'ord 
relief. 

At  the  acme  of  the  eruption  the  temperature  often  runs  up  to  104°  or 
105°  F.  for  a  few  hours,  without  corresponding  severity  of  the  other  symp- 
toms. No  interference  is  necessary  for  a  temporary  elevation  of  this  sort,  but 
for  a  persistently  high  temperature  of  twelve  hours  or  more  some  antipyretic 
must  be  given  or  cooling  baths  resorted  to.  Antipyretics  are  still  on  trial,  but 
the  safest  is  phenacetin.  This  may  be  administered  in  an  initial  dose  of  1 
grain  for  any  age  between  two  and  six  years.  If  the  temperature  falls  after- 
ward, wait  and  observe  the  extent  of  the  depression;  if  not,  repeat  the  dose 
after  the  lapse  of  an  hour ;  should  this  fail,  gradually  increase  the  amount  to 
2  or  3  grains.  The  first  dose  may  be  given  when  the  temperature  ranges 
above  103°,  and  the  drug  may  be  repeated  as  often  as  necessary  to  keep  it 
below  this  point,  the  cardiac  condition  being  carefully  watched  in  the  mean 
time. 

When  baths  are  employed  to  reduce  the  pyrexia,  water  at  a  temperature 
of  95°  to  98°  F.  should  first  be  used ;  if  this  fail,  tepid  or  cold  spongings 
may  next  be  resorted  to,  and  as  a  final  resort  the  tepid  or  cooled  bath  may 


130     AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

be  tried.  In  giving  the  latter  the  child  should  be  undressed  as  quickly  as 
possible,  and  then  immersed  in  a  bath  of  90°  F. ;  cold  water  is  now  rapidly 
added  until  the  temperature  of  the  bath  is  reduced  to  80°.  After  a  sufficient 
intermission — usually  five  or  six  minutes — the  body  is  quickly  dried  with  a 
soft  towel  and  the  patient  put  back  to  bed  betAveen  sheets.  The  effect  of  the 
bath  is  sometimes  very  poAverful.  and  the  child  remains  livid-looking  and 
collapsed  for  some  time.  In  such  case  small  doses  of  brandy  must  be  given 
in  warm   milk  at  short  intervals  and  artificial  heat  applied  to  the  feet. 

It  is  stated  by  some  authorities  that  antipyretics  ought  to  be  employed 
whenever  the  temperature  reaches  102°  F.  Such  a  rule  is  dangerous.  There 
are  many  instances  in  which,  with  a  temperature  of  102°,  the  child  is  very  ill, 
and  this  degree  of  fever  may  be  judged  to  be  more  than  usually  detrimental. 
For  these  a  bath,  either  tepid  or  cold,  cold  sponging,  or  phenacetin,  may  be 
recommended,  but  for  one  such  case  there  are  many  others  that  run  a  perfectly 
favorable  course  with  a  temperature  even  higher  than  this,  and  in  which  it  is 
difficult  to  see  what  benefit  could  have  accrued  from  antipyretics.  Each  case 
must  be  treated  upon  its  own  merits. 

When  in  doubt  as  to  the  propriety  of  using  antipyretic  drugs  or  baths,  it 
is  well  to  try  the  effect  of  moderately  full  doses  of  sulphate  of  quinine.  It  has 
been  my  own  experience  that  this  agent  given  by  the  mouth,  or,  better  still, 
by  the  rectum,  in  suppositories  of  two  to  four  grains  every  three  or  four  hours, 
frequently  reduces  temperature,  and,  should  there  be  much  associated  restless- 
ness, produces  sleep. 

The  treatment  of  convulsions,  broncho-pneumonia,  and  other  disorders 
which  may  be  associated  with  or  follow  after  measles  does  not  differ  from  that 
employed  when  these  affections  occur  idiopathically,  and  therefore  requires  no 
especial  consideration  here. 

Quarantine. — The  rubeolous  patient  should  keep  his  bed  for  eight  or  ten 
days  and  his  room  for  three  weeks ;  then,  if  he  be  quite  well  in  every  respect, 
there  is  little  danger  in  his  mixing  with  his  playmates.  When  one  member 
of  a  household  is  attacked,  it  is  necessary  for  the  other  children  of  the  family 
who  have  not  had  the  disease  to  stop  going  to  school  or  associating  with  other 
children,  as  it  is  probable  that  they  also  have  contracted  the  malady,  and,  as 
it  is  infectious  in  its  early  stages,  they  may  readily  be  the  means  of  giving  it 
to  others.  For  the  same  reason  it  is  unwise  to  send  them  away  from  home ;  at 
the  same  time  they  must  not  come  in  contact  with  the  case  already  developed. 

The  convalescent  should  have  a  warm  bath  and  fresh  clothing  before  ming- 
ling with  his  associates.  Scalding  of  the  bed-  and  body-clothing  and  thorough 
airing  and  cleaning  of  the  sick-room  are  all  that  is  necessary  in  ordinai*y  cases, 
though  in  malignant  epidemics  disinfection  of  the  bedding  and  thorough  fumi- 
gation of  the  chamber  with  sulphur  should  be  insisted  upon. 


SCARLET  FEVER. 

By  MARCUS  P.  HATFIELD,  M.  D., 

Chicago. 


ScAELET  FEVER,  or  Scarlatina,  is  a  self-limited,  contagious,  microbic  disease, 
characterized  by  fever,  angina,  and  a  typical  eruption,  and  followed  by  des- 
quamation and  recovery  in  about  three  weeks  if  the  disease  be  uncomplicated. 

The  health  reports  of  all  of  our  large  cities  show  that  scarlet  fever  is  an 
endemic  disease  of  childhood,  never  being  entirely  stamped  out,  and  afifecting 
now  only  a  trivial  percentage  of  the  population,  and  then  increasing  into  epi- 
demics of  frightful  mortality,  often  from  causes  as  yet  unknown  to  modern 
science. 

According  to  Busey,  it  is  the  most  widely  disseminated  of  the  exanthemata 
of  childhood,  and,  perhaps  rightly,  the  most  dreaded  of  all  the  diseases  of 
children,  whose  susceptibility  varies  not  a  little  Avith  their  age.  Infants  under 
six  months,  as  a  rule,  escape  ;  64  per  cent,  of  all  cases  occur  in  children  under 
six  years  of  age  (Murchison),  after  which  susceptibility  diminishes,  though  liable 
to  as  yet  inexplicable  variations,  for  children  and  nurses  Avho  have  escaped 
half  a  dozen  epidemics  may  succumb  to  the  seventh  after  exposure  apparently 
in  no  wise  different  from  that  which  preceded  it. 

One  attack,  as  a  rule,  protects  from  a  second,  though  well-attested  returns 
are  on  record.  The  majority  of  those  cases  popularly  reported  as  second 
attacks  are  usually  due  to  errors  in  diagnosis.  But  it  must  also  be  remembered 
that  frequent  abortive  attacks  of  sore  throat  are  well  known  to  occur  in  nurses 
or  physicians  attending  cases  of  this  disease. 

Scarlet  fever  may  be  complicated  with  other  of  the  exanthemata,  especially 
varicella.  Cases  of  coincident  scarlatina,  variola,  and  measles  are  reported 
by  Vogel. 

While  the  disease  is  not  so  infectious  as  measles,  as  shown  by  the  fact 
that  42  per  cent,  of  Budert's  unprotected  children  escaped  infection  during 
an  epidemic  in  the  isolated  German  village  of  Neundorf,  it  should  be  remem- 
bered that  the  contagiousness  of  scarlet  fever  varies  greatly  with  the  epidemic. 

Brush's  statement  that  the  colored  race  possesses  an  immunity  from  this 
disease  is  erroneous,  for  the  writer  has  seen  scarlet — or  rather  royal  purple — 
fever  in  a  coal-black  pickaninny,  and  in  Chicago,  at  least,  colored  children  enjoy 
like  privileges  in  this  respect  with  those  of  lighter  skin. 

History. — It  is  more  than  probable  that  scarlet  fever  must  have  existed  as 
far  back  as  there  have  been  masses  of  people  crowded  together  in  great  cities ; 
but  there  are  no  earlier  accounts  of  the  disease  than  those  of  the  seventeenth 
century  (1610-18),  when  epidemics  occurring  in  Spain  and  Italy  were  described 
by  Mercatus,  Heredia,  and  Syambatus  (Bohn).  About  the  year  1625  both 
sporadic  and  epidemic  cases  were  met  with  in  Breslau  and  described  by  a  Dr. 
Doring,  who  is  probably  entitled  to  the  honor  of  being  the  first  German  author 
to  write  on  this  subject.     He  was  closely  followed  by  Sennert's  description  of 

13] 


132    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

the  disease  at  Wittenberg,  later  followed  by  like  outbreaks  at  Brieg  (1642), 
Schweinfurt  (1652),  and  in  Poland  (1664). 

Up  to  the  time  of  Sydenham  scarlet  fever  was  supposed  to  be  a  variety  of 
measles,  being  known  by  such  fanciful  terms  as  "  ingrassius,  rosalia,  rubeolas, 
morbilli  ignei,"  etc.  During  the  years  1670-75,  Sydenham  had  ample  oppor- 
tunity to  study  the  epidemics  raging  in  the  city  of  London,  and  differentiated 
the  disease  from  measles.     The  origin  of  the  name  is  yet  uncertain  (Bohn). 

To  Fothergill  (1750)  justly  belongs  the  credit  of  establishing  the  con- 
tagiousness of  scarlatina,  and  the  facts  upon  which  depend  all  modern  theories 
of  its  prophylaxis.  But  many  writers  believe  that  the  disease  has  steadily  in- 
creased in  virulence,  until  to-day  it  is  the  most  prevalent  and  dangerous  of.  all 
the  diseases  of  childhood. 

Scarlet  fever  is  supposed  to  have  been  brought  to  North  America  in  1735, 
spreading  slowly  from  the  coast  inland,  and  so  infrequently  met  with  that  Dr. 
Rush,  as  late  as  the  beginning  of  the  present  century,  wrote  :  "  No  physician 
would  be  likely  to  see  it  more  than  once  in  his  lifetime."  At  first  it  was 
regarded  as  rather  a  trivial  aifection,  but  malignant  epidemics  swept  through 
Kentucky  and  Ohio  when  the  country  was  almost  an  unbroken  forest.  Then 
came  a  period  of  slight  malignity,  so  that  Professor  Chapman  of  the  University 
of  Pennsylvania  so  late  as  1833—36  positively  denied  the  contagiousness  of 
this  disease. 

Etiology. — He  would  be  a  purblind  physician  who,  in  these  latter  days, 
would  attempt  to  deny  the  microbic  origin  of  scarlet  fever,  but  it  must  as 
frankly  be  admitted  that  our  knowledge  concerning  its  exact  etiology  is  as 
yet  indefinite  and  conflicting.  Klebs  figures  the  peccant  microbe  and  names 
it  Monas  scarlatinosum.  Ecklund  of  Stockholm  minutely  describes  another, 
which  he  is  certain  is  the  cause  of  scarlet  fever,  and  proposes  the  name  Plox 
gcindens,  a  fuller  description  of  which  may  be  found  under  the  heading  of 
Pathology.  Edington  of  Edinburgh  later  isolated  from  the  blood  and  epi- 
dermic scales  of  scarlet-fever  patients  another  microbe,  which  he  and  Dr. 
Shakespeare  of  Philadelphia  unite  in  declaring  to  be  the  specific  cause. 

But,  while  it  is  disheartening  that  as  yet  we  know  so  little  accurately  con- 
cerning the  bacteriology  of  scarlatina,  there  is  much  that  is  well  known  and 
proven  beyond  dispute  in  regard  to  the  spread  of  the  disease  and  the  nature 
of  its  contagion.  First  of  all,  it  can  be  insisted  upon  that  its  contagium  vivum 
is  easily  portable,  tenacious  in  its  power  to  do  evil  for  years,  and  with  great 
probability  originating  in  some  of  the  lower  animals.  The  horse,  the  dog, 
and  the  cow  all  have  had  their  claims  advanced  as  first  owners  of  the  scarla- 
tinal microbe,  and  during  the  Hendon  epidemic  some  years  since  it  seemed  as 
if  the  question  had  been  decided  in  favor  of  the  cow.  Later  and  more  accu- 
rate investigations,  however,  seemed  to  show  that  the  disease  carried  from  the 
diseased  teats  of  the  infected  cows  was  scarlatinal  only  in  the  form  of  the  rash 
communicated  to  human  beings. 

There  is  also  considerable  dispute  as  to  which  of  the  secretions  may  carry 
the  scarlatinal  virus.  Some  writers  insist  that  the  patient  is  a  source  of  infec- 
tion from  the  initial  sore  throat  until  the  last  branny  scales  have  dropped 
away  from  between  the  fingers  and  toes ;  others,  that  infection  may  be  carried 
so  long  as  there  is  a  specific  otorrhoea.  Undoubtedly,  the  micro-organism 
usually  enters  the  system  by  inhalation,  but  there  seems  to  be  good  reason 
for  believing  that  it  may  be  taken  in  with  food  (Smith),  or  carried  from 
person  to  person  by  inoculation  of  scarlatinal  blood  or  blood-serum.  It  is, 
however,  generally  conceded  that  a  scarlet-fever  patient  is  most  dangerous 
during  the  stage  of  desquamation,  and  that  the  branny  scales  of  this  period 


PLATE  V. 


Original  impure  cultures  from  skin. 

V    l.'idll. 


Original  impure  cultures  from  skin. 

V  llKKt. 


Original  impure  cultures  from  skin. 

X  vm. 


Bacillus  Fulvus.  Streptococcus  Rubiginosus.  Diplocoecus  Ascobacillus. 

■   1'""'.  Scarlatina;  Sanguinis. 

X  1000. 


Plates  illustrating  the  cultivation  of  tlie  bacillus  scarlatinpe  according 

Taken  from  Britinh 


PLATE  VI. 


Original  imi>uio  tnbe,  taken  from  the  skin,  but  whicli 


Bacillus  Arborescens 
after  a  week's  erowth. 


Bacillus  Scarlatina 
after  12  days'  growth. 


to  the  methods  of  Drs.  W.  Allan  JaraVson  and  Alexander  Edington. 
Medical  Journal. 


SC ABLET  FEVEB,  133 

are  the  most  frequent  carriers  of  the  contagion,  though  others  claim  like 
dangerous  properties  for  mucus,  urine,  and  the  faeces.  It  is  certainly  true  that  the 
contagion  of  scarlet  fever  may  be  carried  by  almost  every  conceivable  article 
of  apparel  or  material  used  about  the  sick,  for  next  to  the  variolous  microbe 
the  scarlet-fever  contagion  preserves  its  vitality  for  a  longer  time  than  any 
other  of  the  exanthematous  poisons.  Dr.  Holland  relates  an  extraordinary 
case  where  the  virus  survived  two  generations,  being  packed  away  in  clothino- 
in  a  chest  for  thirty-five  years,  at  the  end  of  which  time  it  communicated  the 
disease  to  a  grandchild  for  whom  some  of  his  grandfather's  clothing  was  made 
over.  To  the  writer's  knowledge,  the  disease  remained  hidden  in  a  fur  cloak 
packed  away  for  more  than  a  year,  and  then  communicated  the  disease  to  an 
entire  logging  community  isolated  for  the  winter  in  the  wilds  of  Northern 
Michigan.  Hence  the  exact  origin  of  any  given  case  of  scarlet  fever  is  often 
most  difiicult  to  accurately  settle,  especially  when  we  remember  the  possibility 
of  the  disease  being  carried  by  books,  letters,  or  toys  from  some  previous 
case. 

Next  to  library-books,  letters,  clothing,  and  toys,  milk  seems  frequently  to 
be  the  medium  of  contagion.  In  one  instance  milk  is  known  to  have  carried 
scarlatina  to  one-half  of  the  families  to  which  it  had  been  delivered,  although  it 
had  not  been  touched  by  the  milkman  or  other  members  of  the  infected  family 
(Taylor) ;  and  in  another  the  disease  was  carried  to  all  the  families  served  save 
one,  which  consisted  only  of  elderly  people  (Bell).  Powers  and  Klein  still 
teach  that  the  disease  originates  from  the  sore  teats  of  infected  cattle  sufi"ering 
from  bovine  fever,  but,  after  much  heated  discussion  on  the  subject,  it  appears 
that  the  disease  thus  communicated  is  modified  cow-pox  rather  than  true 
scarlet  fever  (Hendon  epidemic,  1885).  The  persistence  of  the  scarlatinal 
virus  in  clothing  and  apartments  after  ordinary  methods  of  disinfection  is 
sometimes  amazing.  J.  Lewis  Smith  relates  the  case  of  a  Sunday-school 
librarian  who  contracted  the  disease  from  books  returned  from  an  infected 
tenement-house.  One  month  after  his  recovery  the  room  in  which  he  had 
been  sick  and  his  clothing  were  disinfected  with  burning  sulphur,  and  yet' he 
succeeded  in  carrying  the  disease  personally  to  his  sisters  after  a  journey  of 
three  hundred  miles  to  an  isolated  country  town,  to  which  they  had  been 
quarantined.  These  sisters  infected  the  room  in  which  they  were  confined,  so 
that  children  visiting  it,  after  its  disinfection,  in  turn  contracted  the  disease. 
The  writer  knows  of  a  building  in  the  city  of  Chicago  in  which,  in  three 
successive  years,  the  children  of  the  families  moving  into  the  house  con- 
tracted scarlet  fever  in  spite  of  yearly  domestic  disinfections. 

Mode  of  Transmission. — Although  it  is  usually  believed  that  the  scarlet- 
fever  poison  is  not  volatile  and  cannot  be  carried  by  the  atmosphere  solely, 
the  case  sketched  in  the  description  of  Fig.  1,  contributed  by  an  intelligent 
medical  student,  apparently  contradicts  previous  statements  on  this  subject. 

Bacteriology. — Illingworth  still  claims,  I  believe,  that  the  germs  of  scarlet 
fever  are  set  free  during  the  fermentation  of  animal  and  vegetable  refuse.  The 
inhalation  of  these  causes  them  to  lodge  upon  the  mucous  membrane  of  the 
throat,  where  they  propagate,  and,  by  the  reabsorption  of  their  products,  pro- 
duce the  other  lesions  of  scarlet  fever.  Almost  all  other  authorities  believe 
■  that  there  is  a  specific  scarlet-fever  microbe,  which  requires  a  previous  human 
being  for  its  host.  Repeated  efibrts  have  been  made  to  isolate  this  micro- 
organism. As  early  as  1882,  Ecklund  of  Stockholm  thought  he  had  discovered 
it  in  the  form  of  colorless  discoid  corpuscles,  about  one-tenth  the  size  of  the 
red  corpuscle,  and  found  in  immense  numbers  in  the  urine  of  scarlatinal 
patients.     These  he  named  Plox  scindens.     He  states  that  he  had  found  them 


134    AJfi:iiICAJ>t^  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

in  vast  numbers  in  the  soil  and  ground-water  of  the  island  of  Skeppsholm 
during  an  epidemic  of  scarlet  fever  there.  Their  presence  seems  to  be  well 
proven,  but  their  relation  to  scarlet  fever  is  by  no  means  as  definite.     More 

Fig.  ]. 

N 


W 


rr^ ^^1 \ 

V 

3 

)C  5 

"  The  above  nide  map  shows  the  relation  of,  and  distance  between,  several  hoiises  in  the  township  of  Clare- 
mout,  Minn.,  one  inch  representing  a  mile.  In  the  house  .\  lived  Wm.  Connell.  During  February  of 
1879  one  of  his  children  contracted  scarlet  fever  through  a  letter  that  came  from  relatives  in  Toronto, 
Canada.  About  three  days  later  a  second  child  came  down  with  the  disease  and  died  on  the  ninth 
day.  The  wind  had  been  blowing  from  the  north-east,  and  about  this  time  my  younger  brother  came 
down  with  the  disease  in  house  No.  4.  Young  James  Connell  was  burled  on  the  day  after  his  death ; 
and  on  that  day  the  wind  changed  into  the  north-west,  where  it  continued  for  some  time.  The  bed- 
ding and  clothes  of  the  Connells  were  hung  on  the  clothes-line  to  air,  and  in  about  one  week 
from  that  time  the  children  in  house  No.  3  were  taken  with  the  disea.se.  In  house  No.  2,  thirty 
rods  north,  there  were  five  children,  in  house  No.  6  there  were  four  children,  and  in  house  No.  ,=>, 
two  children.  All  of  these  escaped  the  disease.  There  was  absolutely  no  communication  between  the 
houses  on  account  of  the  cold  weather  and  fear  of  the  disease.  Two  years  later  there  came  an  epi- 
demic of  the  disease  in  that  vicinity  of  a  severe  tvpe,  and  all  the  children  in  the  neighborhood  had  the 
disease,  except  those  that  had  had  "it  two  years  previously." 

hopeful  are  the  results  of  Dr.  Edington  of  Edinburgh,  who  began  in  1886  to 
make  investigations  of  the  blood  and  epidermis  in  human  scarlet  fever.  He 
succeeded  in  isolating  a  diplococcus  scarlatimie  sanguinis  and  a  bacillus  scarla- 
tina. Inoculation  of  the  bacilli  produced  in  rabbits  erythema  and  desquama- 
tion ;  in  calves,  fever  and  a  rash,  followed  by  desquamation.  Dr.  Edington  says 
"the  bacilli  measure  1.2  to  1.4  micro-millimetres  in  length  and  0.4  micro- 
millimetre  in  width,  and  are  found  in  the  blood  during  the  first  two  days  only, 
in  the  desquamating  epidermis  only  after  the  twenty-first  day,  and  in  the 
eighteen  intermediate  days  they  cannot  be  demonstrated  in  any  of  the  tissues." 
His  results  have  been  confirmed  by  Dr.  E.  0.  Shakespeare,  who  proposes  the 
provisional  name  of  haciUus  scarlatince  for  this  micro-organism,  and  reports 
that,  "  sown  on  gelatin-plates,  it  forms  little  points  of  liquefaction  after 
several  days.  Sown  in  test-tubes  of  Koch's  jelly,  it  rapidly  liquefies  it, 
but  with  no  distinct  growth-formation.  The  fluid  thus  formed  is  crowded 
with  the  motile  bacilli,  but  a  pellicle  is  not  formed  until  the  liquefaction  is  well 
advanced."  This  occurred  in  every  case  but  one  of  the  tubes  made  from  the 
desquamation  if  taken  after  the  termination  of  the  third  week,  but  never  before 
this.  It  also  occurred  in  every  tube  made  from  scarlatinal  blood  if  taken  before 
the  third  day  of  the  fever.  Inoculation  upon  rabbits  produced  erythema,  best 
marked  in  the  old.  and  in  from  two  to  five  days  a  fine  desquamation.  Avhich  lasted 
for  a  week  to  ten  days.  Temperature.  103°-106°  F.  Similar  results  were 
obtained  from  guinea-pigs,  except  that  the  desquamation  was  more  copious  and 
the  hair  fell  out  if  pulled  upon. 

"A  calf  was  then  inoculated,  and  at  the  same  time  given  some  of  the 


SCARLET  FEVEB.  135 

culture  in  milk.  The  calf  was  in  good  health  at  the  time,  and  had  a  tem- 
perature of  99.5°  F.  Six  hours  from  the  inoculation  the  calf  developed 
great  sickness,  and  the  temperature  taken  in  the  axilla  registered  103°  F. 
[This  was  at  10  p.  M.]  The  calf  was  then  left  for  the  night,  but  in  the  morn- 
ing was  found  dead.  Small  portions  of  the  spleen  and  kidneys  were  taken 
from  the  animal,  placed  in  Koch's  jelly,  and  allowed  to  incubate,  and  developed 
the  characteristic  bacillus  previously  described.  A  second  calf  was  inoculated, 
when  only  one  day  old,  with  the  bacillus,  care  being  taken  that  the  inocula- 
tion was  made  with  the  absolutely  pure  material.  Previous  to  the  injection 
the  calf's  blood  was  examined,  and  found  to  contain  no  organisms.  The  inocula- 
tion was  made  in  this  case  with  a  very  carefully  sterilized  hypodermic  syringe. 
At  6.30  p.  M.  this  was  performed,  the  temperature  per  rectum  then  being 
99.6°  F.  At  10  p.  M.  the  animal  took  milk  freely,  and  the  temperature  re- 
mained practically  the  same.  Next  morning,  temperature  104°  ;  sickness, 
slight  diarrhoea,  and  great  prostration,  and  the  throat  inflamed.  In  the  after- 
noon the  skin  of  the  thorax,  upper  abdomen,  and  inner  side  of  the  foreleg  pre- 
sented a  general  redness,  increasing  toward  evening  (T.  102.8°).  The  next 
morning  the  animal  was  better,  but  rash  still  vivid,  throat  and  posterior  part 
of  the  tongue  inflamed  (T.  102°).  From  this  time  the  beast  steadily  improved, 
and  on  the  sixth  day  desquamation  set  in." 

The  same  bacillus,  according  to  Dr.  Shakespeare's  report,  may  be  obtained 
from  the  blood  of  a  scarlet-fever  patient  during  the  first  two  or  three  days  of 
the  disease,  and  from  the  desquamating  scales  on  the  twenty-first  day  in  an 
ordinary  case;  if  malignant,  they  may  be  obtained  earlier.  These  bacilli 
rapidly  increase  in  warm  milk,  which  they  may  thus  infect. 

"  The  rapidity  of  the  growth  of  this  organism — which  is  such  if  one  in- 
oculate a  flask  of  broth  the  diameter  of  which  is  two  inches  and  a  half,  and 
if  it  be  incubated,  the  pellicle  Avill  develop  and  cover  it  entirely  over  in  the 
course  of  four  hours — suggests  an  explanation  of  the  short  incubation  of 
scarlet  fever  when  furnished  a  proper  pabulum." 

Such,  it  seems  to  the  writer,  is  a  fair  statement  of  our  present  knowledge 
on  the  subject,  to  be  confirmed  or  reversed  by  later  investigations. 

Pathology, — Aside  from  its  bacteriology,  still  in  dispute,  there  cannot  be 
said  to  be  any  pathological  changes  pathognomonic  of  scarlet  fever.  Autopsies 
made  upon  those  dying  in  the  earlier  days  of  the  disease  show  only  the  local 
lesion  of  the  throat  and  engorgement  of  various  internal  organs,  especially  the 
intestines  and  brain.  Deaths  occurring  later  are  generally  due  to  septicaemia 
or  nephritis.  The  former  are  apt  to  show  secondary  pneumonia  and  metastatic 
abscesses,  and  the  blood  coagulates  poorly  and  is  prone  to  form  clots  in  the 
right  ventricle.  The  characteristic  changes  of  pleurisy,  pericarditis,  endo- 
carditis, purulent  meningitis,  empyema,  or  pulmonary  gangrene  may  be  found 
in  these  cases. 

The  kidney  lesions  are  those  of  an  acute  exudative  (Delafield)  or  glomerulo- 
nephritis (Welsh),  the  latter  being  the  true  post-scarlatinal  nephritis.  In  such 
cases  "  the  liquor  sanguinis  and  the  red  and  white  blood-cells  escape  from  the 
renal  vessels  into  the  tubules.  Swelling  or  necrosis  of  the  renal  epithelium,  with 
changes  in  the  glomeruli,  occurs." 

Macroscopically,  the  kidneys  are  large  and  flabby,  and  the  cortex  is  thick 
and  pale,  with  injected  capillaries.  The  tubal  epithelium  is  swollen  and  opaque. 
Hyaline  cylinders  identical  with  the  casts  are  found  in  the  convoluted  tubes, 
and  more  abundantly  in  the  straight  tubes,  along  with  irregular  masses  formed 
from  the  exuded  blood-plasma.  In  the  tubes  are  also  red  and  white  blood- 
cells.    The  glomeruli  exhibit  important  changes.     They  become  larger  or  more 


136  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

opaque,  due  to  the  swelling  and  growth  of  the  cells  on  and  in  the  capillaries, 
"  for  the  glomerular  capillaries  in  their  normal  state  are  covered  on  their  out- 
side bv  nucleated  cells,  and  flat  cells  line  their  inner  surfaces  in  places,  not 
continuously.  On  account  of  these  cellular  changes,  the  individual  capillaries 
in  the  glomerulus  become  indistinct,  but  the  main  divisions  of  the  tufts  are 
visible.  In  very  severe  cases  the  growth  of  the  cells  on  the  tufts  is  so  con- 
siderable that  they  form  large  masses  of  cells  between  the  glomerulus  and  its 
capsule.  The  walls  of  the  arteries  in  the  kidneys  may  be  thickened  by  a 
swelling  of  their  muscular  coats,  and  the  Malpighian  bodies  may  stand  out  like 
grains  of  sand." 

This  connective-tissue  growth  Delafield  considers  characteristic,  ''  involving 
not  the  whole  of  the  kidney,  but  symmetrical  strips  or  wedges  in  the  cortex, 
which  follow  the  line  of  the  arteries.  These  wedges  are  small  or  large,  few  or 
numerous,  regular  or  irregular,  in  different  kidneys,  but  in  every  wedge  we 
find  the  same  general  characters  :  one  or  more  arteries,  of  which  the  walls  are 
thickened;  glomeruli  belonging  to  these  arteries,  with  a  large  growth  of 
capsule ;  cells  compressing  the  tufts  ;  a  gi'owth  of  new  connective  tissue  in  the 
stroma  around  and  parallel  to  the  arteries.  Between  the  wedges  we  find  at 
first  only  the  changes  of  exudative  nephritis ;  later,  a  difiuse  growth  of  con- 
nective tissue.  If  the  nephritis  is  of  acute  type  and  longer  duration,  the 
tissue  is  denser  and  has  more  basement  substance.  Where  the  growth  of  the 
new  tissue  is  abundant  the  tubes  become  small  and  atrophied.  The  exudation 
from  the  blood-vessels  is  very  considerable,  so  that  the  urine  contains  large 
quantities  of  albumin,  many  casts,  and  red  and  white  blood-cells"  (Delafield 
and  Prudden).  The  irregular  distribution  of  these  kidney  lesions,  according 
to  Bartel.  explains  the  contradictory  results  often  obtained  by  successive 
examinations  of  the  urine.  There  may  be  parts  of  the  kidney  which  entirely 
retain  their  functions,  and  from  these  normal  urine  may  be  secreted.  But  that 
a  scarlatinal  dropsy  may  exist  from  beginning  to  end  without  the  presence,  at 
any  time,  in  the  urine  of  either  blood,  albumin,  or  casts,  is  as  improbable  as 
that  dropsy  may  occur  without  nephritis  (Bohn). 

Incubation. — Formerly  a  week  or  ten  days  was  given  as  the  usual  length 
of  the  stage  of  incubation ;  later  writers,  however,  fix  it  at  two  to  five  days, 
and  it  may.  in  malignant  cases,  last  not  more  than  twenty-four  hours.  But 
it  is  often  difficult  to  say  exactly  Avhen  the  stage  of  incubation  ends  and  that 
of  the  initial  sore  throat  begins.  Murchison's  table  (Smith,  p.  275)  shows  that 
in  the  great  majority  of  the  cases  reported  by  him  the  stage  of  incubation  Avas 
■within  five  days,  and  the  latest  writer  on  this  subject  says  that  if  the  initial 
vomiting  be  taken  as  the  conclusion  of  the  stage  of  incubation,  it  will  be 
found  to  be  under  three  days  (Ashby,  p.  248). 

Symptoms. — The  onset  of  scarlatina  is  usually  so  abrupt  that  its  begin- 
ning may  be  fixed  with  considerable  definiteness.  There  is  possibly  a  pre- 
vious slight  duskiness  of  the  skin,  chilliness  and  malaise,  but  usually  the 
first  thing  that  attracts  attention  is  vomiting,  often  without  any  relation  to 
a  previous  meal ;  or  there  may  be  diarrhoea.  Older  children  may  not  actually 
vomit,  but  complain  of  nausea,  languor,  headache,  and  sore  throat,  and  feel 
chilly,  although  the  face  is  flushed,  and  the  thermometer  may  show  a  tem- 
perature as  high  as  103°-105°  F.  If  such  children  are  also  drowsy,  they 
may  become  delirious  in  their  sleep.  The  pulse  is  full  and  strong  (120—160), 
the  skin  is  hot  and  dry.  and  the  throat  feels  stiff"  and  uncomfortable,  and.  if 
examined,  will  show  a  characteristic  punctate  redness.  Such  is  the  ordinary 
onset  of  a  typical  case  of  scarlet  fever,  but  there  is  no  disease  of  childhood 
that  is  liable  to  wider  and  more  eccentric  variations  in  its  onset  and  course, 


PLATE    VII. 


SCARLET  FEVER. 


SCARLET  FEVEB. 


137 


oscillating  between  the  very  slight  abortive  form  and  that  frightful  variety 
called  by  the  French  foudroyant,  or  scarlatina  fulminans,  fortunately  rarely 
met  with ;  for  in  such  cases  the  child  succumbs,  mortally  poisoned  from  the 
very  first  by  the  virulence  of  the  scarlatinal  virus,  without  any  prodromal  stage 
or  hardly  any  symptoms  except  those  which  may  be  referred  to  the  nervous 
system.  These  dreadful  cases  often  run  their  entire  course  in  from  thirty-six 
to  forty-eight  hours  without  eruption  or  sore  throat,  the  only  symptoms  being 
nausea,  dizziness,  loss  of  consciousness,  coma,  violent  delirium,  or  convulsions 
attended  with  abnormally  high  temperature  (107°). 

Scarlatina  simplex  may  be  differentiated  in  twenty-four  hours  by  the  ap- 
pearance of  the  typical  scarlatinal  rash  in  the  form  of  a  scarcely  perceptible 
scarlet  flush  or  pin-point  eruption,  very  closely  resembling  in  color  and  stip- 
pling the  shell  of  a  freshly-boiled  lobster.  The  eruption  usually  begins  on  the 
neck  or  cheeks  or  small  of  the  back,  and  ought  in  forty-eight  hours  to  spread 
nearly  over  the  body,  either  as  a  well-defined  blush  or  in  scarlet  patches — 
scarlatina  Icevigata.  Plethoric  and  blond  children  develop  the  rash  most 
promptly,  and  in  all  cases  its  color  is  heightened  by  the  warmth  of  the  bed, 
by  hot  baths,  or  by  crying.  A  characteristic  white  line  remains  for  a  few 
seconds  after  drawing  the  edge  of  the  nail  or  the  point  of  a  pencil  over  the 
rash.     This  typical  line  is  supposed  to  be  due  to  a  paralysis  of  the  vaso-motor 

Fig.  1. 


Da^ 

1 

3 

3 

4 

5 

6 

102 
101 
100 
99 
98 
97 
96 

so 
St 

<5^ 

■S2 

CO 
CI 

■c: 

§. 
"? 

1 

1 

A 

k 

?v 

s 

C 

o 

/' 

\ 

J 

' 

\ 

A 

-^ 

■/< 

\ 

• 

/ 

V 

k 

/^ 

.- 

V 

\ 

J 

\ 

A 

V 

/ 

\ 

7 

V 

V 

to 

CO 

2 

CO 

00 

CO 

Temperature  Chart  in  a  Mild  Case  of  Scarlatina.    Patient  6  yrs.  old.    (After  Ashby.) 

nerves  of  the  capillaries  in  these  congestive  areas.  Until  the  eruption  is  well 
marked  the  fever  continues  high,  often  dangerously  so,  as  it  is  not  unusual  to 
find  the  temperature  in  impressible  children  mai-king  105°-107°  F.  The  pulse 
is  quick  and  sthenic,  except  in  cases  of  scarlatina  maligna,  where  there  may  be 
general  depression,  delirium,  and  collapse  from  the  very  onset  of  the  disease. 
The  pulse,  as  a  rule,  is  faster  than  the  tempei-ature  would  apparently  call  for, 
ranging  from  130-150,  its  relation  to  the  rash  and  temperature  being  well  shown 
in  the  accompanying  chart,  taken  from  Ashby  (Fig.  1).  Pharyngitis,  with  more 
or  less  soreness  of  the  throat,  is  always  present,  although  it  may  not  be  sufiiciently 
painful  to  cause  the  child  to  complain  (scarlatina  sine  angina).  The  respira- 
tory organs,  except  the  throat,  are  rarely  involved,  so  that  cough  is  generally 
absent.  When  present,  it  is  due  to  faucial  irritation,  except  where  pneumonia 
occurs  later  as  a  dangerous  complication.  The  tongue  is  the  so-called  straw- 
berry tongue — that  is,  covered  with  a  white  fur  with  bright  red  tip  and  borders. 


138    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

When  the  papillae  are  greatly  swollen,  they  cause  the  granular  appearance 
known  as  the  raspberry  tongue.  Some  writers  speak  of  a  pathognomonic 
sweetish  odor  of  the  breath  which  may  be  detected  at  this  time,  but  this  is  by 
no  means  an  invariable  symptom  nor  one  upon  which  much  reliance  should  be 
placed. 

In  a  simple,  uncomplicated  case  the  fever  and  all  threatening  symptoms 
moderate  with  the  appearance  of  the  rash,  with  the  exception  of  a  slight  even- 
ing febrile  exacerbation,  and  any  variation  from  this  rule  betokens  malignancy 
or  some  new  complication. 

From  the  fourth  to  the  sixth  day  desquamation  ordinarily  begins.  Those 
areas  which  are  first  reddened  fade  in  like  order,  and,  as  the  color  disappears, 

Fig.  2. 


Hay  of 
Dkease 

1 

2 

\ 

2 

3 

4 

5 

6 

7 

^41° 
^40° 
^39° 

r38' 

-36° 

Hour 

5- 

< 

5 

5 

< 

00 

5 
0. 
cO 

5 
s 

s 

lb 

s 

N 

a. 

£ 
S 

<N 

a 

105** 
104' 
103' 
102** 

lor 

100" 
99" 
98" 
97** 

96" 

PuUe. 

i 

A 

A 

n 

A 

f' 

n 

/ 

J 

\  1 

I 

/ 

J 

y 

I 

r 

/ 

\  J 

/ 

' 

1 

\ 

1 

_ 

1 

y 

— 



— 1 

1 

1 

/ 

f 

\  1 

/ 

X 

X 

V 

/x 

''■ 

X 

X 

y 

X 

X 

1 

/ 

f 

i 

/ 

1 

1 

% 

/ 

A 

A 

f 

Si 

\/ 

V 

o 

CD 

O 
N 

CO 

CO 

2 

00 

00 
2 

o 
in 

O 

to 

O 

Temperature  Chart  of  Malignant  Scarlet 
Fever.    Death  in  24  hrs.   (After  Ashby.) 


Temperature  Chart  of  Malignant  Scarlet  Fever. 
Death  on  7th  day.    Rasn  indicated  by  *. 


the  skin  is  found  to  be  covered  with  loose  branny  scales.  These  scales  drop 
off  imperceptibly,  except  when  from  itching,  as  is  apt  to  happen  on  the  face 
and  neck,  they  are  scratched  off,  and  the  tender  epidermis  beneath  becomes 
cracked.  In  such  cases  the  scales  may  be  thrown  off  in  slircds,  or  casts  of  the 
entire  lip,  fingers,  or  palms  of  the  hand  may  be  shed.  A  like  desquamation 
occurs  from  the  membranes  of  the  throat,  trachea,  kidneys,  and  intestines, 
though  of  course  the  epithelial  scales  in  these  localities  are  carried  away  in  a 
softened,  macerated  condition. 

Out  of  200  cases  reported,  11  reached  their  highest  temperature  on  the  first 
day,  76  on  the  second,  75  on  the  third,  36  on  the  fourth,  and  only  2  on  the 
fifth  day.  When  the  highest  temperature  is  reached  after  the  fifth  day,  or  if 
the  temperature  has  not  fallen  considerably  by  that  time,  some  complication  is 
certainly  keeping  it  up,  so  that  the  thermometer  and  violence  of  the  nervous 


SCARLET  FEVER.  139 

symptoms  form  a  valuable  criterion  as  to  the  danger  of  the  child.  A  dull,  apa- 
thetic condition  is,  as  a  rule,  more  to  be  dreaded  than  the  usual  restlessness, 
which  is  due  to  continued  reflex  irritation  of  the  rash.  In  hypersesthetic  chil- 
dren this  produces  twitching,  or  even  eclampsia,  which  is  graver  the  later  it 
occurs  in  the  disease. 

Variations. — We  have  previously  described  what  might  be  considered 
a  typical  case  of  uncomplicated  scarlet  fever,  but,  unfortunately,  uncompli- 
cated cases  are  so  rare  that  there  is  no  disease  of  wider  variations  in  every 
symptom. 

The  eruption  may  be  so  light  as  to  escape  detection,  or,  on  the  other 
hand,  instead  of  the  ordinary  scarlatina  Igevigata,  the  eruption  may  appear 
in  the  form  of  small  nodules  {scarlatina  papulosa),  in  which  the  papillse 
of  the  skin  are  swollen,  and  the  whole  body  looks  as  if  covered  with  goose- 
skin.  Or,  again,  these  papillae  may  become  covered  with  vesicles,  and  we  have 
the  form  of  scarlatina  which  is  known  as  scarlatina  miliaria.  Should  these 
vesicles  become  merged  together,  they  give  an  eruption  to  which  the  name  of 
scarlatina  pemphigoides  seu  bullosa  is  given.  Such  variations  are  found  most 
frequently  on  the  face,  and  are  usually  of  grave  import.  Vogel  reports  excep- 
tional cases  in  Avhich  the  eruption  was  intermittent  in  character,  appearing  only 
at  certain  times  of  the  day,  and  for  this  he  proposes  the  name  of  scarlatina 
intermittens.  Lastly,  we  may  find  that  fatal  form  to  which  the  name  of  scar- 
latina petechialis  seu  hcemorrhagica  has  been  given,  where  there  is  an  actual 
extravasation  of  blood  into  the  skin,  and  hence  the  popular  name  of  "  black 
scarlet  fever"  by  which  it  is  sometimes  known.  In  nervous  children  it  is  not 
infrequent  to  find  urticaria  accompanying  scarlet  fever,  masking  the  character- 
istic rash,  Vogel  also  reports  a  curious  variation  of  scarlatinal  rash  in  which 
are  found  sharply-marked,  isolated  areas  which  remain  milk-white  in  color, 
or  at  least  much  whiter  than  normal  integument,  due  to  a  temporary  paralysis 
of  the  arterioles  similar  in  character  to  that  which  follows  the  thumb-nail  mark 
on  the  normal  scarlatinal  flush  ;  but  they  are  more  persistent  in  character  and 
are  usually  of  unfavorable  portent.  Any  intercurrent  disease,  as  entero-colitis, 
which  produces  a  determination  of  blood  from  the  surface  of  the  body,  may 
greatly  delay  the  appearance  of  the  rash  or  render  it  so  light  that  its  dif- 
ferentiation will  be  diflicult. 

Complications. — Throat. — The  angina  of  scarlet  fever  may  assume  any 
form,  from  simple  catarrhal  injection  to  extensive  necrotic  destruction  of  tissue. 
Ordinarily,  a  bright  red  flush,  with  punctate  marks,  such  as  might  have  been 
produced  by  a  small  brush  dipped  in  red  ink  and  dotted  over  the  pillars  of  the 
fauces,  is  the  earliest  and  one  of  the  most  characteristic  symptoms  of  scarla- 
tina. This  may  proceed  no  further  than  to  give  slight  difficulty  in  swallowing 
and  to  impart  a  nasal  tone  to  the  voice.  But,  on  the  other  hand,  and  more 
frequently — especially  if  pharyngeal  disinfection  is  not  practised  from  the  very 
first — the  swelling  becomes  so  great  as  to  make  swallowing  almost  impossible. 
In  such  cases  fibrinous  exudates  appear  on  the  tonsils  and  fauces,  and  should 
the  inflammation  not  be  limited  to  the  palate  and  fauces,  the  exudate  may  ex- 
tend into  the  post-nasal  cavities,  the  larynx,  and  even  into  the  oesophagus  and 
stomach.  More  frequently  it  proceeds  through  the  Eustachian  tube  into  the 
internal  ear.  (See  Otitis  Media.)  The  differentiation  between  the  fibrinous 
exudate  of  scarlatina  and  true  diphtheritic  membrane  is  by  no  means  easy,  the 
more  so  since  undoubtedly  true  diphtheria  is  not  infrequently  grafted  upon  the 
necrosis  of  scarlatinal  angina ;  but  it  may  be  helpful  to  remember  that  the 
exudate  of  scarlatina  is  yellowish  and  pultaceous,  rather  than  the  ashy-gray 
membrane  of  true  diphtheria.      Should   the  presence  of  Loeffler's    bacillus 


140    A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

be  finally  accepted  as  pathognomonic  of  diphtheria,  the  differentiation  may 
then  be  made  absolutely;  whereas  at  present  we  must  frequently  remain  in 
doubt,  since  the  removal  of  the  scarlatinal  exudate  leaves  the  superficial  layers 
of  the  pharyngeal  mucous  membrane  denuded  and  bleeding  exactly  as  in  diph- 
theria. A  similar  gangrenous  process  may  proceed  upward  into  the  pharynx 
or  along  the  Eustachian  tube  into  the  cavity  of  the  middle  ear,  with  all  the 
perils  of  purulent  meningitis  which  this  implies.  Similarly,  as  in  true  diph- 
theria, the  exudate  may  pass  downward  into  the  larynx,  where  its  presence  is 
made  known  by  a  characteristic  croupy  metallic  cough.  If  the  exudate  attacks 
the  nasal  cavities,  this  is  attended  by  a  profuse  excoriating  discharge,  Avhich 
soon  grows  purulent  and  off'ensive  in  odor. 

Adenitis. — All  forms  of  scarlet  fever  are  attended  Avith  inflammation  of  the 
lymphatic  glands  of  the  neck,  and,  as  a  rule,  it  will  be  found  that  the  involve- 
ment of  these  glands  bears  a  direct  relation  to  the  severity  of  the  throat  lesions. 
So  we  find  all  grades  of  adenitis,  from  the  slight  induration  which  may  be 
found  accompanying  all  varieties  of  scarlatina,  to  a  brawny  swelling  of  the 
glands  and  cellular  tissue  embracing  the  whole  neck.  Such  extensive  mischief 
betokens  like  serious  necrotic  processes  taking  place  within  the  phai'ynx,  where 
the  poisonous  debris  clogs  and  inflames  the  lymphatic  glands,  their  pres- 
sure and  morbid  processes  inflaming  contiguous  tissues.  This  cellulitis  may 
extend  from  ear  to  ear,  until  deglutition  becomes  difficult  and  wide  opening  of 
the  mouth  impossible.  If  relief  does  not  come  early  by  resolution,  the  widely- 
distended  tissue  gives  way  to  suppuration  or  gangrene,  and  death  from  haemor- 
rhage or  septicaemia  occurs. 

Scarlatiyial  Arthritis  is  not  infrequently  met  with  in  certain  epidemics  of 
scarlet  fever  during  both  the  eruptive  and  the  desquamative  stage.  This  form 
of  arthritis  attacks  by  preference  the  knee-  and  elbow-joints,  and  scarcely  can 
be  distinguished  by  its  objective  symptoms  from  ordinary  articular  rheumatism, 
being,  like  it,  excessively  painful.  But  arthritis  rheumatica  rarely  ends  in 
pyaemia  or  permanent  articular  osteitis,  as  arthritis  scarlatinae  is  very  prone 
to  do. 

Diarrhcea  and  Dysentery  are  not  at  all  infrequent  complications  after  the 
crisis  of  the  disease,  probably  being  caused  by  desquamation  of  the  intestinal 
epithelium,  analogous  to  that  which  undoubtedly  occurs  in  the  tubuli  uriniferi 
at  this  time. 

Scarlatinal  Nephritis. — Last  and,  justly,  the  most  dreaded  of  the  com- 
plications of  scarlatina,  is  that  form  of  nephritis  which  so  frequently  occurs 
during  the  course  of  the  disease  that  it  may  almost  be  considered  pathognomonic  ; 
for  a  mild  grade  of  renal  catarrh  is  as  constantly  present  as  is  desquamation 
(Steiner).  It  is  true  this  frequently  escapes  observation  and  passes  on  to  re- 
covery without  special  treatment,  but  its  existence  is  always  a  potential  cause 
of  morbus  Brightii  scarlatinosus,  which  should  be  considered  not  as  a  distinct 
disease,  but  as  an  intensification  of  the  previous  catarrh  of  the  tubules  brought 
about  by  chilling  of  the  skin,  etc.  (Bohn). 

Similar  nephritic  catarrh  has  been  noted  in  measles,  small-pox,  pneumonia, 
and  other  diseases,  induced,  as  the  writer  believes,  by  the  passage  through  the 
kidneys  of  irritating  ptomaines  generated  in  the  body  by  the  specific  microbes 
of  these  diseases.  The  excretion  of  these  or  analogous  compounds  through  the 
skin  very  likely  gives  rise  to  the  characteristic  rash,  hence  analogous  lesions 
might  be  inferred  for  the  kidneys.  It  is  a  well-known  fact  that  the  lighter  the 
cutaneous  rash  the  more  liable  are  the  kidneys  to  be  seriously  implicated,  pre- 
sumably from  increased  excretion  of  various  ptomaines  through  organs  now 
endeavoring  to  do  the  work  of  both  skin  and  kidneys.     Daily  examination  of 


SCARLET  FEVEB.  141 

the  urine  should  be  made  for  at  least  two  weeks  in  even  the  mildest  cases  of 
scarlet  fever,  and  will  show  from  the  beginning  of  the  eruption  evidence  of 
renal  catarrh  (epithelial  debris  and  albumin),  although  the  kidneys  are  appar- 
ently working  normally.  While  the  urine  is  high-colored  and  deposits  copious 
urates.  Dr.  Gree  claims  that  urea  is  not  necessarily  diminished.  The  chloride  of 
sodium  is  lessened  until  the  fourth  to  the  sixth  day,  and  phosphoric  acid  after 
crisis;  while  the  urates  or  uric  acid  appear  to  excess  during  convalescence. 
In  other  cases  the  urine  is  cloudy,  and  contains  fatty  renal  epithelia,  more 
rarely  hyaline  casts,  and  red  and  white  blood-corpuscles  (only  exceptionally 
albumin),  all  of  which  disappear  usually  with  the  disappearance  of  the  erup- 
tion, but  may  progress  to  an  actual  catarrhal  nephritis.  This  renal  catarrh  Bartel 
believes  is  due  to  a  specific  poison — ptomaine  (?) — circulating  in  the  blood,  which 
poison  irritates  the  tubules  of  the  kidneys  in  its  passage  through  the  Mal- 
pighian  tufts,  either  directly  or  from  irritating  properties  imparted  to  the  urine 
before  its  percolation  through  the  tubuli  uriniferi.  Others  claim  that  the  source 
of  this  irritation  lies  in  certain  specific  micrococci  circulating  in  the  blood,  being 
analogous  to  diphtheritic  nephritis,  which  Oertel  thinks  due  to  bacterial  emboli. 

A  diminution  in  the  quantity  of  the  urine  is  often  the  first  thing  that 
awakens  the  attention  of  the  physician,  if  he  makes  it  his  duty,  as  he  ought, 
to  keep  himself  posted  daily  until  the  end  of  the  third  week.  The  normal 
amount  of  800  to  900  c.c.  per  diem  may  fall  suddenly  to  100  or  50  c.c,  or 
even  less.  Its  color  is  yellowish-red,  sometimes  almost  yellowish-green  when 
cooled;  turbid,  or  clearing  up  on  standing,  depositing  a  cloudy  precipitate  made 
up  of  kidney  cells  and  casts,  urates,  and  uric-acid  crystals  in  varying  propor- 
tion. At  times  the  urine  is  blood-red  or  smoky  brown,  from  the  blood  it  con- 
tains. Under  the  microscope  the  precipitate  is  found  to  consist  of  varying 
quantities  of  kidney  epithelia,  partly  normal  and  partly  swollen  and  distended, 
cloudy,  and  undergoing  fatty  degeneration.  Besides  these  there  may  be  vari- 
ous forms  and  phases  of  casts,  lymph-corpuscles,  red  blood-corpuscles,  and  the 
crystals  of  urate  of  sodium  and  uric  acid.  The  quantity  of  albumin  found  in 
urine  is  deceptive,  since  in  certain  epidemics  of  scarlatina,  even  where  dropsy 
suddenly  appears,  often  only  faint  traces  of  albumin  may  be  found  in  the  urine. 
Or  albumin  may  be  entirely  absent  during  certain  times  in  the  day,  or  even  for 
several  days  at  a  time,  or  during  the  greater  part  of  the  disease.  Or,  again, 
unmistakable  albuminuria  may  be  present  while  the  urine  is  clear  and  free 
from  all  other  abnormal  elements.  It  may  even  happen  that  frequent  analysis 
of  the  urine  for  days  may  fail  to  show  either  casts,  epithelial  cells,  or  crystals, 
while  all  of  these,  together  with  albumin,  may  be  found  at  a  subsequent  exami- 
nation. 

Scarlatinal  dropsy  is  often  the  first  warning  of  the  existence  of  any  kid- 
ney lesion  in  mild  cases  which  are  supposed  by  parents,  and  even  by  the  phy- 
sician, to  be  well  along  in  convalescence.  As  a  rule,  the  chief  danger  of 
scai'latinal  nephritis  lies  about  the  end  of  the  second  week  or  during  desquamation, 
though  dropsy  may  appear  as  late  as  the  fifth  or  sixth  week.  The  first  symp- 
toms noticed  are  slight  oedema  of  the  face  and  swelling  of  the  eyelids.  These 
are  followed  by  pufiiness  of  the  backs  of  the  hands  and  feet,  sometimes  uni- 
lateral, with  dropsical  enlargement  of  the  abdomen.  In  the  case  of  children 
who  have  not  yet  been  allowed  to  rise  from  their  beds  the  anasarca  is  often 
most  marked  in  the  back  and  in  the  genitals,  which  may  become  frightfully 
swollen  and  sensitive.  As  a  rule,  the  kidney  complication  is  ushered  in  with  a 
return  of  fever,  or  an  increase  in  fever,  if  it  still  be  present.  But  there  is  also  a 
feverless  nephritis,  without  subjective  symptoms,  loss  of  appetite,  or  anything 
abnormal  that  can  be   detected.      In  other  cases    there  is   only  an   evening 


142    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

increase  of  temperature  and  pulse.  Generally  the  skin  is  dry  and  ceases  to 
desquamate.  Pain  over  the  kidneys  is  seldom  complained  of,  unless  questioned 
about  or  obtained  by  pressure.  If  the  disease  in  the  kidney  is  limited,  there 
may  be  only  a  localized  oedema,  such  as  hydrothorax,  hydrops  pericardii, 
oedema  of  the  lungs,  or  dropsical  effusions  into  joints.  This  localized  oedema 
may  follow  a  brief  apparent  convalescence,  during  which  children  recover  their 
appetite,  and  exhibit  no  features  of  illness,  unless  it  be  the  persistence  of 
slight  lassitude  and  fever  at  night.  After  exposure  to  cold  such  cases  develop 
anorexia,  depression,  and  pain  over  one  or  both  kidneys.  The  amount  of  urine 
is  greatly  diminished.  It  is  concentrated,  high-colored,  and  contains  albumin 
and  casts,  and  may  not  measure  more  than  an  ounce  for  the  entire  day,  or  may 
even  be  completely  suppressed.  About  6  per  cent,  of  all  scarlatina  patients 
suffer  from  post-scarlatinal  nephritis,  the  course  and  duration  of  which  depend 
directly  upon  the  extent  of  the  anatomical  lesions  of  the  kidney.  Very  light 
cases  recover  in  a  few  days.  Generally  the  anasarca  and  effusions  increase  for 
several  days — say  a  week  and  over — breathing  being  hindered  by  the  ascites 
and  pleural  eff'usions,  and  the  nights  are  restless.  (Edema  of  the  lungs  pro- 
vokes incessant  coughing.  Swelling  of  the  genitals  is  often  painful,  but  does 
not  noticeably  interfere  with  urination.  Death  may  ensue  suddenly  from  urae- 
mic  convulsions  Avhen  danger  is  least  expected.  Ashby  attempts — and  it  seems 
wisely  to  the  writer — to  diff"erentiate  between  septic  and  post-scarlatinal  nephri- 
tis, either  of  which  may  be  met  with  during  the  course  of  scarlet  fever.  The 
urine  in  the  first  contains  no  blood-corpuscles,  but  is  highly  albuminous,  and  is 
not  attended  with  dropsy  nor  uraemic  convulsions.  Autopsy  in  these  cases 
shows  a  distinctly  softened,  pysemic  kidney,  which  contains  minute  abscesses, 
and  is  mottled  in  its  cortex  with  injected  blood-vessels  and  inspissated  pus. 
Death  occurs  from  pyaemia,  and  not  directly  from  the  kidney  lesions,  which  are 
only  a  part  of  the  more  general  process.  In  the  second  class  of  cases  death 
results  from  uraemia.  The  lesions  of  the  post-scarlatinal  kidney  have  been 
fully  described  under  Pathology. 

Sequelae. — Chroyiic  nasal  catarrh^  ozaena,  pharyngitis,  or  hypertrophy 
of  the  tonsils,  with  acute  attacks  of  quinsy,  or  suppurative  otitis,  with  chronic 
otorrhoea  and  deafness,  more  or  less  complete,  are  among  the  dreaded  reminders 
left  after  scarlatina,  especially  where  the  angina  has  been  malignant.  In  many 
such  cases  the  tonsils  become  deeply  excavated,  and  the  soft  palate  sloughs ;  but 
even  under  these  circumstances  recovery  is  possible.  Or,  as  has  previously  been 
noted,  diphtheritic-like  membrane  may  cover  the  fauces,  palate,  and  even  spread 
on  to  the  epiglottis  and  into  the  larynx.  Death  from  exhaustion  or  haemorrhage 
usually  terminates  such  cases,  or,  if  life  is  for  a  while  prolonged,  death  comes 
later  from  septicaemia,  often  terminated  by  septic  pneumonia  (seventh  to  four- 
teenth day).  But  even  septic  pneumonia  is  not  necessarily  fatal,  for  recovery 
took  place  in  one  of  the  writer's  cases  after  the  appearance  of  this  sequel  sub- 
sequent to  otorrhoea  and  cervical  abscesses  and  sloughing.  The  amount  of 
damage  sometimes  inflicted  by  these  cervical  sloughs  is  frightful.  Smith 
speaks  of  one  which  laid  bare  the  carotid  and  produced  death  by  its  per- 
foration. Williams  relates  a  still  more  remarkable  case,  in  which  superficial 
ulceration  of  the  fauces,  palate,  and  tongue  was  conjoined  with  suppuration  of 
the  lymphatics  of  the  neck.  This  was  followed  by  sloughing,  exposing,  in  the 
triangle  of  the  neck,  a  space  bounded  by  the  edge  of  the  sterno-mastoid,  the 
upper  border  of  the  thyroid  cartilage,  and  the  median  line  of  the  neck.  Never- 
theless, under  antiseptic  treatment,  the  boy  made  a  good  recovery,  although  he 
was  only  six  years  of  age  and  had  previously  been  considered  delicate. 

Broncho-pneumonia^  pleuro-pneumonia,  empyema,  and  peritonitis  are  among 


SCARLET  FEVER.  143 

the  possible  complications  of  scarlatinal  nephritis.  If  the  temperature  runs 
high,  the  tongue  becomes  dry  and  brown,  the  urine  scanty  and  albuminous, 
and  death  rapidly  ensues.  But  milder  cases  are  not  hopeless  if  the  urinary 
secretion  can  be  re-established. 

Cardiac  dilatation,  endocarditis,  and  pericarditis  are  the  more  frequent 
heart-lesions  that  should  be  guarded  against  in  every  scarlatinal  nephritis,  for, 
conjoined  with  increased  arterial  tension  and  general  malnutrition,  they  may 
bring  sudden  death  either  from  heart  failure  or  embolism.  The  possibility  of 
such  untoward  termination  to  nephritis  should  never  be  forgotten,  for  no 
sharper  reproach  can  come  to  the  physician  than  the  thought  that  had  he 
allowed  less  work  to  be  thrown  upon  a  weakened  heart  he  might  have  carried 
his  patient  into  safe  convalescence. 

Otitis,  with  perforation  of  the  membrane,  more  than  any  other  sequela, 
has  too  often  been  left  a  lifelong  reminder  of  scarlet  fever.  In  many  of  these 
cases  little  pain  is  complained  of,  although  the  fever  remains  suspiciously  high 
until  a  purulent  discharge  from  the  ear  makes  its  appearance.  Mastoiditis  or 
purulent  meningitis  may  prove  fatal,  but  in  a  majority  of  these  cases  no  such 
complications  take  place,  and  the  child  recovers,  more  or  less  deaf  or  afflicted 
with  a  chronic  otorrhoea.  According  to  Batut,  statistics  in  Belgium  show  that 
out  of  1892  cases  of  deafness,  216  followed  scarlet  fever.  Another  observer 
found  out  of  400  cases  144  due  to  the  same  cause. 

Synovitis  has  already  been  referred  to  under  the  head  of  Arthritis,  as 
liable  to  occur  about  the  second  week.  Suppuration  and  pyaemia  are  the 
chief  dangers  in  these  cases. 

Cerebral  lesions,  such  as  paralyses,  blindness,  aphasia,  loss  of  memory, 
hemiplegia,  etc.,  are  among  the  sad  sequelae  of  the  ursemic  convulsions  of 
scarlatinal  nephritis. 

Convalescence  from  severe  cases  of  scarlatina  is  always  protracted,  the 
subsequent  anaemia  lasting  for  months  or  years,  especially  in  scrofulous  chil- 
dren, in  whom  the  virulence  of  the  poison  is  most  lasting  in  its  effects.  Many 
of  the  most  discouraging  cases  that  come  into  the  hands  of  the  physician  deal- 
ing largely  with  the  diseases  of  children  are  those  in  which  the  child's  vitality 
has  been  undermined  by  malignant  scarlatina.  Such  children  frequently 
suffer  for  years  from  the  so-called  mucous  disease  of  Eustace  Smith  or  from 
renal  incompetence.  In  other  cases  there  is  a  chronic  otorrhoea  or  offensive 
ozsena,  Avhich  renders  their  lives  miserable,  and  so  saps  their  vitality  that  they 
succumb  easily  to  intercurrent  disease.  This  is  especially  true  of  those  chil- 
dren in  whom  the  functions  of  the  kidneys  have  been  seriously  crippled  by 
post-scarlatinal  nephritis.  Such  a  previous  history  always  awakens  serious 
apprehensions  in  the  presence  of  diphtheria,  typhoid,  or  any  septic  disease. 

Diagnosis. — The  early  diagnosis  of  a  mild  case  of  scarlet  fever  is  often  a 
matter  of  great  difficulty,  but  it  is  a  matter  of  no  little  importance  to  the 
patient,  for  such  mild  cases  seem  to  be  the  ones  most  liable  to  nephritic  com- 
plications. Since  mild  cases  may  communicate  dangerous  attacks  to  those 
more  susceptible,  it  is  always  safe  to  give  the  well  children  the  benefit  of  your 
doubt  by  isolating  all  suspicious  cases.  Nausea,  pain  in  swallowing,  and  fever 
constitute  a  trio  of  symptoms  sufficient  to  isolate  a  patient  until  a  rash  of  some 
kind  appears.  This  may  be  so  light  and  transient,  especially  if  there  be  coin- 
cident diarrhoea,  that  it  may  escape  detection  unless  carefully  watched  for ;  and 
even  then  there  is  an  erythema  scarlatiniforme  that  without  previous  history 
may  deceive  the  very  elect  in  pasdiatrics.  In  such  cases,  however,  the  throat 
does  not  show  the  characteristic  stippling  of  scarlet  fever,  and  a  brisk  emetic 
or  purge  brings  the  case  to  a  speedy  termination.    The  early  differentiation  of 


144    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

rubella  from  scarlatina  is  often  puzzling,  but  Jamieson  calls  attention  to  tlie 
fact  that  in  rubella  the  characteristic  tongue  of  scarlet  fever  is  absent,  while  the 
mild  catarrhal  symptoms  of  the  former  are  not  ordinarily  present  in  the  latter 
disease. 

The  eruption  of  measles  is  most  distinctly  patchy,  and  is  preceded  by 
several  days  of  drowsiness  and  the  symptoms  of  an  ordinary  cold.  But  in  all 
doubtful  cases  isolate  and  wait  for  light,  remembering  "  that  nephritis  occur- 
ring after  an  anomalous  rash  makes  it  practically  certain  the  primary  attack 
was  scarlet  fever."  Broncho-pneumonia  under  similar  circumstances  justifies 
a  diagnosis  of  measles. 

Prognosis  in  scarlet  fever  must  be  largely  influenced  by  the  character  of 
the  then  prevailing  epidemic  and  the  general  condition  of  the  child.  The  viru- 
lence of  the  scarlatinal  poison  and  the  susceptibility  of  the  one  attacked  deter- 
mine the  degree  of  restlessness,  jactitation,  and  delirium  observed.  Initial 
eclamptic  attacks  rarely  occur,  except  in  unusually  nervous,  susceptible  chil- 
dren, and  their  occurrence  is  of  very  unfavorable  portent. 

As  a  rule,  the  early  and  extensive  implication  of  the  cervical  lymphatics  is 
a  forerunner  of  serious  throat  complications.  Nasal  diphtheria  complicating 
scarlatina  is  of  the  gravest  import,  and  the  gravity  is  proportionate  to  the  early 
age  of  the  child,  children  under  four  years  giving  as  high  a  mortality  as  28 
per  cent.  The  younger  the  child  the  more  guarded  should  be  the  prognosis, 
especially  when  associated  with  diarrhoea,  which  is  regarded  by  Ashby  as  a 
very  serious  symptom. 

Where  the  temperature  continues  high  (104°-106°),  and  there  is  much 
diarrhoea  or  extreme  restlessness,  or  the  angina  is  malignant,  the  prognosis  is 
always  grave.  Drowsiness  is  always  an  unfavorable  symptom,  and  a  high  tem- 
perature continued  into  the  second  week  is  sufficient  ground  for  anxiety. 

Desquamation  is  seldom  completed  before  the  sixth  week,  and  is  not  always 
at  an  end  in  twice  that  time,  Finlayson  fixing  the  infective  period  of  this 
disease  as  seven  to  eight  weeks. 

The  nephritis  complicating  or  following  scarlet  fever  is  more  dangerous  than 
the  primary  disease.  Where  persistent  vomiting  occurs,  not  only  on  the  first, 
but  on  subsequent  days,  the  prognosis  is  correspondingly  grave. 

Post-scarlatinal  nephritis  is  the  most  favorable  form  of  parenchymatous  in- 
flammation of  the  kidneys,  usually  ending  in  recovery  in  two  or  three  weeks  by 
means  of  copious  diuresis,  but  it  is  worth  remembering  that  the  excessive  excre- 
tion of  uric  acid,  which  persists  well  into  convalescence,  may  form  gravel  or 
calculi.  As  a  rule,  epithelial  casts  and  detritus  persist  after  the  disappear- 
ance of  the  albuminuria,  sometimes  for  an  exceedingly  long  time,  especially  in 
cachectic  children. 

Death  rarely  occurs  before  the  fourth  day,  and  usually  not  later  than  the 
seventh,  except  from  post-scarlatinal  nephritis.  Sudden  death  may  result  from 
rapid  and  uncontrollable  increase  of  dropsy,  either  into  the  peritoneum,  pleura, 
pericardium,  or  ventricles  of  the  brain,  or  from  oedema  of  the  lungs  or  glottis. 
Or,  stopping  short  of  immediately  fatal  results  from  oedema,  the  end  may  come 
more  slowly  from  inflammation  of  the  lungs  or  pericardium,  or  still  more  slowly 
from  gangrene  of  the  genitals  or  from  bed-sores.  Or,  as  may  be  inferred  from 
the  above,  the  nephritis  may  assume  a  chronic  form. 

The  relation  between  the  intensity  of  the  scarlatinal  eruption  and  the  dan- 
ger of  subsequent  nephritis  is  by  no  means  constant,  although  the  writer  has 
come  to  dread  its  appearance  in  the  lighter  cases  because  these  are  the  ones  in 
which  the  care  of  the  parents  is  apt  to  be  relaxed  with  the  apparent  rapid  con- 
valescence of  the  child. 


SCARLET  FEVEB.  145 

Serious  cerebral  affections,  such  as  paralysis,  blindness,  aphasia,  loss  of 
memory,  hemiplegia,  may  remain  as  sequelae  of  scarlatina. 

Mortality  varies  widely  with  the  epidemic.  That  in  the  Manchester  Chil- 
dren's Hospital  varied  from  6  to  25  per  cent,  according  to  the  epidemic,  the 
average  for  ten  years  (1877-87)  being  11.8  per  cent.  Of  10,000  cases 
reported  by  Collie,  the  mortality  was  12.5  per  cent,  for  all  ages,  that  between 
three  and  four  years  reaching  as  high  as  25  per  cent. 

These  figures,  it  must  be  confessed,  are  too  high  for  the  average  American 
practitioner,  but  he  may,  like  foreign  physicians,  be  compelled  to  radically 
change  his  ideas  on  the  subject.  Brettonneau,  for  instance,  up  to  1799 
thought  scarlatina  the  mildest  of  all  the  exanthemata  ;  and  so  also  the  Irish 
physicians  thought  from  1804  to  1831.  But  Brettonneau  was  obliged  to  entirely 
change  his  views  after  encountering  the  fatal  epidemic  at  Tours  in  1824  ;  and 
a  similar  outbreak  in  Dublin  in  1881  completely  revolutionized  the  views 
of  the  Irish  physicians  in  regard  to  the  fatality  of  scarlet  fever. 

Treatment. — A  hopeful  fact,  always  to  be  borne  in  mind  in  any  choice  of 
treatment  adopted  in  scarlatina,  is  that  it  is  a  self-limited  disease,  and  that  no 
remedy  has  yet  been  discovered  that  will  either  abort  or  greatly  modify  its 
course.  The  medical  literature  of  the  past  twenty-five  years  teems  with  alleged 
specifics,  but  all  of  these  by  subsequent  trials  have  been  found  no  better  nor 
worse  than  those  proposed  before  them.  Nevertheless,  the  intelligent  physi- 
cian owes  it  to  himself  and  his  patients  that  he  shall  not  desert  them  upon  the 
rocks  of  medical  agnosticism  nor  wreck  them  upon  the  snags  of  polypharmacy. 
If  he  cannot  abort  the  disease,  he  may  make  its  course  less  uncomfortable  to 
his  patient,  and  by  careful  foresight  ward  off  many  a  threatening  complication. 

Diet  is  not  unimportant  in  scarlet  fever,  for  our  aim  from  the  very  begin- 
ning should  be  to  tax  the  kidneys,  already  in  a  catarrhal  condition,  as  little  as 
possible  with  nitrogenous  materials.  Hence  the  ideal  food  for  the  scarlet-fever 
patient  is  koumyss,  skimmed  milk,  or  milk  and  Vichy.  But  the  ordinary 
American  child  will  not  long  tolerate  such  light  diet,  especially  when  rapidly 
convalescing,  so  we  are  usually  forced  to  add  to  our  diet-list  broths,  soups, 
light  puddings,  and  baked  apples,  happy  if  thereby  we  reduce  meats  to  a 
minimum.  While  the  writer  cannot  agree  with  Jaccoud  that  a  milk  diet  is  an 
absolute  safeguard  against  post-scarlatinal  nephritis,  it  is  true  that  a  liquid 
diet  and  warmth  should  be  carefully  secured  for  at  least  four  weeks. 

GrENERAL  TREATMENT. — If  the  initial  nausea  is  vexatious,  it  may  often  be 
allayed  by: 

i|i.  Aquae  cinnamomi 

Liquor  calcis .  aa  f.?j. 

Tinct.  gelsemii f^ss. — M. 

Sig.   Teaspoonful  every  hour. 

For  the  high  arterial  tension  and  fever,  tincture  of  aconite,  given  according 
to  the  plan  of  Ringer — i.  e.  a  drop  every  quarter  hour  until  arterial  tension  is 
decreased,  and  then  given  sufficiently  to  hold  the  pulse  at  that  point  every  two 
or  three  hours — is  very  satisfactory. 

Chloral  hydrate  is  a  favorite  with  the  writer,  almost  entirely  displacing  the 
tinct.  ferri  chloridi  of  his  earlier  practice,  except  in  those  cases  where  there  is 
malignant  angina  from  the  beginning.  In  such  cases  nothing  has  been  found 
superior  to  the  tincture  of  the  chloride  of  iron  (one  drop  per  dose  for  each 
year  of  the  child's  age),  with  whiskey  or  brandy,  given  according  to  Dr.  Chap- 
man's plan.     The  surprising  tolerance  of  such  children  for  alcoholic  stimulants 

10 


146    A3fEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

shows  that  their  power  is  expended  otherwise  than  in  their  usual  effects  upon 
the  brain.  Many  such  children  will  take  f  §ss  of  brandy  every  hour  without 
showing  any  of  the  usual  physiological  effects.  In  ordinary  cases,  however, 
small  doses  of  chloral  hydrate  seem  to  be  all  that  is  necessary  to  relieve  rest- 
lessness, moderate  the  angina,  and,  to  a  limited  degree,  act  as  an  antiseptic. 
For  the  first  forty-eight  hours  such  a  prescription  as  the  following  has  often 
proven  most  useful : 

]^.   Chloral  hydrate 3ss-j. 

Camphor  water f  §ss. 

Syrup  of  orange-peel f  giss. — M. 

Sig.   To  alternate  with  aconite  as  required. 

When  the  eruption  is  tardy  in  appearing,  a  hot  salt  or  mustard  bath  will 
expedite  matters,  or,  if  these  are  ineffectual,  packing  in  a  sheet  wrung  out  of 
hot  water  and  sprinkled  with  mustard  rarely  fails. 

The  throat  is  too  often  neglected,  and  yet  here  is  the  focus  from  which 
spread  many  of  the  dangerous  complications  of  this  disease.  Local  antiseptics 
may  be  a  modern  device,  but  Underwood  came  very  near  to  the  writer's  ideas 
when  he  wrote  on  this  subject  many  years  ago :  "  The  throat  must  be  often 
syringed  with  ....  though  the  quality  is  perhaps  of  far  less  importance 
than  its  being  frequently  made  use  of,  which  is  absolutely  necessary,  especially 

in  young  cliildren Even    syringing    the  throat    with    hot  Avater  is 

found  to  administer  immediate  relief."  The  local  treatment  of  the  throat  with 
peroxide  of  hydrogen  spray,  as  directed  under  the  head  of  Prophylaxis,  can 
hardly  begin  too  early,  and  the  same  may  be  said  of  the  inunction  of  the  body 
with  some  antiseptic  ointment.  Quinine  internally  may  be  added  later  if  there 
is  evidence  of  failino;  strength. 

Cerebral  symptoms,  unless  associated  with  scanty  urine,  may  be  rendered 
tolerable  by  the  addition  of  bromide  of  potassium  (grs.  v-x)  to  each  dose  of  the 
chloral  hydrate  mixture,  with  a  mercurial  purge  and  the  application  of  cold 
to  the  head.  Phenacetin  is  sometimes  a  great  comfort  in  such  cases,  but  the 
writer  discourages  the  use  of  the  other  antipyretics  in  scarlet  fever,  except  as  a 
last  resort  in  abnormally  high  temperature.  Even  in  these  cases  persistent 
sponging  with  cool  water,  or  even  cold  affusion,  ought  first  to  be  tried.  Per- 
sistent drowsiness  always  awakes  suspicion  as  to  post-nasal  complications,  and 
emphasizes  the  necessity  of  nasal  irrigation,  frequently  repeated. 

Scarlatinal  arthritis  in  cachectic  children  may  proceed  to  suppuration  and 
destruction  of  the  joints,  but,  fortunately,  most  of  these  cases  are  more  pain- 
ful than  dangerous,  and  yield  promptly,  like  true  rheumatism,  to  fair  doses 
of  salicin  and  codeine  and  wrapping  the  affected  joints  liberally  with  cotton 
batting. 

Cervical  adenitis  is  more  frequently  overtreated  than  neglected,  for  the 
swollen  and  tender  glands  apparently  require  immediate  attention.  And  yet 
the  trouble  lies  farther  back,  for  the  debris  that  blocks  these  inflamed  glands 
comes  usually  from  the  pharynx.  Hence  efficient  pharyngeal  and  nasal  cleans- 
ing Avill  do  moi-e  for  adenitis  than  poultices,  lotions,  or  ointments.  So-called 
energetic  treatment  too  often  precipitates  the  very  troubles  we  are  seeking  to 
guard  against.  Instead  of  poultices  and  iodine,  simple  rest  and  warmth  will 
often  work  wonders  even  in  brawny,  swollen  necks  where  suppuration  appears 
inevitable.  At  all  events,  camphorated  oil,  applied  on  absorbent  cotton,  should 
be  tried  before  proceeding  to  more  vigorous  measures. 

Diarrhoea  is  apt  to  be  quite  persistent,  and  occasionally  painful,  when  once 


SCARLET  FEVER.  147 

it  makes  its  appearance.  So  far,  I  have  rarely  seen  it  assume  a  dangerous 
aspect,  for  it  usually  can  be  lield  in  check  with  paregoric  alone  or  conjoined 
with  bismuth  in  an  emulsion. 

ScARLATll!^ AL  NEPHRITIS. — Individuals  and  epidemics  of  scarlet  fever  vary 
so  greatly  in  their  liability  to  nephritis  that  it  is  difficult  to  rightly  estimate  its 
prophylactic  treatment.  From  60  to  70  is  given  by  various  authors  as  the 
average  percentage  in  dangerous  epidemics,  and  from  this  it  falls  to  6  or  7  per 
cent,  in  ordinary  cases.  The  writer  believes  that  this  latter  proportion  can 
be  still  further  reduced  by  the  proper  care  of  children  in  the  mildest  form  of 
the  disease,  for  these  are  the  very  ones  which  give  us  the  highest  proportion 
of  fatal  cases  of  nephritis.  It  follows,  then,  that  all  children  ill  with  scarlet 
fever  should  be  kept  in  bed  during  the  rash,  no  matter  how  mild  it  may  be; 
and,  furthermore,  such  children  should  be  confined  to  warm  rooms,  or,  better 
still,  to  bed,  for  four  or  six  Aveeks  from  the  appearance  of  the  initial  symptoms. 
At  least  twice  a  week  during  this  time  the  urine  should  be  examined,  and  upon 
the  appearance  of  the  slightest  unfavorable  symjjtom  the  child  should  be  sent 
back  to  bed  again  if  he  has  already  been  allowed  to  be  about  the  room. 

But  should  these  premonitory  symptoms  be  disregarded,  or  if,  in  spite  of 
these  precautions,  scanty  albuminous  urine  and  dropsical  effusions  appear,  then 
the  physician's  most  energetic  efforts  must  be  directed  toward  making  the  skin 
or  intestines  temporarily  assume,  as  far  as  possible,  the  functions  of  the  kid- 
neys, throwing  on  the  latter,  at  the  same  time,  as  little  work  as  possible  in  the 
way  of  the  excretion  of  nitrogenous  refuse.  (See  Diet.)  The  copious  use  of 
water,  if  tolerated  by  the  stomach,  will  act  as  one  of  the  very  best  of  the 
diuretics.  Long  ago  Roberts  placed  pure  spring  water  at  the  head  of  the  list, 
and  the  writer  has  not  yet  found  any  diuretic  to  displace  it,  though  lemon- 
juice,  raspberry  vinegar,  or  skimmed  milk  may  be  added  without  harm  to 
induce  the  child  to  drink  more  freely  of  the  water. 

Should  the  urine  still  remain  scanty,  then  diaphoresis  must  be  induced  in 
order  to  increase  the  action  of  the  skin — first,  by  means  of  baths,  and  then,  if 
necessary,  by  drugs.  A  warm  bath  (98°-100°  F.)  for  fifteen  to  twenty 
minutes  is  often  grateful  to  the  child,  and,  if  supplemented  by  a  flannel  pack, 
is  very  efficient.  The  hot-air  or  steam  bath,  as  described  under  the  treatment 
of  Acute  Nephritis,  may  likewise  be  employed  with  success.  Any  of  these 
methods  will  be  assisted  by  the  internal  use  of  diaphoretics,  chief  of  which 
are  the  preparations  of  jaborandi.  Sips  of  a  hot  infusion  of  the  leaves 
(3j  to  Oj)  act  both  as  a  powerful  diaphoretic  and  sialagogue.  To  avoid  the 
latter  action  Smith  prefers  the  alkaloid  pilocarpine,  ^  to  -^  grain,  conjoined 
with  an  alcoholic  stimulant  every  four  to  six  hours.  Should  this  fail,  the 
same  writer  speaks  highly  of  the  following  prescription : 

^.  Potassii  acetatis 

Potassii  bicarbonatis 

Potassii  citratis aa  ^ij . 

Infus.  tritici  repentis fsviij. — M. 

Sig.   Teaspoonful  every  three  or  four  hours  to  a  child  of  five  years. 

More  palatable  and  fairly  efficient  is  the  following  : 

I|i.  Liq.  ammonii  acetatis 

Syr.  acidi  citrici       da  flij. — M. 

Sig.   Teaspoonful  every  hour  in  hot  lemonade. 


148    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Or,  where  there  is  considerable  dropsical  effusion,  this  can  be  with  advantage 
alternated  with  diuretin  (gr.  j-iv),  given  in  a  large  amount  of  water. 

Dropsy  usually  requires,  in  addition,  the  free  use  of  some  hydragogue  cathar- 
tic, of  which  the  compound  jalap  powder  (gr.  v-x)  is  certainly  the  most  efficient 
and  unpleasant.  Hence,  when  it  is  found  impracticable  to  repeat  the  dose  as 
often  as  required,  it  may  be  supplemented  by  a  cream-of-tartar  lemonade,  made 
by  dissolving  a  tablespoonful  of  the  salt  in  hot  water,  diluting  with  an  equal 
amount  of  cold,  sweetening  to  taste,  and  adding  sufficient  claret  or  port  to  make 
agreeable.     Most  children  will  take  this  laxative  readily. 

Or  the  following  prescription  of  J.  Lewis  Smith  may  be  employed : 

^.   01.  cinnamomi       gtt;  viij. 

Magnesii  sulphatis Sj. 

Potassii  bitartratis 3ij. — M. 

Sig.  One  teaspoonful  repeated  from  two  to  four  hours,  until  catharsis 
occurs. 

But  the  use  of  laxatives  should  be  continued  no  longer  than  is  strictly 
necessary,  for  their  repetition  brings  anaemia,  a  result  greatly  to  be  deplored. 

After  relieving  the  initial  congestion  of  the  kidneys,  stimulating  diuretics 
are  helpful;  and  of  these  digitalis  has  justly  a  high  reputation.  The  infusion 
is  a  reliable  preparation,  and  may  be  given  in  connection  with  acetate  of  potas- 
sium, as  in  the  following  mixture : 

^.  Potassii  acetatis ^ss. 

Infus.  digitalis f^vj. — M. 

Sig.   One  teaspoonful  every  four  hours. 

Local  treatment  will  also  greatly  help  in  relieving  the  fever  and  backache. 
Foreign  writers  speak  highly  of  the  use  of  leeches  over  the  kidneys  in  these 
cases,  but  the  majority  of  American  physicians  are  willing  to  rely  upon  the  use 
of  poultices  or  plasters.  A  large  Avarm  flaxseed  poultice,  containing  mustard 
or  digitalis,  often  acts  like  a  charm.  Smith  prefers  one  made  of  1  part  each 
of  powdered  mustard  and  ginger  to  16  of  ground  flaxseed,  and  advises  dry 
cupping  when  the  child  is  not  frightened  thereby.  Sluggish  kidneys  may  be 
gently  stimulated  by  capcine  plasters  or  some  mildly  stimulating  embrocation, 
and  a  flannel  bandage  worn  day  and  night.  ■ 

It  ought  never  to  be  forgotten  that  while  the  liability  to  heart  failure  is 
not  as  great  in  scarlatinal  nephritis  as  it  is  in  the  convalescence  of  diphtheria, 
yet  it  is  a  possible  danger,  and  one  from  which  death  may  rapidly  occur.  An 
irregular,  flickering  pulse  requires  absolute  confinement  to  bed  and  the  con- 
tinued use  of  some  chalybeate  tonic.  A  pleasant  one  may  be  found  in  the 
following : 

^.   Tinct.  ferri  chloridi f^iij- 

Acidi  phosphorici  dil f^vj. 

Glycerini fSvij. 

Vini  xerici f  §iv. — M. 

Sig.   Teaspoonful  four  times  a  day. 

Haematuria  can  best  be  controlled  by  gallic  acid  and  ergotine,  and  threat- 
ening convulsions  kept  in  check  by  rectal  injection  of  chloral  and  bromide 
of  potassium  (gr.  v  and  gr.  x)  in  milk  or  water.    Nitro-glycerine  tablets  (y^  gr.) 


SCARLET  FEVER.  149 

are  very  valuable  for  temporary  stimulation  of  the  heart,  and  may  be  used  hypo- 
dermatically  if  the  need  be  pressing. 

Prophylaxis. — All  attempts  to  procure  personal  immunity  by  means  of 
inoculation  have  up  to  the  present  time  proved  ineffectual.  The  same  may  be 
said  of  prophylactic  medicaments,  for  it  is  more  than  doubtful  whether  any 
known  drug  has  the  power  to  prevent  the  occurrence,  or  to  greatly  modify  the 
course,  of  scarlet  fever  after  its  incubation.  Even  Hahnemann's  vaunted 
specific,  belladonna,  has  failed  so  often  and  completely  that  it  need  only 
be  mentioned  as  one  of  the  curious  delusions  of  medical  history.  The  same 
may  be  said  of  sulphocarbolate  of  soda  (Beebe's),  quinine,  salicylate  of  sodium, 
and  the  other  alleged  preventives  which  from  time  to  time  appear  and  dis- 
appear in  medical  literature.  The  fact  is  that  epidemics  of  scarlatina  vary 
widely  in  their  intensity  and  danger.  Hence  it  is  that  in  one  epidemic  the 
liability  to  contagion  is  reduced  to  a  minimum,  and  whatever  may  be  used  at 
that  time  receives  credit  for  prophylactic  powers  which  fail  miserably  when 
next  put  to  the  test.  Our  efforts  must,  therefore,  be  confined  to  isolation  of 
the  patient  and  disinfection  of  whatever  touches  or  comes  from  him,  for  it  must 
be  remembered  that  not  only  the  desquamatory  scales,  but  also  blood,  serum, 
breath,  urine,  and  fasces  probably  carry  infection  during  the  entire  course  of 
the  disease. 

Now,  as  every  case  of  scarlatina,  even  the  mildest,  may  communicate  a 
dangerous  form  of  the  disease,  it  is  always  wisest  that  every  case  should  be 
treated  as  if  it  might  develop  a  most  dangerous  epidemic.  Six  weeks  of  quar- 
antine are  none  too  long  for  an  average  case  of  scarlatina,  and  this  should  be 
indefinitely  extended  as  long  as  desquamation  may  require.  Seven  years' 
experience  in  one  of  the  orphan  asylums  of  Chicago  has  convinced  the  writer 
that  this  is  not  only  theoretically  possible,  but  actually  does  prevent  the  spread 
of  the  disease,  for  never  during  these  years  has  there  been  a  general  epidemic 
of  scarlatina  in  the  asylum,  although  sporadic  cases  have  been  not  infrequent. 
In  such  institutions  isolation  can  be  more  effectually  carried  out  than  in  private 
families,  but  the  effort  should  be  made,  and  is  usually  attended  with  the  hap- 
piest results.  Long  ago  Dr.  Budd  wrote  in  reference  to  scarlatina  :  "  Time 
after  time  have  I  treated  this  fever  in  houses  crowded  from  attic  to  basement 
with  children,  who  have  nevertheless  escaped  infection  by  the  simple  method 
of  isolation."  Reliable  statistics  show  that  50  per  cent,  of  the  children  thus 
protected  escape  infection,  and  still  better  results  ought  to  be  obtained  by  local 
and  personal  disinfection  added  to  isolation. 

Disinfection  of  the  sick-room  should  never  be  omitted.  For  this  purpose 
J.  Lewis  Smith  highly  recommends  volatilization  of  the  following  mixture  in 
boiling  water: 

^.  Acidi  carbolici 

01.  eucalypti aa  f5j. 

01.  terebinthinae f^vj. — M. 

Sig.  A  tablespoonful  to  be  added  from  time  to  time  to  a  pan  of  hot  water, 
to  be  kept  boiling  on  a  gas  stove  or  grate  fire. 

The  sick-room  should  be  the  largest,  most  sunshiny,  best-ventilated  room 
in  the  house,  and,  if  possible,  should  have  an  open  fireplace.  All  curtains, 
pictures,  ornaments,  and  furniture  not  absolutely  necessary  for  the  comfort  of 
the  patient  should  be  removed  before  the  child  is  placed  there,  and  no  one  but 
the  nurse  and  physician  allowed  to  enter.  The  nurse  should  wear  a  loose 
wrapper  and  cap,  to  be  dropped  inside  the  door  should  she  be  compelled  to 
meet  other  persons  for  any  purpose  outside  the  door. 


150   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

An  ordinary  bed-sheet,  tacked  by  one  edge  over  the  door  and  kept  moist- 
ened with  a  2  per  cent,  solution  of  carbolic  acid,  has  apparently  been  helpful 
in  preventing  the  spread  of  the  disease  in  asylum  practice,  where,  the  writer 
agrees  with  J.  Lewis  Smith,  the  '•  area  of  contagiousness  is  small,  and  hence 
the  disease  is  more  easily  quarantined  than  either  measles  or  pertussis." 

For  disinfection  of  the  patient  J.  Lewis  Smith  recommends  as  a  local  dis- 
infectant to  the  faucial  mucous  membrane  corrosive  sublimate,  2  grs.  to  a  pint 
of  water  (1  drachm  containing  -^  of  a  grain).  This  may  be  used  as  a  gargle. 
or  as  a  spray  from  a  hard-rubber  atomizer.  The  same  solution  may  be  em- 
ployed for  cleansing  the  nasal  cavities.  The  writer's  preference  for  faucial 
application  is  a  solution  of  eucalyptol  in  peroxide  of  hydrogen  (gtt.  xv  to  f3j), 
used  in  the  cup  of  an  ordinary  steam  atomizer.  The  same  solution  may  be 
applied  upon  a  swab  to  the  fauces  if  there  be  extensive  necrosis;  or,  diluted 
with  an  equal  amount  of  water,  it  may  be  used  for  washing  out  the  nares  with 
a  douche  or  fountain  syringe. 

Others  speak  highly  of  50  per  cent,  boroglycerin  for  topical  disinfection  of 
the  throat,  and  all  sorts  of  more  energetic  disinfectants  have  been  recommended 
(mineral  acids,  chlorine-water,  galvano-cautery,  etc.)  with  less  obvious  justifica- 
tion. 

The  fi'equent  anointing  of  the  body  with  some  form  of  non-irritant  anti- 
septic ointment  in  order  that  the  action  of  the  skin  may  be  encouraged,  rest- 
lessness allayed,  and  the  scattering  of  the  scales  reduced  to  a  minimum,  is 
strongly  advised.  Such  an  ointment  as  carbolic  acid.  grs.  20,  thymol  grs.  10, 
to  vaseline  and  lanoline  each  half  an  ounce,  may  be  favorably  employed.  This 
should  be  applied  at  least  twice  daily,  the  skin  having  been  previously  cleansed 
with  warm  water  in  which  a  little  soda  is  dissolved.  J.  Lewis  Smith  speaks 
highly  of  the  following: 

^.  Acid,  carbolici 

Olei  eucalypti aa  3J  • 

Olei  oliv?e  .  .    .    .' 5vij. — M. 

Sig.  For  inunction  every  three  hours. 

Even  the  old-fashioned  fresh  lard  or  ham-rind  will  be  found  grateful  to  the 
patient  and  helpful  to  the  health  officers.  An  excellent  and  more  elegant 
prescription  is: 

!^.   Thymol ?^-  x. 

01.  theobromae Ij. 

Alcohol q.  s. — M. 

Ft  solutio. 
Sig.  For  inunction  twice  or  three  times  a  day. 

Disinfection  of  the  room  in  which  the  patient  has  been  is  scarcely  less 
important  than  that  of  the  patient,  since  the  virus  of  scarlet  fever  is  so 
tenacious  in  its  potency  that  it  will  persist  for  years  in  houses  or  rooms  not 
properly  disinfected.  If  the  walls  are  papered,  they  may  be  rubbed,  as  is 
done  by  paper-cleaners,  with  slices  of  rye  bread,  which  will  remove  microbic 
spores  and  scales ;  or,  better,  if  possible,  they  should  be  repapered,  calcimined, 
or  whitewashed.  Previous  to  this,  sulphur — 1  lb.  to  each  100  cubic  feet  of 
room-space — should  be  burned  in  the  infected  apartment,  which  should  be 
kept  closed  for  eighteen  hours  thereafter. 

The  efficiency  of  sulphur  dioxide  as  a  disinfectant  is  greatly  increased  by 


SCARLET  FEVEB.  151 

combining  with  it  the  vapor  of  water  in  a  hermetically  closed  room  (Squibb). 
Hence  the  room  should  be  closed  as  tightly  as  possible  by  pasting  strips  of 
paper  over  the  door-jambs  and  keyholes  before  burning  the  sulphur  candles. 
To  increase  the  efficiency  of  the  sulphur  dioxide  by  its  union  with  aqueous 
vapor,  the  candles  may  be  placed  on  bricks  in  an  ordinary  wash-tub  partially 
filled  with  water,  and  allowed  to  burn  in  the  closed  room  until  they  go 
out  for  want  of  oxygen.  After  the  room  has  been  opened  and  aired  as  fully 
as  possible,  it  ought  never  to  be  reoccupied  until  the  walls  have  been  cleaned 
as  previously  directed  or  thoroughly  scrubbed. 

All  sheets,  bedding,  towels,  and  articles  that  can  be  washed  should  be  im- 
mediately thrown  into  boiling  water  after  being  used,  and  those  articles  that 
cannot  be  washed  or  boiled  should  be  fumigated  with  sulphur,  baked,  or,  still 
better,  destroyed  by  burning,  as  should  all  toys  and  books  used  during  the 
convalescence  of  the  patient. 


RUBELLA. 

By  WILLIAM  T.  PLANT,  M.  D., 

Syracuse. 


Perhaps  there  is  no  other  disease  of  brief  duration  and  benign  character 
that  has  been  so  much  written  about  and  so  variously  named  as  rubella.  It 
■was  for  so  long  held  to  be  related  to  measles  or  scarlet  fevei",  or  both,  that  the 
following  names  have  naturally  come  from  such  views  of  its  nature :  French 
and  German  measles  or  scarlet  fever ;  false,  bastard,  and  hybrid  measles  ;  and 
epidemic  roseola.  These  and  others  not  worth  remembering  have  come  down 
to  us.  The  German  name,  Rdtheln,  is  not,  and  will  scarcely  become,  popular 
in  America,  because  of  its  foreign  appearance  and  difficult  pronunciation. 
More  attractive  and  satisfactory  than  all  other  names,  and  now  quite  generally 
adopted  by  English-speaking  people,  is  that  of  rubella — a  diminutive  of 
rubeola,  first  suggested  by  Veale  not  many  years  ago.  Indeed,  the  disease 
seems  to  have  been  waiting  for  a  name,  and  only  lately  to  have  found  a  fitting 
one. 

Previous  to  the  middle  of  the  last  century  rubella  had  had  no  very  clear 
description  or  decided  differentiation  from  measles,  and  almost  down  to  the 
present  time  very  many  in  the  profession  have  regarded  it  as  a  sort  of  modi- 
fied or  mongrel  measles.  Now,  however,  through  a  happy  agreement  of 
medical  opinion,  the  following  points  may  be  regarded  as  settled  :  1st.  Rubella, 
though  much  resembling  measles  and  somewhat  resembling  scarlet  fever,  is  a 
distinct  entity,  independent  of  these  as  of  other  diseases.  2d.  It  confers  no 
protection  against  measles  or  scarlet  fever,  nor  can  either  of  these  affections 
influence  or  prevent  an  attack  of  rubella. 

Rubella  is  an  acute,  contagious,  eruptive  febi'ile  disorder,  due  to  a  specific, 
but  as  yet  unisolated,  poison.  It  runs  a  rapid  course  and  terminates  almost 
always  in  recovery.  It  occurs,  with  few  exceptions,  but  once  in  a  lifetime ; 
and  commonly  travels  in  epidemics  of  rather  limited  extent,  though  sometimes 
it  spreads  over  large  tracts  of  country  in  a  short  time;  and  not  infrequently  the 
observant  physician  encounters  sporadic  cases  whose  origin  he  cannot  make 
out.  At  times  it  appears  to  part  with  its  tendency  to  spread,  though  probably 
at  all  times  its  contagious  property  is  less  pronounced  than  that  of  measles. 

Incubation. — The  period  of  incubation  varies  greatly.  Griffith  observed 
a  large  institution-epidemic,  originating  from  a  child  in  whom  the  eruption 
appeared  upon  the  day  of  admission.  The  first  case  was  observed  after  five 
days,  and  28  cases  developed  within  eleven  days  after  the  earliest  possible 
exposure.  Other  observers  give  periods  varying  from  ten  days  to  three  weeks, 
the  majority  stating  it  to  be  from  two  to  three  weeks.  The  variability  of  this 
period,  as  Griffith  has  pointed  out,  offers  a  striking  contrast  to  the  fixed  period 
of  incubation  of  measles.  Ordinarily,  there  are  no  symptoms  observable  dur- 
ing this  stage.  Occasionally,  Squire  states,  the  throat  is  complained  of,  and 
epistaxis  and  enlargement  of  the  post-cervical  glands  may  be  observed. 
152 


RUBELLA.  153 

Symptoms. — The  prodromal  stage  is  short,  not  more  than  a  few  hours, 
or  a  day  at  the  most,  though  in  many  cases  the  eruption,  like  that  of  varicella, 
may  be  the  first  evidence  of  disease,  especially  in  older  children.  When 
symptoms  are  observed  they  may  comprise  malaise,  nervous  irritability,  slight 
suffusion  of  the  conjunctivae,  perhaps  with  lachrymation  and  slight  coryza,  pains 
in  the  limbs,  drowsiness,  hoarseness,  slight  cough,  sore  throat,  enlargement  of 
post-cervical  and  post-auricular  glands,  with  possibly  an  elevation  of  tempera- 
ture of  1°  to  3°  F.  Any  or  all  of  these  symptoms  may  be  wanting,  and  the 
first  evidences  of  disease,  as  already  stated,  may  be  discovered  in  the  rash. 

The  eruption  of  rubella  appears  first  behind  the  ears  and  upon  the  fore- 
head and  face,  especially  upon  the  oral  circle,  spreading  rapidly  over  the  rest 
of  the  body,  and  reaching  the  legs  last.  When  first  discovered  it  may  have 
already  extended  to  the  chest  or  abdomen.  In  rare  cases  the  distribution  of 
the  rash  may  remain  limited,  as  in  a  case  observed  by  Griffith,  in  which,  though 
the  symptoms  were  severe,  the  rash  could  be  found  only  upon  the  face  and 
neck. 

In  appearance  the  rash  is  maculo-papular,  pin-head  to  split-pea  in  size  and 
pale  rose  in  color.  The  spots  are  usually  discrete,  and  are  separated  by  areas 
of  healthy  skin;  but  in  certain  localities  subjected  to  warmth  and  pressure 
they  may  become  confluent  and  simulate  closely  the  rash  of  scarlatina.  Upon 
the  chest  and  back  the  rash  is  usually  darker  red  in  color,  and  more  pro- 
fuse. From  this,  the  typical  appearance  of  the  eruption,  various  departures 
occur,  so  that  in  one  case  the  eruption  of  measles  may  be  closely  simulated, 
and  in  another  the  rash  of  scarlatina.  This  variability  of  the  eruption  is 
one  of  the  most  characteristic  features  of  the  disease.  A  study  of  these  mani- 
festations seems  to  warrant  the  recognition  of  two  distinct  types  of  variation 
from  the  normally  developed  rash  :  1.  Rubella  Morhilliforme. — ^The  eruption 
is  discrete,  the  papules  are  nearly  the  size  of  a  split  pea,  and  more  or  less 
grouped,  strongly  resembling  measles.  2.  Rubella  Scarlatiniforyne. — Here 
the  whole  body  is  rapidly  covered  with  a  diffuse  rash  of  bright  rosy-red  hue, 
which  is  raised  somewhat  from  the  surface  of  the  skin,  and  often  occurs  in 
patches  with  well-defined  margins.  A  few  papules  may  often  be  found  near 
the  margins  or  within  the  reddened  areas,  and  can  be  best  seen  perhaps  on 
the  fingers  or  wrists,  or  on  the  forehead.  . 

In  some  cases,  indeed,  coalescence  of  papules  may  take  place  after  some 
hours,  and,  as  Tonge-Smith  has  pointed  out,  the  rash  may  thus  become  blurred 
into  a  confluent  blush  on  the  second  day,  so  as  to  be  indistinguishable  from 
scarlatina  except  from  the  history.  Instances,  however,  will  occur  where  the 
greatest  minuteness  of  examination  will  fail  to  give  conclusive  evidence  of  the 
nature  of  the  rash,  particularly  in  the  scarlatiniform  variety. 

In  the  development  of  the  eruption  variations  will  also  be  observed.  Thomas 
states  that  ordinarily  the  maximum  of  the  development  of  the  eruption  on  dif- 
ferent parts  occurs  at  different  times,  following  the  sequence  of  its  first  appear- 
ance, and  this  opinion  is  shared  by  Hardaway,  Emminghaus,  Roth,  and  Grifiith ; 
other  writers  state  that  the  eruption  reaches  its  height  on  the  second,  rarely, 
as  Cheadle  asserts,  on  the  third,  day.  The  average  duration  of  the  eruption  is 
fixed  by  Griffith  at  three  to  four  days,  though  it  often  lasts  a  much  shorter 
time,  or  may  continue  longer.  As  the  eruption  fades,  slight  brownish  or  yel- 
lowish pigmentations  may  be  visible  for  a  few  days.  Desquamation  does  not 
occur  in  all  cases :  according  to  the  testimony  of  a  few  competent  observers 
it  has  never  been  observed.  It  does,  however,  occur,  but  is  always  slight 
and  furfuraceous  in  character,  and  is  usually  completed  in  a  few  days. 

With  the  appearance  of  the  rash  or  slightly  preceding  it  other  symptoms 


154    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

appear.  Catarrhal  symptoms,  referable  to  the  conjunctivae  and  nasal  passages, 
are  frequently  present,  but  in  slighter  degree  than  is  usual  in  measles,  photo- 
phobia and  marked  coryza  being  quite  rare.  A  loose  cough  is  not  unusual,  but 
is  distinctly  less  severe  than  that  of  measles.  Sore  throat  is  one  of  the  most 
constant  of  the  symptoms.  It  appears  usually  as  a  redness  of  the  mucous 
membrane,  especially  marked  about  the  uvula  and  upper  portions  of  the 
anterior  pillars ;  the  tonsils  are  at  times  involved,  and  may  be  considerably 
swollen,  giving  rise  to  pain  in  swallowing.  Griffith  mentions  an  occasional 
eruption  of  small  yellowish-red  or  brownish-red  spots  of  pinhead  size  visible 
over  the  soft  palate  and  uvula  and  the  inner  surface  of  the  cheeks.  This 
sore  throat,  however,  is  of  little  importance,  and  rapidly  subsides,  often  to 
recur  in  the  last  stage  of  the  disease.  This  secondary  angina,  accord- 
ing to  Eustace  Smith,  is  very  characteristic  of  rubella.  The  tongue  is 
either  clean  or  has  a  thin  yellowish-white  coating,  quite  different  from  the 
characteristic  "strawberry"  tongue  of  scarlatina,  the  appearance  of  which 
is  never  simulated,  according  to  the  testimony  of  the  great  majority  of 
writers.  The  temperature  varies  greatly,  ranging  up  to  103°  or  104°  F., 
though,  as  a  rule,  rarely  reaching  101°  F.,  and  often  is  not  materially 
elevated.  It  is  apt  to  be  highest  on  the  first  or  second  day  of  the  rash,  and 
may  then  subside  suddenly  or  fall  gradually  with  the  disappearance  of  the 
eruption.  Pulse  and  respiration  are  rarely  disturbed  except  in  proportion  to 
the  rise  of  temperature. 

Probably  the  most  characteristic  symptom  of  the  disease  is  enlargement  of 
the  lymphatic  glands,  which  to  greater  or  less  degree  is  present  in  almost  every 
case.  Those  mainly  affected  are  the  post-cervical  and  post-auricular  glands, 
but  in  many  cases  the  axillary  and  inguinal  glands  are  also  involved.  The 
swelling  is  hard,  tender,  and  reaches  the  size  of  a  pea.  It  is  an  early  symp- 
tom, noticeable  often  on  the  first  day,  at  times  before  the  appearance  of  the 
rash,  and  practically  it  is  never  delayed  beyond  the  second  day.  Griffith,  how- 
ever, believes  that  this  glandular  swelling,  while  a  very  constant  symptom  of 
rubella,  is  probably  nearly  equally  as  frequent  in  measles,  and  that  it  is  by 
no  means  of  as  great  diagnostic  importance  as  is  usually  supposed. 

Nausea  and  vomiting  are  extremely  rare,  and,  though  reported  in  isolated 
cases,  should  not  be  classed  as  symptomatic  of  this  disease.  The  bowels  also 
show  no  special  disturbance  of  function.  Slight  oedema  of  the  face  may  be 
observed  when  the  rash  is  well  marked.  Itching  of  the  skin  is  rarely  present 
and  is  never  troublesome. 

Reinfection,  or  relapse,  is  of  very  rare  occurrence,  but  has  been  occasion- 
ally observed  within  one  to  three  weeks  after  the  onset  of  the  original  attack. 

Complications  and  Sequelae. — In  the  disease  as  we  know  it  at  the  present 
day  complications  or  sequelae  directly  traceable  to  it  are  extremely  rare.  Those 
most  commonly  mentioned  involve  the  respiratory  organs  and  air-passages,  such 
as  bronchitis  and  pneumonia,  naso-pharyngeal  catarrh,  stomatitis,  and  perma- 
nent enlargement  of  the  tonsils.  Transient  albuminuria  is  mentioned  by  Em- 
minghaus,  Kingsley,  Reed,  Cheadle,  and  others,  while  Mettenheimer,  Tonge- 
Smith,  and  Squire  doubt  its  occurrence,  and  Hardaway  considers  it  entirely 
anomalous,  if  not  due  to  mistaken  diagnosis.  Otorrhoea,  ciliary  blepharitis, 
and  phlyctenular  keratitis  have  been  observed. 

Prognosis. — Rubella  is  not  a  dangerous  disease,  and  recovery  is  usually 
complete  in  a  fortnight.  Death  occasionally  occurs  in  severe  cases  and  in 
some  epidemics,  and  this  from  some  serious  complication. 

Diagnosis. — From  measles  rubella  may  usually  be  distinguished  by  the 
short  duration  of  its  prodromal  symptoms  and  the  absence  of  marked  catarrhal 


RUBELLA.  155 

symptoms  and  hoarse  ringing  cough ;  by  the  slight  degree  and  the  variability 
of  fever ;  by  the  presence  of  sore  throat  and  of  enlargement  of  the  post-cer- 
vical and  post-auricular  glands ;  and,  in  less  certain  degree,  by  the  appearance 
of  the  eruption.  From  scarlatina  it  may  be  distinguished  by  the  absence  of 
vomiting  at  the  onset,  by  the  suffusion  and  faint  congestion  of  the  conjunc- 
tivae ;  by  the  swelling  of  the  lymph-glands,  which  occurs  early,  bears  no  rela- 
tion to  the  severity  of  the  faucial  inflammation,  and  affects  the  post-cervical 
and  post-auricular  glands  rather  than  those  of  the  throat ;  by  the  appear- 
ance of  the  tongue,  and  lack  of  acceleration  of  pulse  out  of  proportion  to  the 
elevation  of  temperature ;  by  the  absence  of  albuminuria ;  by  the  branny 
character  of  its  desquamation ;  and,  finally,  by  the  appearance  of  the  rash, 
which  is  more  rosy  in  color  and  somewhat  raised  from  the  surface,  often  occurs 
in  patches  with  well-defined  margins,  and  is  less  burning  to  the  touch. 

Anomalous  cases,  however,  arise  which  tax  to  the  utmost  the  physician's 
skill  in  diagnosis,  and  the  occurrence  of  other  more  typical  cases  in  the  same 
family  may  be  the  only  means  of  distinguishing  rubella  from  one  or  other  of 
the  more  serious  affections  which  it  simulates. 

Treatment. — Probably  no  disease  needs  less  medical  treatment.  Its  own 
direction  being  toward  recovery,  it  may  generally  be  safely  left  to  follow  it. 
The  patient  should  be  sent  to  bed,  as  well  for  the  safety  of  others  as  for  his 
own.  As  there  is  conjunctival  irritation  in  most  cases,  the  room  should  be 
darkened. 

The  diet  should  be  light  and  bland,  as  toast,  bread  and  warm  milk,  and 
various  broths.  Cool  water  should  not  be  denied.  If  itching  be  trouble- 
some, it  may  be  allayed  by  frequent  tepid  bathing.  Treat  headaches  by 
applying  cloths  wrung  from  cold  lotions  or  by  hot  foot-baths  made  more 
effective  by  mustard. 

The  sore  throat  is  well  treated  by  the  steam  atomizer  or  by  gargles,  as  fol- 
lows : 

I^.  Potassii  chloratis 3iss  ; 

Glycerini fsiij  ; 

Tinct.  ferri  chlorid f§ss ; 

Aquae q.  s.  ad  f^viij. — M. 

Sig.   Gargle  once  in  three  or  four  hours. 

In  a  disease  of  such  mild  character  it  is  doubtful  whether  any  quarantine 
precautions  need  be  advised,  except  to  prevent  loss  of  time  and  inconveni- 
ence in  the  school-room,  where  the  disease  is  readily  disseminated,  often 
by  cases  passing  without  recognition.  From  this  point  of  view  two  weeks 
after  the  beginning  of  the  attack  may  be  considered  an  ample  period  of 
quarantine. 


CHICKEN-POX. 

By  WILLIAM  T.  PLANT,  M.  D., 

Syracuse. 


Varicella,  or  chicken-pox,  the  lightest  of  the  exanthemata  and  usually 
a  disease  of  trivial  importance,  was  first  described  as  a  distinct  aftection  a  few 
years  before  the  close  of  the  seventeenth  century.  There  can  be  no  doubt  that 
it  had  existed  from  a  period  far  remote,  but  it  was  not  until  then  difierentiated 
from  small-pox  and  other  eruptive  disorders.  Dr.  William  Heberden,  an  Eng- 
lish physician  who  lived  between  1710  and  1801,  was  the  first  to  give  a  full 
and  accurate  description  of  this  disease,  though  several  writers  before  his  day 
had  described  it  less  perfectly,  and  one  of  them,  Dr.  Richard  Morton,  gave  it 
its  earliest  and  best  name  of  chicken-pox. 

It  is  an  acute,  infectious,  and  transient  affection,  runs  a  definite  course,  and, 
with  very  few  exceptions,  occurs  but  once  in  the  same  person.  Though  it 
beai's  some  resemblance  to  the  lighter  forms  of  variola,  it  has  no  relation  to 
this  disease,  as  has  been  abundantly  proven  by  the  observations  of  two  cen- 
turies. Therefore,  the  name  varicella,  conferred  upon  it  by  Vogel  in  1764,  is 
founded  upon  error  and  is  misleading. 

It  is  essentially  a  pediatric  disorder,  as  it  only  affects  infants  and  young 
children — at  least  the  writer  does  not  remember  to  have  met  with  it  more  than 
once  or  twice  in  adults.  It  may  be  regarded  as  quite  a  rare  affection  after  four- 
teen or  fifteen  years  of  age.  It  travels  in  epidemics,  often  widespread,  regard- 
less of  season,  race,  country,  or  climate,  and  of  everything  but  age. 

Incubation. — The  incubative  period  is  rather  long.  Henoch  fixes  its 
duration  at  12  to  13  days;  Gerhardt,  14  to  15;  Eichhorst,  13  to  16;  Striim- 
pell,  13  to  17  ;  and  Semtschenko,  3  to  26.  In  cases  of  the  inoculated  disease 
d'Heilly  has  observed  as  short  an  incubation  as  3  days ;  but  with  the  affection 
as  ordinarily  contracted  this  period  of  latency  may  be  assigned  between  the 
loAvest  and  highest  figures  given  by  the  authorities  quoted,  averaging  13  to 
17  days. 

Symptoms. — At  the  close  of  the  incubation  the  active  period  of  the  disease 
is  often  ushered  in  with  a  little  chilliness,  aching  of  head  and  limbs,  diminution 
of  appetite  or  complete  anorexia,  and  perhaps  nausea.  AVith  these  symptoms 
there  is  usually  moderate  fever — from  99°  to  102°.  It  often  happens,  how- 
ever, that  the  eruption  is  the  first  symptom  noticed,  no  complaint  of  illness 
having'  been  previously  made  by  the  child.  Only  in  rare  instances  are  the 
phenomena  of  invasion  alarming  or  even  severe.  Decided  chills,  fever  of  high 
grade,  and  even  delirium,  are  occasionally  met  with  at  the  onset,  and  in  one 
case  under  the  writer's  care  the  disease  was  ushered  in  by  two  severe  convul- 
sions. Some  authors  allude  to  this  very  rare  mode  of  beginning.  But, 
whether  these  first  symptoms  of  invasion  are  usually  mild  or  entirely  unnoticed 
or  exceptionally  severe,  they  are  of  short  duration,  and  the  eruptive  stage  is 
soon  established.     As  it  first  appears,  irregularly  scattered  over  the  body,  the 

156 


CHICKEN-POX.  157 

eruption  consists  of  some  small  rose-red  papules  which  very  quickly  develop 
into  vesicles.  This  change  is  effected  so  quickly  that  very  often  the  papular 
stage  is  over  and  the  vesicular  stage  well  under  way  before  the  eruption  is 
discovered.  The  vesicles  are  seldom  either  numerous  or  large.  Varying  in 
number  from  a  dozen  or  two  to  a  hundred  or  more,  they  are  scattered  rather 
irregularly  over  the  trunk,  limbs,  and  scalp,  but  are  most  abundant  upon  the 
back.  They  seldom  make  very  much  show  on  the  face.  Frequently  a  few 
are  found  on  the  forehead  and  temples  when  all  other  parts  of  the  face  are 
quite  free.  Often,  if  searched  for,  some  blebs  may  be  found  upon  the  mucous 
membrane  of  the  mouth  and  fauces,  where  they  quickly  rupture  and  leave 
small  ulcers.  In  the  severer  cases  mild  sore  throat,  laryngeal  irritation,  or 
slight  hoarseness  is  sometimes  noticeable,  and  in  the  light  of  the  interesting 
observations  of  Boucheron  and  of  Marfan  and  Hall^,  to  be  presently  referred 
to  under  the  heading  of  Complications,  it  seems  quite  certain  that  hypersemia 
of  the  upper  air-passages  and  vocal  cords  may  be  present,  and  that  vesicles 
may  occasionally  form  upon  the  vocal  cords,  and  possibly  still  lower  down  in 
the  bronchial  tree.  ^ 

The  vesicles  of  chicken-pox  are  quite  variable  in  size  :  some  are  not  larger 
than  pin-heads,  while  others  reach  the  size  of  small  peas.  It  was  presumably 
the  resemblance  in  average  size  to  the  "chick-pea,"  or  "cicer,"  of  Southern 
Europe  that  suggested  to  Dr.  Morton  the  name  of  chicken-pox. 

The  tegumentary  covering  of  the  vesicle  is  very  thin,  being  composed  only 
of  the  outer  layers  of  the  skin.  It  contains  an  alkaline  serum  of  crystal 
transparency,  whence  another  admirable  name  for  the  affection,  "  crystalli,'" 
and  the  German  "  Wasserpocken.''  It  was  long  ago  aptly  said  that  the  rash 
of  chicken-pox  suggests  an  appearance  as  if  scalding  water  had  been  flirted 
over  the  surface,  each  drop  having  raised  a  small  transparent  blister.  Some 
of  the  vesicles  are  surrounded  by  a  narrow,  often  linear,  and  very  pink  are- 
ola ;  others  rise  abruptly  from  a  surface  of  natural  color. 

A  peculiar  and  distinguishing  feature  of  chicken-pox  is  that  the  eruption 
comes  out  in  successive  crops.  Before,  or  as  soon  as,  the  first  vesicles  have 
arrived  at  their  full  size  others  are  just  beginning;  and  this  may  be  repeated 
twice  or  thrice,  or  even  four  times. 

In  the  disease  as  ordinarily  observed  the  vesicles  never  become  pustular 
like  those  of  small-pox,  unless  from  scratching  or  other  irritation,  with  conse- 
quent secondary  infection ;  and,  according  to  the  usual  teaching,  they  are 
neither  partitioned  nor  umbilicated,  as  are  those  of  variola,  and  are  rarely  so 
numerous  as  to  become  confluent.  Walsh,  however,  quite  recently  has  stated 
that  the  eruption  may  be  macular  and  papular,  with  an  inflammatory  areola 
about  the  vesicles,  which  may  be  confluent,  umbilicated,  partitioned,  and  pus- 
tular, and  finally  may  leave  depressed  cicatrices  not  unlike  "pockmarks."  In 
these  times  of  general  vaccination,  with  its  protecting  or,  at  least,  mitigating 
influences,  cases  manifesting  such  peculiarities  of  the  eruption  must  be  regarded 
with  grave  suspicion,  and  the  possibility  of  a  masked  variola  must  be  taken 
into  serious  consideration,  especially  if  the  patient  be  an  adult. 

Another  peculiarity  of  this  disease  is  that,  if  the  eruption  is  at  all  copious, 
many,  perhaps  most,  of  the  vesicles  abort  and  shrivel  away  before  making  much 
progress  toward  a  completed  development.  I  have  observed  that  late  vesicles 
are  especially  prone  to  abort.  The  other  vesicles  advance  rapidly  to  maturity 
and  enter  on  a  speedy  decline.  The  fluid  becomes  opalescent  and  turbid,  and 
dries  down  into  a  thin  yellowish  crust  that  soon  crumbles  and  falls  off,  leaving 
a  temporary  redness  of  the  skin.  In  case  of  injury  or  irritation  of  a  vesicle 
suflBcient  to  cause  a  slight  superficial  destruction  of  the  derm,  and  sometimes 


158     AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 


even  without  this  in  vesicles  of  unusual  size,  healing  is  followed  by  a  slightly 
excavated  depression  in  the  surface  of  the  skin.  Many  persons  bear  in  after- 
life one  or  more  of  these  pits  upon  the  face  as  a  reminder  of  this  childish 
malady. 

During  the  eruptive  stage  the  fever,  which  is  almost  uniformly  intermittent 
in  type,  varies  in  degree  with  the  acuteness  of  the  attack  and  the  extent  of  the 
eruption,  mild  cases,  with  only  a  few  vesicles,  being  almost  apyretic ;  severe 
cases,  with  a  profuse  eruption,  being  attended  by  a  temperature  of  104°  or 
more.  The  usual  range  and  duration  of  elevated  temperature  is  illustrated  in 
the  accompanying  charts  (Fig.  1). 

The  whole  course  of  chicken-pox  seldom  exceeds  eight  or  nine  days,  or 
possibly  ten  or  twelve  at  the  most,  and  in  the  uncomplicated  cases  convalescence 

Fig.  1. 


M 

e 

M 

E 

M 

e 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

ME 

:  M 

E 

M 

E 

M 

E 

M 

E 

105° 

104° 

103° 

102° 

101° 

100° 

99° 

98° 

97° 

,<" 

•J 

I 

<i 

.'i 

^ 

^ 

:) 

Ife 

-.v 

t) 

■f. 

k 

?1 

> 

" 

? 

- 

,ti 

t 

'J^ 

t-i 

i 

'* 

s 

.>i 

\ 

'lii 

, 

't 

> 

a 

L 

-? 

* 

» 

•f^ 

'^, 

\ 

i 

tn 

l;^ 

V 

^ 

1 

^ 

1 

>F 

'^ 

^ 

-^^ 

'r'' 

,% 

'- 

^ 

*} 

A 

-^ 

/\ 

iV 

/\ 

i 

<, 

[  I 

V 

*\ 

/   1 

1 

1 

"s 

1 

I 

1 

|| 

1 

] 

1 

1 

/ 

u 

f 

1 

f 

I 

f  ' 

A 

/^ 

1/ 

n 

/ 

' 

^ 

K 

/ 

1 

7 

\j 

C" 

T 

V 

V 

M 

1 

Day  ofDit. 

1 

2 

3 

4 

6 

6 

7 

• 

2 

3 

4 

5 

6 

Temperature  Charts  of  Varicella  (Ashby  and  Wright). 

is  rapid.  As  seen  in  young  infants,  however,  especially  in  those  already 
weakened  by  chronic  digestive  ailments,  the  disease,  however  mild  in  its  mani- 
festations, may  be  followed  by  a  period  of  innutrition  of  more  or  less  gravity. 
In  hospital  epidemics  varicella  is  certain  to  add  to  the  mortality  among  this 
class  of  patients. 

Recurrence. — Second  attacks  of  varicella  are  rare.  In  twelve  epidemics 
studied  by  Semtschenko  in  Kasan,  embracing  872  cases,  only  14  instances  of 
recurrence  were  found,  the  intervals  varying  from  eight  to  eighteen  months 
after  the  primary  attack.  In  5  other  cases  there  were  two  subsequent  attacks 
of  the  disease. 

Complications   and   Sequelae. — While   ordinarily  chicken-pox   runs   an 


CHICKEN-POX.  159 

uneventful  course  in  a  previously  healthy  child,  and  is  followed  by  rapid  and 
complete  recovery,  recent  observations  have  emphasized  the  fact  that  the 
kidneys  may  early  present  inflammatory  changes,  which  may  occasionally  lead 
to  a  fatal  termination.  Attention  was  first  drawn  to  this  in  1884  by  Henoch, 
who  reported  4  cases  of  post-varicellous  nephritis,  one  of  which  terminated 
fatally;  and  since  then  more  than  30  cases  have  been  published,  principally  by 
German  observers.  Cassel,  one  of  the  most  recent  of  these,  saw  6  cases  out  of 
12  in  a  single  epidemic  in  Berlin,  in  1894,  which  showed  albuminuria  or  actual 
nephritis,  the  earliest  on  the  fourth  or  fifth  day  of  the  disease.  Three  of  these 
were  fatal — one,  ten  months  old,  from  nephritis  alone  on  the  twelfth  day,  the 
others  in  association  with  pneumonia.  Two  other  cases  dying  from  nephritis 
have  been  recorded — one  each  by  Hdgyes  and  Hagenbach,  the  latter  referring 
to  the  condition  as  one  of  acute  parenchymatous  nephritis,  while  the  former 
stated  that  the  convoluted  tubules  and  loops  of  Henle  were  alone  affected. 
This  testimony  is  sufiicient  to  indicate  the  necessity  for  keeping  close  watch 
upon  the  urine  during,  and  for  a  time  after,  the  disease. 

Von  Starck  has  seen  in  a  boy  of  two  years,  on  the  tenth  day  following  the 
onset,  a  generalized  oedema  without  albuminuria  or  other  signs  of  nephritis. 
It  was  attributed  to  a  peculiar  action  of  the  virus  of  the  disease  upon  the  ves- 
sels of  the  subcutaneous  connective  tissue,  comparable  to  the  condition  signalized 
by  Quincke  and  others  as  occurring  after  scarlatina. 

The  occurrence  of  a  scarlatiniform  erythema  during  the  decline  of  the 
eruption  has  been  occasionally  observed.  In  one  case  lately  reported  by 
Comby  albuminuria  of  four  days'  duration  and  suppuration  in  a  submaxillary 
lymph-gland  followed  the  erythema.  The  precise  nature  of  this  rare  compli- 
cation is  still  unsettled. 

Suffocative  laryngitis  has  been  observed  in  2  cases  by  Marfan  and  Hall^, 
as  previously  noted — one  preceding,  the  other  accompanying,  the  appearance 
of  the  eruption.  The  first  case,  a  child  of  three  years,  was  seen  first  after  an 
illness  of  three  days.  The  voice  was  hoarse  and  respiration  difficult,  with 
supra-  and  infrasternal  recession.  The  throat  was  reddened,  but  otherwise  not 
abnormal.  On  the  fourth  day  the  eruption  appeared  upon  the  surface,  but 
the  laryngeal  symptoms  increased,  and  necessitated  tracheotomy.  The  child 
recovered.  The  second  case,  in  a  weakly  infant  of  nine  months,  showed  a  sim- 
ilar affection  of  the  larynx  coincident  with  a  profuse  confluent  eruption.  Death 
occurred  on  the  seventh  day  from  acute  diarrhoea  and  broncho-pneumonia.  The 
autopsy  showed  a  small  round,  deep  ulcer  at  the  posterior  part  of  the  margin 
of  the  right  vocal  cord.  Boucheron  also  saw  a  case  which  proved  fatal  from 
spasm  of  the  glottis,  due  probably  to  hypersemia  of  the  vocal  cords. 

Various  other  affections  have  been  noted  as  occasional  complications  of 
this  disease,  among  which  may  be  mentioned  furunculosis,  osteitis,  synovitis, 
otitis  media,  and  submaxillary  and  cervical  adenopathy,  at  times  associated 
with  inguinal  bubo,  and  rarely  going  on  to  suppuration. 

Varicella  may  complicate  or  be  complicated  by  other  infectious  diseases  : 
such  combinations  as  varicella  and  pertussis,  varicella  and  measles,  varicella 
and  scarlatina,  varicella,  measles,  and  pertussis,  and  varicella,  measles,  and 
diphtheria,  are  occasionally  observed.  Profuseness  of  the  eruption  alone  may 
constitute  a  serious  complication,  as  is  illustrated  by  a  fatal  case  in  an  infant 
of  eight  and  a  half  months  seen  by  Nisbet,  who  attributed  its  death  to  the 
fact  that  the  eruption  covered  every  portion  of  the  body,  producing  the  effect 
of  an  extensive  burn. 

Secondary  infections  are  not  very  unusual.  Of  these  erysipelas  is  the  most 
common,  and  is  always  a  grave  complication.     In  a  circumscribed  epidemic 


160     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  15  cases  Bolognini  observed  12  in  which  secondary  infection  of  the  vesicles 
by  staphylococci  and  streptococci  took  place  during  the  stage  of  desiccation, 
causing  the  vesicles  to  enlarge  to  the  size  of  bullae,  which,  breaking,  gave  issue 
to  a  thick  creamy  pus.  In  one  case,  the  only  one  resulting  fatally  from  abscess 
of  the  kidney,  pure  cultures  of  the  streptococcus  were  obtained.  All  of  these 
children  had  transient  albuminuria,  without  other  signs  of  nephritis. 

Varicella  Gangrsenosa. — Among  the  secondary  infections  should  be  con- 
sidered the  rare  condition  which  is  described  under  this  name.  It  was  first 
brought  to  notice  by  Hutchinson  in  1882,  and  was  for  a  time  thought  to  be 
peculiar  to  varicella ;  but  subsequent  observations  have  shown  that  an  identi- 
cal process  may  occur  in  connection  with  vaccinia,  pemphigus,  and  other  dis- 
crete pustular  lesions.  Dermatologists  now  describe  the  general  affection 
under  the  name  of  dermatitis  gangrcenosa  infantum.  Tuberculosis,  rickets, 
and  inherited  syphilis  seem  to  exercise  a  predisposing  influence,  but  it  has  been 
occasionally  observed  in  apparently  healthy  children. 

As  seen  in  connection  with  varicella,  it  may  begin  while  the  vesicles  are 
still  present ;  it  is  then  observed  first  upon  the  head  or  upper  portions  of  the 
body.  It  will  be  noticed  that  ulceration  has  begun  beneath  the  crust,  and 
often  a  pustular  margin  with  an  inflammatory  areola  is  found,  resembling 
closely  a  vaccinal  pustule.  The  destructive  process  extends  in  depth  and 
periphery  until  it  forms  a  black  slough  reaching  an  inch  or  more  in  diameter. 
After  a  time  separation  of  the  slough  occurs,  leaving  a  sharply-cut  oval  or 
roundish  excavated  ulcer.  When  the  vesicles  have  been  closely  aggregated 
several  gangrenous  areas  may  coalesce  to  form  larger  ulcers  of  irregular 
contour. 

When  the  gangrenous  process  begins  as  late  as  two  weeks  or  more  after 
the  onset  of  the  disease,  after  the  varicellous  lesions  have  healed,  the  ulcerations 
are  more  apt  to  begin  upon  the  lower  portion  of  the  body,  especially  upon  the 
buttocks  and  thighs.  Pinhead-sized  maculo-pustules  first  appear,  which  in- 
crease in  size,  rupture,  and  form  crusts,  under  which  the  gangrenous  process 
begins  as  in  the  case  of  pre-existing  varicellous  lesions. 

In  the  severer  cases,  which  begin  early  in  the  course  of  the  exanthem,  haem- 
orrhage into  the  vesicle  precedes  the  other  changes;  and,  with  this,  haemor- 
rhages from  the  nose,  mouth,  or  stomach,  as  Avell  as  beneath  unaffected  por- 
tions of  the  skin,  may  be  observed.  Such  cases  run  a  rapid  course,  and  ter- 
minate with  symptoms  of  general  pyaemia. 

Of  the  pathology  of  gangrenous  varicella  nothing  definite  is  known.  There 
can  be  little  doubt,  however,  that  it  results  from  a  secondary  infection,  in 
the  milder  cases  probably  with  the  ordinary  pyogenic  organisms ;  and  in  the 
more  malignant  cases,  such  as  those  recently  reported  by  Lockwood  and  Silver 
{Archives  of  Pediatrics,  Sept.,  1897),  the  coincidence  of  an  acute  blood-infec- 
tion may  be  reasonably  presumed. 

Even  in  its  mildest  manifestations  gangrenous  varicella  is  a  serious  aff"ec- 
tion,  but  in  the  virulent  types  associated  with  marked  blood-dyscrasia  the 
prognosis  is  wellnigh  hopeless. 

Diagnosis. — It  is  usually  only  to  settle  this  important  question  that  the 
physician  is  summoned.  Apart  from  variola  or  its  milder  manifestation,  vario- 
loid, eruptive  vaccinia  and  herpes  zoster  are  the  only  diseases  with  which 
varicella  might  reasonably  be  confounded. 

From  eruptive  vaccinia,  apart  from  the  history  of  a  recent  vaccination, 
varicella  may  be  distinguished  by  its  successive  crops  of  rapidly  developed 
vesicles,  which  will  have  almost  disappeared  before  the  vaccinal  lesions  could 
have  reached  the  height  of  their  development  and  shown  a  marked  areola. 


CHICKEN-POX.  161 

From  herpes  zoster,  its  more  general  distribution,  which  does  not  follow  the 
course  of  certain  nerves,  and  the  absence  of  pre-eruptive  pain,  should  serve  to 
differentiate  it. 

From  well-marked  variola  and  varioloid,  varicella  should  be  readily  distin- 
guished by  a  consideration  of  the  following  points  of  difference : 

Chicken-pox.  Variola. 

Only  infants  and  young  children  affected.  All  ages  affected. 

Invasion  short ;  general  symptoms  usually  Invasion   three   days ;    general   symptoms 

very  light.  severe. 

Febrile  stage  transient,  commonly  highest  Initial  fever  falls  with  appearance  of  erup- 

at  beginning  of  the  eruption.  tion,  to  be  followed  by  the  secondary  rise 

with  pustulation. 

Eruption  vesicular  almost  from  the  first.  Eruption  papular  for  3  or  4  days. 

Eruption  superficial :  never  shotty.  Eruption  deep-seated  :  hard,  shotty. 

Seldom  umbilicated.  Generally  umbilicated. 

Vesicles  not  distinctly  multilocular.  Vesicles  always  multilocular. 

Vesicles  always  discrete.  Eruption  often  confluent. 

Eruption  little  on  face,  hands,  and  feet.  Eruption  most  on  face,  hands,  and  feet. 

No  pustular  stage.  Pustular  stage  never  absent. 

Uninfluenced  by  vaccination  or  previous  Prevented  by  vaccination  or  previous  small- 
small-pox.  pox. 

Mild  and  abortive  cases  of  varioloid  occur,  however,  and  present  the  great- 
est difficulty  in  diagnosis.  The  invasion  may  be  short,  and  so  mild  as  to 
attract  no  attention  ;  the  lesions  may  be  few  and  scattered  ;  fever  may  be 
insignificant ;  and  the  vesicles  may  abort  before  reaching  the  pustular  stage. 
In  such  a  case  error  in  favor  of  the  milder  disease  is  easily  made,  and  may  be 
followed  by  most  disastrous  consequences.  Only  a  most  careful  study  of  the 
history  and  course  of  development  of  the  attack  can  lead  to  a  satisfactory 
decision ;  and  if  the  patient  should  happen  to  be  an  adult,  this  fact  should 
weigh  decidedly  in  favor  of  the  more   serious   disease. 

Prognosis. — As  a  rule,  when  occurring  in  a  previously  healthy  child, 
chicken-pox  rarely  gives  rise  to  anxiety  as  to  its  outcome.  Among  debili- 
tated, strumous,  and  syphilitic  infants  prognosis  should  be  more  guarded,  lest 
the  gangrenous  complication  supervene,  the  prognosis  of  which  has  been 
already  stated. 

Treatment. — A  disease  whose  course  and  duration  are  fixed,  and  whose 
ending  is  almost  always  favorable,  requires  little  aid  from  medicine.  The 
child  should  be  confined  to  bed  during  the  active  stage  of  the  disease,  and  if 
fever  be  high  a  foot-bath  should  be  given  at  the  start,  followed  by  a  simple 
diaphoretic  febrifuge.  Except  in  the  case  of  very  young  children,  whose 
digestion  is  liable  to  passing  disturbance  from  the  disease,  no  special  restric- 
tion in  diet  need  be  made  unless  the  fever  remains  high  for  several  days. 
As  a  rule,  the  eruption  causes  little  irritation,  and  needs  no  treatment  except 
a  soothing  dusting  powder  upon  the  back  and  upon  the  parts  kept  warm  by 
the  clothing.  Upon  the  face  large  vesicles  may  be  punctured  early,  and 
covered  with  a  thin  film  of  collodion  to  protect  them  against  injury  or 
secondary  infection  from  scratching.  For  similar  reasons  the  child's  hands 
should  be  disinfected  and  the  nails  kept  clean  and  well  trimmed. 

In  all  cases  the  urine  should  be  watched,  and  from  time  to  time  during 
the  course  and  convalescence  should  be  examined  for  albumin  or  other  evi- 
dence of  nephritis.  If  convalescence  be  protracted  and  the  child  exhibit 
evidences  of  anaemia  or  disturbed  nutrition,  iron  and  cod-liver  oil,  with  a 
bitter  tonic,  should  be  prescribed,  with  perhaps  a  change  of  air,  preferably 
a  short  sojourn  at  the   seashore. 

11  .  ' 


162    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Gangrenous  varicella  demands  a  much  more  rigid  treatment.  Constitu- 
tionally, the  strength  must  be  kept  up  by  nourishing  diet  and  by  liberal 
stimulation,  according  to  the  indications,  with  some  suitable  preparation  of 
alcohol,  with  strychnine,  and  with  quinine.  Locally,  the  gangrenous  lesions 
must  be  treated  with  antiseptic  and  deodorizing  washes,  such  as  solutions 
of  permanganate  of  potassium,  peroxide  of  hydrogen,  or  bichloride  of  mer- 
cury, and  kept  covered  with  a  protective  ointment  containing  iodoform, 
ichthyol,   or    some    other  drug  of  this  class. 

Quarantine. — With  a  disease  ordinarily  so  benign  little  effort  is  usually 
made  to  carry  out  quarantine.  In  many  children's  hospitals  epidemics  of 
varicella  run  their  course  unchecked,  usually  for  want  of  sufficient  facilities 
for  isolation ;  and  ordinarily  the  disease  seems  to  have  little  disturbing  effect 
upon  the  children  except  in  the  rare  instances  where  a  gangrenous  compli- 
cation occurs  or  among  the  athrepsic  babies,  as  already  pointed  out.  In 
family  jjractice  a  period  of  three  weeks  from  the  beginning  of  the  disease 
may  be  considered  a  sufficient  time  for  isolation.  As  with  other  infectious 
diseases,  a  thorough  cleansing  of  the  body  and  scalp  and  a  change  of  clothing 
should  be  ordered  before  the  child  is  allowed  to  mix  with  his  playmates 
again.  Without  such  precaution  the  danger  of  infecting  others  may  last  for 
some  time,  as  was  instanced  in  a  case  coming  under  the  author's  observation 
where  the  disease  was  communicated  to  an  infant  by  a  child  who  had  recov- 
ered from  an  attack  fully  four  weeks  before  the  only  occasion  of  their  meeting 
and  playing  together. 


VARIOLA  AND  VARIOLOID. 

By  C.  G.  JENNINGS,  M.  D., 
Detroit. 


Variola,  or  small-pox,  is  an  acute,  specific,  liighly  infectious  disease, 
characterized  by  a  typical  range  of  temperature  and  a  specific  inflammation  of 
the  skin  appearing  usually  on  the  third  day  of  the  disease  as  a  papular  eruption, 
which  quickly  becomes  vesicular  and  finally  pustular.  The  pustules  desiccate, 
and  leave  permanent  cicatrices  wherever  suppuration  has  invaded  the  deep  tissue 
of  the  skin. 

Etiology'. — The  nature  of  the  contagium  of  variola  is  unknown  ;  analogy, 
however,  points  to  a  micro-organism  as  the  infectious  principle.  There  is  no 
evidence  of  the  development  of  the  disease  de  novo,  each  case  being  transmitted 
from  a  parent  case  in  another  individual.  Individuals  of  both  sexes  and  of  all 
ages,  unprotected  by  vaccination,  are  subject  to  the  disease.  Even  the  foetus 
in  utero  does  not  enjoy  immunity. 

The  disease  is  transmitted  by  direct  contact,  through  the  medium  of  infected 
articles  and  through  the  air.  AYhile  scarlatina,  measles,  and  other  exanthemata 
will  infect  at  the  distance  of  only  a  few  feet,  small-pox  has  a  striking  distance 
that  is  very  much  greater.  In  the  Shefiield  epidemic  (1887)  the  influence  of 
the  Shefiield  hospital  could  be  traced  over  an  area  having  a  radius  of  four 
thousand  feet. 

One  attack,  as  a  rule,  renders  an  individual  immune.  In  countries  where 
the  disease  is  prevalent  a  second  attack  is  not  uncommon.  The  writer  saw  a 
negro  woman,  ill  with  discrete  variola,  who  was  sadly  disfigured  by  two  previous 
attacks.  The  disease  prevails  most  extensively  among  unvaccinated  communi- 
ties. The  negro  race  is  particularly  susceptible.  The  disease  is  most  infective 
during  the  periods  of  suppuration  and  desiccation.  Although  apparently  inde- 
pendent of  climate,  small-pox  is  a  disease  of  the  winter  and  spring. 

Pathological  Anatomy. — The  characteristic  anatomical  lesion  of  variola 
is  found  in  the  skin  and  mucous  membranes.  Small  areas  of  congestion  appear 
in  the  skin.  The  vessels  of  the  corium  dilate  and  become  tortuous,  and  the 
connective  tissue  in  the  centre  of  the  congested  areas  is  thickened  by  oedema. 
Coagulation  necrosis  of  the  epithelial  cells  quickly  follows,  with  thickening  of 
the  epidermis.  These  changes  form  the  papules.  Serum  is  poured  out  between 
the  necrotic  cells,  and  a  vesicle  forms.  The  changed  cells  form  a  meshwork  in 
which  the  fiuid  is  enclosed.  Trabeculse  bind  down  the  centre  of  the  vesicle, 
while  its  peripheiy  continues  to  distend,  producing  umbilication.  Pus-cells 
form  rapidly  in  the  vesicle,  and  in  a  few  hours  it  is  transformed  into  a  pustule. 
Infiammatory  injection  and  thickening  of  the  connective  tissue  surrounding  the 
pustule  now  take  place.  If  the  necrotic  process  is  confined  to  the  superficial 
layers  of  the  skin,  resolution  takes  place  without  pitting.  If  the  deep  tissue 
is  involved,  a  cicatrix  results.  Desiccation  of  the  pustule  follows,  leaving  a 
crust  of  dried  cell-debris  and  pus  adhering  to  the  skin.     Then  the  epidermis  re- 

163 


164    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

forms  under  the  crusts,  the  inflammatory  injection  and  infiltration  subside,  the 
crusts  drop  oft",  and  resolution  is  complete. 

The  process  in  the  mucous  membrane  is  the  same.  Perfect  pustules,  how- 
ever, are  rarely  seen,  because  the  macerated  roof  yields  early  to  the  pressure, 
and  an  aphthous-looking  ulcer  results,  often  covei-ed  by  a  pseudo-membrane. 
In  hsemorrhagic  small-pox  the  pustules  contain  blood,  and  extravasations  may 
occur  in  the  skin  and  mucous  membranes  at  any  point,  and  in  the  substance 
of  all  the  organs.  More  or  less  intense  congestion  and  septic  inflammation 
may  be  found  in  the  brain,  liver,  lungs,  kidneys,  and  spleen. 

Incubation. — The  duration  of  the  period  of  incubation  of  variola  is,  on 
the  average,  twelve  days.  Exceptionally  it  may  be  shortened  to  ten  or  length- 
ened to  fifteen  days.  When  transmitted  by  inoculation  the  disease  appears  on 
the  eighth  day  or  sooner.  During  the  period  of  incubation  the  child,  as  a  rule, 
shows  no  symptoms. 

Symptoms. — The  clinical  history  of  small-pox  may  be  divided  into  four 
stages  :  Invasion  ;  eruption  ;  secondary  fever ;   desiccation  or  decline. 

The  stage  of  invasion  is  ushered  in  abruptly.  Older  children  complain 
first  of  chilliness,  and  often  there  is  a  distinct  rigor.  The  phenomena  of  severe 
fever  quickly  follow.  In  addition  to  the  usual  symptoms  of  fever  there  are 
headache  of  unusual  severity,  persistent  vomiting,  great  prostration,  and 
severe  backache.  In  younger  children  and  infants  the  disease  begins  with 
fever,  great  nervous  irritability,  and  vomiting.  Very  often  convulsions  mark 
the  onset  of  the  disease.  They  may  be  frequently  repeated,  with  inter- 
vals of  stupor  or  delirium.  The  skin  is  dry  or  perspiring;  the  tongue  coated, 
with  dark-red  edges.  The  bowels  may  be  constipated,  but  often  a  sharp 
diarrhoea  is  present  during  the  whole  of  the  invasion  stage.  Abdominal  pain 
and  tenderness  are  frequent.  Respiration  is  rapid.  The  pulse  is  full  and 
quick,  ranging  from  120  to  160.  The  temperature  quickly  reaches  a  high 
point,  ranging  from  102°  to  105°  F.,  or  higher.  The  high  temperature  is 
maintained  during  the  invasion  stage  with  but  slight  remissions.  The  maxi- 
mum temperature  of  this  stage  is  usually  reached  just  before  the  appearance 
of  the  eruption.  Partial  paraplegia,  numbness,  and  incontinence  of  urine 
and  fteces,  are  sometimes  seen  in  children. 

In  children  more  frequently  than  in  adults  initial  or  accidental  rashes 
appear  about  the  second  day,  and  cause  much  difficulty  in  diagnosis.  The 
initial  rash  may  be  erythematous,  simulating  scarlatina  or  erysipelas ;  or 
macular,  simulating  measles.  It  is  very  evanescent,  and  usually  ushers  in  an 
attack  of  varioloid.  A  number  of  observers  have  noted  that  the  areas  of  skin 
aff"ected  by  the  prodromal  rash  escape  the  variolous  eruption.  Petechias  from 
one-twelfth  to  one-fourth  of  an  inch  in  diameter  are  sometimes  seen  in  this 
stage  of  the  disease  scattered  over  the  lateral  thoracic  and  lower  abdominal 
regions.     This  rash  is  often  of  grave  prognostic  significance. 

The  average  duration  of  the  stage  of  invasion  is  three  days.  In  grave 
cases  it  is  often  shortened  to  two,  while  in  varioloid  it  is  often  prolonged  to 
four  days.  As  a  rule,  the  longer  the  incubation  stage  the  milder  Avill  be  the 
subsequent  course  of  the  disease.  Notable  exceptions  to  this  rule  are  the 
delayed  rashes  of  cases  complicated  by  severe  internal  diseases,  and,  as  Moore 
observes,  of  cases  showing  an  early  hsemorrhagic  tendency. 

The  Stage  of  Eruption. — On  the  third  day  of  the  disease,  with  the  vari- 
ations noted  above,  the  true  rash  of  small-pox  begins.  The  eruption  shows  first 
on  the  face,  quickly  extending  to  the  scalp  and  neck.  Exceptionally  it  covers 
the  wrists  early.  After  the  face  and  neck,  it  next  invades  the  trunk,  extremi- 
ties, and  finally  the  palmar  and  plantar  surfaces,  taking  from  twenty-four  to 


VABIOLA    AND    VARIOLOID.  165 

forty-eight  hours  to  cover  the  cutaneous  surface.  Rarely,  in  very  young 
infants,  the  rash  appears  first  about  the  lower  part  of  the  abdomen  and  on  the 
inside  of  the  thighs.  Other  exceptions  to  the  usual  sequence  are  sometimes 
met.  The  rash  is  most  abundant  on  the  face  and  on  the  back  of  the  hands.  It 
shows  early  and  abundantly  on  irritated  areas  of  skin. 

The  eruption  begins  as  small,  slightly  raised,  pale-red  macules,  and  passes 
through  four  stages  of  development — viz.  macules,  painiles,  vesicles,  and 
pustules.  The  macules  in  a  few"  hours  become  fine,  conical  papules,  pin-head 
in  size  and  larger.  The  papular  stage  continues  for  two  days.  The  atcU- 
developed  papules  are  hard  and  shotty  to  the  sense  of  touch,  "  feeling  like 
grains  of  shot  underneath  the  skin."  Gradual  augmentation  in  the  size  of  the 
papules  takes  place.  On  the  third  day  a  minute  vesicle  appears  at  the  apex  of 
the  older  papules  ;  it  rapidly  grows,  and  transforms  the  papule  into  an  umbili- 
cated  vesicle  with  cloudy  contents.  By  the  fifth  day  of  the  rash  the  fluid  in 
the  vesicles  becomes  turbid,  and  by  the  sixth  day  it  is  distinctly  purulent. 
The  eruption  has  noAV  reached  the  pustule  stage,  or  stage  of  maturation.  The 
mature  pock  is  globular  and  about  the  size  of  a  pea.  The  increase  of  the  con- 
tents has  distended  the  chamber  and  removed  the  umbilication.  The  pustule 
is,  in  fact,  a  small  abscess.  It  is  usually  surrounded  by  a  swollen,  red,  inflam- 
matory zone,  the  halo  of  the  pustule. 

Synchronous  with  the  development  of  the  cutaneous  eruption  a  true  vario- 
lous exanthem  appears  upon  the  mucous  membranes.  The  visible  mucous 
membranes  are  nearly  always  aifected,  and,  in  severe  cases,  the  rash  extends 
throughout  the  whole  alimentary  and  respiratory  tracts.  The  urethra,  vagina, 
and  conjunctivae  are  often  invaded. 

With  the  appearance  of  the  eruption  a  remarkable  amelioration  in  all  the 
symptoms  takes  place.  The  temperature  rapidly  falls,  often  reaching  the 
normal  point  or  a  little  above  on  the  fifth  or  sixth  day.  This  fall  of  the  tem- 
perature is  pathognomonic  of  the  disease.  The  pulse  loses  its  rapidity  and 
the  gastric  and  intestinal  irritability  subsides.  In  cases  of  severity  the  remis- 
sion is  less  marked,  and  the  severe  symptoms  of  the  incubation  stage  persist 
with  but  little  relief.  In  discrete  small-pox  convalescence  often  sets  in  after 
three  or  four  days  of  the  mild  febrile  movement  which  follows  the  sharp  decline 
of  the  beginning  of  the  eruptive  period. 

In  children,  with  the  beginning  of  the  vesicular  stage  the  eruption  in  the 
mouth  and  throat  becomes  a  source  of  distress  and  danger.  The  vesicles  rup- 
ture, and  a  streptococcus  pseudo-membrane  covers  the  resulting  erosions  and 
often  extends  over  a  large  area  of  mucous  membrane.  Nasal  and  pharyngeal 
obstruction  results,  with  distressing  symptoms,  and  if  the  larynx  be  invaded, 
croup  with  dangerous  stenosis  may  supervene. 

In  typical  variola  the  maturation  of  the  rash  is  accompanied  by  the  onset 
of  the  secondary  fever  or  fever  of  suppuration,  which  is  of  indefinite  duration 
and  varies  in  intensity  with  the  severity  of  the  attack.  The  child  becomes 
restless  and  there  is  mild  or  active  delirium.  The  temperature  ranges  from 
101°  to  104°  F.,  with  morning  remissions  and  evening  exacerbations.  The 
pulse  is  quick  and  hard.  Often  the  symptoms  assume  the  typhoid  type,  with 
low  delirium  or  stupor,  a  rapid,  feeble  pulse,  and  subsultus  tendinum.  A  tem- 
perature that  frequently  rises  above  104°  during  the  stage  of  suppuration  is 
of  grave  significance.     (See  Fig.  1). 

The  stage  of  desiccation  or  decline  begins  on  the  twelfth  or  thirteenth  day 
of  the  disease.  The  pustules  begin  to  dry  up,  the  inflammation  and  swelling 
of  the  skin  subside,  the  temperature  gradually  falls,  and  there  is  a  general 
improvement  in  all  the  symptoms.     Many  of  the  pustules  rupture  and  the 


166    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


exuded  contents  form  discrete  or  coalesced  crusts.     Cicatrization  goes  on  under- 
neath the  crusts,  and  they  finally  drop  oif,  leaving  dark,  violaceous  blotches  that 


Fig.  1. 


Temperature  Chart  of  Variola  of  Moderate  Severity. 

are  gradually  changed  to  white,   irregular,   depressed  cicatrices.     The  whole 
course  of  the  disease  occupies  from  three  to  five  Aveeks. 

Based  upon  the  distribution  and  amount  of  the  rash,  variola  is  classified 
into — 

(1)  Discrete  variola,  in  which  the  rash  is  scanty  and  the  individual  lesions  are 
more  or  less  separated  from  one  another  by  healthy  skin.  The  disease  is  rarely 
dangerous  to  life,  its  .symptoms  are  mild,  and  its  course  is  often  intei'rupted 
before  the  development  of  the  pustular  stage.  The  secondary  fever  is  absent 
or  of  short  duration. 

(2)  Confluent  variola,  which  is  marked  by  an  eruption  that  covers  almo-st 
the  entire  cutaneous  surface  and  invades  the  mucous  membranes  with  great 
severity.  The  pustules  upon  the  hands  and  face  "run  together,  so  that  the 
epidermis  is  raised  by  a  milky,  sero-purulent  secretion;"  on  other  parts  of  the 
body  the  eruption  is  more  or  less  discrete.  The  invasion  stage  is  severe,  and 
the  rash  appears  as  early  as  the  second  day.  Severe  vomiting  and  diarrhoea, 
stomatitis,  salivation,  pseudo-diphtheria,  great  and  painful  swelling  of  the  face, 
hands,  and  feet,  pysemic  absces.ses,  high  fever,  violent  delirium,  and  great  pros- 
tration are  marked  features  of  this  type  of  the  disease.  The  mortality  is  great, 
and  convalescence  is  very  slow  and  often  interrupted  by  serious  sequeliB. 

In  addition  to  these  chief  varieties  we  recognize — 

(3)  Hcemorrhagic  variola,  a  malignant  form  of  the  disease,  characterized 
by  profound  alterations  of  the  blood,  leading  to  the  formation  of  petechial 
blotches  and  ecchymoses  and  more  or  less  profuse  haemorrhages  from  the  mucous 
membranes. 


VARIOLA    AND    VARIOLOID.  167 

(4)  Varioloid  is  variola  modified  in  its  course,  duration,  or  intensity  by 
vaccination,  previous  attacks  of  variola,  or  inherited  insusceptibility.  The 
invasion  stage  of  varioloid  is  more  irregular  in  duration  than  that  of  unmodi- 
fied variola,  and  the  symptoms  may  be  so  mild  as  to  escape  observation,  or  so 
intense  as  to  simulate  the  onset  of  grave  variola.  Three  types  of  variation  in 
the  clinical  history  of  varioloid  may  be  distinguished :  (a)  After  an  invasion 
stage  of  the  severity  of  typical  variola  a  copious  eruption  appears.  With  the 
appearance  of  the  rash,  however,  a  rapid  defervescence  begins,  and  the  eruption 
is  aborted  in  the  papular  or  the  vesicular  stage.  If  it  go  on  to  the  pustular 
stage,  the  pustules  quickly  run  their  course  without  causing  much  discomfort 
to  the  patient,  and  leave  only  faint  cicatrices  or  none  at  all.  Or,  (l))  the  dis- 
ease runs  a  coui'se  typical  in  all  respects,  but  the  pustules  are  few  in  number 
and  the  accompanying  symptoms  very  mild.  Again,  (c)  the  symptoms  of  inva- 
sion are  well  marked.  A  trifling  eruption  of  maculo-papules  appears  and 
quickly  fades.  Instead  of  rapidly  convalescing,  however,  the  patient  shows  a 
period  of  angemia  and  mental  and  physical  prostration  out  of  all  proportion  to 
the  preceding  symptoms. 

Complications  and  Sequelae. — The  complications  of  variola  are  few  in 
number.  Streptococcus  invasion  of  the  subcutaneous  connective  tissue  may 
give  rise  to  multiple  abscesses,  phlegmonous  erysipelas,  boils,  and,  rarely,  in 
scrofulous  children,  to  gangrene;  the  deeper  structures,  the  joints,  and  the  vis- 
cera may  also  be  invaded.  In  children  the  most  frequent  complications  are 
inflammations  of  the  mucous  membranes.  Pseudo-diphtheria  of  the  pharynx, 
nose,  and  larynx  is  frequent  in  severe  variola;  rarely  the  membrane  invades 
the  bronchi.  Bronchitis  and  broncho-pneumonia,  pleuritis  with  resulting  em- 
pyema, purulent  otitis  media,  and  pericarditis  or  endocarditis  often  occur. 
Conjunctivitis  is  present  in  all  bad  cases;  sometimes  the  inflammation  is  very 
severe,  and  results  in  ulceration  of  the  cornea  and  destruction  of  the  eye. 
Enterocolitis  is  often  the  cause  of  death  in  infants. 

Diagnosis. — Typical  variola  in  the  eruptive  stage  presents  no  difiiculty  of 
diagnosis.  Mild  and  atypical  cases,  however,  are  often  very  perplexing.  The 
invasion  stage  may  be  mistaken  for  a  continued  fever  or  pneumonia.  The 
sharp  pain  in  the  back,  the  vomiting,  and  the  marked  nervous  symptoms  should 
put  the  physician  on  his  guard.  The  initial  erythematous  rash,  coming  on  the 
second  day,  and  the  vomiting,  are  very  like  scarlatina.  The  small,  often 
irregular,  and  very  rapid  pulse,  the  peculiar  tongue,  and  the  pharyngitis  are 
distinctive  of  scarlatina.  The  rash  of  scarlatina,  again,  has  a  different  initial 
distribution;  it  first  appears  on  the  face,  neck,  and  front  of  the  chest. 

An  initial  macular  rash,  or  the  papular  stage  of  variola,  may  simulate 
measles.  In  measles  the  gradual  onset  of  the  invasion  stage,  the  tendency  to 
sleep,  the  catarrh  of  the  conjunctival  and  respiratory  mucous  membranes,  the 
absence  of  the  backache,  severe  headache,  and  vomiting,  are  distinguishing  fea- 
tures. With  the  appearance  of  the  rash  in  measles  the  fever  and  all  the  other 
symptoms  increase;  in  variola  they  decrease.  The  "grisolle  sign"  is  a  cer- 
tain means  of  distinguishing  the  papules  of  variola  from  the  macules  of  measles : 
"If  upon  stretching  an  affected  portion  of  the  skin  the  papule  becomes  unpal- 
pable  to  the  touch,  the  eruption  is  caused  by  measles ;  if,  on  the  contrary,  the 
papule  is  felt  when  the  skin  is  drawn  out,  the  eruption  is  the  result  of  small- 
pox." 

The  differential  diagnosis  of  variola  and  varicella  sometimes  presents  great 
difiiculty.  Varicella  is  characterized  by  a  short  period  of  invasion,  the  erup- 
tion usually  being  the  first  indication  of  ill-health .  that  the  child  manifests. 
The  varicellous  vesicle  is  located  beneath  the  most  superficial  layers  of  the  epi- 


168    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

dermis.  The  macular  stage  of  varicella  is  short,  and  the  macule  is  soft  and 
but  slightly  elevated  above  the  surface.  The  vesicle  does  not  become  pustular, 
but  remains  filled  with  clear  or  opalescent  fluid  for  twenty-four  or  forty-eight 
hours,  and  then  dries  into  a  light,  easily-detached  crust.  The  distribution  of 
the  vesicles,  abundantly  over  the  back  and  sparsely  on  the  face  and  hands,  is 
very  characteristic  of  varicella.  Occasionally  only  the  greatest  care  will  enable 
the  physician  to  differentiate  between  these  two  diseases.  No  one  symptom  or 
manifestation  can  be  relied  upon,  but  all  the  points  in  the  history  and  develop- 
ment of  a  given  case  must  be  carefully  considered. 

Prognosis. — The  frequency  of  complications  involving  the  mucous  mem- 
branes in  children,  and  their  feeble  powers  of  resistance  make  the  prognosis  of 
variola  in  early  life  very  grave.  According  to  Moore,  the  disease  is  most 
fatal  in  un vaccinated  children  under  five  years  of  age.  The  vouna;er  the  child 
the  graver  the  prognosis.  "The  influence  of  vaccination  for  good  is  unques- 
tionable, the  mortality  being  50  per  cent,  among  the  unvaccinated  in  general, 
20  per  cent,  among  the  badly  vaccinated,  and  only  2^  per  cent,  among  the 
efficiently  vaccinated"  (Moore).  H?emorrhagic  and  confluent  variola  are  very 
fatal.  The  complications  that  unfavorably  influence  the  result  are — pneumonia, 
empyema,  multiple  abscesses,  septicaemia,  pseudo-membranous  laryngitis,  and 
entero-colitis.  Favorable  cases  present  a  mild  or  no  secondary  fever,  and  are 
not  prolonged  by  complications. 

Treatment. — There  is  no  drug  that  will  prevent  the  development  of  variola 
in  an  infected  individual.  The  efiicacy  of  vaccination  in  arresting  or  modify- 
ing the  disease  after  exposure  is  a  disputed  question.  Curschmann  has  no  con- 
fidence in  the  measure.  Welch,  however,  from  an  experience  in  159  cases, 
believes  it  to  be  of  great  utility,  and  his  results  warrant  the  use  of  the  measure 
in  every  person  exposed  to  variola:  "  In  order  that  protection  shall  be  complete 
it  is  necessary  that  the  insertion  of  the  vaccine  lymph  should  be  made  almost 
immediately  after  the  reception  of  the  contagion  ;  but  if  made  at  a  somewhat 
later  date  a  modifying  effect  may  be  obtained.  No  part  of  the  incubation 
period  should  be  considered  too  late  to  make  use  of  this  remedy,  since  this 
period  is  sometimes  prolonged  beyond  its  usual  limit,  in  which  case  a  late 
vaccination  may  prove  of  value"  (Welch). 

A  child  ill  with  small-pox  should  be  placed  in  a  very  well-ventilated  room 
of  a  temperature  of  65°  to  70°  F.  The  strictest  attention  should  be  paid 
through  the  Avhole  course  of  the  disease  to  the  smallest  details  of  the  hygiene 
of  the  patient  and  the  sick-room.  If  the  attack  be  severe,  the  hair  should  be 
closely  cut.  The  diet  should  be  light  and  nutritious.  Effervescent  waters, 
milk  and  seltzer,  sour  wine,  champagne  or  lemon-juice  and  apollinaris,  Belfast 
ginger-ale,  and  egg-water  form  agreeable  and  nutritious  drinks.  During  the 
period  of  invasion  the  febrile  symptoms,  vomiting,  headache  and  backache, 
and  the  nervous  phenomena  may  demand  treatment.  A  gentle  cathartic  should 
be  given  at  the  onset  of  the  disease.  A  febrifuge,  like  tincture  of  aconite, 
spirits  of  nitrous  ether,  or  a  solution  of  acetate  of  ammonium  may  be  given  in 
proper  doses.  Gastric  irritability  may  be  controlled  by  eff'ervescing  citrate 
of  potassium,  chloroform-Avater,  or  subnitrate  of  bismuth.  Chloroform-water 
and  morphine  are  very  useful,  combined  as  follows: 

I^.  Morphinsesulphatis gr.  |. 

Aq.  chloroformi fgij. — M. 

Sig.   A  teaspoonful  may  be  given  every  half  hour  to  a  child  of  five  years. 

Insomnia  or  convulsions  demand  the  administration  of  chloral  or  bromide 


VABIOLA    AND    VARIOLOID.  169 

of  potassium.  Baths,  temperature  95°  F.,  are  most  useful  to  control  the  fever 
and  nervous  symptoms,  and  they  may  be  repeated  every  four,  six,  or  eight 
hours  as  may  be  necessary.  One  of  the  coal-tar  antipyretics  may  be  given. 
They  have  a  remarkable  power  to  control  the  pain,  nervous  symptoms,  and 
fever  at  the  onset  of  an  acute  disease.  Given  in  proper  doses  and  in  selected 
cases,  their  effect  is  only  for  good.  Applications  that  irritate  and  redden  the 
skin  are  to  be  avoided.  An  ice-bag  or  a  cold-water  coil  to  the  head  lowers 
temperature  and  relieves  cerebral  symptoms. 

During  the  eruptive  stage,  after  the  development  of  the  secondary  fever, 
the  same  conditions  for  internal  treatment  are  met.  The  fever  is  to  be  con- 
trolled, preferably  by  the  bath,  made  lukewarm  or  cool  as  the  season  and  the 
condition  of  the  patient  dictate.  Cool  sponging,  cool  compresses,  or  the  wet- 
sheet  may  replace  the  tub.  The  coal-tar  antipyretics  are  to  be  given  with 
caution.  Delirium  and  convulsions  are  to  be  met  by  bromide  of  potassium, 
chloral,  or  the  bath  ;  insomnia,  by  these  remedies  or  sulphonal.  When  there  is 
intestinal  irritability,  chloranodyne  is  an  admirable  sedative.  Quinine  and  the 
tincture  of  chloride  of  iron  in  full  doses  have  the  confidence  of  able  practi- 
tioners as  being  useful  to  combat  septic  symptoms.  Variola  with  mild  secon- 
dary fever  will  not  usually  demand  alcoholic  stimulants.  In  grave  cases  moder- 
ate stimulation  should  be  begun  early,  and  as  the  strength  wanes  under  the  influ- 
ence of  continued  septic  absorption  the  alcohol  should  be  pushed  to  the  full 
limit.  A  child  of  five  years  will  take  from  two  to  four  ounces  of  whiskey  or 
its  equivalent  in  the  twenty-four  hours,  sometimes  more. 

The  nose,  naso-pharynx,  and  throat  should  receive  strict  attention  to 
relieve  inflammation  and  avoid  septic  absorption.  Irrigation  of  the  pharynx 
with  solution  of  potassium  chlorate,  boric  acid,  or  witch-hazel  should  be  begun 
early.  The  writer  finds  a  solution  of  listerine  and  hydrogen  peroxide  one  of 
the  most  satisfactory  local  remedies  for  pseudo-membranous  and  septic  con- 
ditions of  the  mouth  and  throat,  for  example: 

Solution  of  hydrogen  peroxide(15  vol.), 

Listerine       , each  1  part. 

Water       6  parts. 

This  solution  should  be  thrown  into  the  pharynx  with  an  all-soft  rubber 
syringe,  until  thoroughly  cleansed,  every  one,  two,  or  three  hours.  This  is  the 
most  satisfactory  way  to  cleanse  a  child's  throat.  The  same  solution,  with 
double  the  quantity  of  water,  may  be  used  in  the  nose  with  the  same  syringe. 
When  such  thorough  cleansing  is  not  demanded,  the  spray  from  an  atomizer 
will  serve,  but  it  should  not  be  trusted  in  severe  cases. 

To  limit  the  development  of  the  pustules  and  to  prevent  septic  absorption 
and  pitting  a  great  number  of  methods  of  local  treatment  have  been  proposed. 
Secondary  streptococcus-infection  of  the  pustules  without  doubt  plays  an  im- 
portant part  in  the  cutaneous  destruction,  septic  absorption,  and  deep  pus- 
formations  ;  careful  cutaneous  disinfection  during  the  papular  and  vesicular 
stages  of  the  eruption  will  tend  to  limit  this  secondary  infection.  The  skin 
should  be  bathed  tAvice  a  day  with  soap  and  water,  and  this  followed  by  spong- 
ing with  a  boric-acid  solution  1  :  20,  diluted  listerine,  or  corrosive  sublimate 
1  :  2000.  Omitting  the  soap,  the  baths,  varied  to  suit  the  condition,  may 
be  continued  during  the  whole  course  of  the  disease.  Carbolic  acid  is  an 
excellent  antiseptic  and  cutaneous  analgesic.  It  is  one  of  the  most  efiicient 
remedies  for  the  relief  of  the  itching  and  burning  that  accompany  the  develop- 
jnent  of  the  rash.      Compresses  of  antiseptic  gauze,  wet  with   a  hot   or  cold 


170    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

solution.  1  :  500,  may  be  kept  constantly  applied  to  the  skin.  Carbolic  acid 
may  also  be  used  in  solution  with  glycerin  or  in  an  ointment.  An  ointment  of 
4  parts  of  salicylate  of  sodium  and  100  parts  of  cold  cream  is  commended.  Anti- 
septics may  also  be  used  as  a  spray  or  in  the  form  of  a  powder,  as  subnitrate  of 
bismuth,  boric  acid,  or  a  compound  of  aristol  20  parts,  talc  100  parts.  Powders 
are  most  useful  in  the  late  stages  of  the  eruption.  Early  opening  of  the  pus- 
tules is  a  measure  advocated  by  many  writers.  It  seems  rational  thus  to  treat 
the  pustules  as  small  abscesses — to  open  them  early,  at  least  upon  the  hands 
and  face,  and  treat  them  antiseptically.  A  wet  compress  of  antiseptic  gauze 
applied  after  evacuation  and  thorough  cleansing  with  a  three-volume  solution  of 
hydrogen  peroxide  would  certainly  prevent  additional  destruction  of  the  corium 
from  pus-microbe  invasion. 

In  the  stage  of  decline  iron,  riuiniue.  and  strychnine,  highly  nutritious 
food,  and  moderate  stimulation  are  demanded.  Convalescence  is  often  slow 
and  interrupted  by  complications.  Arsenic,  cod-liver  oil,  malt,  iron,  liquors,  and 
supporting  treatment  generally  are  necessary.  The  various  complications  and 
sequels  should  receive  the  most  approved  medical  and  surgical  treatment. 

Quarantine. — A  child  with  small-pox  should  be  immediately  isolated,  and 
a  rigid  quarantine  maintained  until  the  skin  is  free  from  crusts  and  compli- 
cating suppurations  have  healed — a  period  of  from  five  to  six  weeks.  Con- 
finement in  a  contagious  diseases  hospital  gives  most  certain  protection  to  a 
community,  although  perfect  isolation  can  be  maintained  in  a  private  house. 
For  this  purpose  the  highest,  best-aired,  and  most  remote  room  should  be 
selected,  opening  indirectly,  if  possible,  to  the  rest  of  the  house.  Sheets  wet 
with  an  antiseptic  solution  should  be  kept  hung  over  the  doorway.  All  direct 
communication  of  the  nurse  and  patient  with  other  members  of  the  family 
should  be  interdicted.  Clothing,  dishes,  excreta,  etc.  should  be  disinfected 
before  being  taken  from  the  room.  All  members  of  the  infected  household 
should  cease  direct  communication  with  the  outside  world,  and  all  exposed 
individuals  should  be  quarantined  for  a  period  of  fourteen  days  after  exposure. 


VACCINIA;  VACCmATION. 

By  THOMPSON  S.  WESTCOTT,  M.  D., 

Philadelphia. 


Vacciis^ia,  or  cow-pox,  is  a  contagious  eruptive  disease  of  the  cow,  charac- 
terized by  a  more  or  less  profuse  eruption,  upon  the  udder  and  teats,  of  papules 
which  develop  into  vesicles,  and  these,  by  drying,  into  crusts,  or,  through  rup- 
ture, into  open  ulcers.  By  inoculation  of  lymph  from  its  vesicle  the  disease  is 
communicable  to  man,  and  is  capable  of  conferring  upon  him  immunity  from 
small-pox  more  or  less  complete  and  lasting. 

History. — In  the  closing  years  of  the  eighteenth  century,  among  all  the 
civilized  nations  of  Europe  and  their  colonies,  the  practice  of  inoculating  for 
small-pox  had  become  the  accepted  therapeutic  procedure  for  modifying  the 
ravages  of  this  then  most  familiar  and  loathsome  of  diseases.  The  operation 
was  not,  however,  always  successful  in  producing  mild  cases  of  the  disease,  and 
even  in  its  most  favorable  manifestation  the  communicated  affection  was  still 
variola,  capable  of  being  transmitted  to  others  by  effluvium,  and  necessitating 
careful  isolation,  nursing,  and  medical  treatment.  So  common  was  small-pox 
that,  according  to  the  philosophy  of  the  times,  every  individual  had  either 
passed  through,  or  was  destined  some  time  to  experience,  an  attack  of  the 
disease.  In  1776,  Edward  Jenner,  an  English  country  practitioner  living  at 
Berkeley  in  Gloucestershire,  was  first  attracted  by  a  popular  belief,  common 
among  the  dairy-hands  of  this  county,  that  any  one  who  had  contracted  cow-pox 
from  milking  cows  affected  with  this  disease  was  insusceptible  to  small-pox,  and 
was  not  a  successful  subject  for  variolous  inoculation.  This  tradition  seems  to 
have  been  quite  well  known  among  the  dairy-hands  of  Gloucestershire  and  the 
neighboring  counties,  and  to  have  been  noted  by  other  practitioners  through- 
out the  farming^country.  Intentional  inoculation  of  cow-pox  had  even  been  per- 
formed before  J enner's  attention  was  directed  to  the  matter:  Robert  Fooks,  a 
butcher  of  Bridport,  as  related  by  Pearson,  had  submitted  to  the  inoculation  by 
means  of  a  charged  needle,  as  early  as  1771,  and  Benjamin  Jesty,  a  farmer  of 
Yetminster  in  Dorset,  in  1774  inoculated  his  wife  and  two  sons  with  the  cow- 
pox  as  a  preventive  of  small-pox.  But  it  was  not  until  the  subject  received 
the  careful  study  and  experimentation  of  Jenner,  culminating  in  his  celebrated 
Inquiry^  published  in  1798,  that  the  practice  of  inoculating  cow-pox  was  estab- 
lished upon  a  clinical  and  what,  at  least  for  the  times,  must  be  called  a  scientific 
basis.  The  story  of  Jenner's  struggles  to  convince  his  contemporaries  of  the 
value  of  his  observations  forms  a  most  interesting  and  instructive  chapter  in 
the  history  of  medical  progress.  The  discovery  spread  with  wonderful  rapidity 
throughout  the  civilized  world,  and  it  stands  to-day  as  one  of  the  greatest 
blessings  that  human  thought  and  observation  have  conferred  upon  mankind. 

Etiolog-y. — "Spontaneous"  cow-pox,  the  term  ordinarily  though  not  very 
accurately  applied  to  cases  of  vaccinia  occurring  naturally  in  the  cow,  is  an 

171 


172    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

occasional  disease  among  dairy  herds.  It  is  spread  by  contact,  being  usually 
carried  from  one  animal  to  another  by  the  hands  of  the  milkers,  who  in  this 
way  are  themselves  liable  to  accidental  inoculation.  For  this  reason  the  aflFec- 
tion  is  almost  exclusively  confined  to  milch-cows,  and  the  eruption  limited  to 
the  udder  or  teats,  although  young  calves  or  adult  bulls  may  be  readily  inoculated 
upon  the  belly,  and  exhibit  phenomena  differing  in  no  way  from  those  observed 
in  the  cow. 

The  exact  nature  of  vaccinal  disease  is  a  question  which  has  been  the  sub- 
ject of  repeated  theorizing  and  experimentation  since  the  time  of  Jenner,  and 
even  at  the  present  day  no  consensus  of  opinion  has  been  reached.  Jenner 
held  that  cow-pox  was  occasioned  by  the  accidental  conveyance  of  the  virus  of 
"grease,"  an  eruptive  disease  of  the  heels  of  the  horse,  to  which  also  he 
attributed,  on  conjectural  grounds  merely,  the  origin  of  human  small-pox. 
According  to  his  view,  a  vaccinated  person  was  a  small-poxed  person  who, 
instead  of  suffering  from  the  humanized  and  virulent  form  of  the  disease,  had 
contracted  it  in  its  primitive  mild  character.  This  theory,  at  least  in  regard  to 
its  ingenious  attempt  at  the  etiological  unification  of  cow-pox  and  small-pox, 
can  be  dismissed  as  a  curiosity  of  medical  history. 

A  second  theory  considers  vaccinia  as  a  distinct  disease  of  the  cow  origi- 
nating in  a  specific  contagium,  and  being  in  no  way  related  to  or  capable  of 
being  originated  by  any  other  contagium,  however  closely  its  phenomena  may 
be  simulated.  It  is  evident  that  its  rejection  or  its  acceptance  is  to  b&  based 
upon  the  proof  or  refutation  of  other  theories,  and  thus  it  can  be  more  readily 
discussed  side  by  side  with  the  third  and  remaining  theory. 

This  theory,  which  offers  in  many  respects  the  most  rational  view  of  the 
question,  regards  coAv-pox  as  small-pox  modified  and  attenuated  by  passing 
through  the  system  of  the  cow.  There  can  be  no  doubt  that  variola  can  be 
artificially  communicated  to  the  cow,  and  can  give  rise  to  a  vesicular  eruption 
resembling  in  all  physical  respects  the  lesions  of  spontaneous  cow-pox,  and  that 
virus  from  these  vesicles  can  be  conveyed  to  man,  and  produce  at  the  points  of 
inoculation  local  effects  in  all  appearance  identical  Avith  those  produced  by 
cultivated  vaccine-lymph.  Experiments  of  this  kind  are  now  quite  numerously 
recorded,  among  which  may  be  mentioned  the  successful  variolations  of  the 
cow  performed  by  Gassner  in  1801,  and  after  him  those  of  Thiele  of  Kasan, 
Ceely  of  Aylesbury,  Badcock  of  Brighton,  Martin  of  Attleboro,  Mass.,  Voit, 
Reiter,  and  many  others.  In  some  cases  the  virus  thus  obtained,  when  used 
for  experimental  inoculation  upon  human  subjects,  especially  in  the  early 
removes,  showed  undoubted  evidence  of  being  variolous  by  giving  origin 
through  infection  to  fresh  cases  of  small-pox  some  of  whicli  were  fatal. 
Martin's  variola-lymph  produced  quite  an  epidemic  of  small-pox  in  Attleboro, 
Massachusetts,  in  1836,  and  Reiter's  experiments  in  Munich  in  1839  had  a 
similar  sequel.  It  is  certain,  however,  that  if  in  the  selection  of  a  variolous 
virus  the  same  care  be  exercised  as  was  habitual  with  experienced  small-pox 
inoculators  like  Sutton  and  Dimsdale,  a  variolation  of  the  cow  may  be  effected 
which  will  give  origin  to  a  lymph  that  need  not  necessarily  convey  infection 
to  those  not  inoculated.  This  was  shown  in  the  experience  with  Badcock 's 
variola-lymph  ;  and,  as  Crookshank  remarks,  identical  results  were  obtained 
by  Adams  in  many  cases  where  lymph  from  a  mild  or  "pearl"  case  of  small- 
pox was  taken  as  a  primary  virus  for  successive  arm-to-arm  inoculations,  with- 
out having  been  first  passed  through  the  cow. 

This  whole  subject  was  carefully  investigated  in  1865  by  the  Lyons  Com- 
mission under  the  direction  of  Chauveau,  who,  even  in  1891,  still  showed  him- 
self the  most  distinguished  champion  of  the  dual  nature  of  the  two  diseases. 


VACCINIA.  173 

The  result  of  the  investigation  of  this  committee  unequivocally  pronounced  upon 
the  autonomy  of  cow-pox  and  the  impossibility  of  converting  small-pox  into  cow- 
pox.  A  more  recent  investigation  of  the  question  by  Fleming,  a  well-known 
English  veterinarian,  confirmed  the  conclusions  of  the  Lyons  Commission.  The 
question  is  not,  however,  by  any  means  settled.  Even  as  recently  as  1892, 
Hime  of  England  and  Haccius  and  Eternod  of  Switzerland,  published  care- 
ful studies  in  support  of  the  older  view,  and,  excepting  in  France  and 
America,  the  theory  of  the  identity  of  the  two  diseases  seems  to  be  gaining 
ground. 

To  complete  the  subject  it  may  be  stated  that  several  years  ago  Depaul 
of  Paris  established  the  fact  that  horse-pox,  a  febrile  eruptive  disease  of  the 
horse,  was  capable  of  being  conveyed  by  inoculation  to  the  cow,  and  giving 
rise  to  a  lesion  indistinguishable  from  that  of  cow-pox.  Constantin  Paul, 
indeed,  for  a  time  used  such  virus  for  vaccination,  but  the  practice  fell  into 
disuse  after   the  discovery  of  a  case  of  spontaneous  vaccinia  at  Beaugency. 

Patholog-ical  Anatomy. — The  structure  of  the  vaccine  pock  resembles 
that  of  variola  ( Cornil  and  Ranvier) .  It  is  formed  by  the  softening  and 
liquefaction  of  the  epidermic  cells,  which  appears  to  be  caused  by  the  micro- 
organisms which  early  occupy  the  centre  of  the  pustule.  There  is  a  central 
necrotic  zone,  a  middle  zone  characterized  by  tumefaction  of  the  cells,  and 
a  peripheral  zone  of  irritation  showing  multiplication  of  nuclei  (Pincus).  The 
cavity  of  the  pock  is  partitioned  or  multiloculated,  and  its  base,  thickened  and 
infiltrated  with  lymph,  constitutes  the  "  vaccinal  pulp."  The  derm  is  always 
infiltrated  with  leucocytes.  The  lymph  is  a  clear,  transparent  liquid  up  to  the 
fifth  day  in  the  cow  and  till  the  seventh  or  eighth  in  man ;  it  maintains  its 
infective  qualities  at  a  low  temperature,  but  loses  them  quickly  in  warmth.  His- 
tologically, it  contains  leucocytes,  red  globules  (after  the  eighth  day),  granula- 
tions and  cellular  debris,  free  nuclei,  and  micro-organisms. 

Keber  in  1868,  and  subsequently  Chauveau  and  Burdon-Sanderson, 
observed  the  existence  in  lymph  of  minute  rounded  organisms  to  Avhich  the  terms 
vaccinads  or  microspheres  have  been  applied.  Keber  attributed  to  them  the 
specific  properties  of  the  lymph.  More  recently  (1890)  the  experiments  of 
Straus,  Chambon,  and  Menard  have  shown  that  lymph  from  which  these  bodies 
had  been  removed  by  filtration  loses  its  infective  power,  even  when  injected  in 
quantity  beneath  the  skin,  so  that  it  may  be  concluded  that  these  micro-organisms 
are  the  agents  of  infection.  No  distinct  microbe,  however,  has  as  yet  been 
satisfactorily  isolated.  In  1883,  Quist  cultivated  upon  alkaline  serum  a  coccus, 
which,  when  inoculated  upon  a  child,  rendered  it  refractory  to  subsequent  vac- 
cination. Voigt  (1885)  isolated  three  micro-organisms,  of  which  one,  a  coccus, 
was  found  capable  of  causing  typical  experimental  cow-pox  in  the  calf,  from 
which  the  same  organism  was  again  obtained.  Garr^  (1887)  confirmed  the 
results  of  Voigt,  cultivating  a  coccus  which  existed  in  a  pure  state  under  the 
derm  subjacent  to  the  pustule,  and  which  caused  cow-pox  in  the  calf,  but  not 
in  man  until  after  passage  through  the  calf. 

Varieties  of  Lymph. — Practically,  there  are  two  sources  from  which  vac- 
cine-lymph may  be  obtained — either  directly  from  the  bovine  through  the 
agency  of  vaccine  farms  especially  established  for  its  propagation,  or  indirectly 
therefrom  after  passage  through  the  system  of  one  or  more  human  beings,  the 
healthy  infant  being  the  medium  usually  chosen.  Lymph  from  the  so-called 
cases  of  spontaneous  cow-pox  is  very  rarely  to  be  had,  and  is  said  to  be  untrust- 
worthy in  its  infective  powers  ;  while  variola-vaccine  must  still  be  considered 
as  of  experimental  value  merely,  and  not  to  be  ordinarily  employed.  At  the 
present  day  it  may  be  said  that  in  no  essential  respect  is  humanized  virus  to 


174    A3IEBIGAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

be  preferred  to  animal  lymph,  if  we  except  its  slightly  greater  promptness  of 
action,  which  may,  however,  have  some  value  in  time  of  epidemics.  The  pos- 
sibility of  the  transmission  of  syphilis  through  humanized  lymph  derived  from 
a  syphilitic  patient,  while  exceedingly  rare,  is  still  a  constant  danger,  and  pleads 
strongly  against  the  use  of  any  humanized  virus  except  from  an  unimpeach- 
able source.  In  selecting  lymph,  either  from  the  calf  or  from  the  human 
vaccinifer,  a  characteristic  vesicle  from  the  fifth  to  the  seventh  day  should  be 
chosen. 

Symptoms. — When  carefully  selected  and  cultivated  vaccine-lymph  is 
introduced  by  inoculation  into  the  human  system,  the  following  phenomena  will 
be  normally  observed :  At  or  close  to  the  site  of  inoculation  at  the  end  of  the 
second  or  beginning  of  the  third  day  a  slight  papular  elevation  is  observed  ; 
by  the  fifth  or  sixth  day  this  has  become  a  distinct  vesicle,  of  bluish-white 
color,  with  rounded  elevated  edges  and  a  cupped  central  depression — the  so- 
called  umbilication.  By  the  eighth  day  the  vesicle  is  perfected,  and  is  then 
circular,  pearly  in  color,  and  distended  with  a  colorless  lymph,  the  central 
depression  remaining  well  marked.  On  or  about  this  day  appears  the  areola, 
a  reddish  blush  of  the  skin  surrounding  the  pock  to  a  distance  of  several 
inches,  and  accompanied  by  induration  and  swelling  of  the  underlying  connec- 
tive tissue.  After  the  tenth  day  the  areola  begins  to  fade,  the  vesicular  con- 
tents begin  to  dry  in  the  centre,  the  process  extending  to  the  surrounding 
lymph,  which  becomes  opaque  and  gradually  desiccates,  until  by  the  fifteenth 
day  a  hard  brownish  thick  scab  is  formed,  which  is  gradually  detached  and 
falls  in  the  fourth  week.  A  circular,  depressed,  pitted,  or  sometimes  radiated 
cicatrix  remains.  If  there  have  been  several  points  of  inoculation  close  toge- 
ther, a  compound  vesicle  of  irregular  shape  may  result.  Even  with  a  single 
surface  of  inoculation  one  or  more  additional  vesicles  may  arise  at  some  little 
distance  from  this  point. 

Constitutional  symptoms  are  almost  always  notable  to  some  degree  in  a  case 
of  primary  vaccination.  The  temperature  may  rise  one  or  two  degrees  on  the 
third  or  fourth  day,  and  remain  elevated  for  several  days.  In  children  rest- 
lessness, irritability,  and  loss  of  appetite  may  frequently  be  noticed.  The 
axillary  glands  or  the  inguinal  glands,  depending  upon  the  choice  of  the  arm 
or  leg  for  operation,  will  usually  show  some  swelling  and  tenderness  for  several 
days.  In  many  cases,  mostly  those  of  secondary  vaccination,  the  constitutional 
symptoms  are  more  severe  ;  the  fever  higher,  with  transient  delirium  ;  nausea 
or  perhaps  vomiting  ;  and  distressing  headache.  Itching  of  the  skin  round 
about  the  pock  is  commonly  experienced,  perhaps  throughout  the  whole  course 
of  the  case,  and  this  may  be  so  severe  as  to  constitute  a  true  pruritus. 

Irregularities  in  the  Course. — Various  irregular  manifestations  of  the  pock 
have  been  described  by  earlier  writers,  but  in  later  years,  since  the  more 
general  employment  of  animal  lymph,  these  irregular  forms  have  become  much 
rarer.  One  peculiar  abortive  form,  the  raspberry  excrescence,  should  be  men- 
tioned. Here  the  pock  is  rather  slow  in  appearing,  and  never  reaches  full 
development,  but  becomes  a  flat,  hard,  reddish  papule,  resembling  a  nsevus, 
and  finally,  after  weeks  or  months,  disappears  without  cicatrix.  It  is  probably 
an  abortive  form,  and  does  not  protect  against  small-pox  or  subsequent 
vaccination. 

Another  irregularity  is  the  so-called  eruptive  vaccinia,  in  which  there  is  a 
generalized  eruption  of  pocks,  the  disease  manifesting  itself  as  a  true  exanthem. 
Very  rarely  cases  have  been  observed  in  which  the  susceptibility  of  the  skin 
was  so  great  that  repeated  accidental  auto-inoculations  took  place  from  the 
merest  scratches  of  the  nails. 


VACCINIA,  175 

Complications. — Inflammatory  phenomena,  due  to  traumatism,  irritation, 
infection,  or  special  conditions  of  the  system  predisposing  to  cutaneous  disease, 
are  at  times  manifest.  These  may  vary  from  a  simple  erythema  to  intense 
phlegmonous  inflammation  or  ulceration  and  gangrene,  with  septic  absorption. 
Injury  to  the  pock  before  complete  maturation  may  be  followed  by  a  gangrenous 
condition  of  the  underlying  derm,  sometimes  giving  rise  to  a  peculiar  moat-like 
depression  around  a  central  elevated  core.  Mothers  are  very  prone  to  attribute 
any  irregularities  or  unusual  violence  in  the  maturation  of  the  pock  to  "  bad 
virus."  Occasionally,  especially  when  human  crusts  have  been  used,  this 
may  be  a  just  charge ;  but  it  can  be  authoritatively  stated  that  complications 
arising  from  impurities  of  the  lymph  will  almost  invariably  show  their  presence 
long  before  the  pock  has  reached  its  full  development,  usually  within  a  few 
days  after  the  operation. 

Erysipelas  is  very  prone  to  infect  vaccination  wounds.  It  may  appear  as 
early  as  the  second  or  third  day,  and  in  this  case  the  prognosis  is  especially 
grave.  Vaccination  should  never  be  performed  when  erysipelas  is  prevalent, 
except  in  face  of  the  greater  danger  of  variola. 

G-landular  Enlargement. — The  natural  involvement  of  the  axillary  and 
cervical  glands,  usually  insignificant,  may  in  certain  subjects  become  extreme, 
and  even  go  on  to  suppuration  during  maturation  or  toward  the  decline.  In 
children  of  strumous  habit  vaccination  may  act  as  the  exciting  cause  of  chronic 
enlargement  and  cheesy  degeneration  of  glands  in  these  chains. 

Abscess  and  boils  may  follow  in  various  parts  of  the  body,  especially  in 
children  of  tubercular  tendency. 

Eczema  and  other  skin  affections  are  apt  to  be  aggravated  or  relighted  by 
vaccination.  Various  roseolous  rashes  may  be  observed  during  the  maturation 
of  the  pock,  and  are  only  important  as  requiring  difierential  diagnosis  from 
intercurrent  and  perhaps  more  serious  affections,  such  as  erysipelas,  scarlatina, 
and  rubella.  Impetigo  contagiosa  has  been  observed  not  infrequently,  and 
seems  to  bear  some  relation  to  vaccinia,  which  is  as  yet  not  clearly  understood. 

Syphilis. — Chiefly  to  Viennois  in  France  and  Hutchinson  in  England  are 
we  indebted  for  the  demonstration  that  syphilis  may  be  communicated  by 
humanized  virus  through  contamination  with  the  patient's  blood,  which,  as 
Ricord  has  shown,  is  always  present  in  the  lymph.  Accidental  conveyance  of 
the  disease  by  imperfectly  cleansed  instruments  used  for  vaccinating  is  also  to 
be  mentioned. 

The  treatment  of  complications  will  not  differ  from  that  to  be  employed 
in  the  conditions  occurring  independently  of  the  vaccinal  disease. 

Method  of  Operation. — Inoculation  can  be  accomplished  in  numerous 
ways.  Some  practitioners  advocate  a  series  of  superficial  cross-bar  incisions 
made  with  a  sharply-pointed  lancet  or  the  back  of  the  point  of  an  ordinary 
bistoury ;  others  employ  a  sharply-pointed  rake-like  instrument  made  for  the 
purpose,  while  tattooing  with  a  sharp  needle  point  has  been  advocated.  Alto- 
gether the  most  satisfactory  method  of  preparing  the  spot  for  vaccination,  and 
one  which  robs  the  little  operation  of  its  terror  to  children  and  mothers,  con- 
sists in  gently  scraping  away  the  external  horny  layer  of  epidermis  with  the 
edge  of  a  bistoury  or  lancet  held  obliquely  to  the  surface.  For  this  purpose  a 
dull  instrument  is  sometimes  advocated,  but  a  sharp  edge  is  more  effectual  and 
expeditious.  An  area  as  large  as  the  little  finger-nail  can  be  readily  abraded 
in  this  manner  without  giving  rise  to  a  whimper  on  the  part  of  the  child.  The 
abraded  surface  should  be  slightly  red  and  glazed  by  the  outpouring  of  lymph, 
but  no  blood  should  be  drawn.  The  next  step  is  the  inoculation  of  the  lymph. 
In  arm-to-arm  vaccination  the  lymph  is  directly  transferred  from  the  pock  to 


176    AIIEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  abraded  surface.  When  the  dried  animal  virus  is  used,  it  should  be 
liquefied  by  dipping  into  cold  sterilized  water  just  before  the  surface  is 
prepared,  so  that  in  the  brief  interval  it  may  become    completely  softened. 

Any  portion  of  the  cutaneous  surface  may  be  chosen  for  the  insertion, 
but  customarily  the  outer  aspect  of  the  left  arm  over  the  insertion  of  the 
deltoid  is  selected.  For  cosmetic  reasons  in  girls  the  leg  is  often  preferred, 
and  in  this  case  a  point  over  the  head  of  the  fibula  or  over  the  junction  of  the 
two  heads  of  the  gastrocnemius  is  the  usual  choice.  The  primary  vaccination 
of  the  infant  may  be  undertaken  at  any  time.  In  the  face  of  an  epidemic  the 
new-born  babe  should  be  vaccinated  within  twenty-four  or  forty-eight  hours 
after  birth,  and,  as  the  experience  of  Wolff  has  shown,  in  such  cases  humanized 
lymph  is  to  be  preferred  as  producing  less  constitutional  disturbance.  Ordi- 
narily, however,  the  operation  may  be  deferred  until  about  the  third  month 
when  the  child  is  in  good  physical  condition  and  before  the  disturbances  of 
dentition  have  commenced. 

Protective  Power  of  Vaccination. — The  experience  of  the  past  one  hun- 
dred years  off"ers  the  most  just  and  conclusive  evidence  of  the  poAver  of  vaccina- 
tion as  a  preventive  of  small-pox.  From  one  of  the  commonest  and  most  virulent 
of  diseases  small-pox  has  become  in  civilized  countries  one  of  the  rarest  of  the 
exanthemata.  A  most  significant  fact  in  favor  of  vaccination  is  given  by 
Gay  in  a  study  of  small-pox  in  London.  He  states  that  in  the  last  forty  years 
of  this  century,  owing  to  improved  sanitation,  epidemics  of  measles,  scarlatina, 
diphtheria,  and  whooping-cough  have  all  undergone  a  decrease,  but  that  this 
is  only  a  small  fraction  of  that  which  has  occurred  in  small-pox,  their  highest 
figures  not  amounting  to  a  tenth  part  of  the  decrease  of  small-pox — a  result 
which  is  dependent  upon  only  one  possible  cause,  vaccination.  Drysdale  states 
that  during  the  epidemic  in  Berlin  in  1872  and  1873  the  mortality  rose  to  243 
and  263  per  100,000  ;  then,  vaccination  in  the  first  year  of  life  and  revaccina- 
tion  in  the  twelfth  being  made  compulsory,  during  the  first  year  of  enforce- 
ment (1875)  the  mortality  fell  to  3.6  per  100,000,  to  3.1  in  1876,  and  to  0.3 
in  1877. 

The  protective  power  is  not  absolute  in  all  individuals,  nor  can  the  period 
of  protection  be  stated  for  any  given  case.  Marson,  Avhose  experience  with 
small-pox  in  London  was  very  extensive,  stated  that  the  disease  was  more  fatal 
among  those  Avhose  scars  were  imperfect  or  few  in  number  than  in  those  show- 
ing well-marked  and  multiple  cicatrices.  While  some  doubt  of  the  value  of 
this  theory  may  be  expressed,  it  would  seem  wisest  to  vaccinate  in  all  cases  by 
at  least  two  insertions,  sufficiently  far  apart  to  prevent  coalescence  during 
development  of  the  pocks.  As  a  general  rule,  it  may  be  stated  that  immunity 
in  the  great  majority  of  cases  Avill  be  attained  by  revaccination  every  four  or 
five  years,  and  always  when  small-pox  becomes  epidemic.  If  absolute  im- 
munity from  small-pox  be  not  conferred,  the  course  of  the  disease  will  be 
greatly  modified  and  ameliorated.  In  some  very  rare  instances  vaccination 
and  revaccination  seem  to  offer  no  obstacle  to  the  development  of  severe 
variolous  disease.  According  to  Biedert,  after  a  successful  vaccination  im- 
munity is  secured  in  about  eight  days.  Vaccination  after  infection  with 
variola  does  not  guard  against  the  development  of  the  disease,  but  if  done 
eight  days  before  the  eruption  appears  the  evolution  will  take  place  benignly. 


PAROTITIS. 


By  ANDREW  F.  CURRIER,  M.  D. 

New  York. 


By  the  term  "  parotitis  "  is  to  be  understood  an  inflammation  of  the  parotid 
gland.  By  the  inelegant  term  mumps  we  usually  understand  an  acute  infec- 
tious disease,  often  epidemic  in  character,  in  which  the  parotid  gland  is  ahvays 
inflamed,  other  glands  being  also  involved  occasionally.  If  it  were  possible  to 
dislodge  the  term  "  mumps  "  from  the  mind  of  the  profession  and  the  public, 
it  would  be  in  the  line  of  progress,  for,  like  many  other  terms  which  cling  to 
medical  nomenclature,  it  is  inaccurate,  inelegant,  and  would  be  inexpressive 
were  it  not  for  its  arbitrary  association  with  acute  epidemic  pai'otitis. 

This  affection  is  usually  regarded  as  one  of  the  diseases  of  childhood.  It  is 
unfortunately  true  that  many  mothers  think  it  necessary  that  their  children 
must  experience  this  and  several  other  infectious  diseases  at  some  period  of 
their  childhood,  forgetful  of  the  fact  that  disease  is  always  to  be  avoided  if 
possible.  It  is  true  that  one  attack  of  epidemic  parotitis  usually  furnishes 
immunity  from  others  of  the  same  character,  but  until  we  are  further  advanced 
than  at  present  in  the  science  of  preventive  inoculation  it  will  not  be  wise  to 
encourage  the  acquirement  of  infectious  disease  from  such  a  motive.  Small- 
pox, and  possibly  hydrophobia  and  tetanus,  furnish  exceptions  to  this  rule, 
and  the  day  is  probably  dawning  when  the  list  can  be  lengthened. 

Epidemic  parotitis  is  not  limited  to  the  period  of  childhood.  Many  epi- 
demics are  recorded  in  which  it  prevailed  exclusively  among  men.  This  is 
especially  true  of  soldiers  in  garrisons  and  barracks.  Two  such  epidemics  are 
recorded  by  Girard  in  which  the  testicular  complication  was  severe,  and  others 
by  Gnasco,  Dogny,  Jourdan  and  Laurens.  Males  suffer  with  it  more  frequently 
than  females. 

But  parotitis  is  not  necessarily  an  infectious  disease,  for  there  is  a  form 
which  is  purely  traumatic  and  limited  to  the  parotid  gland,  and  another  which 
may  be  called  an  irritative  form,  in  which  malignant  disease  in  or  near  the 
gland  incidentally  causes  true  inflammatory  action  with  infiltration  and  indu- 
ration. Of  this  form  nothing  further  need  be  said  in  this  connection,  the  con- 
sideration  of  the  subject  being  limited  (1)  to  its  traumatic,  (2)  to  its  infectious, 
aspect. 

Pathological  Anatomy. — Writers  upon  pgediatrics  have  remarked  the 
incompleteness  of  the  knowledge  of  the  anatomy  of  this  subject.  This  is  due 
to  the  small  number  of  fatal  cases,  excepting  those  in  which  the  disease  has 
occurred  as  a  complication,  and  in  which,  from  gangrene  or  abscess,  the 
gland-structure  is  more  or  less  completely  destroyed.  Virchow  studied  the 
disease  in  1858,  and  his  work  is  fundamental  with  reference  to  anatomical 
knowledge  at  that  period.  The  development  of  bacteriological  science  has 
modified  all  our  knowledge  concerning  infectious  disease  and  its  effects.  In 
general  it  may  be  said,  with  Ziegler,  that  the  anatomical  appearances  are  those 
which  are  due  to  inflammatory,  serous,  and  cellular  infiltration  of  the  inter- 

12  177 


178    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

alveolar  fibrous  tissue  of  the  glands,  issuing  either  in  resolution,  fibroid  indu- 
ration, suppuration,  or  gangrene.  Bamberger  describes  the  gland  as  enlarged, 
red,  swollen  with  exudate  in  the  interstitial  tissue,  the  acini  fused  together,  and 
the  cellular  tissue  of  the  entire  gland  involved.  In  severe  cases  the  entire 
glandular  substance  is  involved  and  converted  into  a  fleshy  dry  tumor.  The 
exudate  may  be  absorbed,  the  gland  resuming  its  normal  size  and  consistency, 
or  the  exudate  in  the  cellular  tissue  may  become  thickened  and  organized, 
leading  either  to  permanent  increase  in  size  or  to  atrophy. 

Etiology. — The  two  varieties  or  forms  of  the  disease  to  be  considered  are: 
(1)  the  ti-aumatic,  (2)  the  infectious. 

(1)  The  traumatic  variety  is  the  result  of  blows  or  bruises,  w"itli  more  or 
less  effusion  of  blood  into  the  gland  and  surrounding  tissues.  The  inflamma- 
tion and  swelling  may  be  extensive,  especially  in  syphilitic  or  strumous  sub- 
jects, the  great  sensitiveness  of  the  glandular  system  of  such  individuals  ren- 
dering them  peculiarly  liable  to  disease  of  this  character  even  Avhen  the  injuries 
received  have  only  been  of  moderate  severity.  It  may  also  be  the  result  of 
burns  about  the  face  and  neck  or  of  the  application  of  irritating  chemicals  and 
caustics.  This  form  of  the  disease  is  entirely  distinct  from  the  infectious,  and 
illustrates  the  fact,  which  for  some  time  was  in  dispute,  that  inflammatory  con- 
ditions are  quite  possible  without  the  influence  of  micro-organisms. 

(2)  The  infectious  form  of  the  disease  may  be  simple  or  immediate,  symp- 
tomatic or  metastatic.  That  parotitis  may  be  a  complication  of  so  many  other 
conditions  is  an  argument  against  the  proposition  that  it  is  always  caused  by 
a  specific  microbe.  There  is  scarcely  an  infectious  disease  in  which  it  may  not 
so  appear.  It  may  complicate  pneumonia,  diphtheria,  and  typhoid  fever,  each 
of  which  has  its  specific  cause;  hence  we  are  obliged  to  refer  it  to  that  very 
convenient  class  of  diseases  known  as  mixed  infections,  in  Avhich  the  limita- 
tions to  one  who  is  not  a  bacteriologist  are  as  yet  rather  vague.  It  is  quite 
proper  to  refer  to  the  Avork  which  has  been  done  with  the  view  of  placing  its 
etiolog}'  upon  a  definite  basis  {i.  e.  from  a  bacteriological  standpoint). 

Pasteur  found  a  bacterium  in  blood  taken  from  patients  wath  this  disease, 
but  inoculations  of  animals  with  cultures  obtained  from  it  were  negative. 
Bordas  described  a  bacillus  found  in  the  blood  which  he  termed  bacillus  paro- 
tidis.  In  certain  phases  of  its  development  it  assumed  an  S  or  Y  shape;  when 
divided  the  ends  became  enlarged.  It  died  at  a  temperature  of  140°  F.,  and  its 
spores  at  194°  F.  Its  development  was  arrested  in  1:500,000  solutions  of 
mercuric  bichloride.  Cultures  were  made  from  the  saliva  of  parotitic  patients, 
and  Avere  rich  in  the  microbe.  The  investigations  of  Capitan  and  Charrin  in 
this  field  have  been  more  extensive  than  others,  and  have  to  a  great  degree 
furnished  a  basis  for  other  Avork.  They  first  examined  the  blood,  saliva,  and 
urine  from  six  cases.  In  the  blood  Avere  found  small,  mobile  microbes  in  great 
numbers,  most  of  them  being  spherical,  but  some  rod-shaped.  Similar  bodies 
Avere  found  in  the  saliva,  while  in  the  urine  they  detected  neither  albumin,  sugar, 
nor  microbes.  In  1881,  after  a  study  of  the  blood  in  thirteen  additional  cases, 
they  were  able  to  confirm  their  previous  discoveries.  They  particularly  described 
a  bacterium  two  to  three  thousandths  of  a  millimetre  long  and  also  a  small  micro- 
coccus, the  microbes  appearing  singly,  doubly,  and  in  chains.  Cultures  of  the 
microbes  were  successfully  made,  but  inoculations  of  dogs,  rabbits,  and  guinea-pigs 
Avere  negative.  These  discoveries  Avei^e  verified  by  Vddrenes,  Bouchard,  Netter, 
and  Boinet,  the  latter  finding  the  microbes  in  the  blood  of  fifteen  patients,  also 
in  pus  from  an  abscess  of  the  nucha.  Ollivier  found  the  microbes  in  saliva, 
urine,  and  blood  from  three  subjects,  and  suggested  that  failure  in  the  inocula- 
tion of  animals  Avas  due  to  the  insusceptibility  to  parotitis  of  all  species  of  animals 


PAROTITIS.  179 

upon  which  experiments  had  thus  far  been  conducted.  He  believed  that  we 
could  now  see  in  parotitis  not  the  simple  eifect  of  cold,  or  a  manifestation  of 
the  rheumatic  diathesis,  or  a  propagation  of  a  phlegmasia  of  the  mouth,  but 
an  infectious  disease  caused  by  a  specific  agent  and  propagated  by  the  diffusion 
of  that  agent.     Jaccoud  has  expressed  himself  almost  equally  hopefully. 

In  the  simple  or  immediate  form,  which  is  the  usual  one  in  most  epidemics, 
the  contamination  of  the  atmosphere  with  the  infectious  elements,  especially  in 
schools  or  barracks,  in  which  the  air-supply  is  deficient,  explains  its  dissemina- 
tion. This  statement  harmonizes  with  the  fact  that  it  is  most  prevalent  in  damp 
and  cold  weather  when  the  windows  and  doors  of  houses  are  closed  and  the  tend- 
ency or  the  necessity  is  to  remain  in-doors.  The  elements  of  the  disease  are 
also"  carried  from  house  to  house  in  the  clothes  of  physicians  and  visiting  friends. 
This  explains  the  prevalence  of  epidemics  in  sparsely-settled  localities.  Infec- 
tion is  probably  acquired  in  respiration,  and  those  who  are  mouth-breathers  are 
the  more  susceptible.  Whether  the  long  period  of  incubation  which  follows 
the  reception  of  the  infective  influence  means  retention  of  the  elements  in  the 
ducts  of  the  salivary  glands  or  in  the  glands  themselves,  or  whether  there  is  a 
process  of  germination  within  the  blood  and  localization  in  the  glands,  we  do 
not  know.  The  latter  is  the  more  reasonable  hypothesis  from  the  analogy  with 
other  infective  germs  which  are  known  to  develop  in  the  blood.  As  in  all  other 
infectious  diseases,  the  intensity  is  governed  partly  by  the  activity  of  the  infec- 
tious elements  and  partly  by  the  resistance  of  the  individual. 

In  the  secondary,  metastatic,  or  symptomatic  variety  of  infectious  parotitis 
the  inflammation  is  a  complication  of  a  pre-existing  disorder.  The  list  of 
diseases  in  which  it  may  play  such  a  role  is  a  long  one,  including  the  infectious 
diseases  in  general,  besides  nephritis,  pneumonia,  meningitis,  and  surgical  injur- 
ies of  all  kinds  ;  for  in  all  of  them  sepsis,  and  hence  infection,  are  possibilities. 
As  an  evidence  of  extensive  or  general  systemic  infection  it  is  a  symptom  of 
grave  significance.  AYith  the  diathetic  diseases,  tuberculosis,  syphilis,  and  rheu- 
matism, its  significance  is  less  grave  than  with  the  acute  infectious  diseases. 
In  this  variety  we  cannot  refer  to  a  specific  microbe  as  its  origin.  Some  of  the 
conditions  with  which  it  may  be  associated  have  such  origins  (diphtheria, 
pneumonia),  and  whether  the  complicating  parotitis  is  due  to  the  irritating 
effect  of  such  specific  germs  which  have  been  retained  within  the  gland,  or 
whether  it  is  caused  by  those  germs  (streptococcus,  staphylococcus)  which 
produce  severe  inflammation  wherever  localized,  we  do  not  as  yet  know. 

Incubation. — The  period  of  incubation  of  parotitis  is  a  long  one,  but  it 
varies  with  the  resisting  power  of  the  individual  and  the  virulence  of  the 
infective  material.  The  long  period  of  incubation,  with  the  complicating  con- 
ditions which  may  arise  in  the  mean  time,  may  delay  the  determination  of  the 
diagnosis.  J.  Lewis  Smith  regards  the  disease  as  pi'imarily  a  systemic  infec- 
tious one,  with  an  incubation  period  of  nine  to  twenty-one  days ;  A.  Jacobi 
fixes  it  at  two  to  three  weeks ;  Dauchez.  at  fifteen  days ;  Roth,  at  eighteen 
days  ;  and  Nicholson  reports  a  case  in  which  an  interval  of  six  weeks  elapsed 
between  the  involvement  of  the  two  parotid  glands. 

Symptoms. — The  long  period  of  incubation  may  be  attended  by  symp- 
toms of  impending  trouble.  This  is  especially  true  with  young  children. 
There  may  be  malaise  with  moderate  rise  of  temperature  for  several  days,  and 
with  very  young  children  there  may  be  convulsions,  especially  if  digestive  dis- 
order coexist.  With  glandular  swelling  come  also  induration,  sensitiveness, 
pain  on  motion  of  the  neck  or  jaw,  loss  of  appetite,  restlessness,  and  insomnia. 
With  the  progress  of  the  inflammation  infiltration  of  the  gland  and  the  sur- 
rounding tissues  increases,  and  fever  is  more  pronounced.     These  symptoms 


180    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

may  continue  for  a  week,  and  gradually  subside,  or  the  duration  may  be  less 
prolonged.  The  induration  will  gradually  disappear  and  normal  conditions  be 
resumed,  or  the  gland  may  be  permanently  enlarged  or  it  may  atrophy.  In 
a  certain  number  of  cases  abscess  or  gangrene  will  ensue,  the  gland  will  be 
destroyed,  and  the  final  result  be  fatal  ;  but  in  the  great  majority  these  are 
cases  in  which  the  system  is  so  saturated  with  septic  products  that  the  outcome 
would  be  fatal  even  if  parotitis  did  not  exist. 

The  inflammatory  action  which  involves  the  parotid  glands  may  include  also 
the  other  salivary  glands,  and  even  the  cervical  lymphatic  glands.  These  com- 
plications are  frequently  overlooked,  being  overshadowed  by  the  more  exten- 
sive and  apparent  aff"ection  of  the  parotids.  The  appearance  of  an  individual 
with  parotitis  is  sufficiently  characteristic :  there  is  glandular  swelling,  Avith 
hardness  and  pain  ;  the  swelling  may  be  considerable  or  inconsiderable,  and  of 
course  the  disfigurement  of  the  face  and  neck  will  be  governed  accordingly. 
The  pain  is  constant  and  severe,  especially  in  young  children ;  deglutition  is  dif- 
ficult and  often  impossible  on  account  of  its  painfulness.  If  abscess  develops, 
the  pain  has  the  acute  throbbing  character  of  abscess-formation  everywhere. 
Pain  in  the  contiguous  structures  of  the  ear  is  almost  always  a  marked  feature 
of  the  disease,  and  the  nearness  of  the  carotid  artery  and  cerebral  meninges 
introduces  elements  of  danger  which  must  always  be  remembered,  for  serious 
results  in  this  quarter  are  by  no  means  unknown.  Considering  the  possibilities 
of  serious  consequences,  the  small  percentage  of  fatal  cases  when  the  disease  is 
uncomplicated  is  quite  remarkable. 

Complications. — In  the  traumatic  form,  in  which  the  inflammation  is  a 
simple  one,  complications  are  unusual.  The  inflammation  subsides,  as  such 
conditions  do  elsewhere,  the  result  being  resolution  in  the  mild  cases  and  sup- 
puration in  the  severe  ones,  especially  if  the  tissues  have  been  bruised  and 
broken.  In  the  epidemic  infectious  form  complications  are  extremely  common, 
the  genital  organs  being  most  frequently  implicated.  Thus  with  males  there 
is  often  an  involvement  of  the  testicles,  spermatic  cord,  and  inguinal  glands ; 
with  females,  the  mammas,  ovaries,  labia  majora,  and  inguinal  glands.  These 
complications  may  not  be  evident  until  the  symptoms  in  the  parotid  gland 
have  begun  to  subside.  In  a  recent  epidemic  in  which  one  hundred  and  seven- 
teen cases  were  observed  by  Demme,  two  were  fatal  from  gangrene  of  the  paro- 
tid glands;  in  three  there  was  abscess  of  the  cervical  glands;  in  two  there  was 
acute  nephritis.  Musgrove  and  Slagle  each  saw  a  fatal  case  complicated  with 
ursemia.  P.  Smith  saw  two  cases  which  were  followed  by  insanity,  and  Par- 
rott  one  which  was  complicated  with  orchitis  and  meningitis.  F.  W.  Brown 
records  an  epidemic  of  twenty  cases  in  a  boys'  school,  ten  of  which  were  com- 
plicated with  orchitis.  Jackson  observed  four  cases  complicated  with  influenza. 
This  latter  complication  is  more  frequent  than  is  generally  supposed.  The 
writer  recently  saw  such  a  case  in  an  infant  fourteen  months  old. 

Among  the  sequelee  of  the  disease  Joff"roy  mentions  peripheral  neuritis,  with 
paralysis  of  the  extremities  lasting  four  months.  Rotch  and  Moure  each  saw 
two  cases  of  deafness  ;  and  Dufour,  inflammation  of  the  lachrymal  glands. 
The  evidence  is  therefore  abundant  that  we  have  in  parotitis  an  infectious 
disease  with  multiple  localization. 

Treatment. — If  the  disease  be,  as  it  appears,  an  infectious  one,  we  have, 
as  yet,  no  method  of  treatment  for  aborting  it.  When  the  symptoms  are 
apparent,  the  indication  is  to  relieve  them  as  they  arise.  The  pain  may  be 
soothed  by  small  doses  of  Dover's  powder  or  paregoric,  or  phenacetin  combined 
with  salol.  Hot  applications  to  the  inflamed  parts  are  always  grateful,  and 
the  surface  may  be  kept  moist  with  anodyne  liniments.     The  bowels  must  be 


PAROTITIS.  181 

kept  open,  fever  may  be  reduced  with  aconite,  and  the  diet  must  be  fluid  and 
concentrated.  Hot  liquids  will  usually  be  preferable  to  cold,  and  will  be 
more  quickly  assimilated.  The  skin  should  be  kept  active  by  daily  warm 
baths,  by  alcohol,  and  by  gentle  friction.  The  opiates  suggested  will  usually 
be  sufficient  to  relieve  restlessness  and  induce  sleep.  As  soon  as  the  acute 
symptoms  have  subsided  the  nutrition  should  be  improved  as  rapidly  as  possi- 
ble, and  a  tonic  of  iron,  quinine,  strychnine,  and  arsenic  will  be  indicated. 

Quarantine. — An  important  practical  question  is  that  relating  to  the  time 
in  which  patients  with  infectious  parotitis  should  be  isolated.  This  especially 
concerns  children  who  are  attending  school.  A.  recent  paper  by  Rendu  is 
devoted  to  this  aspect  of  the  subject.  His  studies  have  led  him  to  believe  that 
the  time  of  greatest  danger  of  contagion  is  at  the  close  of  the  incubation  period, 
at  least  twenty-four  hours  before  the  disease  can  be  diagnosticated.  Sevestre 
and  Comby  had  reached  this  same  conclusion.  If  this  be  a  fact,  Rendu's 
opinion  that  it  is  irrational  to  keep  children  out  of  school  three  weeks  after  the 
symptoms  of  the  disease  have  subsided  is  a  just  one,  and  teaches  that  isolation 
should  be  limited  to  a  period  included  between  the  time  when  the  first  symp- 
toms appear  and  the  time  when  the  active  symptoms  have  subsided. 


WHOOPING-COUGH. 

By  J.  P.  CROZER  GRIFFITH,  M.  D., 

Philadelphia. 


Synonyms. — Pertussis ;  Tussis  convulsiva  ;  Hooping  cough  ;  Chin  cough. 

Whooping-cough  is  a  zymotic,  contagious  disease  of  chiklhood,  character- 
ized by  a  catarrh  of  the  respiratory  mucous  membrane  and  a  peculiar  paroxys- 
mal cough. 

No  description  of  any  disease  resembling  pertussis  can  be  found  in  the 
writings  of  the  Greeks,  Romans,  or  Arabians,  and  it  seems  probable  that  the 
failure  to  mention  such  a  peculiarly  characteristic  disorder  is  proof  that  it  did 
not  then  exist  at  all,  or  at  least  in  parts  of  the  world  with  which  medical 
writers  were  acquainted.  In  fact,  no  account  of  it  is  found  until  Baillou,  in 
1578,  described  an  epidemic  which  occurred  at  Paris,  and  spoke  of  it  as  an 
affection  not  previously  known.  Little  or  nothing  more  was  heard  of  it  for  about 
a  hundred  years,  Avhen  Willis  wrote  of  ^'■tussis puerorum  convulsiva  "  in  such  a 
manner  that  its  nature  and  its  identity  with  the  pertussis  of  the  present  day 
can  admit  of  no  doubt.  Epidemics  did  not  become  frequent  until  the  eigh- 
teenth century,  but  the  disease  then  rapidly  spread,  and  by  the  middle  of  that 
century  had  become  widely  diffused.  From  that  period  omvard  it  has  been 
steadily  on  the  increase,  until  it  constitutes  at  present  one  of  the  commonest 
diseases  of  childhood. 

Etiology. — There  are  certain  factors  which  seem  to  exercise  a  decidedly 
predisposing  influence  upon  the  development  of  pertussis.  There  is  a  very 
distinct  tendency  shown  for  it  to  occur  in  epidemics,  which  appear  at  intervals 
of  about  two  years,  yet  with  no  great  regularity  in  this  respect.  The  disease 
may,  however,  occur  sporadically,  although  such  cases  ai'e  always  the  result  of 
some  preceding  case.  In  the  larger  cities  it  is  practically  endemic,  although 
at  times  greatly  more  prevalent  than  at  others. 

The  previous  occurrence  of  the  disease  in  an  individual  precludes  the  de- 
velopment of  a  second  attack.  Nevertheless,  undoubted  exceptions  to  this 
rule  have  been  occasionally  reported,  though  they  are  certainly  rare. 

Whooping-cough  is  more  prevalent  in  the  civilized  portions  of  the  world, 
but  its  absence  from  any  region  seems  to  depend  rather  on  the  fact  that  it  has 
not  yet  been  carried  thither  than  on  any  conditions  of  climate  or  of  race 
which  are  unfavorable  to  its  existence.  The  influence  of  season  has  been 
much  disputed,  and  the  evidence  is  conflicting.  It  is  certainly  no  powerfully 
predisposing  factor.  The  station  in  life  and  the  general  hygienic  conditions 
existing  appear  to  be  without  influence,  except  in  so  far  as  the  ill-ventilated 
houses  of  the  poor  may  possibly  favor  the  increase  of  the  germs  in  number 
or  in  virulence,  even  as  the  crowding  and  lack  of  isolation  certainly  favor  their 
diffusion. 

The  previous  state  of  the  health  seems  to  possess  some  predisposing  power. 

182 


WHO  OPING-  GO  UGH.  183 

Most  observers  agree  that  weakly,  sickly  children  more  readily  contract 
whooping-cough  than  do  those  in  good  health.  It  is  a  well-recognized  fact, 
also,  that  there  is  an  intimate  association  between  epidemics  of  measles  and  of 
whooping-cough,  and  it  is  very  widely  believed  that  the  existence  of  the  first 
disease  strongly  predisposes  to  the  later  development  of  the  second.  Whether 
or  not  the  association  is  an  accidental  one  is  still  unsettled.  The  actual  pres- 
ence of  any  other  disease  is  certainly  no  bar  to  the  occurrence  of  pertussis. 
As  with  other  infectious  disorders,  there  exists  a  certain  individual  suscepti- 
bility to  it.      Some  children  never  contract  it,  though  often  exposed. 

Age  exercises  a  powerful  influence  on  the  development  of  whooping-cough. 
By  far  the  greater  number  of  cases  occur  before  the  sixth  year.  After  this 
time  the  frequency  of  occurrence  diminishes  very  rapidly,  and  after  the  tenth 
year  it  is  comparatively  infrequent.  West  estimates  that  over  one-half  the 
cases  develop  under  the  age  of  three  years.  It  is  sometimes  seen  in  adults, 
but  this  is  rather  uncommon;  the  rarity  being  due  partly  to  the  fact  that  so 
many  have  suffered  from  it  while  children,  and  partly  to  a  lessening  of  the 
susceptibility  with  advancing  years.  It  is  not  common  during  the  first  six 
months  of  life.  It  is,  however,  distinctly  more  liable  to  occur  at  this  time 
and  up  to  the  age  of  one  year  than  are  the  other  infectious  disorders  of  child- 
hood. There  are  even  a  few  well-authenticated  cases  reported  in  which  it 
appeared  to  have  been  contracted  during  foetal  life. 

It  has  been  widely  stated  that  girls  are  more  liable  to  develop  whooping- 
cough  than  are  boys.  Statistics,  however,  are  somewhat  at  variance,  but 
certainly  show  that  there  is  no  very  material  difierence  in  the  number  of  each 
sex  attacked. 

The  sole  exciting  cause  of  pertussis  is  contagion,  and  so  powerful  is  this 
contagiousness  that  by  far  the  greater  number  of  children  exposed  to  the 
disease  will  contract  it.  It  is  contagious  during  any  part  of  its  course,  but 
particularly  in  the  paroxysmal  stage.  It  is  least  so  in  the  terminal  stage.  The 
nature  of  the  infectious  principle  can  best  be  discussed  when  considering  the 
pathology  of  the  afi"ection. 

As  a  rule,  actual  contact  with,  or  close  approach  to,  the  sick  child  is  neces- 
sary for  its  development  in  a  second  case,  but  even  a  momentary  exposure  of 
this  sort  is  often  sufficient  to  ensure  an  attack.  Several  observers  have  claimed 
that  the  disease  does  not  spread  readily  in  well-ventilated  and  roomy  hospital 
wards.  My  own  experience  has  not  been  at  all  in  accord  with  this.  The 
infectious  germs  appear  to  be  located  in  the  secretion  of  the  respiratory  tract, 
and  are  spread  by  this  and  by  the  expired  air.  Cases  have  been  reported 
which  show  that  whooping-cough  is  mediately  contagious  through  a  third  party 
or  through  handkerchiefs  or  clothing  which  have  presumably  been  infected  by 
the  sputum  of  a  patient.  It  is  probable,  however,  that  the  disease  is  rarely 
contracted  in  this  way. 

The  contagiousness  of  pertussis  extends  slightly  to  the  lower  animals,  and 
cases  are  on  record  in  which  these  have  contracted  it  from  the  human  subject. 

The  path  by  which  the  germs  enter  the  system  is  not  certainly  known. 
Although  nearly  all  the  evidence  is  in  favor  of  the  respiratory  tract,  the  few 
published  cases  of  pertussis  in  the  new-born  indicate  the  possibility  of  their 
entrance  in  other  ways,  as  by  the  foetal  circulation. 

Pathology. — There  are  no  post-mortem  appearances  characteristic  of  per- 
tussis. The  most  constant  change  found  is  redness  and  swelling  of  the  mucous 
membrane  of  the  respiratory  tract,  with  the  presence  of  a  considerable  quantity 
of  viscid  mucus.  There  is  often  observed  a  tendency  to  congestion  of  various 
parts  of  the  body,  due  to  the  disturbance  of  the  circulation  which  naturally 


184  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

attends  the  paroxysms.     There  are  also  found  the  various  lesions  correspond- 
ing to  the  complications  which  have  existed  during  life. 

The  nature  of  pertussis  has  heen  a  much-mooted  question,  and  is  not  even 
yet  entirely  settled.  It  has  been  frequently  claimed  that  the  disease  is  a 
functional  disturbance  of  either  the  pneumogastric,  phrenic,  recurrent  laryngeal, 
or  sympathetic  nerves  or  of  the  medulla.  According  to  this  view,  it  is 
simply  a  neurosis.  Other  writers  have  viewed  it  as  a  simple  bronchial  catarrh 
due  to  cold  merely,  with  which  is  associated  a  certain  nervous  element.  En- 
largement of  the  ti-acheal  and  bronchial  glands  has  also  been  urged  as  the 
cause  of  the  disease,  through  their  irritating  pressure  upon  the  terminal  fila- 
ments of  the  pneumogastric  nerve. 

The  eminently  contagious  nature  of  whooping-cough,  its  occurrence  in  epi- 
demics, the  existence  of  a  period  of  incubation,  and  the  immunity  from  second 
attacks  seem  to  prove  beyond  a  doubt  that  it  is  to  be  classed  among  purely 
infectious  disorders.  Although  this  is  the  view  which  has  recently  found  very 
general  acceptance,  it  is  by  no  means  a  new  idea.  Even  Linnteus  attributed 
pertussis  to  the  presence  in  the  nose  of  the  larvse  of  insects.  Poulet  dis- 
covered bacteria  in  the  expired  air  of  patients  with  pertussis.  Letzerich  found 
a  micrococcus  in  the  sputum  which  he  believed  to  be  the  specific  germ,  and  was 
able  to  produce  the  disease  in  animals  by  introducing  the  secretion  into  the 
trachea.  Deichler  claimed  that  there  was  always  present  in  the  sputum  an 
organism  of  the  nature  of  a  protozoon  which  possessed  amoeboid  motion.  But, 
although  other  investigators  have  repeatedly  described  various  organisms  as 
existing  on  the  respiratory  mucous  membrane,  the  researches  of  Afanassiew  in 
1887  have  attracted  the  most  attention.  This  observer  isolated  a  short  bacillus, 
which  he  named  the  bacillus  tussis  convulsivce,  and  of  which  he  was  able  to 
obtain  pure  cultures  upon  various  media.  Animals  inoculated  upon  the  respi- 
ratory mucous  membrane  with  these  cultures  exhibited  some  of  the  symptoms 
of  the  disease  and  developed  catarrhal  conditions  of  the  respiratory  tract,  with 
a  tendency  to  broncho-pneumonia.  These  observations  have  been  confirmed  by 
others,  and  a  toxine  has  also  been  reported  as  present  in  the  urine  of  patients 
with  pertussis  which  is  identical  with  that  produced  by  Afanassiew's  bacillus. 

Even  though  it  be  admitted  as  most  probable  that  some  micro-organism  is 
the  cause  of  the  malady,  it  is  by  no  means  clear  how  the  symptoms  are  pro- 
duced or  where  the  principal  seat  of  the  infection  is.  Some  writers  have 
claimed  that  the  trigeminal  nerve  is  in  a  sensitive  state,  and  that  it  is  the  irri- 
tation of  its  terminal  filaments  by  the  infectious  catarrhal  process  on  the  nasal 
mucous  membrane  which  brings  on  the  paroxysms  by  a  reflex  action.  Others, 
again,  have  stated  that  the  bronchial  mucous  membrane  is  the  portion  of  the 
respiratory  tract  chiefly  involved,  and  that  the  terminal  filaments  of  the  pneu- 
mogastric are  those  irritated.  The  careful  investigations  of  Meyer-IIuni  and 
of  V.  Herff,  however,  indicate  that  the  catarrhal  inflammation  is  most  pro- 
nounced in  the  mucous  membrane  of  the  nose,  larynx,  and  trachea  down  to 
the  bifurcation,  but  especially  so'  on  the  posterior  wall  of  the  larynx  in  the 
inter-arytenoid  region,  the  so-called  "cough  region."  In  the  production  of 
the  cough  it  would  seem  probable  that  a  small  quantity  of  mucus,  perhaps 
arising  from  below,  accumulates  upon  the  surface  of  the  "cough  region,"  and 
there  irritates  powerfully  the  hyper-sensitive  filaments  of  the  superior  laryngeal 
nerve.  Through  a  reflex  action  a  sei'ies  of  clonic  spasms  of  the  expiratory 
muscles  is  then  set  up.  At  last  the  crowing  inspiration  occurs,  this  depending 
upon  a  spasm  of  the  glottis,  which,  in  its  turn,  proceeds  from  an  irritation  of 
the  convulsive  centres  in  the  medulla.  This  process  is  repeated  again  and  again 
until  the  ofi"ending  secretion  is  expelled. 


WHO  OPING-  CO  UGH.  185 

The  presence  of  this  secretion  does  not  seem,  however,  to  be  an  essential 
to  the  production  of  the  cough,  since  paroxysms  may  be  brought  on  by  excite- 
ment and  other  causes.  This  appears  to  indicate  that  the  irritation  of  the 
superior  laryngeal  nerve  may  be  central,  due  to  systemic  infection.  A  great 
preponderance  of  the  nervous  element  of  the  disease  over  the  catarrhal  is 
further  shown  by  the  greater  frequency  with  which  the  paroxysms  occur  at 
niofht,  since  this  condition  very  possibly  depends  upon  a  less  degree  of  resistance 
of  the  respiratory  centre  during  the  night,  and  a  consequent  greater  ease  with 
which  convulsive  expiratory  efforts  are  brought  about. 

We  therefore  clearly  have  to  do  in  whooping-cough  with  an  infectious, 
catarrhal  process  which  affects  particularly,  and  produces  an  unusual  sensitive- 
ness in,  the  mucous  membrane  presided  over  by  the  superior  laryngeal  nerve. 
But  still  more  prominent  is  a  great  excitability  of  the  nerve  itself  and  of  the 
other  nervous  portion  of  the  respiratory  apparatus,  this  being  probably  due  to 
the  circulation  in  the  blood  of  some  noxious  substance,  the  product  of  the  in- 
fecting germs,  which  possesses  a  special  power  over  the  portion  of  the  nervous 
system  which  controls  cough.  The  apparent  value  in  many  cases  of  local 
treatment  directed  to  the  respiratory  mucous  membrane  indicates  that  the 
abode  of  the  germs  is  in  this  region,  whence  the  poisonous  products  of 
their  growth  are  absorbed.  On  the  other  hand,  the  existence  of  pertussis  in  the 
new-born,  the  result  of  foetal  infection,  points  to  the  presence  of  the  microbes 
themselves  in  the  circulation  and  in  other  parts  of  the  body  besides  the  respi- 
ratory tract.  From  this  point  of  view  their  situation  in  the  latter  region  would 
be  a  localization  entirely  secondary  to  the  general  systemic  infection  and,  so  to 
speak,  excretory.  Which  of  these  theories  is  correct  cannot  as  yet  be  deter- 
mined, although  the  resemblance  of  the  disease  to  other  infectious  disorders  cer- 
tainly  supports  the  latter  view. 

Incubation. — A  period  of  incubation  precedes  the  development  of  the 
symptoms.  Its  exact  duration  cannot  be  easily  determined,  since  the  onset  of 
the  disease  is  so  insidious,  and  statements  vary  in  regard  to  it.  It  is  clearly 
somewhat  variable  in  length,  and  probably  lasts  from  two  to  seven  days,  with 
an  average  of  three  to  four  days. 

Symptoms. — It  is  customary  to  divide  the  course  of  the  disease  into  three 
stages  :  1st,  the  catarrhal  or  premonitory  stage ;  2d,  the  paroxysmal  or  con- 
vulsive stage ;  and  3d,  the  terminal  stage  or  stage  of  decline.  This  classifica- 
tion is  convenient,  but  somewhat  artificial,  since  the  stages  only  very  gradually 
pass  into  each  other,  and  their  duration  cannot,  therefore,  be  accurately  deter- 
mined. 

1.  Catarrhal  Stage. — There  is  little  in  this  which  is  characteristic  of  the 
disease.  The  child  gradually  begins  to  exhibit  symptoms  of  a  severe  cold, 
with  malaise,  perhaps  slight  hoarseness,  stoppage  of  the  nose,  tickling  in  the 
throat,  sneezing,  irritation  of  the  eyes  and  a  dry,  annoying  cough.  Fever  is 
generally  slight  and  apt  to  come  on  in  the  evening  only.  Although  it  has 
been  claimed  that  the  elevation  of  temperature  is  an  evidence  of  the  infection, 
it  is  more  likely  that  the  degree  of  fever  is  dependent  solely  upon  the  intensity 
of  the  catarrh. 

Under  treatment  there  may  be  a  temporary  improvement  in  some  of  the 
symptoms,  but  all  of  them  soon  return  in  force,  and  the  cough  particularly  is 
troublesome  and  gradually  grows  worse  in  spite  of  medicine  given.  As  days 
pass  by  it  shows  a  greater  tendency  to  occur  in  long,  severe  paroxysms,  and  is 
also  much  more  annoying  by  night.  On  examination  of  the  chest  only  a  very 
few  r41es  may  be  heard.  Nothing,  indeed,  is  found  to  account  for  the  severity 
of  the  cough.     Sometimes,  though  less  commonly,  the  first  stage  is  characterized 


186  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

bv  a  severe  bronchitis,  with  corresponding  auscultatory  signs  and  the  presence 
of  high  fever. 

The  duration  of  the  first  stage  averages  about  two  weeks,  but  it  is  subject 
to  great  variations.  Sometimes  only  two  or  three  days  elapse  before  the  child 
begins  to  whoop.  The  younger  the  age,  the  shorter,  often,  is  the  duration  of 
the  catarrhal  stage.  In  some  instances  the  disease  never  passes  beyond  the 
first  stage,  the  diagnosis  in  such  cases  depending  largely  upon  the  existence  of 
the  affection  in  other  members  of  the  family. 

2.  Paroxysmal  Stage. — The  complete  development  of  the  paroxysmal 
cough  marks  the  beginning  of  the  second  stage.  The  exact  time  of  onset  is, 
as  already  stated,  often  difficult  of  determination.  Except  for  the  rarer  cases 
in  which  the  whoop  never  occurs,  it  is  convenient  and  most  customary  to  date 
the  paroxysmal  stage  from  the  first  appearance  of  this  sj^mptom. 

The  paroxysm  of  pertussis — or  the  "kink,"  as  it  is  frequently  called — is 
very  characteristic.  Just  before  it  begins  the  child  seems  anxious  and  irri- 
table, or  perhaps  very  quiet.  It  experiences  some  sort  of  a  warning  sensation, 
as  a  pain  in  the  region  of  the  sternum,  or  nausea,  or  a  tickling  in  the  nose,  or 
a  similar  sensation  in  the  larynx  with  an  irresistible  desire  to  cough.  It  at 
once  drops  its  playthings,  runs  to  its  mother  or  nurse,  or  grasps  some  near  object 
for  support;  or,  if  asleep,  quickly  rises,  sits  upright,  and  begins  to  cough. 
Sometimes,  however,  the  cough  seems  to  come  suddenly,  without  the  premoni- 
tory sensation.  The  cough  consists  of  a  number  of  short,  explosive  expiratory 
efforts  very  rapidly  following  one  another,  and  without  any  inspiration  between 
them.  These  continue  so  long  and  are  so  violent  that  the  face  becomes  turgid 
and  cyanotic,  the  tongue  is  protruded  and  driven  against  the  teeth,  saliva 
flows  from  the  mouth,  the  eyeballs  are  prominent,  the  eyes  water,  and  the 
pulse  becomes  rapid  and  small.  The  paroxysm  lasts  a  few^  seconds  until  at 
last  both  cough  and  all  respiration  cease.  Then  comes  a  peculiar,  loud,  crow- 
ing inspiration,  the  ivlioop.,  which  is  the  result  of  the  air  passing  through  the 
spasmodically  closed  glottis.  Immediately  there  begins  another  series  of 
expiratory  efforts,  to  be  agairr  followed  by  the  whooping  inspiration ;  and  this 
process  repeats  itself  several  times.  The  later  series  of  expulsive  efforts  is 
accompanied  by  abundant  expectoration  of  ropy  mucus  and  very  often  by 
vomiting.  As  the  parox3"sm  ceases  the  cyanosis  disappears,  and  the  child  is 
often  left  pale  and  exhausted  for  a  short  time ;  but  if  it  is  strong  and  other- 
wise well  it  soon  resumes  its  play.  Sometimes  a  crowing  inspiration  imme- 
diately precedes  the  first  series  of  expirations.  Occasionally,  too,  after  the 
attack  seems  to  be  over  there  is  a  period  of  rest  for  a  moment,  and  the  whole 
process  is  then  repeated.  A  series  of  paroxysms  may  thus  continue  for  as 
long  as  ten  to  thirty  and  even  more  minutes.  The  usual  duration  of  an 
attack,  however,  is  from  a  few  seconds  up  to  one  or  two  minutes.  The  sAvell- 
ing  of  the  face,  the  puffiness  of  the  eyes,  and  some  degree  of  blueness  of  the 
tongue  persist  more  or  less  betAveen  the  paroxysms,  and  may  constitute  quite 
notable  features  of  the  disease.  In  bad  cases  the  paroxysms  may  be  attended 
by  haemorrhage  from  the  mouth  or  nose  or  beneath  the  conjunctiva  or  else- 
where. Involuntary  voidance  of  urine  or  faeces  may  be  occasioned  by  the  vio- 
lence of  the  attack. 

The  frequency  of  paroxysms  and  their  intensity  vary  greatly.  In  mild 
cases  there  may  not  be  more  than  six  to  twelve  in  the  twenty-four  hours,  while 
in  the  severer  ones  they  may  number  from  forty  to  eighty.  They  are  always 
more  numerous  at  night.  An  attack  of  coughing  is  often  brought  on  by 
exercise,  crying,  singing,  loud  speaking,  eating  or  drinking,  excitement  of 
any  kind,  a  sudden  change  of  temperature  in  the  air,  or  the  breathing  of  air 


WHOOPING-COUGH.  187 

overloaded  with  carbonic  dioxide.     Depression  of  the  tongue  with  a  spatula, 

producing  gagging,  is  very  apt  to  bring  on  an  attack. 

The  general  condition  of  the  patient  does  not  suffer  materially  in  mild 
cases.  Sometimes,  however,  there  is  much  exhaustion  from  the  frequent 
coughing  and  the  loss  of  sleep,  or  vomiting  may  so  regularly  follow  the 
paroxysms  that  the  nutrition  suffers  greatly  and  emaciation  becomes  marked. 
In  the  milder  cases  vomiting  does  not  at  all  interfere  with  the  appetite,  and 
the  child  is  soon  ready  to  eat  again ;  so  that  quite  sufficient  food  is  retained 
for  the  bodily  needs. 

More  or  less  fever  may  occasionally  be  present  in  the  second  stage,  espe- 
cially at  night,  but,  as  a  rule,  fever  is  absent,  and  if  continuously  present 
makes  the  existence  of  some  complication  probable.  The  urine  in  whooping- 
cough  sometimes  contains  sugar  and  frequently  albumin.  It  was  at  one  time 
claimed  that  it  was  always  saccharine.  Auscultation  of  the  chest  in  the  interval 
between  the  paroxysms  reveals  nothing  abnormal,  or  only  the  presence  of  a 
few  mucous  rales.  During  the  whooping  inspiration  nothing  at  all,  or  at  most 
only  a  very  feeble  inspiration,  can  be  heard.  During  the  expiratory  efforts, 
too,  very  little  respiratory  sound  is  audible,  and  scarcely  more  than  the  sensa- 
tion of  a  series  of  impulses  can  be  perceived. 

The  total  duration  of  the  paroxysmal  stage  is  exceedingly  variable.  In 
general  terms  it  may  be  given  as  from  three  to  six  weeks,  but  it  may  last  a 
shorter  or  a  much  longer  time  than  this. 

3.  Terminal  Stage. — The  second  stage  merges  so  gradually  into  the  suc- 
ceeding one  that  no  exact  boundary  between  them  can  be  recognized.  The 
third  stage  may  be  said  to  begin  when  the  severity  of  the  disease  is  clearly 
diminishing.  The  attacks  now  grow  less  frequent  and  less  severe  ;  the  whoop- 
ing and  vomiting  persist  for  a  time,  but  gradually  disappear ;  and  the  cough, 
although  still  paroxysmal,  grows  distinctly  looser  and  of  a  more  catarrhal 
nature,  and  finally  assumes  the  character  of  that  of  simple  bronchitis.  Haem- 
orrhages occur  much  less  frequently,  if  at  all ;  the  bronchial  secretion  is  now 
more  muco-purulent,  and  the  general  health,  if  previously  affected,  improves. 
Finally  the  cough  disappears  entirely  and  the  disease  is  over. 

The  duration  of  this  stage  is  very  variable.  It  may  last  from  about  ten 
days  up  to  several  months,  depending  upon  hygienic  and  other  conditions. 
Thus  the  approach  of  the  winter  season  is  liable  to  prolong  it  indefinitely. 
Not  infrequently,  after  all  cough  has  ceased  and  the  child  has  appeared 
well,  the  development  of  a  nasal  or  bronchial  catarrh  may  be  attended  by  a 
return  of  the  paroxysms.  Such  a  return  cannot,  however,  be  properly  desig- 
nated a  part  of  the  third  stage. 

Complications  and  Sequelae. — Of  the  very  numerous  complications  of 
pertussis  those  connected  with  the  respiratory  tract  are  most  prominent. 
Bronchitis  may  be  so  in  excess  of  the  degree  of  catarrh  usually  present  that  it 
constitutes  a  complication.  This  is  not  an  infrequent  occurrence.  Atelectasis 
very  often  develops  in  young  children.  It  may  affect  only  a  small  part  of  the 
lung  or  may  be  more  extensive  and  threaten  life,  and  is  especially  apt  to  be 
witnessed  in  weakly  and  rachitic  children.  Widespread  broncho-pneumonia  is 
one  of  the  most  common  and  most  dangerous  complications  of  whooping- 
cough.  It  usually  comes  as  a  result  of  atelectasis,  but  sometimes  independ- 
ently of  it,  and  tends  to  run  a  very  tedious  course.  As  it  develops  the 
paroxysmal  nature  of  the  cough  is  very  liable  to  diminish  or  disappear.  Like 
atelectasis  it  is  particularly  prone  to  be  seen  in  weakly  children  or  when 
measles  has  immediately  preceded  pertussis,  or  in  children  who  have  been  sub- 
jected to  improper  hygiene,  especially  exposure    to  cold.      Pleural  effusion, 


188   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

empyema  and  croupous  pneumonia  are  of  less  frequent  occurrence ;  pneumo- 
thorax is  rare ;  emphysema  is  common,  but  is  generally  only  temporary. 
Sometimes,  however,  it  is  permanent  throughout  more  or  less  of  the  lungs. 
Emphysema  of  the  subcutaneous  connective  tissue  has  been  reported  but  is 
very  uncommon.  (Edema  of  the  glottis  is  sometimes  seen.  The  coexistence 
of  pseudo-membranous  laryngitis  is  to  be  regarded  as  accidental. 

A  complication  so  frequent  that  it  almost  deserves  to  be  called  a  symptom 
is  the  occurrence  of  a  superficial  yellowish-gray  ulceration  over  or  at  the  sides 
of  the  frgenum  of  the  tongue.  It  is  probably  produced  by  the  forcible  impulse 
of  the  tongue  against  the  lower  incisor  teeth  during  the  act  of  coughing.  It 
has  occasionally  been  seen  in  other  disorders  than  whooping-cough. 

Vomiting  is  generally  to  be  regarded  as  a  symptom  of  the  disease,  but  the 
irritability  of  the  stomach  may  become  so  great  that  it  constitutes  a  genuine 
and  very  troublesome  complication.  In  such  cases  vomiting  is  very  frequent 
and  takes  place  after  every  slight  cough.  Loss  of  appetite,  indigestion,  and 
diarrhoea  are  common  complications,  the  latter  being  of  a  somewhat  chronic 
nature,  with  the  evacuation  of  considerable  mucus.  Prolapse  of  the  rectum 
may  result  from  the  violence  of  the  cough,  and  hernia  may  be  brought  about 
in  the  same  way. 

Hi^morrhages  from  various  parts  of  the  body  occur  during  the  paroxysms. 
Bleeding  from  the  nose  and  mouth  is  so  frequent  that  it  is  to  be  included 
among  the  symptoms  of  the  disease.  Subconjunctival  hsemorrhage  is  not 
uncommon.  Bleeding  from  the  ear  is  a  rare  complication  and  haemorrhage 
from  the  lungs  is  also  unusual.  Htematemesis,  in  which  the  blood  comes  origin- 
ally from  the  stomach  and  is  not  previously  swallowed,  is  certainly  exceptional. 
Haemorrhage  into  the  skin  occasionally  occurs.  Hi^morrhage  into  the  meninges 
or  within  the  brain  is  not  an  unusual  complication,  and  is  doubtless  the  cause 
of  many  instances  of  convulsions  and  other  cerebral  symptoms. 

Convulsions  are  a  dangerous  complication  and  are  not  infrequent,  particu- 
larly in  young  subjects.  A  persistent  spasm  of  the  glottis  may  sometimes 
cause  death.  Hemiplegia,  aphasia,  sudden  blindness  and  other  evidences  of 
cerebral  disturbance  may  be  occasional  complications. 

General  oedema  of  the  skin  has  sometimes  complicated  the  disease.  Acute 
nephritis  has  been  quite  often  reported. 

Whooping-cough  may  be  associated  with  diphtheria,  varicella,  scarlatina, 
or.  in  fact,  any  of  the  infectious  diseases,  but  particularly  with  measles.  The 
latter  combination  especially  renders  the  prognosis  more  unfavorable. 

Rachitis,  anemia  and  other  constitutional  maladies  may  complicate  per- 
tussis and  influence  its  course  unfavorably,  or  they  may  develop  as  sequels  to 
it.  Tuberculosis  is  a  sequel  very  liable  to  arise  in  those  who  are  predisposed 
to  it  or  whose  general  nutrition  has  greatly  suffered  during  the  first  disease.  Its 
usual  seat  is  the  bronchial  and  intestinal  glands  or  in  some  of  the  patches  of 
broncho-pneumonia,  but  from  these  foci  a  more  or  less  Avidely-spread  infection 
may  start.  Epilepsy,  various  paralyses,  aphasia,  blindness,  deaf-mutism  fol- 
lowing rupture  of  the  drum-membrane,  disseminated  sclerosis  and  other  con- 
ditions have  been  reported  as  occasional  sequels.  Some  of  them  are  to  be 
viewed  as  accidental  merely. 

Diagnosis. — In  the  early  stages  of  the  disease  the  diagnosis  can  seldom  be 
made  with  any  certainty.  The  absence  or  scarcity  of  physical  signs  in  the 
lungs,  combined  with  the  very  harassing  cousrh,  which  is  markedly  worse  at 
night,  renders  the  case  suspicious.  This  is  especially  true  if  whooping-cough  be 
prevalent  at  the  time,  or  if  there  be  a  history  of  exposui'e  to  contagion.  If  the 
cough  assume  a  decidedly  paroxysmal  character,  the  diagnosis  becomes  still 


WHO  OPING-  CO  UGH.  189 

more  probable.  The  occurrence  of  the  whoop  is  usually  conclusive,  and  even 
in  those  cases  where  this  at  no  time  develops,  the  nature  of  the  cough,  with 
such  attending  symptoms  as  vomiting,  injection  of  the  conjunctivae  and  the 
like,  makes  the  diagnosis  fairly  easy. 

Severe  acute  bronchitis  of  the  smaller  tubes  may  sometimes  be  attended  by  a 
very  spasmodic  cough  and  may  simulate  pertussis  closely  ;  but  the  presence  of 
numerous  rales,  Avith  decided  fever  and  dyspnoea,  and  the  absence  of  more  than 
a  slight  whoop  will  aid  in  distinguishing  it.  The  same  difficulty  in  diagnosis, 
and  for  similar  reasons,  may  exist  in  cases  where  pertussis  closely  follows 
measles,  since  the  severe  bronchitis  already  present  may  appear  to  account  fully 
for  the  severity,  and  even  the  paroxysmal  nature,  of  the  cough.  The  development 
of  broncho-pneumonia  during  the  first  stage  of  pertussis  may  render  the  later 
diagnosis  very  difficult,  since  it  is  apt  to  modify  greatly  the  character  of  the 
cough  or  even  to  prevent  entirely  the  occurrence  of  the  Avhoop.  Tuberculosis 
of  the  bronchial  glands  may  produce  a  paroxysmal  cough  much  resembling  that 
of  pertussis.  It  is  to  be  distinguished  by  a  history  of  previous  wasting  and 
ill-health,  the  chronic  course  Avithout  distinct  stages,  the  imperfect  development 
of  the  paroxysms,  which  are  unattended  by  abundant  mucous  expectoration 
or  vomiting,  and  the  presence  of  fever.  Sometimes  evidences  of  tuberculosis 
of  the  lungs  are  also  present.  A  prolonged  third  stage  of  pertussis  may  readily 
simulate  pulmonary  tuberculosis,  and,  indeed,  it  may  be  possible  that  the  latter 
disease  is  developing  as  a  sequel.  Only  the  later-  course  of  the  case  can 
decide. 

Prognosis  and  Mortality. — Although  the  prognosis  is  favorable  in  most 
cases,  yet  pertussis  is  a  far  more  dangerous  disease  than  is  ordinarily  supposed. 
In  England  and  Wales  120,000  persons  died  of  it  betAveen  the  years  1858  and 
1867,  and  85,000  succumbed  in  Prussia  betAveen  1875  and  1880.  Dolan  ranks 
it  third  among  the  fatal  diseases  of  childhood  in  England,  and  says  it  causes 
one-fourth  of  the  annual  mortality  among  children  in  London.  Smith  esti- 
mates that  during  fifty  years  there  Avere  4840  deaths  from  it  in  New  York  City, 
or  1  in  every  76  deaths  from  any  cause.  The  relative  mortality,  as  compared  with 
the  number  of  cases  of  the  disease,  is  also  larger  than  is  commonly  believed. 
Statistics  vary  regarding  it,  but  it  may  be  said  to  range  from  3  to  15  per  cent. 

It  is  upon  the  great  frequency  of  the  complications  that  the  high  rate  of 
mortality  depends,  for,  if  uncomplicated,  the  disease  is  not  often  dangerous.  The 
younger  the  child  the  more  unfavorable  is  the  prognosis.  The  mortality  is  very 
much  greater  under  two  to  three  years  of  age  than  after  this  period,  while  after 
the  fifth  year  it  is  trifling.  The  prognosis  is  rather  more  unfavorable  in  females 
than  in  males,  OAving  possibly  to  a  less  degree  of  strength  of  constitution  pos- 
sessed by  the  former.  The  patient's  previous  general  condition  and  the  amount 
of  care  received  Avhile  sick  affect  the  prognosis  very  materially.  The  children 
of  the  poor,  badly  nourished  and  neglected  as  they  so  frequently  are,  are  con- 
sequently apt  to  suffer  most.  Rachitis  or  any  other  constitutional  debilitating 
disorder  influences  the  course  of  the  disease  unfavorably.  The  presence  of 
the  winter  season  increases  the  danger  through  the  greater  liability  of  respira- 
tory complications.  On  the  other  hand,  the  heat  of  summer  brings  on  debili- 
tating intestinal  disorders.  As  already  stated,  convulsions  and  broncho- 
pneumonia are  frequent  and  dangerous  complications  and  the  cause  of  many 
deaths. 

Many  cases  pass  safely  through  the  attack,  but  die  from  the  sequelae.  Some 
become  marasmatic  and  die  without  the  exact  cause  being  discovered,  although 
many  of  these  are  undoubtedly  tubercular.  Other  cases  show  definite  symptoms 
of  tuberculosis  of  various  parts  of  the  body. 


190  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Treatment. — Prophylaxis. — In  view  of  the  highly  contagious  nature  of 
the  disease  prophylactic  treatment  should  be  carefully  carried  out.  Children 
who  have  not  yet  suffered  from  it  should  be  rigidly  kept  from  the  slightest  inter- 
course with  those  who  are  even  suspected  of  being  in  the  first  stage  of  the 
malady.  Inasmuch  as  there  exists  the  greatest  possible  carelessness  on  the  part 
of  parents  of  the  sick  regarding  the  danger  to  others,  it  is  better  that  unin- 
fected children  be  removed  entirely  from  the  neighborhood  Avhenever  feasible. 
Particularly  is  this  true  in  the  case  of  delicate  infants. 

How  long  the  danger  of  infection  continues  and  how  long  quarantine  must 
be  maintained  are  not  absolutely  certain.  It  is  admitted  that  the  infectiousness 
diminishes  durino;  the  third  stage,  and  it  mav  be  assumed  that  bv  the  end  of 
two  months  after  the  onset  of  the  disease  the  danger  has  entirely  ceased.  A 
still  better  criterion,  however,  is  the  entire  cessation  of  the  cough. 

If,  after  the  child  has  been  apparently'  entirely  well  for  a  brief  period,  the 
cough,  with  or  without  the  whoop,  returns,  it  is  probably  safe  to  consider  that 
the  risk  of  infection  is  over  in  spite  of  this.  It  often  happens  that  the  whoop 
will  thus  return  at  intervals  during  months,  or  even  for  a  year,  whenever  slight 
bronchitis  is  contracted.  Quarantine  during  this  entire  period  is  manifestly 
unnecessary  and  impossible.  The  same  is  true  of  those  cases  which  continue 
to  whoop  once  or  twice  a  day  for  an  indefinite  time.  In  such  we  may  consider 
that  after  two,  or  at  most  three,  months  the  disease  itself  is  over,  and  that 
simply  a  neurosis  remains:  the  "habit,"  so  to  speak,  of  whooping  persists. 

Although  Avhooping-cough  seems  in  nearly  every  instance  to  be  communi- 
cated by  the  breath  only,  yet,  to  avoid  the  possibility  of  transmission  in  other 
ways,  disinfection  of  the  clothing,  bed-linen,  and  the  like  should  be  carried  out 
systematically,  and  the  rooms  used  should  receive  a  final  disinfection  before 
being  inhabited  by  other  children. 

Treatment  of  the  Attack. — The  hygienic  treatment  of  pertussis  is  of  the 
utmost  importance.  Inasmuch  as  air  loaded  with  carbonic  dioxide  has  been 
proven  to  bring  on  paroxysms  of  cough,  children  should  be  kept  in  fresh  air 
as  much  as  possible.  At  the  same  time  the  very  great  sensitiveness  of  the 
respiratory  mucous  membrane  must  be  borne  in  mind,  and  all  possibility  of 
taking  cold  must  be  avoided.  In  winter,  therefore,  it  is  often  best  to  confine 
the  patient  to  the  house  except  on  dry  and  still  days.  Where  possible  it  is 
well  to  utilize  two  airy  rooms,  one  of  which  shall  be  thoroughly  ventilated  and 
then  warmed  while  the  other  is  in  use.  The  child  can  be  changed  from  one 
to  the  other  several  times  a  day.  The  clothing  should  be  warm  enough  to 
prevent  chilling  and  consequent  taking  cold.  The  food  should  be  nutritious, 
easy  of  digestion  and  assimilation,  and  frequently  administered  in  cases  where 
vomiting  is  a  prominent  symptom.  In  some  cases  of  this  kind  it  may  be  neces- 
sary to  employ  nutrient  enemata. 

It  sometimes  happens  that  change  of  climate  will  act  most  favorably  upon 
the  course  of  a  case  of  pertussis.  This  is  particularly  true  of  the  third  stage 
if  unusually  prolonged. 

The  host  of  remedies  recommended  for  pertussis  is  proof  in  itself  that  none 
of  them  constitute  an  infallible  cure.  Rather,  however,  than  decry  all  medi- 
cation, as  is  the  habit  with  some,  we  should  remember  that  negative  results  in 
the  hands  of  one  physician  cannot  vitiate  positive  results  with  any  certain 
method  of  treatment  in  the  hands  of  another  competent  observer.  Nothing  is 
more  certain  than  that,  although  no  medication  is  curative  in  all  instances, 
many  different  methods  of  treatment  are  of  undoubted  value  in  different  cases. 
Where,  therefore,  we  fail  with  one,  another  must  be  tried  in  the  effort  to  dis- 
cover the  remedy  useful  for  the  particular  case.     It  must  also  be  borne  in  vam^ 


WHOOPING-COUGH,  191 

that  to  test  the  value  of  a  remedy  we  must  give  it  in  sufficiently  large  dose, 
and  further  that  it  must  be  administered  at  the  height  of  the  disease,  and  not 
when  the  third  stage  has  already  commenced,  at  which  time  almost  anything 
may  seem  to  do  good. 

In  the  mild  cases,  where  paroxysms  are  but  few  and  of  little  severity,  it  is 
best  to  omit  all  medication  intended  to  control  the  disease,  and  simply  to  keep 
a  careful  supervision  over  the  patient.  In  severer  cases,  however,  treatment  is 
demanded.  The  condition  existing  in  each  individual  case, — and,  to  a  less 
extent,  the  stage  of  the  disease — will  exert  an  influence  upon  the  choice  of 
drugs  to  be  employed.  During  the  first  stage,  when  the  cough  is  hard  and 
tight,  with  little  expectoration  and  without  full  development  of  the  paroxysmal 
character,  the  medicines  to  be  selected  are  those  useful  in  an  ordinary  bronchial 
catarrh.  The  same  plan  of  treatment  may  be  needed  in  the  second  stage,  while 
in  other  cases  the  copious  expectoration  permits  the  freer  use  of  sedatives. 
But  inasmuch  as  the  cough  from  the  outset  does  not  depend  upon  a  simple 
bronchial  catarrh,  it  is  ofrener  better  to  begin  the  employment  of  remedies 
directed  against  the  peculiar  nervous  character  of  the  disease  as  early  in  the 
case  as  the  diagnosis  can  be  made.  This  need  not  interfere  with  any  symptom- 
atic treatment  indicated.  When  the  third  stage  is  well  under  way  attention 
must  be  paid  principally  to  the  accompanying  bronchitis.  Stimulating  lini- 
ments to  the  chest  may  be  useful,  and  tonic  remedies  are  often  demanded. 

An  attempt  to  consider  all  the  drugs  which  have  been  employed  for  the 
treatment  of  pertussis  would  be  so  much  a  waste  of  time  and  space  that  only 
the  most  important  of  them  can  be  mentioned  here.  Belladonna  is  one  of 
those  best  and  longest  known  and  most  widely  used.  Sometimes  doses  of 
moderate  size  suffice,  but  in  other  cases  it  is  necessary  to  give  it  in  increasing 
amounts  until  constitutional  effects  are  seen.  It  often  does  great  good,  and 
often,  too,  entirely  fails  to  relieve.  The  initial  dose  for  a  child  of  two  years  may 
be  two  minims  of  the  tincture  or  one-twelfth  of  a  grain  of  the  extract  three  or 
four  times  a  day.  Alum  is  sometimes  of  distinct  benefit,  particularly  when  the 
abundance  of  the  secretion  appears  to  be  the  cause  of  frequent  paroxysms.  It 
may  be  given  in  doses  of  two  grains  every  three  or  four  hours  at  two  years  of 
age.  It  may  sometimes  be  combined  advantageously  with  belladonna.  Quinine 
has  been  widely  used  with  varying  results.  On  the  whole,  it  may  be  con- 
sidered a  useful  remedy.  When  given  internally  the  doses  should  be  rather 
large — as  one  grain  every  two  to  four  hours  at  two  years  of  age — to  produce  an 
effect  upon  the  disease ;  but  there  is  risk  of  disturbing  the  digestion  with  it. 
It  may  be  administered  with  advantage  in  suppositories,  or,  if  by  the  mouth, 
disguised  in  syrup  of  verba  santa  or  syrup  of  licorice.  Chloral  is  often  use- 
ful to  produce  sleep  at  night.  Two  to  four  grains  may  be  given  at  bed-time 
to  a  child  two  years  old.  There  is  some  evidence  that,  administered  at  inter- 
vals during  the  day,  it  exerts  also  a  direct  influence  upon  the  course  of  the 
disease.  It  can  be  exhibited  either  by  the  mouth  or  by  enema.  Its  power  of 
depressing  must  not  be  forgotten.  Opium  is  frequently  of  the  greatest  service 
in  obtaining  temporary  relief.  Comparatively  restful  nights  can  often  be  pro- 
cured by  means  of  its  administration  at  bed-time..  It  should,  however,  be  re- 
served for  the  severest  cases.  Bromide  of  potassium  or  of  some  other  base  has 
been  much  recommended,  and  is  often  of  distinct  value.  It  lessens  the  nervous 
irritability,  and  in  this  way  diminishes  the  frequency  and  intensity  of  the 
paroxysms.  Its  administration  should  be  started  immediately  if  evidence  of 
nervous  disturbance  indicate  impending  convulsions.  The  dose  at  two  years 
of  age  may  be  two  to  five  grains,  repeated  according  to  the  demands  of  the 
case.     It  mav  often  be  advantageously  combined  with  belladonna.     Cannabis 


192   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Indica  has  been  much  used,  and  is  probably  one  of  the  most  reliable  means 
of  treatment.  Asafoetida  is  still  a  favorite  "vvith  many.  Carbolic  acid,  in  doses 
of  one  minim  at  two  years  of  age,  has  been  found  of  service  in  many  instances, 
but  its  toxic  properties  must  not  be  forgotten.  Peroxide  of  hydrogen  has 
been  highly  praised,  as  have  terpene  hydrate  and  infusion  of  wild  thyme. 
Ouabaine  has  been  highly  recommended.  The  dose  is  one-thousandth  of 
a  grain  every  three  hours  at  five  years  of  age.  It  is  a  powerful  respiratory 
paralyzer. 

Among  the  most  important  of  other  drugs  which  have  been  recommended 
for  internal  administration,  and  which  have  doubtless  proved  of  service  in 
some  cases,  are  pilocarpine,  lobelia,  resorcin,  grindelia,  castania,  drosera,  cam- 
phor, quebracho,  hyoscine,  turpentine,  benzole,  carbonate  of  iron,  and  conium. 

Antipyrine,  first  recommended  by  Sonnenberger,  has  been  used  with 
excellent  results  by  so  many  that  its  value  in  the  disease  is  now  beyond  ques- 
tion. Although,  like  other  remedies,  it  often  fails  to  relieve,  many  of  the 
reported  failures  with  it  are  doubtless  due  to  the  fact  that  it  was  not  given  in 
sufiiciently  large  dose.  Children  bear  it  surprisingly  well,  and  bad  results 
following  its  administration  are  rare.  The  initial  dose  should  be  small,  and 
the  amount  gradually  increased  until  a  child  two  years  old  receives  one  to  two 
grains,  or  even  more,  every  three  hours.  In  a  desperate  case  of  pertussis  in  a 
four-months-old  child  under  my  care,  in  which  three-quarters  of  a  grain  of 
antipyrine,  given  every  three  hours,  failed  entirely  to  relieve,  an  increase  of 
the  dose  to  one  grain  every  three  hours  rapidly  brought  the  patient  from  a 
condition  of  the  greatest  danger  to  one  of  comparative  health.  The  child  had 
suffered  from  very  frequent  and  violent  attacks  of  cough,  followed  by  spasm 
of  the  glottis  of  so  long  duration  that  intense  cyanosis  with  entire  apnoea  and 
loss  of  consciousness  repeatedly  resulted.  "Within  forty-eight  hours  after  the 
treatment  had  been  instituted  the  little  patient  had  passed  an  entire  night  and 
and  until  afternoon  on  the  next  day  with  but  a  single  paroxysm. 

Phenacetin  will  sometimes  be  of  service  in  cases  Avhere  antipyrine  has 
failed,  and  the  reverse,  of  course,  also  holds  good.  Acetanilid  has  sometimes 
proved  of  use,  but  is  less  often  employed  and  of  less  value  than  are  its  two 
cogeners. 

Bromoform,  one  of  the  newest  remedies  for  pertussis,  was  first  recom- 
mended by  Stepp  in  1889,  and  has  been  largely  used.  It. may  be  given  in 
doses  of  from  two  to  four  drops  three  or  four  times  a  day  at  two  years  of  age. 
It  can  be  dropped  upon  moistened  sugar  or  given  in  a  mixture  with  alcohol, 
syrup,  and  water.  My  experience  with  it,  although  satisfactory  to  some  extent, 
has  not  been  as  much  so  hitherto  as  published  results  had  led  me  to  hope.  Some 
cases  improved,  but  oftener  small  doses  failed  to  be  of  service,  Avhile  larger  ones 
rendered  the  patient  so  sleepy  and  stupid  that  the  remedy  had  to  be  abandoned. 
Nevertheless,  the  large  number  of  reported  cases  in  which  the  results  have  been 
extremely  good  indicate  that  the  remedy  is  certainly  of  great  value. 

Local  treatment  of  the  respiratory  mucous  membrane  has  been  largely  em- 
ployed. One  of  the  most  popiilar  methods  is  the  insufilation  of  quinine  in  the 
form  of  a  fine  powder.  This  may  be  applied  directly  to  the  larynx  by  the 
physician  twice  a  day,  or  nasal  insufflations  may  be  made  by  the  attendants 
several  times  daily.  Excellent  results  have  been  obtained  in  each  way. 
About  one  grain  of  quinine  should  be  used  at  a  time.  Resorcin  has  been 
highly  recommended  by  Moncorvo.  A  1  per  cent,  solution  may  be  applied  to 
the  pharynx  and  the  opening  of  the  larynx,  or  a  powder  may  be  insufflated 
into  the  nose,  using  one-half  to  one  grain  at  a  time  for  this  purpose  several 
times  each  day.     The  local  application  of  a  solution  of  cocaine  has  been  advo- 


WHO  OPING-  CO  UGH.  1 93 

cated,  but  is  not  without  danger,  as  reported  cases  have  shown.  It  has, 
however,  often  been  of  service  in  mitigating  the  severity  of  the  disease.  The 
solution  should  be  of  the  strength  of  from  1  to  4  per  cent. 

With  the  steam  or  hand-ball  atomizer  the  fauces  and  nares  may  be  sprayed 
with  the  substances  mentioned  or  with  a  weak  solution  of  morphia.  Bromide  of 
potassium  in  solution  is  sometimes  of  much  service,  and  tannin  can  be  employed 
in  the  same  way.  Peroxide  of  hydrogen,  in  the  dilution  of  one  part  in  five, 
may  be  sprayed  in  the  nares  and  upon  the  fauces,  and  very  excellent  results  have 
been  claimed  for  it. 

Benzoin,  boric  acid,  salicylic  acid,  iodoform,  tannin,  and  other  drugs,  in 
powdered  form,  have  found  their  supporters  as  useful  agents  for  nasal  insuf- 
flation. Benzoin  is  one  of  the  best  of  them.  Good  effects  can  also  be  secured 
with  boric  acid. 

Various  volatile  substances  may  be  used  with  the  atomizer  in  the  form  of 
vapor  from  boiling  water.  Carbolic  acid  is  one  of  the  best  of  these,  and  it  is 
often  of  great  advantage  to  allow  the  sick-room  to  be  permeated  by  it.  The 
action  upon  the  cough  is  probably  due  in  part  to  the  anaesthetic  effect  of  the 
carbolic  acid,  and  largely  to  the  influence  of  the  moist  atmosphere  of  the  room, 
which  loosens  the  mucus  and  facilitates  its  expectoration.  Thymol,  eucalyptol, 
and  turpentine  may  be  vaporized  in  a  similar  way.  Chloroform  and  ether  have 
been  recommended  for  their  general  anaesthetic  effect. 

Remarkable  results  have  been  reported  from  the  fumigation  of  the  sick- 
room by  burning  sulphur.  The  child  is  to  be  washed  in  the  morning,  dressed 
in  clean  clothes,  and  placed  in  another  room.  The  night-room  is  in  the  mean 
time  thoroughly  fumigated  with  the  sulphurous  vapor,  closed  during  five  hours, 
and  then  aired.  The  patient  sleeps  in  this  room  at  night.  A  single  employment 
of  this  procedure  has  been  effective  in  some  cases. 

The  inhalation  of  the  air  in  the  purifying-rooms  of  gas-works  is  a  method 
of  treatment  formerly  much  in  vogue.  The  employment  of  the  pneumatic 
cabinet  has  likewise  been  recommended.  The  use  of  the  constant  electric  cur- 
rent has  been  advocated  by  several  clinicians.  The  routine  administration  of 
emetics,  once  a  popular  procedure,  is  no  longer  in  favor. 

Complications  demand,  of  course,  treatment  applicable  to  them  individually. 

13 


TYPHOID  FEVER. 

By  F.  GORDON  MORRILL,  M.  D., 

Boston. 


Synonyms. — Enteric  fever;  Slow  fever;  Fall  fever;  Gastric  fever; 
Inftintile  remittent  fever. 

Definition. — An  acute,  infectious,  continued  fever,  due  to  a  specific  cause, 
and  characterized  by  prostration,  wasting,  enlargement  of  the  spleen,  inflam- 
mation of  Peyer's  patches  and  the  solitary  follicles  of  the  intestine,  and  an 
eruption  of  rose-colored  spots,  which  disappear  on  pressure  being  applied, 
and  return  rather  slowly  when  it  is  removed.  In  children  the  solitary  fol- 
licles rarely  ulcerate,  the  eruption  may  be  absent,  and  it  is  sometimes  impos- 
sible to  demonstrate  enlargement  of  the  spleen.  The  word  "  typhoid,"  first 
suggested  by  Louis  on  account  of  the  supposed  resemblance  of  the  disease  to 
typhus,  has  met  with  general  acceptance  in  America  and  England,  while  in 
France  the  term  "  dothienent^rie  "  is  frequently  used  by  those  who  object  to 
"typhoid"  as  misleading.  "Enteric  fever"  is  perhaps  preferable,  as  sug- 
gesting the  specific  lesions  of  the  disease,  and  is  frequently  employed  as  a 
substitute  for  the  original  name  by  precisians  or  by  medical  writers  for  the 
purpose  of  avoiding  constant  repetition. 

History. — Previous  to  1840  it  was  believed  that  children  were  exempt 
from  typhoid,  although  good  descriptions  of  cases  (some  with  autopsies)  had 
been  published  by  Abercrombie,  West,  and  others.  During  that  year,  how- 
ever, Rilliet  and  Taupin  published  results  of  separate  and  independent 
investigations  of  enteric  fever  in  children,  and  the  fact  of  their  susceptibility 
to  the  disease  has  since  then  become  generally  recognized.  Later  on  it  was 
proved  that  while  typhoid  is  rare  in  infancy,  it  may  occur  in  children  at  any 
age.  Even  so  close  an  observer  as  Bouchut  denied  in  1867  that  the  disease 
ever  occurred  during  the  first  year  of  life  ;  but  as  a  matter  of  fact  the  specific 
micro-organism  of  typhoid  has  been  found  in  the  liver  and  spleen  of  an  infant 
who  breathed  only  twelve  hours,  and  whose  birth  took  place  during  the 
fourth  week  of  the  disease  in  the  mother;  and  in  similar  instances  the 
specific  intestinal  lesions  have  been  discovered.  So  it  may  be  stated  that,  in 
childhood  at  least,  no  age  is  exempt. 

Etiology. — As  to  the  age  at  which  children  are  most  susceptible  to  the 
infection,  statistics  vary,  but  the  risk  probably  increases  from  birth  up  to  the 
tenth  year,  and  then  remains  about  the  same  until  puberty  is  attained.  The 
influence  of  sex  is  not  apparent,  although  more  boys  than  girls  find  their 
way  into  hospitals.  The  distribution  of  the  disease  is  quite  impartial,  no 
climate  being  exempt.  In  America  it  is  everywhere  the  prevailing  fever. 
The  influence  of  season  is  very  marked,  a  large  majority  of  cases  occurring 
during  the  late  summer  and  early  autumn  months.  A  dry  hot  summer 
increases  the  prevalence  of  typhoid — a  fact  which  Pettenkofer  attributes  to 
the  more  thorough  drainage  of  the  soil  into  wells  and  springs,  which  are  low, 

194 


TYPHOID  FEVER.  195 

and  the  water  of  "which  is,  of  course,  concentrated ;  while  Baumgarten  sug- 
gests that  at  such  times  the  poison  is  more  easily  disseminated  in  the  air. 
Neither  of  these  explanations  is  quite  satisfactory,  while  each  contains  an 
element  of  truth. 

Family  predisposition  to  contract  the  disease  is  not  infrequently  observed. 
A  marked  instance  of  this  susceptibility  is  cited  by  the  late  Charles  Warring- 
ton Earle  (in  his  article  on  typhoid  fever  published  in  the  first  edition  of  this 
book),  where  seven  persons  of  one  family  contracted  enteric  fever  by  visiting 
an  infected  room  or  nursing  other  cases  so  caused.  As  a  rule,  the  previous 
condition-  of  health  plays  but  an  insignificant  part  in  the  etiology  of  typhoid, 
Avhich  is  directly  caused  by  absorption  from  the  alimentary  canal  of  the 
specific  micro-organism  (named  after  its  discoverer,  Eberth),  which  is  a  short, 
thick  bacillus  with  rounded  ends  and  containing  glistening  spots  which 
remain  unstained  when  subjected  to  the  ordinary  process.  It  occurs  singly 
or  in  chains,  and  its  appearance  varies  in  accordance  with  the  medium  in 
which  it  is  grown.  The  variety  of  ways  by  which  different  authorities  say  it 
can  be  distinguished  from  the  bacillus  coli  communis  is  suggestive  of  the  fact 
that  there  is  a  great  liability  to  error ;  and  in  this  connection  it  is  proper  to 
state  that  it  is  claimed  that  the  Eberth  bacillus  has  been  found  in  the  fecal 
evacuations  of  persons  free  from  any  suspicion  of  typhoid,  and  who  had  never 
had  the  disease.  That  the  bacillus  is  often  swallowed  Avith  impunity  is  un- 
doubtedly true — the  soil  must  suit  the  seed,  as  in  other  infections.  Whether 
the  Eberth  bacillus  can  remain  inactive  in  the  alimentary  canal  for  any  con- 
siderable length  of  time,  and  then  suddenly  cause  disease  (as  does  the  Klebs- 
L5flfler  bacillus  in  the  throat  and  nose),  remains  to  be  proved.  Be  this  as  it 
may,  the  poison  finds  entrance  to  the  body  through  the  nose  or  mouth,  and 
usually  in  articles  of  food  or  drink. 

Water  that  has  been  contaminated  by  the  discharges  of  those  having 
the  disease  is  by  far  the  commonest  source  of  infection.  Examples  of 
this  contamination  through  cess-pools,  drains,  and  the  washing  of  excreta 
for  a  considerable  distance  into  streams  and  reservoirs  are  too  well  known 
to  bear  repetition  here.  In  Paris  the  river  Seine  has  a  firmly  established 
reputation  as  a.  conveyer  of  the  enteric  bacillus.  When  the  usual  sources 
of  supply  for  certain  quarters  of  the  city  fail,  Seine  water  is  substituted, 
and  an  epidemic  of  typhoid  follows  with  unfailing  regularity  in  the  course 
of  two  or  three  weeks  from  the  time  when  it  is  turned  on.  The  bacillus 
grows  rapidly  in  fresh  milk,  which  is  a  frequent  source  of  infection,  and  is 
sometimes  responsible  for  outbreaks  confined,  in  the  main,  to  children. 
Washing  the  cans  in  infected  water  is  the  usual  explanation  of  the  contami- 
nation. Any  article  of  food  or  drink  may  be  infected  by  the  person  having 
the  disease,  or,  indirectly,  through  carelessness  on  the  part  of  the  attendants. 
Oysters  may  absorb  the  micro-organism  from  drainage,  the  bacillus  retain- 
ing its  characteristics  perfectly  well  after  a  fortnight's  sojourn  in  sea-water. 
Freezing  does  not  destroy  its  vitality,  and  ice  may  thus  act  as  a  carrier  of 
the  disease. 

In  view  of  the  infinite  variety  of  ways  (food,  drink,  bedding,  toys,  books, 
utensils  of  all  sorts,  and  probably  the  air  we  breathe)  in  which  the  bacillus, 
moist  or  dry,  may  be  distributed,  it  is  a  matter  of  surprise  that  the  disease  is 
not  even  more  prevalent,  as  it  doubtless  would  be  if  every  one  swallowing  the 
poison  were  susceptible. 

After  entering  the  alimentary  canal,  the  micro-organism  penetrates  the 
mucous  membrane  and  gives  rise  to  profound  constitutional  disturbance, 
together  with  characteristic  changes  in  the  intestines  and  other  organs.     The 


19G     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

length  of  time  which  may  elapse  after  exposure  before  the  symptoms  mani- 
fest themselves  varies  within  wide  limits.  It  is  fixed  by  the  Clinical  Society 
as  "eight  to  fourteen,  sometimes  twenty-four,  days."  Liberal  as  this  rule 
is,  there  are  well-marked  exceptions  to  it.  In  a  recent  epidemic  near  Boston 
two  children  Avere  taken  obviously  sick,  with  what  proved  to  be  typhoid  fever, 
forty-eight  hours  after  drinking  for  the  first  and  only  time  infected  milk,  to 
which  the  source  of  trouble  was  clearly  traced.  In  other  instances  five  days 
covered  the  period  of  incubation  in  children,  and  a  somewhat  longer  period 
in  adults  of  the  same  families. 

Morbid  Anatomy. — The  post-mortem  appearances  which  enteric  fever 
causes  in  adults  will  be  mentioned  only  for  the  purpose  of  contrasting  them 
with  lesions  of  the  same  organs  as  observed  in  children. 

Rose  spots  usually  disappear  after  death,  while  accidental  eruptions 
(sudamina,  etc.)  persist. 

The  duodenum  may  be  slightly  congested,  while  the  changes  in  the 
jejunum  and  ileum  are  usually  due  to  hyperplasia,  and  not  (as  in  adults)  to 
ulceration.  Peyer's  patches  and  the  solitary  follicles  are  surrounded  by 
zones  of  congestion,  but  induration  is  rarely  perceptible  to  the  touch ;  in 
other  Avords,  the  congestion  is  not  sufficiently  intense  to  interfere  seriously 
with  the  blood-supply,  and  for  this  reason  ulceration,  except  to  a  slight 
degree,  is  seldom  present.  Whatever  the  intestinal  lesions  may  be,  they  are 
seen  in  greatest  number  in  the  immediate  vicinity  of  the  ileo-cnecal  valve. 

According  to  the  combined  statistics  of  Pfeiffer  and  Montmollin,  lesions 
of  the  intestinal  mucous  membrane,  varying  from  the  (usual)  superficial  con- 
gestion to  deep  ulceration  with  perforation,  were  present  in  72  per  cent,  of 
their  cases. ^ 

Ulcerations,  when  seen,  rarely  exceed  ten  or  twelve  in  number,  and 
their  superficial  character  contrasts  strongly  with  similar  lesions  in  adults, 
which  so  frequently  involve  the  submucosa,  and  may  be  so  confluent  in  the 
neighborhood  of"  the  ileo-caecal  valve  as  to  form  an  eschar  of  great  size. 
Instances  of  deep  ulceration  are  rare  in  children,  but  when  present  are  due 
to  the  same  process  as  in  adults,  which  reaches  its  height  in  eight  or  ten 
days,  and  then  undergoes  a  retrograde  change  or  produces  necrosis.  Retro- 
gression is  fortunately  the  rule  in  children,  and  ulceration  seldom  reaches 
the  muscular  coat  of  the  intestine,  which  in  adults  usually  constitutes  the 
floor.  Perforation  is  very  rare,  but  does  occur.  As  a  rule,  the  solitary 
follicles  do  not  ulcerate :  they  are  swollen  and  often  present  the  appearance 
described  by  French  writers — a  beard  of  two  days'  growth.  In  rare  in- 
stances they  ulcerate,  and  I  find  in  the  records  of  the  Boston  Children's 
Hospital  one  case  in  which  this  lesion  was  present  in  the  solitary  follicles  of 
the  caecum,  extending  several  inches  below  the  valve. 

The  mesenteric  glands  are  swollen,  particularly  in  the  vicinity  of  the 
ileo-cnecal  valve,  and  the  intensity  of  this  condition  does  not  necessarily  cor- 
respond to  the  extent  of  the  intestinal  lesions.  Peritonitis,  with  or  (rarely) 
without  perforation,  is  observed  very  exceptionally.  The  spleen  is  certainly 
of  normal  size  in  some  cases,  but,  as  a  very  general  rule,  is  swollen  and 
hyperaemic.  If  death  occurs  at  a  late  stage  of  the  disease,  it  may  be  soft, 
and  has  been  known  to  fracture  (ante-mortem)  on  palpation.  Hgemorrhagic 
infarcts  are  common.  The  liver  may  be  hyperfemic  and  enlarged  in  severe 
cases,  or  it  may  be  soft  and  the  bile  colorless ;  but,  as  a  rule,  hepatic  lesions 
are  slight  and  insignificant  as  compared  Avith  those  of  adults. 

'  It  must  be  borne  in  mind  that  this  estimate  applies  to  fatal  cases,  in  which  intestinal 
lesions  are  naturally  much  more  frequent  and  serious  than  in  those  who  survive. — F.  G.  M. 


TYPHOID  fever:  197 

The  brain  is  singularly  free  from  important  pathological  changes,  and 
even  in  cases  -svhere  nervous  symptoms  have  been  decidedly  marked,  nothing 
beyond  a  congestion  of  the  pia  mater  and  (to  a  slighter  degree)  of  the  brain- 
substance,  together  with  extremely  moderate  distention  of  the  arachnoid,  is 
observed.  The  heart  is  pale,  and  often  softened  by  granular  or  fatty  degen- 
eration of  its  muscular  fibres.  Passive  congestion  of  the  lungs  is  common, 
and  patches  of  broncho-pneumonia  of  the  deglutition  type  are  not  rare.  The 
kidneys  may  show  signs  of  granular  degeneration,  but  rarely  of  true  ne- 
phritis. The  voluntary  muscles,  particularly  the  pectorals,  recti  abdominis, 
and  adductors  of  the  thighs,  may  be  in  the  same  condition  as  those  of  the 
heart  just  described.  This  of  course  may  be  the  case  after  any  prolonged  sick- 
ness, and  is  not  peculiar  to  typhoid  fever. 

Ulcerations  of  the  laryngeal  cartilages,  periostitis,  osseous  necrosis,  and 
suppurative  parotitis  are  extremely  rare,  but  have  all  been  observed.  In  the 
case  Avhich  I  have  referred  to  as  appearing  in  the  Children's  Hospital  records 
Eberth's  bacillus  was  found  in  the  lungs  and  in  great  abundance  in  the 
spleen,  liver,  and  kidneys. 

Symptoms. — After  a  variable  time  from  the  date  of  exposure  the  child 
begins  to  lose  its  interest  in  play,  shows  signs  of  lassitude,  and  is  inclined  to 
lie  down.  Headache,  anorexia,  chills  or  chilly  sensations,  nausea,  epistaxis, 
pain  in  the  back  or  legs,  diarrhoea  (or  constipation)  may  be  present.  This 
condition  of  things  may  continue  for  a  week,  or  even  longer,  before  the  child 
takes  to  bed  and  is  obviously  sick.  More  rarely  the  onset  is  sudden  and 
accompanied  Avith  vomiting.  In  either  case,  in  the  absence  of  any  suspicion 
of  typhoid  infection,  the  patient's  condition  often  passes  as  the  result  of 
indigestion  or  having  '^  taken  cold."  But  the  usual  remedies  fail  to  give 
relief — the  symptoms  persist,  and  are  so  marked  as  to  make  it  evident  that 
no  temporary  indisposition  can  account  for  them  satisfactorily.  The  arbitrary 
date  of  the  commencement  of  the  '-run  "  of  the  fever  is  now  fixed. 

The  degree  of  constitutional  disturbance  which  typhoid  gives  rise  to  in 
children  is  usually  much  less  than  that  which  it  causes  in  adults ;  but  it  is 
sufficiently  well  marked,  as  a  rule  (in  America,  at  least,  where  the  abortive 
and  extremely  mild  types  are  comparatively  rare),  by  the  end  of  a  w-eek  to 
enable  one  to  make  a  diagnosis.  The  child  lies  with  flushed  cheeks  and  an 
expression  of  marked  apathy,  which  remains  present  until  the  fever  subsides, 
and  occasionally  for  days  after  the  temperature  has  become  normal.  The 
abdomen,  flat  at  first,  becomes  swollen  and  tender  on  pressure,  particularly 
in  the  right  iliac  fossa.  Sometimes  abdominal  pain  is  voluntarily  complained 
of.  The  spleen  is  apt  to  be  swollen,  and  its  lower  edge  can  be  felt  (usually 
below  or  under  the  false  ribs,  but  occasionally  more  toward  the  front)  in  a 
majority  of  cases.  Rose  spots  may  be  visible  on  the  abdomen,  the  lower 
portion  of  the  thorax,  the  inner  surfaces  of  the  thighs,  or  between  the 
shoulder-blades.  A  moderate  diarrhoea  may  be  present,  but  constipation  is 
more  frequently  the  rule  during  the  first  week  after  the  child  comes  under 
observation.  The  urine  is  scanty  and  high-colored.  Bronchitis  or.  rather, 
cough,  is  not  uncommon.  The  skin  is  usually  dry  and  hot,  but  perspiration 
is  exceptionally  observed  during  the  early  stage. 

The  lips  are  dry  and  scaly.  Sordes  may  collect  on  the  teeth  and  gums 
if  care  is  not  observed.  There  is  no  characteristic  appearance  of  the 
tongue,  Avhich  is  almost  always  moist,  red  on  the  tip  and  along  the  edges, 
and  coated  with  a  yellow  deposit  which  is  variable  in  thickness  and  distri- 
bution, sometimes  covering  the  entire  upper  surface,  or  being  confined  to  the 
anterior  half  or  to  the  lateral  portions  only..     Anorexia  is  complete,  but  the 


198     A2IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

child  takes  kindly  to  cool  liquids.  Sleep  is  apt  to  be  disturbed,  and  mild  delir- 
ium is  not  uncommon  during  the  night.  The  pulse  beats  from  120  to  140  per 
minute,  and  the  temperature  reaches  104°  to  105°  F.  (oftener  the  former)  at 
night,  -ft-ith  morning  remissions  of  1.5°  to  3°  F.  As  the  disease  progresses 
emaciation  becomes  marked.  Diarrhoea  and  abdominal  pain.  Avhich  may 
precede  or  follow  the  loose  discharges,  are  common,  but  constipation  may 
continue  until  the  case  terminates.  Attacks  of  nausea  lasting  two  or  three 
davs  may  occur;  Prostration  and  apathy  are  more  profound,  and  there  may 
be  retention  of  urine. 

Toward  the  end  of  the  second  week  of  the  child's  confinement  to  bed  in 
mild  cases,  or  a  few  days  later  in  those  of  average  severity,  the  tempera- 
ture begins  to  descend  by  lysis  (often  preceded  by  very  marked  morning 
remissions),  and  soon  reaches  the  normal  point.  Convalescence  now  begins : 
the  appetite  becomes  ravenous,  and,  if  no  relapse  occurs,  complete  recovery 
in  all  but  the  matter  of  physical  strength  soon  follows.  The  an?emic  pallor 
and  weakness  caused  by  enteric  fever  are  very  marked.  The  child's  first 
attempts  to  walk  with  its  attenuated  legs  bear  testimony  to  the  severe  con- 
stitutional disturbance  it  has  passed  through.  The  hair  falls  out  to  a  greater 
or  less  extent,  and  this,  together  with  a  perceptible  increase  in  height 
(typhoid  stimulates  the  growth  of  the  long  bones),  causes  the  patient  to  pre- 
sent a  curious  aspect. 

The  usual  features  of  an  average  case  having  now  been  roughly  outlined, 
special  symptoms  and  complications  will  be  considered : 

Relapse. — A  recrudescence  of  fever  from  no  apparent  cause  is  not  un- 
common. It  is  apt  to  occur  a  very  few  days  after  the  beginning  of  convales- 
cence, and  usually  lasts  a  day  or  two  only.  True  relapse,  due  to  reinfection 
after  a  perceptible  period  of  apparent  convalescence,  is  usually  of  sudden 
onset,  and  occurs  with  varying  frequency  in  different  epidemics.  At  the 
Boston  Children's  Hospital  17  per  cent,  of  100  recorded  cases  have  had  a 
relapse  on  the  (average)  thirty-third  day  after  the  first  symptoms  of  the  orig- 
inal attack  were  noted.  The  mean  duration  of  these  relapses  was  seventeen 
days.  Of  those  affected,  V2  were  girls  and  5  were  boys — a  fact  which  cor- 
roborates, in  a  modest  way,  Montmollin's  statement  that  the  frequency  of 
relapse  is  influenced  by  sex.  As  a  rule,  the  relapse  is  neither  so  long  nor  so 
grave  as  the  original  fever,  but  occasionally  it  may  be  severe  enough  to  cause 
death.  A  second  relapse  may  occur.  This  happened  in  4  of  the  17  cases  I 
have  referred  to,  and  all  of  them  recovered.  Instances  of  a  third  relapse 
have  been  recorded — the  greatest  number  which  I  have  seen  mentioned  in 
connection  with  the  typhoid  fever  of  childhood.  Intercurrent  relapses  are 
not  very  uncommon,  and  an  unusually  prolonged  pyrexia  may  often  be 
accounted  for  in  this  way.  The  symptoms  of  relapse  differ  in  degree  only 
from  those  which  the  patient  has  already  had. 

Respiratory  System. — Epistaxis  is  rather  common,  and  of  no  importance 
save  from  a  diagnostic  standpoint.  It  Avas  noted  in  5  per  cent,  of  70  cases 
by  Forchheimer,  and  in  20  per  cent,  of  the  100  cases  which  I  have  mentioned. 
Cough  is  frequent,  and  is  usually  caused  by  slight  bronchial  catarrh  or 
some  ordinary  affection  of  the  upper  respiratory  tract :  I  find  it  noted  in  36 
per  cent.  Well-marked  signs  of  bronchitis  are  somewhat  rare.  Broncho- 
pneumonia (often  of  the  deglutition  variety)  occurred  in  7  per  cent.,  and  in 
1  fatal  case  the  Eberth  bacillus  was  found  in  the  inflamed  lobules.  Conges- 
tion of  the  bases  is  usual  in  prolonged  cases,  and  would  be  even  more  common 
if  children  did  not  voluntarily  change  position  far  oftener  than  do  adults. 
Frank  pneumonia  is  extremely  rare,   although  typhoid  patients  are  by  no 


TYPHOID  FEVER.  199 

means  proof  against  other  infections.  Ulceration  of  the  vocal  cords  and 
necrosis  of  the  laryngeal  cartilages,  with  resulting  stenosis,  have  been  observed. 
The  ordinary  forms  of  sore  throat  are  common  enough,  and  diphtheria  can  be 
readily  contracted  during  the  course  of  enteric  fever. 

Digestive  System. — The  lips  are  dry  and  apt  to  crack  if  the  child  is 
allowed  to  pick  at  them.  Herpetic  eruptions  are  not  common.  The  gums 
may  be  soft  and  swollen.  The  brown  tongue  so  often  observed  in  adults  is 
seldom  seen.  The  organ  may  be  dry  and  red,  but  soreness  is  seldom  present. 
The  bowels  are  usually  constipated  at  first,  and  diarrhoea  is  apt  to  come,  if  at 
all,  during  the  second  week.  There  may  be  seven  or  eight  discharges  in 
tAventy-four  hours,  which  may  or  may  not  be  of  the  familiar  "pea-soup" 
variety.  This  condition  usually  subsides  rather  slowly  under  appropriate 
treatment,  but  is  apt  to  recur.  Involuntary  discharges  are  rare  excepting  in 
very  young  children.  Abdominal  pain  on  pressure  increases  during  the 
second  week.  Intestinal  haemorrhage  (as  would  be  naturally  expected  from 
the  rarity  of  deep  ulceration)  is  seldom  observed.  It  was  noted  in  4  per  cent, 
of  the  100  cases  mentioned.  In  2  of  these  it  consisted  of  small  quantities  of 
blood  passed  with  each  evacuation  for  several  days,  and  both  recovered.  In 
1  instance  it  was  slight,  but  the  case  was  one  of  intense  typhoid  infection,  with 
many  lesions  of  the  internal  organs,  and  the  bleeding  caused  death  from  ex- 
haustion. An  autopsy  failed  to  reveal  the  vessel  from  which  the  blood  had 
escaped,  in  spite  of  a  very  careful  and  prolonged  search.  In  the  fourth  case 
two  profuse  hgemon-hages,  which  occurred  within  twenty-four  hours,  were 
speedily  followed  by  perforation,  peritonitis,  and  death.  Perforation  (said 
to  be  more  common  than  hgemorrhage)  is  rare.  Professor  d'Espine  (of  Geneva) 
has  seen  but  one  case.  It  is  apt  to  occur,  if  at  all,  at  a  late  stage  of  the  dis- 
ease, and  has  been  observed  in  one  instance  five  weeks  after  the  beginning 
of  convalescence.  Peritonitis  without  perforation  has  been  observed  by  J.  C. 
Wilson,  J.  Simon  (of  Paris),  and  other  leading  authorities,  but  is  extremely 
rare.  Usually  it  is  the  direct  result  of  perforation,  and  if  the  rupture  takes 
place  at  a  point  which  is  in  contact  with  a  solid  viscus  or  a  coil  of  intestine, 
the  peritonitis  may  be  limited  and  recovery  follow.  Otherwise  the  contents 
of  the  alimentary  canal  escape,  and  speedily  cause  acute  general  inflammation 
of  the  peritoneum  (accompanied  by  pallor,  clammy  sweats,  abdominal  disten- 
tion, small  and  frequent  pulse),  which  proves  quickly  fatal.  Enlargement 
and  suppuration  of  the  parotid  gland  have  been  observed  by  various  author- 
ities. 

The  Shin. — Rose  spots,  if  present,  usually  make  their  appearance  within 
a  week  after  the  disease  is  fairly  established.  As  a  rule,  they  are  not  so 
well  marked  in  children  as  in  adults,  and  are  less  common  and  numerous  in 
America  than  in  Europe,  where  an  abundant  eruption  is  regarded  as  a  good 
omen.  Ashby  and  Wright  state  that  they  are  absent  in  only  25  per  cent, 
of  all  (English)  cases.  I  find  them  noted  in  53  per  cent,  on  the  (average) 
twelfth  day  after  the  first  appearance  of  any  symptoms  of  the  disease.  In  rare 
instances  they  are  seen  during  a  relapse,  when  careful  daily  investigation  has 
failed  to  discover  them  during  the  original  attack.  Furunculosis  may  occur 
at  a  late  stage  or  during  convalescence.  Sudamina  and  eruptions  resembling 
rose  spots,  but  failing  to  disappear  under  pressure,  are  common — more  par- 
ticularly the  latter.  The  nails  become  fissured  transversely  from  temporary 
cessation  of  growth.  Wilson  mentions  a  faint  difiuse  erythema  of  the  legs 
during  the  first  Aveek.  Acute  otitis  media  with  perforation  (unless  relieved 
by  incision)  occurs  in  a  certain  percentage  of  cases,  and  this  may  or  may  not 
influence  the  range  of  the  temperature.     In  40  cases  which  entered  my  wards 


200     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILD  REX. 

during  the  fall  of  1896,  it  was  observed  5  times.  Bed-sores  are  easily  avoided, 
except  in  the  severest  cases. 

The  Spleen. — It  is  probable  that  the  spleen  is  enlarged  to  some  extent 
in  all  cases  at  some  period  of  the  disease,  although  this  cannot  always  be 
demonstrated  bv  percussion  or  palpation.  The  fact  that  this  organ  has  been 
found  to  be  of  normal  size  in  a  few  cases  which  have  been  autopsied  is  no 
proof  that  it  had  not  been  enlarged  during  the  acute  stage  of  the  fever.  To 
palpate  the  spleen  the  child  is  made  to  lie  upon  its  right  side,  with  the  knees 
flexed  and  drawn  up,  and  the  fingers  are  gently  but  firmly  pushed  upward 
under  the  false  ribs  ;  then,  if  the  patient  can  be  induced  to  take  a  deep  breath, 
the  lower  edge  can  often  be  felt.  Percussion  of  the  organ,  unless  the  results 
are  corroborated  by  palpation,  is  not  satisfactory.  In  40  recent  cases  at  the 
Children's  Hospital  the  spleen  was  palpable  in  23.  The  enlargement 
usually  disappears  very  soon  after  the  temperature  becomes  normal.  If 
it  remains,  relapse  may  be  expected.  Splenic  enlargement  is  of  course 
not  peculiar  to  enteric  fever,  but  may  be  present  in  any  infectious  disease. 
Bartholow  cites  a  case  of  rupture  of  the  organ  from  slight  violence,  and  the 
fact  that  at  autopsies  it  has  been  sometimes  found  to  be  a  mere  bag  of  pulp 
shows  the  possibility  of  such  an  accident  being  caused  by  too  vigorous  efforts 
to  detect  a  symptom  which  is  rarely  essential  to  enable  one  to  distinguish 
typhoid  fever  from  other  diseases.  Hepatic  enlargement  is  very  seldom  of 
sufficient  extent  to  be  noteworthy. 

The  Urine. — Ehrlichs  diazo  reaction,  a  description  of  which  is  hardly 
needed  here,  has  been  found  present  in  186  of  196  cases  of  enteric  fever 
(Osier).  Its  diagnostic  value  is  much  impaired  by  the  fact  that  it  is  not 
infrequently  seen  in  other  acute  febrile  affections.  In  50  selected  cases 
Dr.  J.  Bergen  Ogden  of  Boston  found  that  the  reaction  was  present  between 
the  (average)  fourteenth  and  twentieth  days  of  the  disease,  and  remained  so 
for  from  six  to  eight  days. 

Xervous  Sjjstem. — Complete  indifference  to  surroundings  is  the  rule,  and 
delirium,  if  present,  is  usually  of  a  mild  and  harmless  type.  Occasionally  a 
child  will  try  to  get  out  of  bed,  and  is  somewhat  difficult  to  manage,  and 
mechanical  restraint  is  required  in  rare  instances.  Mild  delirium,  associated 
perhaps  with  night-terrors,  is  not  at  all  unusual,  and  is  easily  controlled  by 
appropriate  means.  Trembling  of  the  hands  and  twitching  of  the  facial 
muscles  are  rare.  I  have  seen  this  in  the  form  of  a  one-sided  affection,  and 
the  movements  resembled  those  of  chorea.  Retention  of  urine  is  less  com- 
mon than  in  adults.  Hypernesthesia  of  the  lower  extremities  and  pain  in  the 
feet  and  ankles  are  sometimes  observed,  but  any  marked  degree  of  peripheral 
neuritis  is  extremely  rare ;  and  the  same  may  be  said  of  cerebral  meningitis. 
Ominous  brain-symptoms  (active  delirium,  intense  cephalalgia,  strabismus, 
vomiting,  and  retraction  of  the  head)  have  been  known  to  disappear  in  a  few 
days.  Mental  disturbances  (delusions,  melancholia,  etc.).  which  appear  in 
exceptional  cases  during  the  course  of  enteric  fever,  sometimes  continue  long 
after  convalescence  has  been  established,  but  they  tend  to  disappear  as  the 
childs  strength  becomes  restored,  and  seldom  last  more  than  a  few  weeks. 
Transitory  aphasia  and  hemiplegia  have  been  noted  at  a  late  period  of  the 
disease.  It  may  be  said,  in  a  general  way,  that  all  nervous  symptoms  occur- 
ring during  typhoid  in  children  are  likely  to  disappear  in  time. 

The  Heart  and  Pulse. — Slight  myocarditis  with  a  feeble  apex-beat  and 
softened  first  sound,  accompanied  by  a  feeble  and  perhaps  dicrotic  pulse, 
are  common.  In  severe  cases  the  pulse  intermits  or  becomes  irregular,  and 
in  those  in  which  the  condition  of  the  heart  is  the  direct  cause  of  death  the 


TYPHOID  FEVER. 


201 


sounds  may  assume  a  foetal  rhyttim,  which  precedes  a  fatal  termination  for  a 
day  or  two  only.  The  average  rate  of  the  pulse  is  from  120  to  150,  and  its 
curve  quite  closely  follows  that  of  the  temperature  on  the  chart.  A  slow 
pulse  with  a  high  temperature  is  occasionally  observed  for  a  day  or  two,  but 
the  reverse  is  extremely  rare.  In  3  of  the  cases  which  I  have  mentioned  a 
pulse  of  180  was  recorded,  and  2  of  them  proved  fatal.  Endocarditis  and 
pericarditis  are  seldom  seen. 

Temperature. — It  is  said  that  the  temperature  during  the  initial  stage 
lacks  the  characteristics  which  are  of  such  essential  aid  to  the  diagnosis  of 

Fig.  1. 


DAYS   OF 
MONTH 

20 

21122 

23 

24 

25 

26 

27 

28 

29 

30 

1 — 
1 

2 

3 

4  i  5  1  C 

7 

3 

"I    ['  1  '  [   'i  '■']■"!         ill         ■ 

9    10ln:12|l3  1415'16:17)18[19;20  2l!22j23  21  25 

DAYS  OF 
DISEASE 

1 

2 

3 

i 

5 

6 

- 

S 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23  24 

25:26 

27 

28 

29 

30 

31 

32 

3. 

34 

35 

107° 
106° 
105° 
101° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 

s 

£{ 

5 

K 

A 

A 

f 

« 

A  A 

X 

A^ 

/  ^ 

s 

' 

< 

M 

\/\ 

A 

\/\ 

A 

y^ 

\/ 

^ 

/ 

i/^ 

i/ 

^A 

/ 

i/ 

/ 

» 

V 

V 

V 

H 

\ 

A 

A 

« 

A 

/ 

V 

I 

^ 

r 

V 

L 

\\, 

Ar^' 

\\\\\\. 

A 

\ 

/ 

V 

vv 

H 

A/ 

\  /^v 

U 

s 

V  !V 

III 

Ljt; 

n 

{    1 

Showing  temperature  of  initial  stage.    (Boy  aged  5  years.) 

enteric  fever  in  adults,  but  an  instance  in  which  an  accurate  record  of  the 
temperature  was  kept  for  several  days  before  the  diagnosis  was  made  does 
not  confirm  this  statement.  As  may  be  seen  by  reference  to  Fig.  1,  the  tem- 
perature rose  steadily  and  reached  102°  F.  in  forty-eight  hours,  Avhen  morn- 
ing remissions  promptly  occurred,  while  the  evening  temperature  continued 
to  mount  higher.     The  remissions  average  about  1.5°  F.  after  the  disease  is 

Fig.  2. 


DAYS   OF 
DISEASE 

8 

9  |10il]H2|13:14 

15  16  17 

18 

19 

— 1 
20 

21 

22 

23 

24 

107° 
106° 
105° 
104" 
103° 
102° 
101° 
100° 
99° 
98° 

1 

k 

A 

i 

\f\ 

r 

L 

r 

/ 

V    V 

^    A   A 

A 

/ 

Ir 

ni 

i/^ 

/ 

/ 

i 

V  y  vy  f  "^ry^ 

I 

/ 

'■'             ^     '     X 

/ 

\ 

M       li 

_ 

_ 

Showing  marked  morning  remissions  during  the  last  days  of  a  short  case,  also  slight  recrudescence  oi 

fever.    (Boy  aged  6  years.) 

fairly  established,  and  may  be  counted  on  with  a  considerable  degree  of  cer- 
tainty. During  the  few  days  preceding  convalescence  they  often  cover  from 
2°  to  3°  F.,  this  corresponding  (to  a  degree  which  the  comparative  insig- 
nificance of  the  intestinal  lesions  would  lead  one  to  expect)  to  the  second 
stadium  as  seen  in  adults.  During  this  short  stage  of  marked  remissions  the 
morning  temperature  may  be  normal  for  two  or  three  days  before  convales- 


202     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


cence  is  attained,  as  shown  in  Figs.  2  and  3.  Lysis  is  the  general  rule, 
but  occasionally  the  termination  is  somewhat  abrupt,  as  it  is  apt  to  be  in  the 
abortive  cases  of  adults.  The  average  highest  temperature  observed  in  100 
cases  at  the  Children's  Hospital  was  10-1:.5°  F.,  and  this  was  noted  on  the 
(average)  twelfth  day  from  the  first  appearance  of  symptoms.     The  extremes 


Fig.  3. 


DAYS   OF 
MONTH 

26 

27 

28 

29 

30 

31 

1 

2 

3 

i 

5 

6 

7 

8 

9  ilO 

u 

12 

13  U 

15 

DAYS  OF 
DISEASE 

5 

G 

7 

8 

9 

10 

11 

12 

13 

U 

15 

16 

17 

18 

19 

20 

21 

22 

23 

2i 

25 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98" 

-1 

/ 

A 

1^ 

1 

1 

r^ 

/ 

\/\ 

J  J 

L  A  A 

/ 

A 

K 

l/ 

rj  vv 

r 

/ 

\n 

r 

•1 

i 

V 

1 

y 

A 

A 

A 

If 

/' 

/ 

/ 

A 

A 

f 

/ 

/ 

P 

7 

\a 

/ 

1 

V 

yr 

/ 

1 

Showing  morning  remissions  a  few  days  before  convalescence.    (Boy  aged  12  years.) 

were  101°  and  107.8°  F.,  the  latter  case  recovering.     In  5  of  7  fatal  cases  a 
temperature  of  105°  F.  or  more  was  reached. 

As  regards  the  duration  of  the  fever,  a  normal  morning  temperature  was 
observed  on  the  (average)  twenty-fourth  day,  and  a  normal  evening  tempera- 
ture on  the  (average)  twenty-ninth  day  after  the  first  appearance  of  symp- 
toms. This  of  course  applies  to  pyrexia  as  a  symptom  per  se,  and  not  to  the 
child's  general  condition,  convalescence  being  not  infrequently  well  under- 
way before  an  absolutely  normal  temperature  could  be  recorded.  A  fall  of 
temperature  accompanies  any  considerable  h?emorrhage.  Fig.  4  shows  the 
descent  attending  two  evacuations  of  coffee-colored  blood  (at  least  eight  ounces 

Fig.  4. 


1 

i 

1 

' 

1 

r, 

1 

^V 

^y 

^ 

^^A 

*X^ 

X 

^v\ 

f 

X 

^^ 

r 

\ 

12 

4 

8 

12 

4 

8 

12 

4 

8 

12 

4 

a 

12 

4 

a 

12 

4 

a 

12 

4 

8 

12 

S 

< 

1 

i 

^ 

\ 

A 

f 

\ 

h 

\ 

y 

^ 

f 

»^ 

\ 

/ 

\ 

V 

/ 

V 

/ 

1 

/ 

1 

If 

V 

I 

li 

^^ 

1 

Showing  sudden  faU  of  temperature  after  eacli  heemorrhage.    (Boy  aged  10  years.) 

each  time)  occurring  on  successive  days.  In  one  instance  a  sudden  depres- 
sion (6.8°  F.)  from  no  apparent  cause  was  noted,  and  slow  recovery  followed. 
Examination  of  a  number  of  four-hour  charts  of  cases  in  which  neither  anti- 
pyretics nor  cold  baths  were  used  shows  that  during  the  acute  stage  the 
lowest  temperature  is  recorded  at  8  a.  m.,'  and  the  highest  from  twelve  to 


TYPHOID  FEVEB, 


203 


fourteen  hours  later.  A  slight  remission  occurs  after  micldav  and  midnight. 
Fig.  5  sho^vs  the  tempera- 
ture, pulse,  and  respiration 
of  a  case  of  double  relapse, 
together  with  the  number  of 
evacuations  daily,  the  pati  ent 
eventually  recovering. 

Diagnosis. — It  is  usually 
a  sufficiently  easy  matter  to 
recognize  enteric  fever  in  a 
child  when  the  disease  has 
become  fairly  established, 
but  during  the  first  four  or 
five  days,  in  the  absence  of 
other  cases  in  the  neighbor- 
hood, it  is  frequently  impos- 
sible. The  symptoms  may 
correspond  to  those  caused 
by  digestive  troubles,  or  by 
some  fancied  exposure  to 
"taking  cold."  or  by  ephem- 
eral fever  due  to  an  unknown 
cause.  In  hospitals  the  pa- 
tient is  seldom  seen  until 
there  is  good  evidence  of 
serious  illness.  The  diseases 
with  which  typhoid  is  most 
likely  to  be  confounded  are 
—  tuberculous  or  epidemic 
meningitis,  acute  miliary 
tuberculosis  without  brain- 
symptoms,  frank  pneumonia, 
and  malaria.  Tuberculous 
meningitis  is  liable  to  oc- 
cur in  hospital  patients 
under  constant  observation 
for  disease  of  the  hip  or 
spine,  and  the  records  of 
cases  of  this  kind  show  that 
night-cries,  a  well-marked 
tache  cerebrale,  and  in- 
equality of  the  pupils  (aside 
from  the  peculiarities  of 
pulse  and  temperature)  are 
the  earliest  signs  Avhich  are 
of  essential  aid  in  making 
a  diflFerential  diagnosis.  Ep- 
istaxisand  bronchial  catarrh 
are  of  diagnostic  value  in 
favor  of  typhoid,  while 
vomiting  and  headache  are 
more  persistent  in  tuber- 
culous meningitis.     The  temperature  of  an  established  case  of  enteric  fever 


Fig.  5. 

3 
< 

RESPIRATIONS 

PULSE 

TEMPERATURE 

3> 

S  g  g  s  s  S 

0  S  0  3  0  0 

^,  5c^  -3.  S  ^  S^  S^  -^^  Si_  S_  5_ 

lO 

- 

"--^^ 

s 

^ 

- 

lo 

^ 

*^ 

-^ 

^ 

^ 

J 

^ 

s 

S 

" 

!i; 

r 

r 

^ 

z. 

CT 

\ 

i 

s 

5 

s 

- 

•  '   I 

y 

s 

s 

li 

- 

*^ 

*=~>, 

<^ 

.<! 

ir. 

^ 

"=^-._^ 

^^ 

OC 

_^_ 

5JJ 

> 

<^ 

-^ 

5 

/• 

<; 

'£ 

- 

M 

s 

S 

S 

- 

^ — --5, 

r 

^^. 

g 

K 

S 

r 

k. 

^ 

^c 

- 

n- 

k 

<-. 

^ 

ii 

- 

< 

^ 

' ^ 

g 

CT 

<. 

^ 

"^ 

a 

-- 

1 

^ 

s 

.-J 

-' 

* 

r — ^ 

1       ^ 

<! 

:Z 

'■>■- 

* 

'^ 

!      '         "i*.,^^ 

s 

s 

^ 

Ji 

J 

:            J^ 

^ 

s 

0 

J- 

^ 

*~"~x 

s 

ii 

= 

Q 

J 

^ 

K 

^ 

f 

S 

"=~— 3. 

2 

S 

o. 

?^ 

7*- 

"^■^s. 

^ 

:r 

U 

\ 

^ 

^ 

5 

5 

10 

> 

^ 

^ 

s 

s 

IS= 

7 

y 

^ 

rj 

n 

a= 

^ 

^ 

s 

oc 

Ni 

\ 

^ 

"=^— ~, 

£ 

0 

M 

s 

\  1 

1 

J 

£ 

s 

^ 

/ 

1 

1  J 

"^^ 

= 

t 

o 

< 

1 

!^ 

<> 

^c 

tc 

o 

<> 

■^  : 

n 

'& 

>o 

<" 

•<~^ 

"^  '       '    ' 

:; 

s 

-. 

^ 

J 

^ 

s 

fe 

ro 

/' 

s 

<. 

~ 

g 

o. 

\ 

V 

> 

•^ 

" 

- 

y 

r^ 

^ 

s 

ac 

^D 

\ 

< 

< 

s 

S 

/ 

C 

J 

c 

0 

ro 

\ 

^ 

^ 

zl 

" 

'     r 

-> 

tz 

K 

i. 

\ 

<^ 

-i 

- 

^ 

/ 

IS 

;     M 

£; 

'- 

7 

\ 

1   I 

'rv  1  h  ;  ■ 

ci 

C3 

^ 

\ 

\ 

i   i 

\i  1 

g 

= 

- 

r> 

] 

y 

ri 

.^ 

- 

^ 

( 

i 

2: 

zr. 

CC 

- 

^ 

<>    '  ' 

-^ — ~„ 

s; 

= 

■^ 

■? 

^ 

s 

c 

^ 

^ 

^ 

^ — ' 

i^    ■ 

i: 

:: 

io 

^^1 

1 

^\ 

1 

<> 

g 

Jo 

=. 

511 

< 

1  i 

\   -= , 

S 

10 

u 

/  1  1 

s^ 

1  i 

^ 

= 

:;: 

Ji 

^ 

^ 

1^ 

5 

Ci 

iJ 

^ 

<^ 

t 

1    y   : 

§ 

s& 

^ 

y 

z 

1 

^ 

r; 

.^ 

J. 

•s 

^ 

7 

i 

CC 

J. 

( 

y 

1    1 

'   '        \ 

£ 

= 

- 

^ 

^ 

\ 

S 

s 

_ 

N 

7^ 

j.,-"^ 

i 

i; 

ro 

^ 

^ 

^ 

^ 

tc 

- 

< 

^ 

^ 

s 

- 

J 

1 J 

< 

> 

r; 

K 

- 

C 

fi 

-J 

a 

^ 

^ 

J? 

1 

~ 

= 

ro 

^ 

) 

i:^ 

.-» 

- 

N 

-J 

CC 

y 

rJ 

cs 

:; 

i   , 

= 

0 

howing  respiration,  pulse,  and  temperature  of  a  case  with  double 
relapse.    (Boy  aged  8  years.) 


204     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

diifers  from  that  of  a  beginning  tuberculous  meningitis,  -which  is  very  irreg- 
ular and  seldom  reaches  104°  F.  until  unmistakable  signs  of  brain-trouble  are 
present.  A  very  quick  pulse  with  a  low  temperature  is  common  enough  in 
tuberculous  meningitis,  but  rare  in  typhoid,  in  which  disease  the  pulse  follows 
(juite  closely  the  temperature-curve  on  the  charts.  Irregularity  of  the  respi- 
ratory rhythm  is  sometimes  observed  in  tuberculous  meningitis.  In  any  event, 
a  tapping  of  the  spinal  arachnoid  or  an  examination  of  the  blood  (to  be  spoken 
of  later  on)  soon  clears  up  cases  which  may  remain  doubtful  in  the  absence 
of  other  Avell-marked  diagnostic  signs. 

The  onset  of  well-marked  cerebro-spinal  fever  is  sudden,  and  accompanied 
by  intense  cephalalgia,  dilated  or  contracted  pupils,  which  fail  to  respond  to 
light,  and  retraction  of  the  head  and  neck — symptoms  rarely  present  in  the 
typhoid  of  children,  and  almost  never  in  the  early  stage  of  the  disease.  As 
a  matter  of  fact,  one  is  much  more  apt  to  mistake  a  "  cerebral  "  frank  pneu- 
monia for  cerebro-spinal  meningitis  than  the  latter  for  an  enteric  fever. 

In  acute  general  tuberculous  infection  the  abdomen  is  usually  flat,  the 
temperature  irregular,  while  the  family  history  of  the  patient  and  the  pres- 
ence of  enlarged  superficial  glands  may  aid  in  diagnosis.  Bronchial  catarrh 
is  common  to  both  miliary  tuberculosis  and  typhoid,  and,  so  far  as  the  spleen 
is  concerned,  a  considerable  enlargement  may  be  present  in  either.  Rose 
spots,  epistaxis,  and  splenic  enlargement  may  all  be  absent  in  enteric  fever, 
and  the  resemblance  to  general  tuberculosis  may  be  so  close  that  only  an 
examination  of  the  blood  can  conclusively  settle  the  question. 

Malaria  in  children  is  very  apt  to  be  accompanied  by  quotidian  (double 
tertian)  paroxysms,  which  may  cause  it  to  be  confounded  with  typhoid.  But 
the  absence  of  rose  spots  and  abdominal  tenderness,  together  wuth  the  effect 
of  one  fair-sized  dose  of  quinine  (administered  immediately  after  a  paroxysm), 
quickly  decides  a  question  which  is  otherwise  easily  answered  by  an  exami- 
nation of  the  blood. 

Frank  pneumonia  may  closely  resemble  enteric  fever  when  the  physical 
signs  of  consolidation  fail  (as  they  sometimes  do)  to  develop  for  several  days. 
The  temperature  of  the  two  diseases  is  very  similar  (barring  the  usual  irregu- 
larity of  the  morning  remissions  in  pneumonia) ;  abdominal  pain  is  common 
in  either ;  and  in  the  absence  of  rose  spots,  abdominal  tenderness,  and  en- 
largement of  the  spleen,  Widal's  blood-test  may  be  required  to  enable  one  to 
reach  a  conclusion. 

"  Cerebral  "  pneumonia,  as  I  have  before  remarked,  is  more  likely  to  be 
confounded  with  epidemic  meningitis  than  with  typhoid ;  but  apex-pneu- 
monia may  come  and  go  Avith  few  if  any  signs  pointing  to  pulmonary  trouble. 
The  evidence  obtained  by  listening  to  the  chest  may  be  very  indefinite — a 
mere  suggestion  of  bronchial  respiration  and  dulness,  which  vanish  rapidly 
and  require  frequent  examinations  to  detect. 

Grippe  is  distinguished  by  a  degree  of  prostration  disproportionate  to  the 
other  symptoms,  the  absence  of  the  characteristic  temperature  of  enteric 
fever,  and  the  fact  of  its  being  epidemic.  Very  young  children  suffering 
with  grippe  are  apt  to  be  extremely  irritable — a  mental  condition  which  con- 
trasts strongly  with  the  apathy  usual  in  typhoid.  In  the  early  stage  of 
either  disease  there  may  be  fever,  delirium,  bronchial  catarrh,  muscular 
pains,  and  diarrhoea,  while  later  on  the  absence  of  rose  spots,  enlargement  of 
the  spleen,  and  abdominal  tenderness  may  render  the  differential  diagnosis 
extremely  difficult. 

In  all  doubtful  cases  evidence  which  seems  to  be  almost  always  reliable 
can  be  obtained  by  means  of  the  test  discovered  and  perfected  by  Pfeiffer, 


TYPHOID  FEVER.  205 

Gruber,  Durham,  and  Widal.  This  consists  in  adding  one  part  of  blood-serum 
from  a  suspected  case  to  ten  parts  of  a  bouillon  culture  of  typhoid  bacilli.  If 
the  culture  is  fresh  and  the  serum  that  of  a  person  having  enteric  fever,  a  cha- 
racteristic reaction  takes  place,  which  may  be  briefly  described  as  a  gradual 
loss  of  motility  on  the  part  of  the  bacilli  after  their  aggregation  into  groups. 
This  same  reaction  can  be  obtained  from  the  milk  of  nursing  women  who  may 
happen  to  have  typhoid,  and  occasionally  from  the  urine ;  but  the  latter  is  not 
reliable,  as  the  same  phenomena  may  be  produced  by  the  urine  of  healthy  per- 
sons. The  reaction  can  also  be  obtained  Avith  dry  blood,  a  drop  of  which  upon 
a  folded  piece  of  sterilized  non-absorbent  paper  is  examined  "  by  moistening 
Avith  a  drop  of  sterilized  water,  mixing  the  solution  with  a  drop  of  the  bouillon 
culture,  and  examining  the  mixture  as  a  hanging-drop  preparation  under  a  dry 
lens  of  medium  power."  '  It  is  claimed  that  this  method  is  less  likelv  to  give 
rise  to  confusion  than  the  one  in  which  serum  is  employed,  unless  the  exami- 
nation be  made  without  delay. 

The  great  convenience  of  the  dried-blood  test,  as  compared  with  that  in 
which  fresh  serum  must  be  used,  makes  it  a  subject  for  congratulation  that 
its  reliability  has  been  established  by  Drs.  Johnston  and  McTaggart.  As  a 
rule,  they  have  found  the  reaction  well  marked  and  prompt  after  the  fifth 
day  of  the  disease.  Samples  of  blood  kept  dry  in  the  ordinary  air  and  tem- 
perature of  the  laboratory  for  sixty  days  still  gave  a  good  reaction. 

Prognosis. — The  combined  statistics  of  Baginsky,  Steffen,  Montmollin, 
Henoch,  and  AVolfberg  give  an  average  mortality  of  7  per  cent.  Comby 
states  that  it  is  between  6  and  7  per  cent.  It  is  my  impression  that  it  is 
about  the  same  in  America  as  in  Europe.  At  the  Boston  Children's  Hos- 
pital it  has  been  nearly  7  per  cent.  The  above  figures,  taken  in  the  main 
from  results  obtained  in  hospital  practice,  cannot  accurately  represent  the 
mortality  of  all  cases,  many  of  which  are  so  light  as  to  pass  unrecognized, 
and  a  certain  proportion  of  which  occur  among  children  of  the  well-to-do, 
who  are  treated  in  their  homes  and  Avhose  previous  nourishment  and  sanitary 
environment  have  been  good.  Perhaps  4  per  cent,  is  a  fairer  estimate  of 
the  proportion  of  fatal  cases.  Special  symptoms  which  point  to  a  fatal 
termination  are — pneumonia  involving  any  considerable  extent  of  lung, 
tuberculosis,  previous  poor  health,  intense  pyrexia,  marked  weakness  and 
irregularity  of  the  heart,  parotitis,  considerable  haemorrhage,  peritonitis  from 
perforation,  and  symptoms  of  cerebral  complications  lasting  more  than  a  week. 
The  intensity  of  infection  must  be  considered,  as  well  as  the  fact  that  a  mild 
attack  may  kill  a  tuberculous  or  syphilitic  child.  Copious  and  obstinate  diar- 
rhoea and  prolonged  vomiting  are  unfavorable  signs. 

Treatment. — Adequate  ventilation,  liberal  air-space,  strict  attention  to 
the  comfort  and  cleanliness  of  the  patient,  and  the  steady  maintenance  of  a 
temperature  of  ^z>^  to  70°  F.  are  to  be  ensured.  Children  with  typhoid 
fever  have  no  appetite,  as  a  rule,  for  solid  food^  but  they  are  (fortunately) 
thirsty,  and  take  cold  milk  with  relish.  ■  Three-  or  four-ounce  portions  of 
milk  (less  to  very  young  children)  should  be  given  every  three  hours.  In 
this  way  a  child  five  years  old  will  take  from  eighteen  to  thirty  ounces  in 
twenty-four  hours,  and  older  ones  in  proportion  up  to  two  quarts,  which  is 
apparently  the  limit  of  their  capacity.  Should  nausea  or  vomiting  interfere, 
the  milk  should  be  diluted  with  Celestins  Yichy,  or  lime-water,  and  given  in 
very  small  but  frequently  repeated  portions.  As  a  rule,  the  stomach  yields  to 
this  simple  treatment  within  forty-eight  hours,  but  if  these  measures  do  not 

1  Drs.  AVyatt  Johnston  and  D.  D.  McTaggart  of  Montreal,  in  the  American  Medico- Surgical 
Bulletin,  Jan.  10,  1897. 


206     AMEBIC  AX  TEXT-BOOK  OF  DISEASES  OF  CHILD  BEX. 

suffice,  it  is  best  to  withdraw  the  milk  and  substitute  teaspoonful  doses  of  egg- 
albumin-water  with  a  few  drops  of  brandy.  In  eases  of  considerable  severity, 
where  there  are  signs  of  prostration,  brandy  should  always  be  used.  A  teaspoon- 
ful ter  in  die  is  often  enough  to  regulate  a  weak  pulse  and  contributes  greatly 
to  the  child's  comfort,  but  there  should  be  no  delay  in  increasing  the  amount 
if  the  patient  fails  to  respond  to  this  very  moderate  stimulation.  In  looking 
over  the  records  of  the  Children's  Hospital,  I  find  but  one  case  in  which  so 
much  as  three  ounces  was  given  for  any  length  of  time — this  in  the  middle 
of  a  second  relapse,  from  which  the  patient  (a  puny  child  five  years  old)  com- 
pletely recovered.  There  are  but  few  children  that  will  not  derive  benefit 
from  moderate  stimulation  at  some  period  of  an  attack  of  enteric  fever.  Cold 
Avater  is  often  craved,  and  may  be  given  quite  freely  if  the  amount  of  milk 
taken  besides  is  sufficient  to  nourish  the  patient.  During  the  acute  stage  the 
diet  should  be  restricted  to  milk  only,  any  change  being  liable  to  produce 
gastric  or  intestinal  disturbance.  When  the  temperature  shows  that  lysis  has 
begun,  or  when  sharp  morninor  remissions,  together  with  the  child's  brighter 
aspect,  signal  the  speedy  advent  of  convalescence,  some  form  of  predigested 
starch  and  somatose  may  be  safely  given.  The  possibility  of  relapse  must 
be  borne  in  mind,  and,  whether  the  improvement  is  followed  by  uninterrupted 
recovery  or  merely  precedes  by  a  few  days  the  occurrence  of  reinfection,  an 
increase  of  nourishment  is  plainly  indicated.  After  convalescence  (which  is 
tedious  in  the  mildest  cases)  is  fairly  under  way,  the  ravenous  appetite  may 
be  satisfied  with  no  untoward  results,  unless  a  slight  recrudescence  of  fever 
(not  a  relapse)  gives  warning  that  the  digestive  powers  are  being  overtaxed. 

The  Brand  method,  so  far  as  I  have  been  able  to  ascertain,  has  never  been 
systematically  employed  in  any  large  number  of  cases  in  children ;  but  the 
marked  reduction  in  the  mortality  of  the  disease  attending  this  treatment  in 
adults  certainly  warrants  its  thorough  trial  in  cases  where  a  sufficient  number 
of  competent  attendants  can  be  had  to  ensure  its  being  properly  carried  out 
— a  condition  by  no  means  easy  to  fulfil. 

In  the  first  stage,  if  constipation  is  present,  calomel  can  safely  be  given, 
both  as  a  purge  and  an  intestinal  disinfectant.  Less  than  a  grain  (given  in 
triturates  of  gr.  -^  every  hour)  is  usually  enough  to  produce  one  or  two  free 
evacuations.  If  diarrhoea  is  present  when  the  patient  has  been  ill  but  a  short 
time,  calomel  may  still  be  used  in  the  same  way  before  employing  drugs  to 
check  the  trouble.  Of  all  intestinal  antiseptics  for  continuous  use  (and  the  diar- 
rhoea of  enteric  fever  yields  but  slowly  to  treatment,  as  a  rule),  salicylate  of 
bismuth  gives  as  satisfactory  results,  perhaps,  as  any.  Given  in  five-  or  ten- 
grain  doses,  ter  in  die  (and  an  additional  dose  during  the  night  if  the  trouble 
persists  and  disturbs  the  child's  sleep),  it  usually  modifies  the  number  and 
character  of  the  evacuations  in  a  few  days,  and,  should  the  same  condition 
recur  (as  it  often  will),  there  is  no  apparent  advantage  gained  by  changing 
the  treatment,  so  far  as  I  have  observed.  Cool  bathing  will  reduce  a  high 
temperature,  but  the  relief  thus  obtained  is  slight  (a  descent  of  1-2°  F.), 
and  so  temporary  as  to  hardly  compensate  for  the  trouble  involved.  Lacto- 
phenin  and  pepsol  (gr.  3-8)  in  divided  doses  are  very  effective  antipyretics, 
and  perfectly  safe  unless  there  is  some  obvious  contraindication  to  their  use. 
The  former  is  not  quite  so  effective  as  the  latter,  Avhich  Avill  cause  an  average 
reduction  of  4°  F.  three  hours  after  its  administration.  Quiet  sleep  may 
often  be  obtained  in  this  way  where  the  temperature  is  high,  and  no  harm 
result,  as  far  as  I  have  been  able  to  observe,  from  employing  either  drug  in 
suitable  cases.  If  insomnia  is  a  marked  feature  of  a  case  in  which  the  con- 
dition of  the  patient  does  not  warrant  the  exhibition  of  antipyretics,  trional 


TYPHOID  FEVER.  207 

in  five-grain  doses  is  indicated.  Very  moderate  doses  (lUij-v)  of  digitalis  are 
most  effective  in  regulating  a  weak  or  irregular  pulse  when  brandy  fails  to 
accomplish  the  purpose. 

In  ordinary  cases  the  drugs  that  I  have  mentioned  will  fulfil  all  the 
usual  indications  for  interference  with  the  natural  course  of  a  disease  which, 
fortunately,  tends  to  recovery.  Hsemorrhage,  perforation,  organic  brain- 
trouble,  and  the  overwhelming  intensity  of  the  infection,  as  seen  in  typhoid 
fever  of  adults,  are  rare  in  children,  and  hence  the  treatment  is  comparatively 
simple.  Haemorrhage  is  the  most  frequent  complication  that  demands  imme- 
diate and  active  treatment,  and  in  case  of  any  considerable  bleeding  the  foot 
of  the  bed  should  be  raised,  ice-bags  applied  to  the  abdomen,  and  astringent 
remedies  (gallic  acid  or  a  combination  of  lead  and  opium)  given,  together  with 
ergotin  by  hypodermatic  injection.  Perforation,  if  in  a  position  to  cause 
general  peritonitis,  is  speedily  fatal  without  surgical  aid,  which  should  be 
instantly  obtained,  and  the  results  of  which  are  thus  far  very  encouraging, 
as  shown  by  the  statistics  of  Drs.  W.  W.  Keen  and  Thompson  S.  Westcott 
of  Philadelphia — 83  operations  with  19.36  per  cent,  of  recoveries.  Five  of 
the  cases  operated  upon  were  children,  two  of  whom  were  saved. ^ 

Bed-sores  are  easily  avoided  by  strict  attention  to  keeping  the  child  dry 
and  clean.  Sordes  are  prevented  by  a  little  care  on  the  part  of  the  attend- 
ants. Acute  active  delirium  is  rare,  but  forcible  restraint  is  occasionally 
required  to  prevent  a  child  from  getting  out  of  bed.  Mental  disturbances, 
which  persist  after  convalescence  is  reached,  almost  invariably  disappear 
without  special  advice  or  treatment.  Ominous  symptoms  of  cerebral  trouble 
occurring  during  the  acute  stage  often  vanish  so  quickly  as  to  preclude  the 
possibility  of  their  being  due  to  organic  lesions.  I  have  the  notes  of  a  case 
in  Avhich  a  convergent  strabismus,  delirium,  somnolence,  and  a  tdclie  cerehrale 
disappeared  twenty-four  hours  after  they  were  noted.  The  application  of 
ice-bags  to  the  head  and  an  increase  of  stimulation  are  usually  indicated 
when  nervous  symptoms  predominate. 

Prophylaxis. — All  soiled  diapers  and  sheets  are  to  be  at  once  removed 
and  allowed  to  soak  for  six  hours  in  a  1  :  40  solution  of  carbolic  acid,  and 
then  boiled  and  washed  in  vessels  devoted  especially  to  this  purpose.  The 
nates  must  be  carefully  wiped  with  cloths  dampened  with  a  1 :  40  solution. 
These  should  be  burned  or  treated  in  the  same  manner  as  the  diapers  after 
being  once  used.  Discharges  which  are  received  in  bed-pans  are  to  be  cov- 
ered with  a  1  :  20  solution  of  carbolic  acid  or  Avith  thin  whitewash,  and, 
after  any  solid  fragments  have  been  thoroughly  broken  up,  should  be  allowed 
to  stand  twenty  minutes  before  being  emptied  into  the  hopper,  which  must  be 
'kept  scrupulously  clean.  Rubber  covers  should  be  provided  for  the  bed,  and 
washed  off  with  the  1 :  40  carbolic  solution.  Cups,  glasses,  spoons,  and  feed- 
ing utensils  of  every  description  should  be  washed  in  a  carbolic  solution  after 
use,  and  subsequently  boiled.  The  attendants  ought  to  refrain  from  eating 
or  drinking  when  in  the  patient's  immediate  vicinity,  and  should  wash  their 
hands  and  use  a  nail-brush  frequently.  All  clothing  and  linen  which  comes 
in  contact  with  the  child's  person  should  be  disinfected,  and  washed  apart 
from  the  belongings  of  other  members  of  the  household.  A  bichloride  solu- 
tion of  1  :  1000  may  be  substituted  for  the  carbolic  acid  in  the  receptacles  for 
linen  and  other  articles  previous  to  their  being  boiled  and  washed.  The  con- 
stant odor  of  carbolic  acid  in  a  private  house  is  unpleasant,  and  is  at  times 
(for  obvious  reasons)  impolitic. 

^  These  statistics  are  included  in  a  monograph  on  the  "  Surgical  Complications  and  Sequels 
of  Typhoid  Fever,"  by  W.  W.  Keen,  M.  D. 


EPIDEMIC  CEREBRO-SPmAL  MENINGITIS. 

By  ROLAND  G.  CURTIN,  M.  D., 

Philadelphia. 


Synonyms. — Epidemic  meningitis ;  Fever  with  cerebro-spinal  meningitis ; 
Meningeal  fever ;  Petechial  fever ;  Malignant  purpuric  fever ;  Spotted  fever ; 
Cold  plague. 

Definition. — Epidemic  cerebro-spinal  meningitis  is  a  specific  infectious  fever 
(probably  of  microbic  origin)  in  -which  the  poison  seems  to  have  a  special  pre- 
dilection for  the  meninges  of  the  brain  and  spinal  cord.  It  attacks  the  young 
with  greater  frequency  than  any  of  the  fevers  outside  of  those  belonging  espe- 
cially to  childhood,  and  with  more  severity  than  any  of  the  continued  fevers. 
The  onset  is  abrupt  (without  prodromes).  The  prominent  symptoms  are  chill, 
more  or  less  marked ;  vomiting ;  headache ;  delirium,  generally  present  in  the 
first  and  second  day,  later  stupor  and  coma ;  pains,  muscular  and  neuralgic,  in 
trunk  and  limbs ;  stiffness  or  contraction  of  the  muscles  of  the  neck,  rarely  lower 
down  the  back — all  of  which  symptoms  indicate  inflammation  of  the  meninges 
of  brain  and  spinal  cord.  Recovery  may  be  quite  rapid,  when  the  disease 
is  of  short  duration  and  the  nervous  system  is  not  seriously  affected.  In 
most  cases,  however,  recovery  is  exceedingly  slow.  Death  is  common  among 
children,  especially  in  severe  epidemics.  The  immediate  causes  of  death  are 
convulsions,  kidney  complications,  exhaustion,  bed-sores,  and  abscesses  or 
gangrene. 

If  epidemic  cerebro-spinal  fever  occurred  prior  to  the  commencement  of 
the  present  century,  it  was  not  recognized  as  a  distinct  disease.  It  was  first 
discovered  in  Geneva.  In  America  the  first  reported  cases  occurred  in  Med- 
field,  Mass.,  in  1806,  and  since  that  time  it  has  occurred  in  frequent  epi- 
demics in  different  parts  of  North  America,  and  in  fact  it  is  reported  as  an 
irregular  epidemic  visitor  in  all  parts  of  the  Avorld.  A  sporadic  form  of  cerebro- 
spinal fever  is  recorded  yearly  in  the  mortality  statistics  of  all  the  larger  cities 
of  the  United  States :  in  studying  the  death-reports  it  must  be  acknowledged 
and  remembered  that  some  physicians  call  simple  acute  meningitis  and  other 
meningeal  forms  -of  disease,  especially  the  continued  fevei's  and  tubercular 
meningitis,  by  the  name  of  cerebro-spinal  fever. 

Etiology. — The  specific  cause  has  not  been  positively  determined.  There 
are  physicians  who  have  announced  the  discovery  of  a  microbe  similar  in  appear- 
ance to  the  pneumococcus,  but  it  has  not  been  satisfactorily  proved  that  this  is 
the  specific  causative  germ.  However,  it  is  generally  conceded  that  the  dis- 
ease is  of  microbic  origin. 

In  a  New  York  medical  society  meeting  recently  a  physician  stated  that  he 
had  made  autopsies  upon  3  cases  of  so-called  sporadic  cerebro-spinal  fever,  and 
found  specific  germs  of  other  diseases,  all  different.  One  had  the  typhoid  fever 
germ  without  intestinal  evidence  of  the  disease.     I  am  of  the  opinion  that 

208 


EPIDEMIC   CEREBROSPINAL    MENINGITIS.  209 

when  we  perfect  our  bacteriological  knowledge  all  these  sporadic  cases  will  be 
found  to  be  due  to  infection  of  the  brain  and  spinal  cord  by  germs  that  usually 
affect  other  tissues. 

Epidemic  cerebro-spinal  meningitis  is  an  infectious  disease,  and  it  is  ques- 
tionable whether  it  is  contagious  or  not.  Widely-separated  districts  are  simul- 
taneously visited  by  epidemics,  and  over  extended  districts  isolated  individuals 
are  attacked  at  the  same  time ;  so  that  the  idea  of  its  being  transmitted  by 
direct  contact  in  these  cases  is  untenable.  Owing  to  the  fact  that  this  disease 
has  followed  epidemics  of  influenza,  and  on  account  of  the  many  points  of  sim- 
ilarity in  the  two  affections,  Drs.  Job  Wilson  and  J.  J.  Levick  have  been  led 
to  suppose  that  there  is  some  connection  between  the  two  diseases.  It  is  more 
common  in  the  winter  and  spring  than  in  the  summer  months ;  hence  the  name 
"cold  plague"  has  been -given  to  it.  Slight  injuries,  especially  to  the  head, 
fatigue,  exposure  to  cold,  and  mental  depression  are  exciting  causes. 

Pathology. — In  the  early  or  congestive  stage  nothing  is  found  in  the  brain 
and  spinal  cord  except  a  congested  condition  of  the  meninges;  the  blood-ves- 
sels are  enlarged  and  gorged  with  blood  of  a  dark  color ;  later,  after  exudation 
has  taken  place,  the  serous  plastic  exudate  is  found,  especially  upon  the  pia 
mater.  In  some  malignant  cases  the  exudation  is  found  to  be  sero-purulent. 
The  lungs  are  observed  to  be  in  a  state  of  hypostatic  congestion :  where  lung 
complications  have  preceded  death  we  find  evidences  of  croupous  or  catarrhal 
pneumonia,  and  not  infrequently  inflammation  of  the  pleura  and  pericardium. 
Parenchymatous  inflammation  of  the  liver  has  been  noted  by  some  writers. 
Congestion  and  sometimes  an  inflammatory  condition  of  the  kidney  are  found. 
The  heart  is  flabby,  and  the  blood  in  malignant  cases  is  frequently  observed 
in  a  fluid  condition.  The  dusky  spots  or  mottling  that  are  occasionally  encoun- 
tered in  malignant  cases  may  be  found  in  all  the  internal  organs  as  well  as  on 
the  skin. 

Symptoms. — The  first  symptom  generally  noticed  is  a  chill,  which  may 
be  a  slight  creep  or  a  profound  rigor ;  this  usually  comes  on  without  any  warn- 
ing, and  generally  in  the  later  part  of  the  day ;  it  sometimes  follows  fatigue  or 
perhaps  exposure  to  cold,  and  occasionally  follows  injuries  to  the  head.  Some 
cases  are  stricken  down  suddenly,  as  if  by  a  blow,  without  any  previous  warn- 
ing. Headache  is  one  of  the  most  constant  symptoms ;  it  is  not  always  an 
indication  of  the  gravity  of  the  disease.  The  pain  is  almost  always  frontal, 
generally  located  between  the  eyes,  and  quite  often  spoken  of  as  bitemporal; 
it  is  not  infrequently  located  in  the  occipital  region.  It  is  sometimes  excru- 
ciating, causing  the  patient  to  cry  out  and  toss  about;  at  other  times  it  is  a 
dull,  heavy  ache.  It  is  sometimes  intermittent,  at  others  constant;  it  may  be 
fixed  or  lancinating.  The  pain  in  the  head  seems  to  be  the  cause  of  one  of  the 
prominent  facial  symptoms — viz.  knitting  of  the  eyebrows.  An  attack  may  be 
ushered  in  by  a  convulsion,  or  by  a  sudden  giddiness,  causing  the  patient  to 
have  a  staggering  gait;  this  giddiness  may  only  be  present  while  the  patient  is 
sitting  or  standing,  or  may  continue  after  assuming  a  recumbent  position.  This 
symptom  is  sometimes  complained  of  throughout  the  disease. 

Delirium  is  rarely  absent ;  it  is  more  apt  to  be  noticed  early  in  the  case, 
extending  through  the  stage  of  congestion  and  sometimes  through  the  whole  of 
the  inflammatory  stage ;  it  is  exceedingly  variable ;  it  may  be  wild  excitement, 
terrorizing,  playful,  or  sombre.  The  child  may  continually  mutter  or  now  and 
then  cry  out.  Delirium  is  especially  common  in  children,  and  may  indicate 
the  gravity  of  the  disease.  Coma  almost  invariably  precedes  death,  and  is 
always  to  be  considered  a  grave  feature ;  coma  vigil  is  a  serious  ataxic  symp- 
tom, in  which  the  patient  lies  on  his  back,  chin  raised,  eyelids  widely  separated, 


210    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

appaj-ently  regarding  fixedly  some  object  above  the  head  of  his  bed,  and  is 
accompanied  by  constant  jactitation. 

The  headache,  as  before  stated,  often  gives  the  appearance  of  great  sufier- 
ing,  the  brows  being  knit,  especially  when  the  patient  is  aroused ;  the  cheeks 
are  often  flushed  early  in  the  disease,  but  not  always  so ;  later  the  face  is  fre- 
quently pale.  In  some  rare  cases  the  flush  is  not  to  be  seen  at  any  stage  of 
the  disease.  In  some  patients  the  features  are  swollen  and  of  a  dull,  dusky, 
purplish  hue.     Strabismus  is  more  frequent  in  children  than  in  adults. 

Spinal  pains  are  quite  common,  the  pain  being  in  the  back  of  the  neck,  some- 
times extending  down  to  the  lower  end  of  the  spine.  Pressure  and  movement 
have  the  effect  of  increasing  the  suffering ;  the  limbs  and  trunk  are  sometimes 
verv  painful ;  the  pain  may  be  of  neuralgic  character,  radiating  from  centre  to 
peripherv.  and  may  attack  one  set  of  nerves,  and  remain  constant  or  change 
to  other  nerve-trunks  or  groups.  Local  muscular  pains  and  soreness  are  not 
infrequently  present. 

Tonic  spasms  give  rise  to  tetanoid  symptoms,  such  as  opisthotonos,  pleuro- 
sthotonos,  emprosthotonos :  the  former  is  the  most  common,  the  head  being 
drawn  back  and  the  spine  curved  backward,  so  that  the  patient's  body  is  some- 
times supported  by  the  occiput  and  heels.  Forced  movement  increases  the 
spasm  as  well  as  the  spinal  pains.  In  many  cases  these  muscular  spasms  are  a 
simple  stiffness  of  muscles  or  groups  of  muscles. 

Clonic  spasms  are  frequently  met  with.  Subsultus  is  one  of  the  common 
symptoms,  sometimes  amounting  to  a  violent  agitation ;  more  commonly  it  is 
simply  a  twitching,  and  may  be  the  forerunner  of  convulsions  ;  this  symptom 
is  sometimes  present  before  the  inflammatory  changes  in  the  nervous  system  are 
sufficiently  developed  to  produce  it ;  hence  the  reasonable  supposition  that  it  is 
a  result  of  the  irritation  produced  by  the  blood-poison. 

Paralysis  occurs  as  a  result  of  a  loss  of  nerve-power,  which  may  be  caused 
either  bv  central  trouble  or  by  inflammation  of  the  trunk  of  the  nerve  supply- 
ino'  the  part.  These  paralyses  are  sometimes  temporary,  at  other  times  long 
continued  or  permanent.  Sudden  loss  of  hearing  or  sight  usually  comes  on  at 
the  time  the  effusion  takes  place.  Strabismus  is  especially  common  m  children, 
and  is  often  a  precursor  or  an  associate  of  convulsions.  The  conjunctivae  are 
quite  frequently  congested ;  at  other  times  this  symptom  is  absent,  especially  in 
the  milder  cases.  In  almost  every  case  where  there  is  kidney  complication  the 
conjunctival  congestion  is  associated  with  a  purulent  secretion,  which  then  be- 
comes quite  diagnostic.  The  pupil  varies  greatly  ;  early  in  the  disease  it  may 
be  found  to  be  dilated  or  contracted,  but  it  is  generally  dilated.  In  cases  with 
coma  and  convulsions  it  is  almost  invariably  dilated.  Photophobia  is  especially 
common  in  children. 

The  effect  of  the  blood-poison  upon  the  kidneys  is  to  produce  a  catarrhal 
inflammation  in  these  organs  similar  to  the  catarrhal  troubles  found  in  other 
organs. 

The  respiratory  apparatus  is  involved  in  the  disease,  and  some  of  the  fatal 
complications  are  seated  in  the  lungs.  Respiration  is  exceedingly  variable. 
Early  in  the  disease  it  is  likely  to  be  hurried,  and  at  times,  later  on,  it  may  be 
exceedingly  slow  ;  it  is  sometimes  interrupted  or  jerking,  and  the  Cheyne- 
Stokes  variety  is  not  infrequently  seen  in  the  later  stages  of  fatal  cases.  This 
latter  is  not  so  grave  a  symptom  in  the  case  of  children  as  in  adults.  In  some 
instances  death  occurs  suddenly  from  paralysis  of  the  muscles  of  respiration. 
Pleurisv.  pneumonia,  and  bronchitis  are  complications  which  may  occur  at  any 
time  during  the  course  of  the  disease. 

In  exceedingly  malignant  epidemics  there  is  a  dusky  mottling  of  the  skin 


EPIDEMIC    CEBEBBO-SPINAL    MENINGITIS.  211 

and  the  internal  organs,  the  color  being  purplish  ;  whence  the  name  of  "  spotted 
fever"  often  applied  to  the  disease.  These  spots  (which  are  oval  in  shape)  are 
usually  from  one-third  to  one-half  an  inch  in  their  longest  diameter.  I  have 
seen  them  on  almost  every  tissue  or  organ,  external  and  internal,  of  the  body ; 
after  death  they  may  be  of  a  slate-color  with  a  chocolate  tinge,  or  quite  black. 

1  had  an  opportunity  in  1864  of  seeing  14  cases  of  epidemic  cerebro-spinal  fever, 
4  of  which  died ;  2  out  of  the  4  cases  had  these  spots.  In  the  Philadelphia 
Hospital  epidemic  I  saw  over  200  cases :  the  mortality  was  43 ;  of  the  fatal  cases, 

2  had  these  mottlings ;  one  of  them  was  the  first  case  that  occurred,  and  died 
after  fifteen  hours'  illness'.  About  sixteen  years  ago  I  was  called  in  consultation 
to  see  two  young  girls  near  Point  Breeze,  Philadelphia;  they  both  had  these 
mottlings  ;  one  died  in  twenty-four,  the  other  in  thirty-six,  hours.  At  the  time 
only  one  other  suspected  case  had  occurred  in  the  neighborhood ;  this  also  was 
a  malignant  one.    The  two  girls  had  visited  the  abode  in  which  this  patient  died. 

Aside  from  the  mottlings,  there  is  nothing  else  that  seems  characteristic  of 
this  disease  in  connection  with  the  skin.  Cutis  anserina,  simple  erythema, 
rubeoloid  eruption  of  a  bright  cherry-red  color  in  sthenic  cases  (darker  in  the 
adynamic),  dermatitis,  miliary  eruptions,  herpes,  petechise,  and  ecchymoses, 
have  all  been  noticed.  Hypersesthesia  is  one  of  the  most  characteristic  symp- 
toms ;  the  skin  is  sore  to  the  slightest  touch,  and  at  times  the  pressure  of 
the  bed-clothes  is  sufiicient  to  produce  great  discomfort.  Anaesthesia  of  the 
skin  has  also  been  observed ;  it  may  be  a  simple  numbness,  at  other  times  a 
positive  insensibility.  In  some  cases  the  skin  is  found  to  be  very  hot ;  in  others 
it  may  be  quite  cool ;  and  occasionally  the  patient  is  drenched  in  perspiration 
even  when  the  symptoms  are  not  of  a  grave  nature. 

The  temperature  of  cerebro-spinal  fever  is  exceedingly  varied,  so  that  in  a 
group  of  cases  in  the  same  epidemic  it  is  quite  dissimilar.  The  local  inflam- 
mation causes  changes  which  prevent  anything  like  uniformity.  In  the  explo- 
sive form,  the  so-called  fulminant  variety,  it  may  be  beloAv  normal ;  in  all  others 
there  is  more  or  less  elevation.  In  some  instances,  early  in  the  disease,  the 
temperature  is  not  very  high,  and  in  others  it  rises  to  a  high  elevation  after 
the  chill.  When  the  local  inflammations  occur  it  is  generally  higher.  In  chil- 
dren at  this  stage  it  is  usually  from  100°  to  101°.  The  diurnal  variation  is 
less  than  in  typhus  or  typhoid  fever.  A  sudden  fall  or  rise  of  temperature 
almost  invariably  ushers  in  serious  symptoms :  in  fatal  cases  it  has  been  found 
at  the  time  of  death  to  be  as  high  as  from  107°  to  110°. 

The  pulse  in  cerebro-spinal  fever  in  children  is  usually  quite  rapid  ;  in 
adults  at  the  second  and  third  stages  of  the  disease  it  may  be  abnormally  slow. 
The  diff'erence  is  owing  to  the  modified  nerve-influence  which  the  disease  is 
prone  to  exert. 

Complications. — Among  the  complications  observed  in  this  disease  may 
be  mentioned  pleurisy,  pericarditis,  endocarditis,  parenchymatous  degeneration 
of  the  liver  and  kidneys,  and  intestinal  catarrh.  "  (Edema,  hypostatic  conges- 
tion of  the  lungs,  bronchitis,  atelectasis,  and  broncho-pneumonia  are  not 
uncommon  lesions  in  cerebro-spinal  meningitis"  (Welch). 

Sequelae. — Parotitis;  gangrene;  furuncle;  abscesses;  muscular  and  mental 
weakness ;  epilepsy ;  impaired  nerve-power,  sometimes  amounting  to  paralysis ; 
general  or  special  persistent  emaciation ;  and,  in  children,  effusion  following  the 
inflammation  of  the  membranes  of  the  brain  sometimes  results  in  chronic  hydro- 
cephalus. Dr.  Chas.  K.  Mills,  in  a  paper  read  before  the  Philadelphia  Neuro- 
logical Society  in  March,  1888,  called  attention  to  the  occurrence  of  multiple 
neuritis  as  a  complication  of  this  disease,  and  also  suggested  that  multiple  neu- 
ritis might  be  the  only  result  of  the  same  infection  that  causes  the  meningitis. 


212    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Diagnosis. — In  the  earlier  stages,  especially  in  children,  it  may  be  mis- 
taken for  scarlet  fever.  This  is  true  where  there  is  a  general  erythema  or  der- 
matitis. The  existence  of  the  epidemic  influence  of  either  disease  or  the  pres- 
ence or  absence  of  severe  throat  symptoms  will  greatly  assist  in  the  diagnosis. 
The  redness  of  the  skin  coming  on  in  epidemic  cerebro-spinal  fever  generally 
appears  later  than  that  of  scarlet  fever,  in  which  it  usually  happens  in  the  first 
twenty-four  hours.  The  eruption  is  quite  transitory,  and  is  not,  as  a  rule, 
followed  by  desquamation  or  itching. 

The  abrupt  onset  and  the  greater  activity  of  the  symptoms,  the  absence  of 
tubercular  manifestations  elsewhere,  the  rarity  of  eruptions  and  extreme  mus- 
cular contractions,  the  slow  regular  course,  and  the  higher  temperature  would 
distinguish  epidemic  cerebro-spinal  fever  from  tubercular  meningitis.  The 
absence  of  exciting  causes,  the  extremely  faint  muscular  spasms,  and  the  sen- 
sitiveness of  the  skin,  all  help  in  distinguishing  it  from  simple  or  secondary 
meningitis. 

The  muscular  spasms  and  general  and  muscular  pains  usualW  distinguish 
this  disease  from  ordinary  cases  of  pneumonia,  typhus,  and  typhoid  fever;  but 
in  the  meningeal  forms  of  these  diseases  it  is  extremely  difficult  to  make  a 
diagnosis,  though  the  sudden  onset  with  meningeal  symptoms  will  greatly  assist. 
The  earlier  symptoms  should  be  studied  to  find  out  Avhether  there  were  evi- 
dences of  pneumonia  or  any  other  previous  disease.  Abdominal  symptoms 
occurring  early  might  suggest  typhoid  fever.  The  eruption  of  typhus  is  the 
distinguishing  mark  in  that  affection.  Rigidity  of  the  muscles,  present  in 
cerebro-spinal  fever,  is  absent  in  the  preceding  diseases.  I  have  known  mis- 
taken diagnoses  to  be  made  in  cases  of  small-pox  in  the  earlier  stages. 

Prog-nosis. — This  is  always  grave  in  children,  more  so  than  in  adults.  When 
we  take  into  consideration  the  extreme  susceptibility  of  the  nervous  system  of 
a  child,  we  can  readily  see  how  dangerous  this  disease  is  during  the  earlier 
years  of  life.  Prognosis  in  adults  is  a  difficult  task,  for  in  simple  cases  sudden 
grave  complications  sometimes  present  themselves  later  in  the  disease,  and,  on 
the  other  hand,  a  case  with  the  severest  early  symptoms  may  be  followed  by 
speedy  convalescence.  It  is  a  disease  in  which  it  is  impossible  to  estimate  the 
complications  which  may  arise. 

Unfavorable  signs  are  profound  coma ;  low  typhoid  symptoms ;  ur?emia ; 
great  blood  dyscrasia,  shown  by  marked  ecchymosis  ;  continued  convulsions 
and  prolonged  high  fever.  Protracted  cases  are  likely  to  be  followed  by  fatal 
exhaustion. 

Treatment. — The  types  and  lesions  of  the  disease  are  so  various  that  the 
details  of  the  treatment  are  exceedingly  difficult  to  formulate  to  meet  all  cases. 

The  prophylactic  treatment  consists  in  careful  attention  to  sanitation,  as  the 
disease  is  invited  by  uncleanliness  of  person  or  surroundings  ;  the  same  is  true  of 
over-crowding.  Exposure  to  heat  or  cold,  and  fatigue,  either  bodily  or  mental, 
are  favorable  to  the  onset  of  the  disease.  Children  in  a  locality  where  the 
aff"ection  is  prevalent  should  be  furnished  with  fresh,  nourishing,  and  easily- 
digested  food;  they  should  be  isolated  from  the  sick,  and  should  have  plenty  of 
sleep  and  pure  air.  Clothing  from  about  the  sick  should  be  destroyed  or  care- 
fully disinfected.  The  weak,  old,  and  nervous  should  be  removed  from  infected 
localities. 

Almost  every  remedy  in  the  medical  category  has  been  tried  to  abort  this 
disease :  bloodletting  has  had  its  votaries,  and  others  have  highly  extolled  the 
virtue  of  mercurials  in  the  earlier  stages ;  emetics,  again,  have  been  recom- 
mended, but  all  have  largely  been  abandoned.  The  plan  pursued  by  most 
recent  authorities  is  to  treat  the  disease  symptomatically. 


EPIDEMIC   CEBEBBO-SPINAL    MENINGITIS.  213 

In  the  first  stage  we  have  a  congested  condition  of  the  meninges  of  the 
brain  and  spinal  cord :  the  indication  is  to  aid  in  the  reduction  of  the  quan- 
tity of  the  blood  in  the  meningeal  blood-vessels  ;  first,  for  the  purpose  of  reliev- 
ing the  symptoms,  and,  secondly,  to  reduce  the  inflammation  and  modify  the 
inflammatory  products.  One  of  the  difiiculties  of  administering  medicine  by 
the  mouth  is  the  common  symptom  of  vomiting,  which  is  sometimes  veiy  per- 
sistent. Venesection  should  not  be  practised  in  children.  Some  of  the  German 
writers  use  early  local  bloodletting  by  wet  cups  and  leeches.  Dry  cups  to  draw 
blood  from  the  internal  congested  vessels  without  removing  it  from  the  body  are 
of  great  value.  The  external  application  of  cold  to  the  head  by  ice,  ice-water 
cloths,  cold-Avater  cloths,  is  useful,  and  some  have  used  hot  baths  to  the  body, 
hoping  to  draw  blood  from  the  centre  to  the  periphery.  Hot  mustard  foot- 
baths can  be  used  with  advantage  to  relieve  the  pain  in  the  head  and  back. 
If  the  stomach  should  bear  it,  potassium  bromide  and  ergot  may  be  adminis- 
tered ;  if  not,  the  former  may  be  given  by  enema,  the  latter  hypodermatically, 
for  the  purpose  of  favorably  influencing  the  capillary  congestion.  For  the 
pain  in  the  muscles  the  antipyretics  have  been  used  ;  phenacetin  is  probably  the 
safest  and  best  of  all.  It  should  be  used  in  small,  frequently-repeated  doses, 
and  its  use  should  be  discontinued  if  the  patient  becomes  weak  or  exhausted. 
A  mustard  plaster,  one  part  mustard  to  three  of  flour,  placed  over  the  spine, 
often  relieves  the  pain  in  that  location,  and  counter-irritation  to  the  nape  of  the 
neck  diminishes  the  pain  in  the  head  and  relieves  the  delirium.  Care  should 
be  taken  not  to  raise  a  blister,  which  would  seriously  complicate  the  case. 
Liniments  over  the  same  region — turpentine  or  chloroform — may  be  used  for 
similar  purpose.  Belladonna  seems  to  aff"ord  relief  to  the  neuralgic  pains  and 
muscular  spasms.  Dr.  J.  M.  DaCosta  highly  lauds  the  use  of  hyoscine  hydro- 
bromate  for  the  muscular  spasms  in  this  disease.  For  insomnia  early  in  a  case 
chloral  may  be  cautiously  used  in  conjunction  with  potassium  bromide.  Chloral 
sometimes  causes  cerebral  excitement,  and  when  this  occurs  it  should  be  dis- 
continued. Opium  has  always  been  used  with  the  happiest  results.  It  has  been 
recorded  that  in  some  cases  large  doses  of  opium  are  tolerated.  The  salicylates 
and  gelsemium  will  allay  the  pains  in  the  trunk  and  limbs,  but  will  not  relieve 
the  pain  in  the  head.  A  dark,  quiet  room  should  be  selected  for  the  patient  in 
any  stage ;  this  is  of  great  importance  where  there  is  cerebral  excitement. 

In  the  second  stage  the  exudate  is  thrown  out ;  it  may  be  serous,  plastic,  or 
even  sero-purulent ;  the  blood-vessels  are  dilated  and  engorged.  Absorptive 
remedies  are  now  to  be  used.  Potassium  iodide  to  produce  absorption  of  the 
exudate,  and  oil  of  turpentine  internally  have  been  used  late  in  this  stage  for 
the  same  purpose,  with  seeming  good  results.  Arsenic  and  iron  are  of  great 
use  during  convalescence  to  improve  the  blood.  Stimulants,  especially  for  chil- 
dren, should  be  used  with  great  caution,  as  an  excess  will  irritate  the  brain  and 
excite  the  circulation  in  either  the  first  or  second  stage.  Hypophosphites,  espe- 
cially with  strychnine,  are  beneficial  during  convalescence.  Cod-liver  oil  when 
digested  often  produces  the  happiest  results.  In  the  later  stages  of  convales- 
cence massage  is  of  great  importance  to  stimulate  the  circulation  in  the  mus- 
cles and  nerves.  Electricity  is  indicated  for  paralysis  or  weakness  of  the  nerve- 
trunks.  For  the  same  purpose  alternate  hot  and  cold  aff"usions  to  the  weakened 
parts,  and  exercise,  carefully  regulated  as  to  time  and  amount,  greatly  assist  in 
strengthening  the  muscles  and  nerves. 


EPIDEMIC  INFLUENZA. 

By  CHAS.  WARRINGTON  EARLE,  M.  D., 

Chicago. 


Influenza  is  a  general  infectious  disease  producing  catarrhal  difficulties  of 
either  the  respiratory  or  gastro-intestinal  tract,  or  painful  symptoms  referable 
to  the  nervous  system.  In  addition  to  the  symptoms  thus  indicated,  it  is 
attended  with  prostration  out  of  propoi'tion  to  the  apparent  involvement  of 
the  organs  named,  and  is  liable  to  be  followed  by  sequelte  which  aflFect  pro- 
foundly the  further  usefulness  and  comfort  of  the  unfortunate  victim.  This 
disease  has  been  recognized  and  described  in  our  country  for  two  hundred  and 
fifty  years,  the  first  epidemic  occurring  about  1647.  Other  epidemics  have 
taken  place  from  time  to  time,  and  have  been  referred  to  by  writers  under  dif- 
ferent names  ;  but  the  disease,  as  it  affects  us  particularly,  and  its  history,  as 
we  understand  it  at  the  present  moment,  have  come  to  us  in  the  three  consecu- 
tive epidemics  of  1890, 1891,  and  1892.  At  the  time  of  writing  (January,  1893) 
only  a  few  sporadic  cases  have  taken  place  during  this  year,  and  they  have  not 
been  severe.  We  cannot  yet  speak  of  an  epidemic  of  1893.  During  the  period 
referred  to,  great  attention  has  been  given  to  the  study  of  the  disease  by  our 
profession,  and,  in  certain  instances,   by  governmental  authorities. 

Etiology. — It  has  not  been  believed  until  recently  that  the  causes  of  this 
disease  are  really  known.  Certain  hypothetical  causes  have  been  advanced, 
such  as  air,  contagion,  local  conditions,  general  influences,  etc.  But  during 
the  last  three  or  four  years  very  close  investigations  in  regard  to  its  etiology 
have  been  made.  The  reports  of  the  British  medical  government  clearly  show 
that  the  spread  of  the  disease  depends  upon  human  intercourse,  and  that  it 
spreads  no  faster  than  human  beings,  parcels,  or  letters  can  travel. 

Bacteriological  investigations  have  been  carried  on  with  great  accuracy 
during  this  time.  Filatow  wrote  fully  concerning  the  history  and  symptoms 
of  the  disease  under  consideration,  and  Seifert  investigated  the  bacteriological 
history  three  or  four  years  ago ;  but  particular  investigations  have  been  carried 
on  during  the  past  year  in  the  Berlin  Institute  by  Drs.  Pfeiffer,  Kitasato,  and 
Canon ;  and  Sternberg  remarks  that  there  is  good  reason  to  believe  that  the 
bacillus  discovered  by  these  investigations  is  the  specific  cause  of  the  disease. 
The  following  rfeum^  from  Dr.  Sissley  of  London  gives  much  regarding  the 
etiology  of  the  scourge  under  discussion : 

(1)  The  first  case  of  influenza  in  a  town  is  generally  a  patient  who  has 
come  from  an  isolated  place. 

(2)  Isolated  cases  precede  the  epidemic. 

(3)  Influenza  extends  along  the  lines  of  human  intercourse. 

(4)  Isolated  persons,  such  as  prisoners  and  inmates  of  asylums  and  con- 
vents, often  escape  the  disease. 

(5)  The  number  of  those  affected  in  an  epidemic  increases  till  a  maximum 
is  reached,  and  then  declines,  as  in  the  case  of  other  contagious  diseases. 

214 


EPIDEMIC  INFLUENZA.  215 

There  is  no  doubt  that  nursing  children  three  or  four  months  of  age  feel 
the  influence  of  la  grippe.  Dr.  Townsend  of  Boston  has  placed  on  record  a 
case  where  the  mother  had  an  attack  of  influenza  about  the  time  of  her  con- 
finement, and  the  child  in  a  few  hours  after  birth  began  to  sneeze  and  had  all 
the  symptoms  of  this  infection ;  and  an  English  observer  records  the  case  of 
an  infant  who  died  on  the  third  day  of  its  life  from  this  disease.  It  is  somewhat 
difficult  to  diagnosticate  influenza  in  very  young  infants,  but  it  is  fair  to  sup- 
pose that,  when  the  infection  is  present  in  the  house  and  parents  and  nurses 
are  under  its  influence,  if  infants  present  unusual  symptoms  of  fever,  exhaus- 
tion, and  the  involvement  of  one  of  the  three  systems  which  are  usually  select- 
ed by  this  infection,  the  disease  is  due  to  the  poison  of  influenza. 

The  exact  point  at  which  the  infection  may  gain  entrance  to  the  system  has 
probably  not  been  ascertained.  That  it  may  enter  through  either  the  aliment- 
ary canal  or  the  lungs  there  is  no  doubt,  and  in  all  probability  these  are 
usually  the  points  of  entrance.  One  observer  believes  that  the  conjunctiva 
is  in  many  instances  the  structure  through  which  the  poison  attacks  the  system. 

Influenza  and  Diphtheria. — The  marked  similarity  between  the  remote 
effects  of  the  poisons  of  diphtheria  and  influenza  is  very  great,  and  it  is  quite 
possible  that  the  pathological  findings  in  influenza  may  be  quite  as  numerous 
and  significant  as  we  already  know  they  are  in  diphtheria.  We  possibly  do 
not  know  the  exact  cause  of  influenza,  but  we  are  certainly  warranted  in 
assuming  that  there  is  a  most  profound  toxic  eff"ect  in  influenza  as  well  as  in 
diphtheria.  The  depression  is  profound,  the  recovery  slow  and  tedious,  and 
the  involvement  of  the  nervous  system  in  both  diseases  is  extremely  signif- 
icant. The  action  of  these  two  poisons  upon  the  heart  is  somewhat  similar. 
Every  practitioner  of  experience  has  noticed  the  slowness  of  the  pulse  and  its 
irregularity,  and  in  some  instances  death  has  occurred  in  such  an  unexpected 
manner  that  we  could  attribute  it  to  nothing  less  than  degeneration  of  the 
heart-muscle. 

Pathology. — There  are  but  few  special  post-mortem  findings  known  to  this 
disease  which  are  of  value  to  us  as  relating  to  children.  Nearly  every  study 
has  been  based  upon  examinations  made  in  adults,  and  the  records  of  autopsies 
made  solely  and  particularly  to  find  the  results  of  influenza  on  the  tissues  of 
the  young  are  extremely  meagre.  Ashby  and  Wright  state  that  "  at  the  post- 
mortem no  grave  lesion  is  found,  but  there  is  usually  venous  congestion  and 
marked  injection  of  the  venous  capillaries  ; "  and  Vargas  of  Barcelona,  whose 
opportunities  for  seeing  many  cases  profoundly  sick  with  influenza  have 
certainly  been  very  great,  after  remarking  that  rapid  deaths  are  usually  due 
to  severe  attacks  aff"ecting  the  nervous  system,  says  that  while  we  cannot  state 
that  there  is  an  apoplectic  form,  in  some  cases  the  post-mortem  revealed  the 
venous  plexus  congested,  and  also  cerebral  haemorrhages.  The  same  author 
also  asserts  that  in  cases  where  the  gastro-intestinal  symptoms  predominated 
there  was  tumefaction  of  Beyer's  glands  and  of  the  solitary  follicles. 

In  115  references  to  influenza  found  in  the  British  Medical  Journal  of 
1891  and  1892,  not  one  speaks  particularly  of  the  pathology  as  it  is  found  in 
children.  And  in  the  works  of  Filatow  and  Uff"elmann,  both  written  in  1892, 
absolutely  nothing  is  said  regarding  this  part  of  our  subject.  The  special 
eff"ects  of  the  poison  of  influenza  upon  the  tissues  of  the  young  have  yet  to  be 
described. 

Incubation. — This  may  be  only  a  few  days,  possibly  only  a  few  hours, 
or,  on  the  contrary,  the  influence  of  the  poison  may  be  felt  for  weeks  before 
the  active  development  of  the  disease.  Others  who  have  studied  the  disease 
believe  that  two  or  three  days  is  the  usual  time  of  incubation. 


216    AMERICA  X  TEXT- BO  OK  OF  DISEASES  OF  CHILD  REX. 

Clinical  History. — The  disease  affects  more  particularly  one  of  three  groups 
of  organs :  First,  the  respiratory  and  circulatory  apparatus ;  second,  the  gastro- 
intestinal canal:  third,  the  nervous  system. 

Sometimes  the  infection  localizes  itself  in  the  respiratory  tract,  spending  its 

energy  there,  and  the  patient  will  pass  through  a  severe  catarrhal  bronchitis  or  a 

pneumonia  with  such  general  prostration  as  to  endanger  his  life :  or  the  disease 

manifests  itself  as  a  catarrhal  inflammation  of  the  stomach  and  bowels,  with  a 

tendency  to  collapse  on  account  of  the  extreme  weakness  which  is  induced;  or, 

closelv  following  the  severe  headache,  which  indicates  that  the  nervous  system 

is  the  first  to  be  attacked,  have  come  threatened  convulsions  and  meningitis. 

We  have  these  organs  affected  singly,  or  in  some  cases  a  complication  involv- 

ino;  almost  all  of  them,  such  as  a  bronchitis  with  ^astro-intestinal  disturbance, 

^  ... 

or  a  gastro-intestinal  disturbance  with  great  nervous  prostration. 

The  invasion  is  rapid,  and  the  disease  is  frequently  ushered  in  with  a  chill 
followed  b}'  delirium  and  rapidity  of  pulse.  The  face  in  many  cases  is  red  from 
the  commencement  of  the  disease,  and  there  is  earache,  vomiting,  and  an 
increase  in  temperature.  The  fever  is  not  high  in  the  majority  of  cases,  but 
occasionally  an  unusually  high  temperature  is  noticed.  In  a  majority  of  cases, 
at  some  time  during  the  disease,  the  temperature  is  subnormal,  varying  from 
one-half  to  two  degrees  below  the  standard  of  health.  This  condition  of  tem- 
perature is  undoubtedly  a  result  of  the  action  of  the  poison  upon  the  general 
nutrition,  the  imperfect  action  of  the  lungs  which  is  present  in  many  cases, 
and  the  general  depression  of  the  vital  forces.  There  is  also  loss  of  weight. 
This  has  been  particularly  brought  out  by  Hansen  of  Copenhagen,  who  con- 
cludes that,  while  in  some  cases  there  is  simply  a  standstill,  in  many  there  is 
an  absolute  diminution  in  normal  weight.  It  is  fair  to  conclude  that  this 
evidence  of  waste — in  other  words,  work — represents  the  conflict  between  the 
poison  of  influenza  and  its  stibjects.  In  some  cases  this  diminution  of  weight 
is  noticed  when  there  are  no  other  signs  of  the  disease  present.  And  finally 
there  is  a  very  pronounced  general  weakness  never  before  experienced  by  the 
patient,  and  in  no  one  organ  or  system  of  organs  is  it  more  noticeable  than  in 
the  circulatory  apparatus.  The  pulse  is  usually  accelerated,  sometimes  very 
rapid,  and  the  heart,  in  many  instances,  never  regains  its  strength  and  vigor. 

Special  Features. — Respiratory  Symptoms. — A  catarrh  of  the  respiratory 
organs  takes  place  with  great  frequency,  and  in  its  various  phases  extends  to 
every  part  of  this  system.  Sometimes  the  upper  breathing  apparatus  is  attacked 
first,  and  the  disease  rapidly  spreads  and  involves  the  rest.  The  eyes  are  usu- 
ally red  and  suffused,  and  in  many  cases  not  only  is  the  middle  ear  involved, 
but  disease  of  this  organ  remains  as  a  sequel  for  a  long  time.  A  general  catar- 
rhal bronchitis  is  frequently  present,  and  in  some  instances  pneumonia  with  all 
its  characteristic  symptoms.  There  is  in  many  cases,  early  in  the  disease,  an 
apparent  localization  of  the  infection  in  one  or  both  of  the  lungs,  threatening  a 
pneumonia,  but  this  usually  clears  up  in  a  very  short  time,  and  the  disease  be- 
comes diffused  throughout  both  lungs.  Very  often  there  may  be  only  a  severe 
and  perplexing  cough,  without  any  phj^sical  signs.  Respiration  is  sometimes  slow, 
and  in  a  few  cases  breathing  for  a  few  seconds  has  absolutely  stopped.  These 
peculiar  paroxysms  have  been  repeated  several  times  during  the  day,  and  in  a 
few  instances  life  has  been  preserved  during  these  attacks  only  by  artificial 
respiration.  Thoracic  pains  are  sometimes  intense,  and  call  for  the  external 
application  of  anodynes. 

Circulatory  Symptoms. — There  is  usually  from  the  first  a  rapidity  and 
weakness  of  the  heart,  and  syncopal  attacks  occur  in  many  cases.  Depression 
in  the  action  of  this  organ  and  failure  in  its  supply  of  nerve-force  seem  entirely 


EPIDEMIC  INFLUENZA.  217 

out  of  proportion  to  all  other  symptoms.  While  in  many  cases  the  temperature 
and  pulse  seem  fair,  there  is  an  unusual  muscular  weakness  and  a  tendency  to 
syncope.  I  have  not  noticed  organic  heart  disease,  but  cyanosis  has  been 
present  in  a  few  cases,  and  in  many  instances  palpitation  and  short  breathing 
are  not  only  noticed  during  the  active  history  of  the  disease,  but  also  inter- 
minably follow  its  unfortunate  victim. 

G-astro-intestinal  Symptoms. — The  tongue  is  frequently  flabby  and  coated, 
and  shows  indentations  of  the  teeth,  indicating  malnutrition.  The  appetite 
is  often  entirely  absent,  and  persistent  vomiting  takes  place  in  many  cases. 
Herpes  labialis  is  sometimes  noticed,  as  also  sordes.  Diarrhoea  to  such  an 
extent  as  to  become  exhausting  is  frequent;  constipation  is  sometimes  present. 
In  some  cases  the  diarrhoea  and  vomiting  are  so  frequent  and  persistent,  and 
the  child  becomes  so  rapidly  collapsed,  that  if  the  case  occurred  in  the  summer 
a  diagnosis  of  cholera  infantum  would  undoubtedly  be  suggested.  As  the 
result  of  this  great  withdrawal  of  fluids  from  the  body,  the  eyes  and  fontanelles 
are  greatly  depressed,  and  the  child  becomes  restless  and  rapidly  goes  into 
collapse. 

Nervous  Symptoms. — Extreme  irritability  and  fretfulness  are  found  in 
the  majority  of  childish  patients.  Headache  and  joint  and  muscular  pains  are 
frequent  and  sometimes  intolerable.  In  many  cases  there  are  noticed  an  indif- 
ference and  a  hebetude  which  closely  simulate  a  typhoid  condition.  Convul- 
sions take  place  in  a  small  percentage  of  children,  and  congestion  of  the 
brain  with  drowsiness  may  be  noticed.  In  one  case  which  came  under  my 
observation  the  child  did  not  close  its  eyes  for  four  nights.  It  was  not  uncon- 
scious, but  indifferent,  and  wanted  to  be  left  alone.  In  a  few  cases  meningitis 
will  seem  imminent,  and  the  diagnosis  will  sometimes  necessarily  be  held  in 
abeyance.  In  some  children  afflicted  with  influenza  there  is  developed  an 
obstinacy  which  is  truly  remarkable  ;  they  sometimes  resist  the  slightest  touch, 
and  refuse  all  examination  on  the  part  of  the  physician.  This  peculiarity  is 
regarded  by  some  observers  as  of  diagnostic  importance  in  differentiating  from 
typhoid  fever. 

Temperature. — In  addition  to  what  I  have  already  said,  I  have  noticed 
that  the  fever  may  be  very  high  and  yet  recovery  take  place.  On  the  other 
hand,  a  temperature  of  101°  to  102.5°  F.  may  persist  for  a  period  of  two  or 
three  months.  In  these  cases  I  have  suspected  and  have  repeatedly  examined 
for  evidence  of  tuberculosis,  and  have  not  found  it,  the  patient  finally  making 
a  good  recovery  after  this  long  period  of  sickness.  In  general,  we  may  make 
the  statement  that  the  temperature  is  more  irregular  in  influenza  than  in  any 
other  disease. 

Complications  and  Sequelae. — These  are  numerous  and  varied,  and  attack 
nearly  every  function  and  organ  of  the  body.  Glandular  enlargements  are 
frequent.  Inflammation  of  the  parotid  gland  may  take  place.  Abscess  of  the 
antrum  and  inflammation  of  the  connective  tissue  of  the  neck  have  been  noticed. 
Tuberculosis  and  tubercular  meningitis  may  follow  in  a  few  cases.  Conjunc- 
tivitis may  remain,  and  catarrhal  inflammation  of  the  middle  ear,  resulting 
often  in  perforation  and  profuse  discharge,  will  be  noticed.  At  times  this 
involvement  of  the  middle  ear,  while  always  a  serious  complication,  may  even 
threaten  the  life  of  the  patient.  Diseases  of  the  skin  are  sometimes  noticed, 
such  as  erythema,  herpes,   and  urticaria. 

Among  the  more  general  diseases  that  have  been  observed  are  rheumatism, 
chorea,  nephritis,  and  periostitis.  Children  having  a  tendency  to  rickets  have 
been  known  to  develop  the  disease  after  having  had  an  attack  of  influenza. 
Among  the  complications  which  I  have  noticed,  and  which  I  have  not  seen 


218    AJfEBICA^^  TEXT-BOOK  OF  DISEASES  OF  CHILDBEJS. 

recorded,  is  purpura.  Of  this  I  have  seen  four  cases,  all  in  young  people,  and 
attended  with  extreme  -weakness  and  with  evidence  of  more  or  less  blood- 
chauge. 

As  is  not  unusual  in  adults,  acute  mania  has  been  observed  to  follow 
the  disease  occasionally  in  children,  but  generally  ends  in  complete  recovery. 
Dr.  Julius  Althus,  in  an  extensive  article  on  mental  affections  after  influenza, 
gives  cases  illustrating  neurasthenia,  hypochondriasis,  melancholia,  delirium 
from  inanition,  homicidal  tendencies,  and  general  paralysis.  He  believes  that 
the  psychoses  observed  after  epidemic  influenza  are  far  greater  than  those  after 
any  other  infectious  disease. 

Diagnosis. — From  the  rapidity  with  which  it  seizes  the  patient,  influenza 
might  be  mistaken  for  sunstroke,  an  acute  poisoning,  or  malignant  malaria.  It 
can  be  confounded  with  all  diseases  of  the  respiratory  apparatus,  with  typhoid 
fever,  and  with  meningitis. 

From  a  simple  catarrh,  influenza  will  be  distinguished  by  the  fact  that  it  is 
epidemic,  and  that  there  is  greater  prostration,  which  continues  for  a  longer 
period  of  time,  than  in  the  first-named  disease.  The  temperature  is  also  higher, 
and  there  is  a  tendency  to  catarrhal  difficulties — at  first  local,  but  rapidly 
spreading  to  other  portions  of  the  body.  A  mild  catarrh,  with  severe  neuralgia 
and  with  unusual  pain  in  the  limbs,  should  be  diagnosticated  as  influenza 
if  this  disease  be  prevalent.  The  same  may  be  said  in  regard  to  an  irri- 
table stomach,  with  diarrhoea  and  an  unusual  prostration.  This  in  a  time  of 
epidemic  should  certainly  be  classed  as  influenza.  From  pneumonia  and  bron- 
chitis, simple  or  capillary,  we  differentiate  influenza  by  the  absence  of  the  usual 
physical  signs,  although  at  the  commencement  of  the  grippe  in  many  cases 
there  will  be  symptoms  of  pneumonia,  and  it  seems  as  if  localization  had  indeed 
taken  place  ;  but  frequently  in  a  few  hours  this  becomes  diffused,  and  a  general 
bronchitis  with  the  excruciating  pain  and  prostration  belonging  to  influenza  is 
detected. 

From  typhoid  fever  influenza  is  differentiated  by  the  fact  that  no  rose-spots 
appear  and  no  enlarged  spleen  is  found,  and  the  catarrhal  condition,  more  par- 
ticularly in  the  respiratoi'y  tract,  predominates  over  all  other  symptoms.  If 
diarrhoea  exists  in  influenza,  it  will  be  noticed  that  a  cough  and  a  catarrhal 
state  of  the  air-passages  has  preceded  its  development.  The  fever  in  influenza 
is  irregular ;  in  typhoid  it  is  so  regular  and  constant  that  it  almost  makes  its 
own  diagnosis.  It  is  not  usual  to  notice  the  apathetic  facial  expression  that 
we  have  in  typhoid.  The  fiice,  however,  is  usually  flushed  in  influenza — more 
frequently  pale  in  the  continued  fever.  There  are  no  rose-spots  in  influenza, 
no  tenderness  and  orurffling  in  the  right  inguinal  region. 

From  meningitis  influenza  can  usually  be  diagnosticated  by  careful  obser- 
vation of  the  eye  and  by  the  want  of  the  rigidity  of  the  muscles  which  we 
find  in  meningitis.  The  disease  of  the  brain  usually  develops  rapidly,  and  if 
death  does  not  take  place  it  disappears  quickly.  I  must,  however,  say  that 
the  differentiation  of  meningitis  from  certain  forms  of  la  grippe  is  attended 
with  great  trouble,  and  a  diagnosis  must  in  some  cases  be  withheld.  When  the 
fever  persists  after  all  other  symptoms  of  influenza  have  subsided,  and  there  is 
a  cough  with  gradual  emaciation,  the  closest  care  must  be  taken  that  a  tuber- 
cular disease  does  not  come  in.  Particular  attention  should  be  given  to  nutri- 
tion, and  every  means  should  be  taken  to  diagnosticate  the  disease  early. 

Prognosis  and  Mortality. — In  this  connection  an  interesting  topic  might 
be  discussed  as  to  whether  one  attack  of  influenza  protects  from  subsequent 
attacks.  I  do  not  think  that  this  question  at  present  can  be  fully  answered, 
but  the  general  statement  can  be  made  that  many  families  particularly  aflSicted 


EPIDEMIC  INFLUENZA.  219 

in  1889  did  not  develop  the  disease  in  1890  or  1891.  There  are  those  who 
are  immune  from  the  disease,  and  others  in  whom  it  has  developed  three  con- 
secutive years. 

The  mortality  is  different  in  different  epidemics,  and  the  character  of  the 
epidemic  must  be  considered,  as  in  all  other  infectious  and  contagious  diseases. 
In  some  epidemics  children  are  particularly  liable  to  contract  the  disease,  while 
in  others  adults  seem  to  be  selected.  And  again  in  a  more  general  epidemic 
it  has  been  noticed,  as  I  can  personally  attest,  that  children  often  are  not 
attacked  until  the  disease  has  prevailed  for  some  time.  When  the  attack  is 
moderately  severe,  I  regard  it  a  dangerous  malady  for  a  child,  particularly  if 
he  has  anaemia  or  any  vicious  constitutional  tendencies.  Death  has  taken  place 
in  twenty-four  hours.  It  may  come  from  almost  every  complication,  but,  in  the 
main,  exhaustion  and  bad  nutrition  bring  about  the  fatal  result.  Death  may 
come  with  such  rapidity  that  in  summer  insolation  is  suggested,  and  at  other 
times  malignant  malaria.  In  the  fulminant  variety  with  rapid  death,  the  severe 
symptoms  will  be  referable  to  the  nervous  system,  while  throughout  the  entire 
history  of  other  cases  the  poison  selects  the  respiratory  or  gastro-intestinal 
tract,  and  death  comes  as  it  does  in  those  diseases  when  not  complicated  with 
influenza.  But  it  must  be  remembered  that  there  is  always  a  tendency  to  col- 
lapse and  a  prostration  out  of  proportion  to  other  symptoms. 

The  length  of  time  consumed  in  convalescence  from  this  disease  is  wonder- 
ful. The  pains  and  general  weakness  do  not  disappear  for  weeks  ;  and  I  may 
add  that  many  of  the  sequelae  remain  for  years,  and  not  only  produce  suffer- 
ing, but  shorten  the  life  of  the  individual. 

Treatment. — I  have  no  particular  remedy  or  combination  of  remedies  to 
suggest.  I  think,  however,  that  care  should  be  taken  to  prevent  the  contagious 
element  from  spreading  and  gaining  a  hold  on  the  community,  and,  in  view  of 
the  great  mortality  and  the  immense  money  loss  which  this  disease  causes,  it 
appears  to  me  that  the  time  will  come  when  it  will  be  regarded  as  the  duty 
of  all  municipal  authorities  to  assume  such  control  of  the  disease  as  science 
suggests. 

Let  the  people  understand  that  it  is  a  contagious  disease,  and  instruct  them 
how  to  prevent  its  spreading  by  contact.  All  handkerchiefs  and  cloths  used 
b}^  the  patient  must  be  immersed  in  some  antiseptic  fluid,  and  all  cuspidors  and 
articles  of  furniture  which  come  in  contact  with  the  germs  of  the  disease  should 
be  carefully  disinfected. 

A  generous  diet  must  be  insisted  upon,  some  stimulation,  and  a  conservation 
of  all  the  strength  of  the  patient  observed  from  the  outstart. 

For  the  general  pain  which  pervades  the  entire  system,  which  sometimes  is 
the  first  and  most  prominent  symptom,  nothing  has  given  me  such  good  results 
as  phenacetin  and  salicylate  of  sodium.  The  catarrh  of  the  respiratory  tract 
which  speedily  prostrates  young  children  should  be  early  treated  with  stimu- 
lants, including  the  ammonia  preparations  and  the  ordinary  expectorants.  The 
gastro-intestinal  catarrh  must  not  be  neglected,  but  should  receive  attention 
from  the  first.  It  is  a  clinical  fact,  which  must  have  been  observed  by  many, 
that  in  some  of  the  neglected  cases  there  is  just  as  profound  and  general  col- 
lapse from  the  copious  diarrhoeal  discharges  and  vomiting,  which  we  sometimes 
see  in  this  form  of  the  disease,  as  from  those  which  take  place  in  severe  cases 
of  cholera  infantum.  They  should,  then,  have  attention  from  the  very  first. 
For  the  extreme  fatigue  and  depression  not  only  alcoholic  stimulants,  but  the 
effervescing  waters  with  quinine,  should  be  administered.  If  the  stomach  is 
particularly  irritable,  let  the  quinine  be  administered  by  inunction  or  by  the 
rectum.     Children  take  eagerly  and  with  good  results  whipped  egg-albumin 


220    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

with  sterilized  water  and  a  little  stimulant  and  sugar.  Champagne  is  excel- 
lent for  the  depression  which  is  so  evident  among  these  little  people.  When 
there  is  great  prostration  following  the  involvement  of  any  of  the  three  systems 
we  have  mentioned,  the  carbonate  of  ammonium,  camphor,  and  musk,  fortified 
by  the  conjoint  use  of  digitalis  and  nux  vomica,  are  indicated. 

When  the  patient  begins  to  pass  out  from  the  more  painful  and  acute  mani- 
festations of  the  disease,  in  addition  to  a  generous  diet  a  tonic  composed  of  the 
compound  syrup  of  hypophosphites,  extract  of  malt,  and  pepsin  cordial,  equal 
parts,  with  a  very  small  amount  of  elixir  of  bark,  iron,  and  strychnine,  acts 
efficiently. 


ERYSIPELAS. 

By  FREDERICK  A.  PACKARD,  M.  D., 

Philadelphia. 


Erysipelas  is  an  acute,  specific,  contagious,  inflammatory  disease  of  skin 
and  mucous  membranes,  accompanied  by  marked  general  symptoms,  and  cha- 
racterized by  peculiar  local  lesions  at  the  seat  of  inoculation,  by  its  tendency  to 
spread,  and  by  the  presence  in  the  affected  area  of  a  micrococcus  that  is  capable 
of  reproducing  the  disease  in  other  individuals. 

The  word  "erysipelas  "  is  probably  derived  from  ipudpoi;,  red,  and  TZsXla, 
shin.  Numerous  qualifying  words  have  been  used  to  signify  the  point  of 
involvement,  the  course  of  the  disease,  the  appearances  presented  by  the  local 
lesion,  the  age  at  which  the  disease  occurs,  etc.  The  terms  "  traumatic  "  and 
"  idiopathic  "  have  been  used  to  distinguish  cases  wherein  there  is  or  is  not  an 
antecedent  obvious  wound  of  the  skin  at  the  seat  of  the  local  lesion.  No 
qualifying  words  should  be  used  as  implying  an  essential  difference  in  the  pro- 
cess, as  it  is  a  disease  sui  generis,  no  matter  under  what  circumstances  it  may 
occur. 

History. — Erysipelas  has  been  known  from  the  time  of  Hippocrates,  but 
the  descriptions  of  the  disease  given  by  most  writers  prior  to  those  of  the  last 
century  show  that  many  diverse  diseases  were  included  under  this  name. 
When  humoral  pathology  occupied  men's  attention,  this,  in  common  with  many 
other  maladies,  was  supposed  to  be  the  outward  expression  of  morbid  humors 
in  the  body.  At  a  later  date  it  was  looked  upon  as  a  simple  dermatitis ;  still 
later,  as  a  simple  lymphangitis.  The  contagiousness  of  the  disease  was  pointed 
out  by  Lorry  in  1777.  A  microbic  origin  was  first  suspected  by  Martin  in 
.1865.  The  question  of  priority  in  demonstrating  this  origin  is  still  a  matter 
of  dispute.  Between  1868  and  1870,  Nepveu  and  Hueter  described  the  occur- 
rence of  microscopic  organisms  in  connection  with  the  disease.  It  need  only 
be  stated  here  that  the  description  given  by  Nepveu  corresponds  more  closely 
than  does  that  of  Hueter  to  the  micro-organism  now  established  as  the  cause 
of  the  disease.  Since  1870  many  observers  have  studied  the  disease  from  a 
bacteriological  aspect,  but  it  is  especially  to  Fehleisen  that  we  owe  our  present 
knowledge  of  the  life-history  and  etiological  r6le  of  the  micrococcus  described 
by  him  in  1882. 

Btiolog-y. — The  disease  is  limited  in  its  occurrence  to  no  part  of  the  civil- 
ized world,  but  its  favorite  habitat  is  the  temperate  zone.  It  but  rarely  occurs 
in  the  tropics,  being  less  rare  in  regions  far  removed  from  the  equator.  In 
Greenland,  for  example,  occasional  widespread  epidemics  have  occurred. 

The  predisposing  effect  of  season  can  be  readily  seen  by  the  accompanying 
chart  (Fig.  1).  It  will  there  be  found  that  by  far  the  greater  number  of  fatal 
cases  in  Philadelphia  occur  during  the  latter  part  of  the  first  and  the  early 
portion  of  the  second  quarter  of  the  year ;  that  is,  during  the  early  spring 
months.  Allen  analyzed  566  cases  applying  for  treatment,  and  obtained 
practically  the  same  result. 

221 


222  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


It  appears  to  be  most  prevalent  among  the  poorer  classes.     This  may  be 
due    to  several  causes — the  greater  liability   to  injury,  frequency  of  chronic 


- 

QUARTER 

2 

- 

Fig. 

QUARTER 

1 

• 

3".' 

QUARTER 

4-rH 

QUARTER 

WEEKS  or  YEAR 

1 

>  » 

♦ 

( 

e 

7 

8 

9 

1011 

12  IS 

14]1S 

1017 

18 

19 

Srt 

21 

sas 

SE4| 

2e| 

2dt: 

28 

29  80|S 

182 

38 

34| 

8&I 

8fi 

»* 

88 

89 

H 

41 

42 

43 

44 

46)48 

47 

4g| 

49 

&0{lil|62l 

62 

** 

1 

47 

4* 
4« 

41 

/ 

' 

«» 
«7 
S» 
8fr 
S4 

• 

' 

1 

1 

A 

' 

1 

/ 

1 

82 

/ 

\ 

1 

\ 

/' 

V 

\ 

ZL      **^ 

1 

V 

' 

1 

cc    2» 

V 

( 

-^     M 

1 

\ 

1 

^  " 

/ 

E- 

H     '■» 

\l 

St 

19 

18 

i; 

\ 

A 

, 

\ 

/ 

\ 

V 

J 

r 

J 

i& 

V 

1 

/ 

\ 

/ 

A 

II 
i» 
11 

10 

^ 

A 

\ 

r 

A, 

/ 

1 

1 

\ 

1/ 

' 

/ 

Y 

7 

/ 

'S 

-^ 

r 

V 

/ 

b 

4 

1 

I 

* 

.     ■» 

lL 

L 

_ 

u 

u 

L 

J     1 

\ 

_^ 

u 

u 

1 

L 

J 

LL 

1 

u 

.„ 

J 

u 

_ 

1— 

L 

_ 

Chart  showing  the  Number  of  Fatal  cases  of  Erysipelas  in  Philadelphia  occurring  in  different  seasons 

from"  1874  to  1891. 

superficial  inflammatory  troubles,  lack  of  cleanliness,  Avant  of  ordinary  sanitary 
precautions,  and  neglect  of  proper  isolation  amongst  those  attacked. 

The  question  of  age  as  a  predisposing  factor  is  difficult  to  determine,  as 
only  fatal  cases  appear  in  the  reports  of  boards  of  health.  Of  12,556  fatal 
cases  of  the  disease  in  England  betAveen  the  years  1862  and  1868,  there 
occurred  under  one  year  of  age  31  per  cent.  ;  under  five  years,  5.9  per  cent. ; 
under  fifteen  3'-ears,  2.9  per  cent. ;  under  twenty-five  years,  4.2  per  cent. ;  under 
forty-five  years,  12.4  per  cent.  ;  under  sixty-five  years,  20.9  per  cent.  ;  above 
eighty-five  years,  1.4  per  cent.  In  Philadelphia,  during  the  period  between 
1874  and  1891,  there  occurred  1253  deaths  from  erysipelas.  Of  these,  380 
were  in  children  under  one  year  of  age,  35  between  one  and  two,  23  between 
two  and  five,  25  between  five  and  ten,  6  between  ten  and  fifteen,  the  remain- 
ing 784  cases  occurring  in  those  past  the  latter  age.  All  that  can  be  said, 
therefore,  is  that  no  age  is  exempt.  The  large  number  of  fatal  cases  occurring 
in  the  first  year  of  life  may  be  due  to  the  almost  uniform  fatality  of  the  disease 
during  the  early  part  of  that  period,  and  cannot  be  taken  as  an  index  of  the 
actual  number  of  cases  occurring  in  infants. 


ERYSIPELAS.  223 

What  part  filth  and  defective  drainage  may  play  in  its  production  has  not 
been  definitely  settled.  In  the  older  hospitals  of  Europe  frequent  epidemics 
have  oqcurred ;  but  it  is  not  alone  in  these  that  erysipelas  appears,  new  and 
apparently  sanitary  institutions  being  also  the  scene  of  its  occurrence.  A 
well-known  and  oft- quoted  instance  of  the  effect  of  polluted  air  is  that  which 
occurred  in  the  Middlesex  Hospital,  where  a  defective  drain  was  on  two 
occasions  the  apparent  cause  of  an  outbreak  of  the  disease,  starting  in 
the  bed  nearest  to  its  position  in  the  wall.  It  is  said  to  be  frequent  in  the 
immediate  neighborhood  of  badly-kept  stables. 

The  most  important  etiological  factor  is  contagion.  The  contagious  principle 
has  but  a  limited  area  of  influence,  as  is  shown  by  some  of  the  histories  of 
local  epidemics  within  hospital  wards,  wherein  patients  upon  one  side  of  a 
ward  have  been  affected  seriatim  on  both  the  right  and  left  of  the  individual 
first  attacked.  Those  in  attendance  upon  a  case  are  apt  to  contract  the  disease. 
One  attack  seems  rather  to  predispose  to,  than  to  protect  against,  a  recurrence, 
due  probably  to  the  fact  that  some  breach  of  the  surface  produced  by  a  chronic 
affection  admits  the  poison. 

The  contagious  principle  is  the  streptococcus  erysipelatis.  Although  pre- 
vious investigators  had  discovered  micrococci  in  the  local  lesion,  the  most 
careful  and  conclusive  woi^k  upon  the  subject  was  performed  by  Fehleisen,  hence 
the  micro-organism  is  frequently  spoken  of  as  the  streptococcus  of  Fehleisen.  By 
him  it  was  found  in  the  lymphatic  vessels  and  spaces  of  the  skin  and  subcu- 
taneous cellular  tissue,  and  in  the  superficial  layers  of  the  corium.  It  occurs 
as  a  single  cell  or  in  the  form  of  diplococci  or  chains  of  various  length.  The 
individual  cell  measures  about  0.3^  in  diameter.  It  is  readily  cultivated  upon 
gelatin  and  blood-serum,  where  the  colonies  form  as  dull-white,  round  points, 
closely  marginated  or  fusing  at  points  of  contact.  It  grows  well  at  the  tem- 
perature of  the  human  body,  is  facultatively  aerobic,  and  develops  well  in  vacuo. 
Not  only  has  the  inoculation  of  pure  cultures  been  successfully  practised  upon 
animals,  but  the  disease  has  been  inoculated  upon  human  beings  as  a  therapeutic 
measure. 

In  order  that  the  parasite  may  gain  access  to  the  lymph-spaces,  it  is  essen- 
tial that  some  breach  of  the  surface  should  exist.  This  means  of  entry  may  be 
supplied  by  some  wound  accidentally  received  or  purposely  inflicted,  by  the 
unhealed  navel  of  the  new-born,  scarifications  made  for  purposes  of  vacci- 
nation, the  local  lesion  of  vaccinia,  the  ulcers  of  varicella,  solutions  of  continuity 
produced  by  eczema,  intertrigo,  ecthyma,  or  pemphigus,  or  by  ulcers  resulting 
from  chronic  inflammation  of  the  mucous  membranes  of  the  mouth  or  upper 
air-passages.  It  is  owing  to  the  frequency  of  lesions  at  the  points  of  union  of 
skin  and  mucous  membrane  that  the  local  manifestations  frequently  begin  at 
those  situations. 

Pathological  Anatomy. — After  death  the  body-heat  is  maintained  for  a 
long  time,  and,  according  to  Eulenburg,  there  is  a  post-mortem  rise  of  tempera- 
ture to  a  point  .9°  C.  (1.5°  F.)  above  that  observed  before  death. 

At  the  seat  of  the  local  lesion  the  vivid  color  gives  place  to  a  mere  yellow- 
ish discoloration,  and  much  of  the  swelling  observed  during  life  disappears. 
When  the  skin  is  incised  there  exudes  a  varying  quantity  of  more  or  less 
discolored  serum.  The  skin  and  subcutaneous  tissue  are  somewhat  thickened 
and  cannot  be  readily  separated.  Microscopical  examination  of  the  affected 
skin  shows  that  beyond  the  peripheral  margin  there  are  numbers  of  micrococci 
in  the  lymphatic  vessels.  As  sections  are  made  from  without  inward,  the 
greatest  histological  changes  are  seen  at  the  visible  margin  of  the  patch,  where 
there  are  much  serous  infiltration  separating  the  cells,  and  infiltration  by  round 


224   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  wandering  cells,  many  micrococci  being  contained  in  the  latter.  From 
this  point  the  alterations  progressively  diminish  as  the  part  earliest  attacked  is 
reached,  until  complete  restitutio  ad  integrum  is  found  to  have  occurred. 
The  hair-shafts  are  unaltered,  but  there  is  serous  and  cellular  infiltration  of  the 
root-sheath,  and  micrococci  may  be  found  in  the  space  between  the  latter  and 
the  root.  In  lately-developed  vesicles  upon  the  surface  no  micro-organisms  are 
to  be  found,  but  in  those  of  longer  existence  various  forms  abound.  In  phleg- 
monous erysipelas  there  is  an  admixture  of  the  staphylococcus  pyogenes  with 
the  streptococcus  erysipelatis. 

The  mucous  membranes  that  are  affected  show  the  same  appearance  as  does 
the  skin,  save  for  the  normal  structural  differences  in  the  tissue.  Attacking 
the  larynx,  the  disease  produces  marked  swelling  in  the  parts  around  the 
glottis.  (Edema  of  the  rima  glottidis  may  be  present.  The  trachea  and 
bronchi  may  be  of  a  brillant  red  color,  with  paler  areas  corresponding  to  the 
cartilaginous  rings.  Three  forms  of  pulmonary  lesion  may  be  found :  (1)  an 
accidental  croupous  pneumonia,  with  the  ordinary  appearances  of  that  lesion  ; 
(2)  intense  congestion,  either  general  or  limited  to  diseased  branches  of  the 
bronchial  tree,  with  scattered  areas  of  red  or  gray  hepatization  within  the 
congested  area ;  (8)  an  acute  infective  interstitial  pneumonia  from  bacterial 
embolism,  with  subsequent  dissemination  of  micrococci  in  the  interlobular 
connective  tissue.  In  cases  where  the  disease  has  spread  from  the  air-passages 
the  alveoli  contain  large  numbers  of  leucocytes  and  many  micrococci,  instead 
of  the  fibrin   and  epithelial  cells  seen  in  croupous   and  catarrhal  pneumonia. 

Inflammation  of  the  pleura  may  be  found  from  ■  extension  of  the  disease 
through  the  chest-wall  or  as  secondary  to  subpleural  pulmonary  lesions.  The 
pleural  cavity  may  contain  serous  or  purulent  exudate.  The  streptococcus  has 
been  found  in  pleural  exudate.  Suppurative  anterior  mediastinitis  has  been 
observed.  Pericarditis  is  rarely  seen,  but  endocarditis,  affecting  chiefly  the  free 
borders  or  the  whole  of  a  leaflet  of  the  valves  of  the  left  side,  is  occasionally 
present.  Granular  degeneration  of  the  myocardium  also  occurs,  due  doubtless 
to  the  elevation  of  temperature.  The  endothelium  of  the  blood-vessels  has  been 
found  to  be  swollen,  granular,  and  with  indistinct  nuclei.  Tutschek  reports  a 
case  of  thrombosis  of  the  abdominal  aorta.  The  streptococcus  has  been  found 
in  the  blood  of  the  skin,  subcutaneous  adipose  tissue,  and  in  the  capillaries  of 
the  lungs,  liver,  spleen,  and  kidneys. 

The  stomach  may  exhibit  marked  engorgement  of  its  vessels,  the  intestinal 
tract  patchy  redness.  Multiple  minute  duodenal  ulcers  have  been  seen.  In 
the  large  intestine  the  typical  erysipelatous  local  lesions  may  be  found  in  cases 
where  the  disease  has  spread  from  the  perineum  through  the  anus  to  the  rectal 
mucous  membrane. 

The  liver  may  be  large  and  congested  in  rapidly  fatal  cases ;  in  those  of 
longer  duration  it  is  more  often  pale,  soft,  and  the  seat  of  fatty  degeneration. 
Many  observers  have  found  the  streptococcus  within  the  organ. 

By  most  authors  the  spleen  is  said  to  be  increased  in  volume,  as  would 
be  expected  from  the  frequency  of  its  enlargement  during  life  in  non-fatal 
cases ;  but  Denucd  found  it  small,  soft,  and  hyperfemic. 

Peritonitis  is  comparatively  rarely  found,  most  instances  of  its  occurrence 
beins:  in  the  new-born,  where  the  abdominal  wall  has  been  the  seat  of  the 
primary  process. 

In  spite  of  the  prominence  of  cerebral  symptoms  during  life,  there  are  but 
seldom  found  any  marked  structural  alterations  within  the  cranium.  The 
membranes  may  be  anaemic  or  their  vessels  intensely  engorged  with  blood. 
Actual  meningitis  is  rarely  seen.     An  instance  is  reported  by  Osier  of  menin- 


ERYSIPELAS.  225 

gitis  and  thrombosis  of  the  lateral  sinus  in  a  fatal  case  of  facial  erysipelas 
wherein  the  process  could  be  traced  along  the  trunk  of  the  fifth  cranial  nerve. 

From  the  frequent  presence  of  albuminuria  it  is  to  be  expected  that  in 
fatal  cases  the  kidneys  would  show  structural  alterations.  In  five  cases 
examined  by  Denuc^  these  organs  showed  nephritis  in  degrees  varying  with  the 
duration  of  the  case.  Langer  has  reported  a  fatal  case  of  erysipelas  of  the  scalp 
occurring  in  a  seven-weeks-old  boy,  and  complicated  by  hgemoglobinuria, 
wherein  the  kidneys  showed  infarcts  and  miliary  abscesses.  In  the  articular 
inflammatory  exudate  that  sometimes  occurs  SchUller  found  the  streptococcus. 

Symptoms. — In  spite  of  the  fact  that  in  six  cases  purposely  inoculated 
by  Fehleisen  the  initial  chill  occurred  in  from  fifteen  to  ninety-one  hours,  the 
incubation  for  cases  accidentally  inoculated  may  be  reckoned  as  requiring  a 
period  of  from  three  to  seven  days. 

The  onset  may  be  sudden,  the  first  symptom  being  a  chill  with  rigor.  In 
other  cases  feelings  of  languor  and  vague  discomfort  in  the  part  that  later 
becomes  the  seat  of  the  local  lesion  may  precede  the  occurrence  of  chill.  In 
young  children  the  occurrence  of  an  initial  convulsion  is  not  infrequent.  The 
attack  may  begin  Avith  severe  inflammation  of  the  upper  air-passages  or  throat, 
the  skin  lesion  not  appearing  for  twenty-four  or  thirty-six  hours  after  the  first 
signs  of  illness.  The  temperature  rises  rapidly  to  102°,  103°,  or  even  105°  F. 
The  affected  area  soon  becomes  the  seat  of  burning,  smarting  pain.  The  local 
appearances  at  this  time  may  merely  amount  to  slight  redness  and  glossiness. 
In  a  short  time  there  is  slight  elevation  of  this  reddened  area  above  the  sur- 
rounding healthy  surface,  the  color  deepens  in  shade,  and  there  are  pitting  and 
pain  upon  pressure.  The  color  is  readily  dispelled  by  pressure,  but  quickly 
returns  upon  the  withdrawal  of  the  finger.  The  pain  becomes  more  intense, 
and  there  is  a  sensation  of  stinging  and  stretching  in  the  afiected  part.  The 
tongue  is  coated,  there  is  anorexia,  thirst  may  be  marked,  varying  degrees  of 
cephalalgia  are  present,  while  nausea  is  a  frequent  source  of  complaint.  Vomit- 
ing is  not  frequent  in  cases  of  ordinary  severity.  At  this  stage  the  pulse  is 
usually  full,  bounding,  and  rapid.  Upon  the  second  day  the  temperature-chart 
shows  a  slight  morning  remission.  The  redness  and  swelling  extend  from  the 
original  site  to  cover  a  larger  area ;  the  eyes  may  be  invisible  from  swelling  of 
the  lids,  the  ears  swollen  and  distorted,  and  the  lips  thickened.  Cephalalgia 
becomes  intense,  especially  if  the  scalp  be  invaded ;  insomnia  and  delirium 
frequently  appear.  Albuminuria,  with  a  copious  deposit  of  amorphous  urates, 
will  usually  be  found  after  the  first  few  days.  On  the  second  or  third  day  the 
local  appearances  of  the  part  first  attacked  reach  their  highest  degree  of  devel- 
opment. Thereafter  the  redness  and  swelling  of  that  part  subside.  Meanwhile 
the  local  process  may  have  steadily  advanced  from  the  point  of  its  original 
appearance  until  large  areas  of  skin  are  involved.  When  extension  ceases  the 
temperature  rapidly  falls,  the  pulse  becomes  less  bounding  and  its  frequency 
diminishes,  pain  lessens,  the  associated  symptoms  rapidly  subside,  and  the 
patient  enters  upon  convalescence.  During  convalescence  the  affected  skin  has 
a  faint  yellowish  discoloration  and  is  the  seat  of  desquamation,  the  epidermis 
separating  in  branny  scales  or  in  large  flakes,  and  in  cases  where  the  scalp  has 
been  invaded  the  hair  falls.  Albuminuria  may  persist  in  lessening  degree  for 
several  days  after  the  cessation  of  other  symptoms. 

Important  variations  from  this  ordinary  type  occur  and  require  separate 
consideration. 

Erysipelas  of  the  new-born  begins  either  at  the  navel  or  at  a  point  nearer 
to  the  symphysis  pubis.  Thence  extension  rapidly  occurs  until  the  skin  of  the 
whole  abdomen,  that  of  the  extremities,  or  even  larger  portions  of  surface,  may 

15 


226  AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

be  involved.  The  infont  exhibits  extreme  restlessness  and  has  high  fever,  may 
vomit  frequently,  and  soon  passes  into  an  asthenic  condition  that  speedily  ends 
in  death.  In  other  cases  the  process  extends  along  the  still  patulous  umbilical 
vein,  reaches  the  liver,  and  may  lead  to  fatal  peritonitis.  After  the  early  days 
of  infancy  are  passed  the  disease  shows  the  same  characters  in  children  as  in 
adults. 

Where  the  mouth,  tonsils,  pharynx,  or  nares  are  primarily  attacked,  the 
local  appearances  are  those  of  an  intense  inflammation  of  the  part  affected,  but 
swelling  is  more  marked  than  usually  occurs  with  ordinary  inflammation,  and 
the  tendency  to  spread  to  adjacent  structures  and  the  skin  is  a  peculiarity  of 
great  diagnostic  importance.  From  the  nares  it  may  extend  to  the  lachrymal 
duct  and  attack  the  skin  near  the  internal  canthus.  From  the  upper  air- 
passages  the  process  may  extend  to  the  bronchi  or  to  the  lungs,  producing  the 
symptoms  and  physical  signs  of  an  intense  bronchitis  or  pneumonia.  In  the 
primarily  laryngeal  form  hoarseness  begins  early,  and  may  be  rapidly  followed 
by  symptoms  of  suft'ocation  due  to  the  intense  swelling  of  the  mucous 
membrane. 

The  eruption  exhibits  certain  peculiarities  worthy  of  further  study.  Exten- 
sion usually  takes  place  most  rapidly  in  one  direction,  but  not  in  an  even  line, 
as  flame-like  tongues  of  redness  frequently  jut  out  in  advance.  The  area  of 
redness  and  swelling  is  bounded  by  an  abrupt  fall  to  the  level  of  the  healthy 
surface.  Extension  from  the  face  usually  occurs  upward,  reaching  the  hairy 
scalp  or  even  passing  backward  to  the  nape  of  the  neck  or  to  the  trunk. 
From  the  trunk  it  may  spread  to  the  extremities  or  head,  and  vice  versd.  One 
striking  peculiarity  of  the  eruption  is  its  liability  to  terminate  at  natural 
boundaries — the  borders  of  the  hairy  scalp,  the  various  folds  of  the  face,  the 
groin.  Where  the  underlying  bone  is  close  to  the  surface  the  eruption  is  fre- 
quently absent ;  thus  the  chin  may  be  spared,  while  the  rest  of  the  face  is 
much  swollen.  Conversely,  where  the  skin  is  but  loosely  attached  to  under- 
lying structures — as  in  the  scrotum,  labia  majora,  and  eyelids — swelling  is  very 
marked,  and  gangrene  may  occur  from  interference  with  the  circulation. 
Besides  redness  and  swelling,  other  appearances  are  usually  present  in  the 
affected  area  of  skin.  Vesicles,  or  even  bull»  with  clear  or  muddy  contents, 
are  apt  to  form.  Pustules  are  rarely  seen,  but  in  some  regions  with  resisting 
skin  a  verrucose  appearance  may  be  presented  from  cellular  infiltration. 
Minute  points  or  quite  extensive  areas  of  gangrene  may  occur.  The  bursting 
of  the  vesicles  and  bullae  causes  the  formation  of  yellowish  or  brownish 
crusts.  After  the  active  process  in  a  part  has  subsided  the  surface  is  covered 
with  bran-like  scales,  large  flakes  of  detached  epithelium,  and  crusts  of  varied 
hue.  The  hair  may  fall  very  rapidly,  leaving  the  scalp  bare,  smooth,  and 
shining. 

The  temperature-curve  follows  quite  accurately  the  extension  and  subsidence 
of  the  local  process.  After  the  latter  has  entirely  subsided  there  may  remain 
an  elevated  temperature,  owing  to  the  presence  of  irritation  or  actual  inflam- 
mation of  various  organs.  Cavafy  has  reported  five  cases,  and  I  have  seen  one, 
of  erysipelas  of  the  face  without  pyrexia. 

Not  only  may  the  urine  contain  albumin  and  an  excess  of  urates,  but  hya- 
line and  granular  tube-casts  may  also  be  present.  These  disappear  after  the 
cessation  of  the  disease  in  the  majority  of  cases.  Their  presence  may  be  the 
evidence  of  the  rekindling  of  a  pre-existing  disease  of  the  kidneys,  in  which 
case  they  Avill  usually  ]iei'sist  or  even  increase  as  time  passes. 

Complications  and  Sequelae. — The  lung  is  perhaps  the  most  frequent 
seat  of  complication  in  erysipelas.     Pneumonia  of  the  ordinary  type  is  of  not 


ERYSIPELAS.  227 

infrequent  occurrence,  or  the  specific  process  may  attack  the  lung-structure. 
Pleurisy  (with  or  without  eiFusion),  empyema,  peri-  and  enclo-carditis  at  times 
occur.  Pleurisy  occurred  twice  in  eight  cases  purposely  inoculated  by  Fehleisen. 
Previously-existing  nephritis  is  apt  to  be  awakened  into  activity,  and  uraemia 
may  be  the  immediate  cause  of  death.  Hsemoglobinuria  may  be  a  compli- 
cation, as  in  the  case  reported  by  Joseph  Langer.  In  facial  erysipelas  suppu- 
rative inflammation  of  the  orbital  connective  tissue  is  much  to  be  dreaded,  and 
is  frequently  fatal  from  extension  to  the  cerebral  meninges  through  the  optic 
foramen  or  sphenoidal  fissure.  Amblyopia  or  complete  amaurosis  may  result 
from  pressure  upon  the  optic  nerve  or  vessels  of  the  eyeball.  Obstinate  vomit- 
ing is  at  times  a  serious  complication.  Diarrhoea  frequently  occurs,  and  the 
stools  may  contain  blood.  After  the  active  signs  of  disease  have  disappeared 
superficial  abscesses  frequently  form. 

Erysipelas  is,  according  to  Gowers,  rarely  followed  by  paralysis.  Optic 
neuritis,  optic  atrophy,  or  thrombosis  of  the  retinal  vessels  may  follow  com- 
pression of  the  optic  nerve  and  ophthalmic  blood-vessels  in  cases  of  orbital 
cellulitis.  Amblyopia  may  be  due  to  retinal  haemorrhages,  detachment  of  the 
retina,  or  opacities  in  the  vitreous.  In  9209  cases  of  adventitious  deafness 
analyzed  by  W.  B.  Post,  erysipelas  was  the  alleged  cause  in  36. 

Diagnosis. — In  ordinary  cases  the  diagnosis  is  readily  made.  The  sudden 
onset  of  marked  constitutional  symptoms  coincidently  with  or  rapidly  followed 
by  the  red,  elevated,  painful  lesion  of  the  skin,  the  peculiar  qualities  of  the 
latter,  and,  in  particular,  the  tendency  to  spread,  sufiiciently  stamp  the  disease. 
When  the  mucous  membranes  are  first  attacked  it  may  be  impossible  to  make 
a  positive  diagnosis  until  the  skin  becomes  alFected ;  but  here  also  the  rapid 
and  continuous  spread  of  the  disease  along  the  mucous  membrane,  together 
with  the  intense  swelling  and  brilliant  redness  of  the  part,  should  suggest  the 
erysipelatous  nature  of  the  inflammation. 

Where  the  poison  has  entered  through  the  lesions  produced  by  eczema  of 
the  hairy  scalp,  such  as  is  so  frequently  seen  in  the  neglected  children  of  the 
poor,  the  cause  of  the  constitutional  symptoms  may  be  only  discovered  upon 
the  extension  of  the  local  process  to  the  forehead,  neck,  or  ears. 

From  simple  erythema  the  diagnosis  is  made  by  the  tense  swelling,  the 
sharply-defined  border,  the  more  marked  ambulatory  character  of  the  lesion, 
the  fever,  and  other  marked  systemic  symptoms  of  erysipelas. 

From  angeio-neurotic  oedema  this  afi'ection  diff'ers  in  all  points  save  the  fact 
of  the  presence  of  swelling.  From  ordinary  urticaria  it  may  be  distinguished 
by  the  rapid  appearance  and  reappearance  of  "hives,"  and  by  the  occurrence 
of  the  eruption  simultaneously  in  different  portions  of  the  body. 

The  local  appearances  of  acne  rosacea  sometimes  closely  resemble  those 
of  erysipelas,  but  the  clinical  history,  the  rapidity  of  extension,  and  the 
constitutional  symptoms  of  the  latter  disease  clearly  differentiate  the  two 
aff"ections. 

From  malignant  oedema  the  diagnosis  must  be  made  by  the  method  of 
spreading  and  the  local  appearances  peculiar  to  the  two  diseases.  Malignant 
oedema  more  frequently  occurs  at  points  where  the  skin  is  particularly  thin 
than  does  erysipelas. 

Prog-nosis. — In  uncomplicated  cases  the  usual  result  is  in  complete  and 
rapid  cure.  In  the  new-born  (that  is  to  say,  in  those  under  the  age  of  fifteen 
days)  the  disease  is  practically  always  fatal,  owing  in  part  to  the  lack  of  resist- 
ing power  in  those  so  young,  in  part  to  the  ease  with  which  extension  occurs, 
and  in  great  part  to  the  liability  to  the  occurrence  of  phlebitis  of  the  umbilical 
vein  and  of  peritonitis.     In  older  children  complete  cure  usually  results. 


228  AMEBIC  AN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Among  especially  unfavorable  occurrences  may  be  mentioned  suppuration 
in  the  orbital  space,  gangrene,  signs  of  inflammation  of  the  lung,  pericardium, 
or  endocardium.  When  optic  neuritis,  optic  atrophy,  or  thrombosis  of  the 
retinal  arteries  occurs,  the  prognosis  as  to  return  of  vision  is  unfavorable. 
Permanent  baldness  but  seldom  results,  in  spite  of  the  complete  alopecia  that 
often  is  present  immediately  after  the  attack. 

Treatment. — In  this  disease  the  same  rules  in  regard  to  isolation  should 
be  followed  as  in  other  contagious  diseases,  save  only  in  the  degree  to  which  it 
should  be  practised.  Occurring  in  the  medical  wards  of  a  hospital,  it  may 
not  attack  other  individuals,  providing  that  the  beds  are  in  not  too  close  appo- 
sition. The  contagiousness  of  erysipelas  is  not  sufficient  to  warrant  the  exclu- 
sion of  cases  from  medical  wards  that  are  properly  separated  from  the  surgical 
and  obstetrical  departments.  It  is  sufficient  that  the  patient  be  so  placed  that 
he  may  be  surrounded  by  those  having  no  breach  of  cutaneous  or  mucous  sur- 
faces. In  surgical  and  obstetrical  wards  cases  of  erysipelas  should  be  excluded, 
and  the  occurrence  of  an  attack  should  be  the  signal  for  immediate  isolation. 

No  safer  means  for  the  prevention  of  the  disease  exists  than  the  use  of 
thoroughly  antiseptic  methods  as  regards  the  wards,  the  operating-room  and 
its  appurtenances,  the  persons  of  operators  and  assistants,  and  the  dressings 
employed.  "Where  attacks  recur  in  an  individual  any  existing  lesion  that  may 
give  entrance  to  the  poison  should  receive  careful  and  prompt  treatment. 

In  the  case  of  a  self-limited  disease,  and  one  that  rapidly  subsides  w'ithout 
warning,  deductions  as  to  the  efficacy  of  any  particular  line  of  treatment  must 
be  most  carefully  drawn.  The  methods  employed  in  erysipelas  are  too  numer- 
ous to  be  here  enumerated  ;  suffice  it  to  mention  a  few  of  those  that  have  stood 
the  test  of  prolonged  use  by  various  observers. 

A  mercurial  purgative  is  advantageous  in  the  early  stages  and  before  the 
institution  of  any  line  of  treatment.  But  two  drugs  deserve  mention  as  hav- 
ing any  effect  upon  the  course  of  the  disease — tincture  of  the  chloride  of  iron 
and  jaborandi.  After  prolonged  trial  the  first  of  these  seems  to  have  some 
influence  in  modifying  the  severity  and  shortening  the  course  of  the  attack. 
It  is  best  given  in  large  doses,  5  to  15  drops,  every  three  or  four  hours  accord- 
ing to  the  age  of  the  child.  Under  its  use  there  is  usually  found  a  rapid  cessa- 
tion of  extension  of  the  local  process  and  subsidence  of  the  general  symptoms. 
Jaborandi,  or  its  alkaloid  pilocarpine,  was  first  recommended  by  DaCosta,  and 
has  had  numerous  advocates  since  the  announcement  of  its  value  in  erysipelas. 
In  children,  however,  it  must  be  given  with  caution  and  in  doses  carefully 
graduated  to  the  age  of  the  child,  the  object  being  to  give  by  hypodermic 
injection  an  initial  dose  of  pilocarpine  sufficient  to  produce  a  pronounced 
sweat,  and  thereafter  to  give  every  four  hours  doses  of  the  fluid  extract  of 
jaborandi  sufficient  to  maintain  a  gentle  diaphoresis.  In  adults  the  method  is 
decidedly  beneficial,  but  in  children  its  use  requires  caution  and  careful  watch- 
ing by  an  intelligent  attendant. 

The  almost  purely  mechanical  rules  that  govern  the  extension  and  limita- 
tion of  the  local  process  have  led  to  various  attempts  to  substitute  artificial 
boundaries  for  those  of  nature.  For  this  end  pressure  applied  in  advance  of 
the  lesion  has  been  extensively  employed  by  means  of  tight  bandages  of  elastic 
material,  by  the  application  of  strips  of  adhesive  plaster,  and  by  collodion.  In 
many  situations  no  form  of  pressure  is  practicable  save  that  by  collodion  ;  but 
the  depth  to  which  the  constriction  by  collodion  reaches  is  too  slight  to  offer 
any  obstacle  to  the  spread  of  the  process.  Where  the  other  methods  are  avail- 
able the  application  of  constricting  bandages  sufficiently  tight  to  accomplish 
the  object  in  view  is  apt  to  be  too  painful   for  their  long  continuance.     As, 


ERYSIPELAS.  229 

however,  this  does  not  preclude  the  emploTment  of  other  methods  of  treat- 
ment, it  should  be  tried  wherever  practicable. 

Attempts  have  been  made  to  stay  the  spread  of  this  specific  inflammation 
by  the  production  of  simple  inflammatory  exudation.  For  this  purpose  incis- 
ions were  made  or  the  solid  stick  of  nitrate  of  silver  was  applied  to  the  skin 
beyond  the  afi"ected  area.  Scarification  of  the  healthy  skin  beyond  the  edge 
of  the  patch  has  been,  and  is  still,  used  by  some  for  the  same  purpose.  Hueter 
first  introduced  the  injection  of  2  per  cent,  carbolic-acid  solution  under  the 
skin  threatened  with  attack.  In  some  cases  it  seems  to  have  limited  the  pro- 
cess, but  the  method  is  not  always  successful.     It  is.  however,  rational. 

As  applications  to  the  diseased  area  many  materials  have  been  recommended, 
such  as  flour,  lycopodium,  or  other  bland  powders,  white  paint,  lead-water  and 
laudanum,  cold  water,  vinegar  and  water,  turpentine,  and  tar.  These  are  now 
but  seldom  used,  except  white  paint  and  lead-water  and  laudanum.  The  exclu- 
sion of  air  of  itself  seems  to  relieve  much  of  the  discomfort  and  pain.  On  this 
account  any  emollient  application  is  agreeable.  To  the  fatty  base  various  sub- 
stances may  be  added.  One  of  the  most  agreeable  is  the  hydrochlorate  of 
cocaine  in  the  proportion  of  16  grains  to  the  ounce.  This  usually  relieves 
pain  very  markedly.  Eesorcin  in  the  strength  of  a  drachm  to  the  ounce  may 
be  used.  Koch  recommends  the  application,  by  means  of  a  bristle-brush,  of 
a  mixture  of  creolin  1  part,  iodoform  4  parts,  and  lanolin  10  parts.  Spraying 
of  the  affected  surface  with  a  solution  of  corrosive  sublimate  has  been  recom- 
mended, but  greater  relief  of  discomfort,  with  more  likelihood  of  reaching:  the 
deeper  parts,  can  be  obtained  by  the  use  of  constant  applications  of  emollient 
preparations. 

The  diet  should  be  nourishing  and  easily  digestible.  Milk  should  consti- 
tute the  basis  during  the  acute  stage  of  the  disease,  but  eggs,  broths,  and  soft 
milk  foods  may  be  given,  except  when  fever  is  so  great  as  to  interfere  with  the 
process  of  digestion.  In  all  cases  occurring  among  the  debilitated,  and  par- 
ticularly in  very  young  children,  stimulants  will  be  almost  invariably  required. 
The  amount  to  be  given  depends  upon  the  age  and  condition  of  the  patient. 

For  extreme  elevation  of  temperature  the  application  of  cold  externally  by 
means  of  sponging  with  cool  or  cold  Avater,  the  wet  pack,  or  the  cool  bath 
should  be  employed.  Where  the  hyperpyrexia  resists  these  measures,  or  where 
they  cannot  be  properly  applied,  antipyrine,  acetanilid.  or,  better  still,  phena- 
•cetin,  may  be  cautiously  tried.  The  drugs  mentioned  should  only  be  employed 
with  extreme  care  and  in  minimum  effectual  doses. 

For  delirium  bromide  of  potassium  or  sodium  may  be  given,  either  by 
mouth  or  rectum.  Cold  applications  to  the  head  may  be  sufiicient  to  mode- 
rate the  symptom.  Opiates  are  to  be  used  only  as  a  last  resource  and  with 
great  circumspection,  not  only  because  of  the  danger  attending  their  use  in 
childhood,  but  also  because  of  the  liability  to  insufficiency  or  actual  inflam- 
mation of  the  kidneys  in  this  disease. 

Impending  suffocation  from  swelling  of  the  rima  glottidis  may  require  tra- 
cheotomy. Any  purulent  collections  that  may  form  should  be  promptly 
released  by  the  knife. 

After  the  subsidence  of  the  disease  tonics  with  h^ematinics  will  be  required. 
The  alopecia  that  occurs  in  some  cases  usually  requires  no  special  treatment, 
but  friction  of  the  scalp  and  the  use  of  cantharidal  preparations  will  hasten 
the  growth  of  the  hair. 

Therapeutic  Use. — A  few  words  must  be  added  regarding  the  use  of  ery- 
sipelas as  a  therapeutic  measure.  For  many  years  back  there  are  to  be  found 
reports  of  cases  wherein  an  intercurrent  attack  of  erysipelas  was  followed  by 


230  A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

an  amelioration  or  complete  subsidence  of  the  primary  affection.  The  fre- 
quency of  this  phenomenon  led  to  the  intentional  inoculation  of  erysipelas 
for  the  cure  of  various  affections  that  were  resistant  to  other  measures  of 
treatment,  were  inaccessible  to  the  surgeon's  knife,  or  whose  existence  was 
incompatible  with  that  of  erysipelas.  Among  the  affections  alleged  to  have 
been  cured  by  such  an  attack  of  erysipelas  or  by  the  intentional  inoculation 
of  the  streptococcus  of  Fehleisen  may  be  mentioned  various  lymphosarcomata, 
epitheliomata,  lupus,  and  various  other  chronic  superficial  ulcerations,  keloid, 
neuralgia,  various  psychoses,  acute  polyarthritis,  and  pulmonary  tuberculosis. 
The  antagonism  between  erysipelas  and  diphtheria  has  led  to  the  inoculation 
of  the  former  upon  the  latter  disease. 

While  many  favorable  reports  as  to  the  action  of  erysipelas  in  the  reduction 
or  complete  removal  of  sarcomatous  and  carcinomatous  tumors  are  to  be  found, 
there  are  others  where  either  no  result  has  been  obtained  or  where  recurrence 
of  the  growth  has  taken  place,  or  even  death  has  been  brought  about  by  the 
erysipelatous  attack.  The  cases  of  neuroses  and  neuralgia  that  are  found  to 
have  been  relieved  by  an  attack  of  the  disease  can  be  duplicated  by  those 
wherein  cure  has  resulted  after  many  different  mental  or  physical  impressions. 

In  regard  to  the  superficial  skin  lesions,  the  favorable  action  of  erysipelas 
may  be  explained  by  the  local  influence  of  the  inflammation  produced  as  part 
of  the  latter.  As  to  the  favorable  result  in  a  case  of  pulmonary  tuberculosis 
reported  by  Chelmonsky,  it  can  only  be  said  that  further  evidence  must  be 
brought  forward  before  any  definite  curative  influence  of  erysipelas  upon  this 
pulmonary  lesion  can  be  acknowledged. 

Attractive  as  is  the  theory  of  the  antagonistic  action  of  the  bacterial  products 
in  one  disease  upon  its  own  micro-organisms  or  upon  those  of  another  malady, 
it  seems  as  yet  unjustifiable  to  purposely  add  to  the  existing  affection  a  disease 
which,  while  usually  ending  in  recovery,  not  only  may  of  itself  prove  fatal, 
but  which  is  often  observed  as  the  final  and  fatal  complication  of  many  long- 
standing cases  of  incurable  disease. 


CHOLERA  ASIATICA. 

By  EDWARD  O.  SHAKESPEARE,  A.  M.,  M.  D., 

Philadelphia. 


This  disease  would  be  most  properly  designated  as  cholera  infectiosa  epi- 
demiea,  for  in  this  term  a  definite  idea  of  its  chief  characteristic  and  of  its 
most  marked  tendency  would  be  included. 

Cholera  Asiatica  is  an  exceedingly  dangerous  specific  human  disorder,  pri- 
marily of  the  digestive  tract,  occasioned  directly  by  the  ingestion,  entrance  into 
the  small  intestine,  and  exuberant  multiplication  there  of  special  minute  vege- 
table parasites,  the  spirilla  cholerse  Asiaticse,  the  so-called  "comma  bacilli" 
of  Koch.  The  special  poison  elaborated  by  the  growth  of  the  parasites  in  the 
intestines  attacks  the  epithelial  lining  of  the  latter,  ultimately  reaches  the  cir- 
culation and  the  nerve-centres,  and  causes  the  complex  phenomena  which  cha- 
racterize the  disease. 

The  intestinal  contents,  the  vomit,  and  the  stools  of  the  attacked  contain 
these  specific  parasites  in  enormous  numbers,  and  they  are  infectious  so  long  as 
the  latter  retain  their  vitality  and  power  of  reproduction  ;  so  long  as  their 
infectious  quality  persists  they  are  capable,  under  favorable  circumstances,  of 
causing  an  attack  of  the  same  disorder  in  another  exposed,  susceptible  person, 
and  of  giving  rise  to  a  local  or  widespread  epidemic  of  the  same  disease.  For 
the  latter  reason  does  the  danger  to  the  public  always  outweigh  in  magnitude 
even  that  to  the  individual  attacked. 

Cholera  Asiatica  is  endemic  in  the  lower  two-thirds  of  the  presidency  of 
Bengal,  roughly  corresponding  to  the  delta  of  the  Ganges  and  the  Brahma- 
pootra ;  it  becomes  epidemic  in  other  parts  of  Hindostan  and  of  the  world  only 
periodically,  after  more  or  less  irregular  intervals  of  entire  absence.  During 
the  intervals  of  epidemics,  except  as  scattered  cases  shortly  preceding  or  fol- 
lowing such  visitations,  and  as  an  essential  part  of  the  latter,  it  does  not  exist 
outside  the  endemic  area :  it  has  no  more  affiliation  with  or  relation  to  our 
somewhat  common  so-called  summer  cholera — otherwise  termed  cholera  nostras, 
cholera  morbus — than  it  has  with  some  acute  attacks  due  to  arsenical  poison- 
ing, to  ptomaine-poisoning  from  ingestion  of  decomposed  food,  or  to  acute  per- 
nicious malaria,  or  to  still  other  very  different  disorders,  all  of  which,  never- 
theless, not  infrequently  present  very  similar  symptoms  and  terminations. 

Etiology. — Although  abounding  filth  of  the  surroundings — that  is,  of 
the  district  or  the  locality,  of  the  domicile,  of  the  home-life,  and  of  personal 
habits — favors  infection  and  the  subsequent  development  of  an  individual 
attack,  and  the  initiation,  continuance,  and  spread  of  an  epidemic  of  cholera 
Asiatica,  neither  a  personal  seizure  nor  an  epidemic  outside  that  endemic  area 
which  is  the  natural  home  of  this  disease  can  occur  (not  even  when  the  person 
or  population  wallow  in  every  sort  of  reeking  abomination),  unless  the  special 
infection  be  first  introduced.  In  other  words,  no  amount  of  filth  is  capable  of 
producing  a  spontaneous  generation  of  the  specific  infection  which  is  the  active 

231 


232    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cause  of  this  disease ;  nor,  without  the  activity  of  this  specific  cause,  is  any 
other  agency  or  influence  capable  of  producing  the  disease. 

The  active  specific  cause  of  cholera  Asiatica  is  the  presence  and  multipli- 
cation in  the  intestinal  canal  of  the  subject  of  numbers  of  very  minute  vege- 
table parasites,  certain  well-defined  species  of  bacteria  known  as  the  spirillum 
cholerae  Asiatics  discovered  by  Koch  in  1883,  and  because  of  their  usual 
resemblance  under  the  microscope  to  the  written  comma,  and  of  the  name  of 
its  discoverer,  commonly  called  the  "  comma  bacilli  of  Koch." 

The  term  "bacillus"  as  applied  to  this  vegetable  micro-organism  is,  how- 
ever, a  misnomer,  for  the  species  is  now  regarded  by  nearly  all  competent 
authorities  as  a  member  of  the  group  of  spirilla.  As  commonly  encountered 
in  the  intestinal  contents  or  vomit  of  a  victim  of  the  disease,  and  in  artificial 
culture  media  when  growth  is  recent  and  rapid,  if  a  fresh  preparation  be 
placed  under  a  microscope  of  very  high  power  and  excellent  definition,  this 
micro-organism  is  usually  so  actively  mobile  as  to  defy  distinct  vision.  If  the 
fresh  preparation  has  been  made  from  a  recent  pure  culture,  and  there  be  plenty 
of  fluid  under  the  thin  cover-glass,  the  movements  of  the  comma  bacilli 
remind  one  of  the  rapid,  darting,  zig-zag  movements  of  the  individuals  of  a 
swarm  of  small  flies,  and  of  the  impossibility  of  distinct  vision  of  any  one  of 
the  swarm.  If,  however,  a  smear-preparation  from  such  a  culture  be  made, 
and  after  drying  and  flaming  in  the  usual  manner,  this  be  properly  stained, 
mounted,  and  examined,  it  will  be  seen  that  each  form  is  more  or  less  curved — 
a  few  almost  imperceptibly  so ;  a  few  others  nearly  as  much  as  a  semi-circle  ; 
the  greater  number  having  a  curvature  representing  an  eighth  or  a  quarter 
of  a  circle.  The  length  may  vary  from  one-seventh  to  one-fourth  the  average 
diameter  of  the  red  blood-corpuscle  of  man,  the  width  being  about  a  fourth 
its  length.  Examined  critically  it  can  often  be  seen  that,  instead  of  form- 
ing a  segment  of  a  circular  ring,  the  individual  form  is  in  reality  a  portion 
of  a  spiral.  The  ends  are  blunt  but  rounded,  sometimes  slightly  tapering,  then 
presenting  an  outline  similar  to  the  fennel-seed.  When  proper  methods  of  stain- 
ing are  used  each  end  of  the  "•  comma  bacillus  "  is  found  to  be  furnished  with 
one  or  more  flagella,  which  act  as  motive  organs.  Cultivated  in  bouillon  by 
the  hanging-drop  method,  besides  the  above-described  forms  there  are  usually 
seen  a  variable  number  of  more  or  less  long  and  complete  spirilla.  Old  cul- 
tures in  bouillon,  in  gelatin,  in  agar,  and  in  other  media  nearly  always  contain 
the  comma  and  spiral  forms,  and  intermingled  with  these  are  frequently  other 
shapes,  which  many  authorities  regard  as  involution  forms.  Chief  among  the 
latter  are  spherules  of  a  diameter  from  that  of  a  cross-section  of  the  comma  to 
that  of  a  red  blood-corpuscle  of  man,  and  even  greater.  It  is  pretty  certain 
that  neither  the  comma  nor  the  spirillum  forms  contain  spores  ;  vacuoles  have 
been  mistaken  for  them.  In  the  vomit  and  intestinal  contents  of  the  attacked 
the  comma  forms  are  always  present  for  a  number  of  days,  and  short  and 
incomplete  spirils  may  sometimes  be  demonstrated  in  smear-preparations. 

The  comma  bacillus  of  Koch  multiplies  commonly  by  two  modes,  each  of 
which,  however,  constitutes  essentially  a  process  of  fission :  a,  the  comma 
doubles  its  length,  and  then  divides  into  two  ;  5,  before  dividing  the  comma 
continues  its  elongation  into  a  longer  or  shorter  spiril  filament,  which  ulti- 
mately becomes  segmented  in  order  that  finally  the  segments  may  separate  to 
form  new  and  separate  commas.  Of  these  two  processes  of  multiplication,  the 
former  is  by  far  the  more  rapid.  Elongation  and  division  of  the  one  comma 
into  two  have  been  actually  observed  under  the  microscope  to  take  place  in 
twenty  minutes.  With  such  a  rate  of  multiplication  demonstrated,  one  can 
easily  form  some  adequate  conception  of  the  otherwise  inconceivable  rapidity  of 


PLATE  Vni. 


• 

^t^g 

l^ 

^ 

*. 

I 

H 

•  • 

tF 

Fig.  1.  Photo-micrograph  :  Smear  preparation  from  pure  cultiire  of  comma  bacillus  of  Koch.    X  1200. 
Fig.  2.  Photo-micrograph :  Smear  preparation  from  (old)  piire  culture  in  gelatin  of  comma  bacillus  of 

Koch,  showing  oogonia  of  Ferrdn  or  involution  forms  of  other  authors.    X  1200. 
Fig.  3.  Photo-micrograph :  Gelatin-plate  colony  of  comma  bacillus  of  Koch.    X  50. 
Fig.  4.  Photograph :  Gelatin  tube-culture  of  comma  bacillus   of  Koch,  72  hours  old,  surface  inclined. 

Natural  size. 


CHOLERA  ASIATICA.  233 

propagation  and  enormous  power  of  dissemination  in  river-water  of  the  specific 
infectious  principle  of  Asiatic  cholera  contained  in  the  discharges  from  the  bowels 
of  a  few  cases,  numerous  examples  of  which  the  history  of  this  disease  affords  ; 
one  of  the  most  striking  being  the  most  recent — namely,  that  of  the  river  Elbe 
in  1892.  Of  other  possible  modes  of  multiplication,  only  two  may  be  merely 
mentioned  here :  that  by  intervention  of  so-called  arthrospores  of  Hiippe,  who 
claims  that  these  reproductive  bodies  approach  the  tenacity  of  life  and  the 
power  of  resistance  of  genuine  spores ;  and  that  of  so-called  "  oogonia  "  of  Fer- 
ran — both  modes  being  a  form  of  multiplication  by  budding. 

The  multiplication  of  the  comma  bacillus  of  Koch  in  artificial  culture 
media  has  been  found  to  vary  greatly  under  different  constitution  of  media 
and  varying  conditions  of  temperature,  etc.  During  the  development  and 
continued  growth  of  these  organisms  in  artificial  culture  media,  chemical  com- 
binations are  split  up  and  various  new  chemical  products  formed,  as  the  neces- 
sary accompaniment  of  the  nutrition,  life,  or  death  of  the  microbes  ;  and  these 
resultant  new  chemical  products  vary  in  quantity  or  composition,  or  both,  with 
the  varied  chemical  and  physical  complexion  of  the  culture  media,  the  external 
conditions  of  temperature,  moisture,  free  oxygen,  light,  etc.  Thus  it  seems  to 
be  now  pretty  clearly  established  that  in  artificial  culture,  among  many  other 
characteristics,  the  cholera  microbe  will  not  develop  at  a  temperature  below  57^° 
F.  or  above  107|-°  F. ;  that  freezing,  unless  it  be  prolonged,  does  not  kill  this 
microbe,  but  places  it  in  a  state  of  hibernation,  as  it  were,  ready  to  resume 
again  all  its  vital  and  pathogenic  functions  with  the  return  of  sufficient  heat ; 
then,  on  the  contrary,  when  a  temperature  of  107f  °  F,  is  exceeded  the  vital 
functions  of  the  microbe  are  more  and  more  inhibited  permanently,  if  the  tempera- 
ture be  continued,  until  a  point  is  reached,  at  about  140°  F.,  where  the  life  of  the 
microbe  is  destroyed  absolutely  in  a  very  few  minutes ;  that  multiplication  is  more 
rapid  in  fluid  media  of  suitable  constitution  ;  that  the  culture  fluid,  as  a  rule, 
possesses  more  virulence  when  the  inoculated  microbes  are  very  recently  obtained 
from  an  active  case  of  cholera  than  when  a  long  time  has  elapsed  ;  that  the  pres- 
ence of  peptone  in  the  culture  medium  seems  to  materially  increase  the  develop- 
ment of  the  virulent  power  of  the  microbe,  especially  when  free  oxygen  and 
light  are  excluded ;  that  there  is  scarcely  any  fluid  or  solid  moist  nutrient 
material  of  animal  or  vegetable  composition,  of  a  neutral  or  slightly  alkaline 
reaction  and  not  containing  a  substance  possessing  antiseptic  properties,  upon 
or  in  which  it  will  not  grow  ;  and  there  are  at  the  same  time  many  fruits  and 
vegetables  upon  the  pulp  or  surface  of  which  the  microbes  of  cholei"a  will  not 
only  live  for  hours  and  days,  but  will  multiply  there  even  when  the  object  gives 
a  slightly  acid  reaction.  This  microbe  will  live  and  multiply  enormously  for  a 
time  in  pure  water,  in  foul  water,  even  in  sewerage,  and  in  sea-water ;  it  will 
live  for  a  considerable  time  and  multiply  enormously  in  milk,  whether  fresh  or 
previously  sterilized  ;  it  is  capable  of  living  and  multiplying  for  a  time  in  vari- 
ous common  beverages  and  on  various  common  articles  of  food.  It  will  retain  its 
vitality,  sometimes  multiply  exuberantly,  on  various  textile  fabrics  of  vegetable 
or  animal  nature  for  days,  and  in  some  cases  weeks  and  even  months,  if  they  be 
not  thoroughly  desiccated  or  exposed  to  the  sun's  rays,  and  contain  no  antisep- 
tic susbtance  ;  if  such  fabrics  be  kept  decidedly  damp  or  wet,  the  germ  is  capa- 
ble of  enormous  multiplication,  and  of  retaining  its  infectious  and  reproductive 
power  to  a  virulent  degree  for  indefinite  periods,  lasting  for  weeks  or  months, 
provided  the  sunlight  does  not  fall  upon  it.  If,  however,  these  fabrics  are 
thoroughly  dry  before  the  microbe  is  placed  upon  them,  and  remain  or  quickly 
become  thoroughly  dry  afterward,  it  soon  dies — more  quickly  still  if  exposed 
to  the  sunshine  or  bright  reflected  light.     Whilst  the  propagative  power  of  the 


234    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cholera  microbe  outside  the  human  body,  under  favorable  circumstances,  is  so 
enormous  as  to  be  almost  incredible,  fortunately  for  man  it  is,  of  all  the  dangerous 
pathogenic  microbes  known,  the  most  susceptible  to  restraining  or  destructive 
influences.  Whilst  it  is  too  often  true  that  an  individual,  a  community,  a  city, 
a  whole  nation,  or  even  a  continent,  presenting  favorable  conditions  for  the 
free  propagation  of  the  infection,  oftentimes  suffers  consequences  which  in 
their  swiftness,  gravity,  and  manifold  relations  may  be  appalling,  yet  there  is 
no  infectious  epidemic  disease  w^hich  can  so  certainly  and  so  easily  be  warded 
off  or  arrested  as  can  Asiatic  cholera. 

Mention  has  already  been  made  of  the  ingestion,  entrance  into  the  small 
intestine,  and  exuberant  multiplication  there  of  the  "  comma  bacillus  of  Koch  " 
as  necessary  conditions  precedent  to  an  attack  of  Asiatic  cholera.  Even  with 
these  it  is  probable  that  there  must  be  one  more  condition  before  a  serious  attack 
follows — namely,  susceptibility  to  the  disease  on  the  part  of  the  individual. 
Since  desiccation  is  one  of  the  sure  and  rapid  means  of  killing  the  microbe  of 
cholera,  and  since  the  comma  bacillus  does  not  exist  in  the  lungs  or  intestinal 
organs,  in  the  blood,  lymph,  or  muscular  tissue,  or  in  the  nervous  system  of  a 
person  suffering  an  attack  of  cholera,  it  is  obvious,  a  priori,  that  the  active 
infection  of  this  disease  is  neither  inhaled  nor  does  it  enter  through  the  cuta- 
neous surfaces.  But  in  this  matter  we  are  not  obliged  to  rely  upon  inductive 
reasoning,  for  there  is  not  a  single  example  known  of  either  mode  of  infec- 
tion in  the  clinical  history  of  cholera  or  in  laboratory  experience  with  this  dis- 
ease. The  cholera  microbe  must  be  sivallotved  and  pass  from  the  stomach  into 
the  small  intestine  alive  and  endowed  with  vigorous  powers  of  propagation 
and  pathogenesis,  before  cholera  can  be  naturally  produced  in  man. 

There  are  various  means  and  modes  by  which  the  infection  of  cholera  may 
be  introduced  into  the  oesopliagus  of  man.  It  may  be  conveyed  by  various 
fluids  imbibed,  such  as  water,  milk,  beer,  weak  tea,  etc. ;  by  various  articles 
of  food,  such  as  raw  vegetables,  bread,  butter,  fruits,  meats,  etc.  ;  by  contact 
of  the  mouth  with  hands  in  some  way  soiled  through  careless  handling  of 
objects  contaminated  with  numbers  of  the  microbe,  such  as  the  clothing  w^orn 
by  the  sick,  the  bed-linen  used  by  them,  the  vessels  containing  the  vomit  or 
stools,  etc.  ;  by  water  used  for  lavatory  purposes  or  the  washing  of  dishes  or 
other  food-receptacles ;  by  water  used  for  washing  the  mouth  and  teeth,  etc. 
The  corollary  of  all  this  is  that  Asiatic  cholera  is  not  acquired  by  inhalation 
or  mere  contact  with  persons  suffering  from  the  disease,  or  with  things  contam- 
inated with  the  infectious  principle.  Moreover,  there  seems  to  be  a  natural 
insusceptibility  on  the  part  of  many  to  an  attack  of  cholera,  although  they 
be  undoubtedly  exposed  to  the  infection.  Numerous  examples  of  this  personal 
immunity  are  furnished  by  every  great  epidemic,  especially  when  the  outbreak 
has  been  caused  by  contamination  of  the  common  supply  of  drinking-water. 
Furthermore,  there  is  incontrovertible  evidence  to  prove  that  there  is  an 
acquired  immunity  of  variable  duration  following  a  natural  attack  of  Asiatic 
cholera,  whether  the  latter  have  been  grave  or  mild.  Indeed,  it  is  pretty  cer- 
tain that  a  natural  attack  so  light  as  to  have  escaped  recognition  is  capable  of 
producing  such  an  immunity.  That  an  immunity  can  be  acquired  artificially 
by  means  of  inoculations  of  various  kinds  and  in  various  ways  now  seems  to 
be  an  established  foct.  I  need  only  mention  in  this  connection  the  pioneer 
work  of  the  Spanish  physician.  Dr.  J.  Ferran  in  1884  and  1885,  and  after 
him  the  investigations  of  Petri,  Brieger,  Wasserman,  and  Kitasato,  Klemperer, 
Klebs,  and  Hafkine,  which  with  those  of  others  constitute  a  body  of  experi- 
mental data  so  convincing  as  to  leave  but  little,  if  indeed  any,  room  for  rea- 
sonable doubt.     Whether  or  not  an  attack  of  cholera  follow  introduction  of  the 


CHOLERA  ASIATICA.  235 

special  contagium  vivum  into  the  stomach  of  man  may  depend  upon  one  or  more 
of  several  conditions.  The  acid  gastric  juice  of  the  stomach  is,  when  present 
in  sufficient  quantity  relative  to  the  number  of  cholera  microbes,  capable 
of  quickly  killing  them.  Hence  at  times  when  the  stomach  is  properly  func- 
tionincr  and  the  number  of  the  cholera  bacilli  swallowed  is  not  excessive, 
there  is  far  less  probability  of  these  microbes  passing  the  pylorus  alive  and 
still  retaining  their  vigorous  pathogenic  powei'S  than  when  either  there  is 
little  or  no  acid  in  the  stomach  or  but  little  relative  to  an  excessive  number  of 
comma  bacilli  introduced.  Then,  again,  the  factor  of  personal  susceptibility 
— or,  if  we  prefer  its  complement,  Ave  may  say  the  factor  of  personal  immu- 
nity— may  intervene  (after  the  cholera  microbes  have  passed  into  the  small 
intestine  alive,  virulently  pathogenic  and  in  sufficient  numbers,  wuth  certain 
limitations),  either  to  render  an  attack  of  cholera  more  certain  of  development 
and  more  violent,  or  to  prevent  it  entirely,  or  to  render  it  milder,  respectively, 
as  the  case  may  be.  Thus  there  is  strong  reason  to  believe  that  in  Asiatic 
cholera  as  in  other  infectious  diseases,  whether  the  degree  of  susceptibility  or 
the  degree  of  immunity  of  any  person  be  great  or  little,  the  dosage  of  the 
infectious  material  is  a  matter  of  importance  for  the  generation  or  the  violence 
of  an  attack.  Any  degree  of  immunity  can  be  overwhelmed  by  an  excessive 
dose,  and  any  degree  of  susceptibility  can  be  rendered  insufficient  by  too  small 
a  dose.  These  considerations  explain  why  it  is  that  of  so  many  exposed  to  the 
infection  of  cholera  only  a  comparative  few  suffer  an  attack  which  is  recognized 
as  such.  They  also  explain  why  a  few  foolhardy  persons,  whose  skepticism 
seems  to  be  greater  than  their  power  of  discrimination,  have  ostentatiously 
swallowed  voluntarily,  in  former  times,  some  of  the  intestinal  discharges  of 
cholera  victims,  and  in  later  times,  some  quantities  of  pure  culture  of  the 
cholera  microbe,   and  have  lived  to  preach  their  false  doctrine. 

When  a  sufficient  number  of  vigorous  pathogenic  cholera  microbes  is  intro- 
duced into  the  stomach  and  passes  with  vital  properties  unimpaired  into  the 
small  intestine  of  a  susceptible  person,  an  attack  of  infectious  cholera  may  be 
developed.  In  such  a  case  the  cholera  microbes  multiply  enormously,  and 
often  with  great  rapidity,  in  the  small  intestine.  With  their  growth  there, 
under  favorable  conditions  not  yet  well  determined,  a  virulent  specific  chemical 
poison  is  generated.  Whether  this  poison  be  essentially  a  jytomavne  analo- 
gous to  the  highly-poisonous  vegetable  alkaloids,  as  some  contend,  or  a  species 
of  virulent  albumose,  as  others  maintain,  or  a  special  pathogenic  enzyme,  as 
a  few  affirm,  or  possess  other  characteristics,  or  be  a  combination  of  two  or 
more  of  these,  it  would  be  unprofitable  to  discuss  in  this  place.  Whatever 
the  nature  of  this  specific  chemical  poison  may  be,  it  is  pretty  certain  that 
when  generated  in  sufficient  quantity  it  attacks  primarily  the  epithelium  of 
the  mucous  membrane  of  the  small  intestine,  exciting  in  it  the  phenomena 
of  irritation  and  degeneration  in  varying  degrees — according  to  the  concen- 
tration of  the  poison  and  the  susceptibility  of  the  person — from  initial  cloudy 
swelling  all  the  way  to  complete  fatty  degeneration  and  desquamation.  The 
irritant  poison  penetrates  beyond  the  epithelium  and  excites  in  a  susceptible 
person  a  round-celled  infiltration  of  the  connective  tissue  underlying  the  epi- 
thelium ;  it  may  even  exert  its  irritant  powers  upon  the  submucous  layer  of 
connective  tissue,  and  sometimes  its  influence  may  even  extend  outward  into 
the  muscular  and  subsei'ous  coats  of  the  intestine  calling  forth  in  them  vary- 
ing inflammatory  phenomena.  Klebs  pointed  out  that  autopsies  of  rapid 
cases  of  cholera  showed  invariably  the  inner  surface  of  the  small  intestine  to 
be  covered  with  a  very  tenacious  coating  of  mucus,  and  the  experience  of 
most   observers  confirms  him.     Another  characteristic  is  that  the  serous  mem- 


236    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

brane  of  the  small  intestine  is  likewise  the  seat  almost  always  of  a  viscid  cover- 
ing, consisting  mainly  of  degenerated  and  proliferated  endothelium.  The 
inflammatory  action  in  the  mucous  and  submucous  coats  of  the  small  intes- 
tine may  become  so  intense  as  to  result  in  more  or  less  extensive  necrosis. 
Very  generally  the  mucous  membrane  is  hypememic.  This  hypera^mia  may 
be  very  difl'use  or  it  may  be  limited  to  larger  or  smaller  areas.  It  is  usually 
most  marked  in  the  region  of  the  ileo-cisecal  valve  and  around  the  Peyer's 
glands.  The  Peyer's  glands  and  the  solitary  follicles  are  usually  infiltrated 
and  prominent,  and  this  is  so  common  that  some  French  authors  have  regarded 
cholera  as  a  specific  psorenteritis.  The  infiltration  of  these  glands  may  in  some 
instances  be  so  intense  as  to  end  in  necrosis  and  ulceration.  Notwithstand- 
ing the  fact  that  the  chemical  poison  of  cholera  attacks  locally,  first,  the  intes- 
tinal epithelium,  and  then  the  subjacent  layers  of  connective  tissue,  sometimes 
even  to  the  point  of  denudation  and  limited  destruction  of  the  latter,  the  cholera 
microbe  itself  never  penetrates  the  coats  of  the  intestine  except  when  they  are 
denuded,  and  then  does  not  pass  beyond  the  most  superficial  portion  of  the 
exposed  connective  tissue :  it  never  enters  the  lacteals  or  reaches  the  general 
circulation.  The  chemical  poison,  however,  which  is  produced  in  the  intesti- 
nal canal  by  the  growth  of  the  cholera  microbes  therein,  does  not  limit  its 
action  to  a  local  attack  upon  the  intestinal  epithelium  or  upon  the  subjacent 
tissues ;  but  it  is  taken  up  by  the  intestinal  absorbents  or  the  capillaries  of  the 
villi,  and  enters  the  general  circulation  of  the  blood  to  be  distributed  to  every 
organ  and  tissue  in  the  body,  to  develop  in  the  susceptible  its  secondary  or 
constitutional  action.  It  may  be  said,  therefore,  that  cholera  infectiosa  epi- 
demica  is  essentially  a  specific  systemic  intoxication.  It  may  not  always  hap- 
pen that  the  whole  or  the  greater  portion  of  the  specific  poison  which  pro- 
duces an  attack  of  Asiatic  cholera  has  been  generated  within  the  intestinal 
canal  of  the  victim ;  there  is  strong  reason  for  the  belief  that  exceptionally,  at 
least,  the  offending  material  ingested  already  contains,  before  swallowing,  a 
suflficient  quantity  of  the  specific  chemical  poison  of  cholera  to  produce  an 
attack  of  the  disease.  It  is  probable  that  at  least  some  of  those  attacks  with 
a  violent  onset  in  a  very  few  hours  after  exposure  to  the  infection  have  resulted 
in  such  a  manner,  especially  if  the  autopsy  show,  as  it  sometimes  does,  very 
little  alteration  of  the  intestinal  mucous  membrane.  I  can  conceive,  for 
example,  how  milk  diluted  with  water  contaminated  with  cholera  dejecta,  and 
then  allowed  to  stand  for  several  hours  in  a  warm  place,  can  act  as  a  quick 
and  fatal  poison  when  swallowed  in  large  quantities.  In  such  a  case  it  would 
matter  not  if  the  bacteria  were  killed  in  the  stomach  by  the  action  of  the  gas- 
tric juice ;  the  preformed  chemical  poison  of  cholera  when  absorbed  from  the 
intestine  and  circulated  in  the  blood  might,  if  in  sufiicient  quantity,  still  be 
capable  of  causing  a  violent,  and  even  a  mortal,  attack  of  cholera.  The 
stools  from  such  a  victim  of  the  cholera  poison  might  still  contain  some  quan- 
tity of  that  poison,  but  could  not,  in  the  absence  from  them  of  the  living 
pathogenic  comma  bacillus  of  Koch,  be  infectious.  In  other  words,  from 
such  a  victim  a  new  case  of  cholera  could  not  arise,  much  less  an  epidemic. 
Furthermore,  although  the  symptoms,  course,  termination,  and  post-mortem 
appearances  observed  in  such  a  case  would  naturally  be  those  characteristic  of 
cholera,  yet  a  culture  test  of  the  stools  would  necessarily  be  negative  in  result, 
and  therefore  misleading  as  to  the  origin  of  the  attack,  if  not,  indeed,  of  its 
nature.  A  priori,  it  is  just  among  j^oung  children,  who  consume  habitually 
large  quantities  of  milk,  that  we  should  look  for  the  largest  proportion  of 
such  toxic  non-contagious  attacks  of  cholera. 

Symptoms. — For   convenience  of  description  in  part,  and   in   part    also 


CHOLERA  ASIATIC  A.  237 

because  the  common  course  of  the  attack  furnishes  the  basis  of  the  division, 
clinical  writers  have  been  in  the  habit  of  discussing  the  symptoms  of  Asiatic 
cholera  under  four  periods  :  a,  the  prodromal  period ;  5,  that  of  serous  evacu- 
ation ;  c,  that  of  algidity  or  collapse ;  d^  that  of  reaction. 

a.  The  prodromal  j^eriod,  or  period  of  incubation,  varies  in  duration  from 
a  few  hours  to  perhaps  five  days.  Probably  its  average  length  may  be  most 
accurately  reckoned  at  forty-eight  hours.  It  is  the  time  which  elapses  between 
the  ingestion  of  the  infectious  material  and  onset  of  pronounced  symptoms. 
During  the  early  part  of  the  period,  sometimes  during  the  whole  of  it,  the 
subject  is  apparently  in  his  accustomed  health,  whilst  in  the  latter  part  of  it,  and 
occasionally  throughout  its  entire  length,  and  increasing  in  severity  toward  its 
transition  into  the  next  period,  there  may  be  a  general  feeling  of  distress  in  the 
abdomen,  or  even  a  tendency  to  nausea,  with  or  without  tenderness,  restlessness, 
rumbling,  and  increased  peristaltic  movement  of  the  intestines  sometimes  visi- 
ble or  palpable  through  the  abdominal  walls  ;  laxness  of  the  bowels  or  decided 
diarrhoea,  with  colored  semifluid,  feculent,  or  decidedly  fluid,  usually  painless, 
sometimes  copious,  evacuations.  All  of  these  symptoms  may  be  present,  or 
only  one  of  them,  or  they  all  may  be  absent.  There  is  nothing  at  all  dis- 
tinctive in  their  character  which  is  in  any  way  suggestive  of  their  special 
nature.  They  excite  suspicion  only  when  it  is  known  or  suspected  that  the 
person  may  have  been  exposed  to  the  infection  of  cholera,  or  when  the  disease 
is  present  in  the  locality.  There  is  no  indication  of  systemic  intoxication  dur- 
ing this  period.  The  cholera  microbe  has  merely  reached  the  small  intestine, 
and  is  more  or  less  quietly  gathering  its  forces  for  the  active  attack.  It  is 
engaged  in  multiplying  itself  and  in  generating  its  specific  poison.  The 
assault  on  the  epithelial  lining  of  the  small  intestine  may  have  actually 
begun,  and  some  breaches  in  its  integrity  have  been  accomplished ;  sufiicient 
of  the  chemical  poison  may  have  been  generated  for  the  production  of  some 
hyper^emia  of  the  mucous  membrane,  or  even  for  the  excitement  of  some  infil- 
tration of  the  subepithelial  connective  tissue  ;  but  there  has  been  as  yet  no  sys- 
temic absorption  of  the  specific  chemical  poison  ;  the  action  of  the  special 
poison  is  still  local,  although  there  may  be  experienced  a  degree  of  prostra- 
tion out  of  all  proportion  to  the  diarrhoea  present. 

h.  The  period  of  serous  evacuations  may  be  regarded  as  that  of  sys- 
temic intoxication,  and  its  duration  may  last  from  a  few  hours  to  a  day  or  two. 
The  prodromal  diarrhoea,  if  it  have  existed,  now  usually  assumes  more  gravity. 
The  discharges  become  more  frequent,  copious,  and  fluid.  Often,  but  not 
always,  every  trace  of  color  disappears  from  the  stools.  The  latter  now  fre- 
quently present  the  well-known  rice-water  aspect :  they  are  thin,  very  watery, 
and  hold  in  suspension  more  or  less  minute  whitish  flakes  or  shreds  in 
great  numbers  ;  they  look  like  a  watery  gruel,  in  fact  closely  resemble  the 
aspect  of  barley-water  or  macaroni-water.  They  may  sometimes  still  be 
slightly  colored,  and  they  are  not  infrequently  fi'othy  or  somewhat  bloody. 
In  fact,  there  is  many  a  case  of  cholera  Asiatica  where  the  stools  are  bilious 
or  lack  entirely  the  familiar  rice-water  appearance.  Often  the  desire  to  evacu- 
ate the  bowels  is  sudden  and  absolutely  uncontrollable,  and  the  contents  of  the 
lower  colon  and  rectum  are  sometimes  expelled  with  great  force  without  pain 
and  in  enormous  quantity,  saturating  the  bed  and  covering,  or  deluging  the 
clothing  if  the  patient  be  still  up  and  moving  around.  Nausea  and  vomiting 
are  now  usual  accompaniments.  At  first  the  vomit  may  be  bilious  ;  later  it 
assumes  the  rice-water  or  gruel  aspect.  The  amount  of  fluid  discharged  from 
the  anus  and  mouth  is  often  excessive.  Prostration  quickly  becomes  extreme, 
and  thirst  intense.      The   cry  for  water  is  constant,  yet  it  is  rejected  by  the 


238    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

stomach  almost  immediately  after  it  is  swallowed.  The  enormous  exudation  of 
fluid  into  the  intestinal  canal  reduces  correspondingly  the  volume  of  the  lymph 
in  the  tissues  and  organs,  and  of  the  blood  in  the  circulatory  system.  The  tis- 
sues become  abnormally  dry  and  shrunken,  and  the  blood  markedly  thickened. 
The  number  of  the  corpuscles  of  the  blood  is  relatively  much  increased  per 
cubic  centimetre  ;  it  is  sometimes  nearly  doubled.  The  heart  has  not  of  itself 
the  power  to  propel  this  thickened  fluid  with  sufficient  vigor  to  prevent  venous 
stagnation.  At  first  the  pulse  is  very  frequent  for  a  time  ;  indeed,  palpitation 
ma}'  add  to  the  general  distress  and  anxiety  of  the  patient ;  besides  being 
accelerated,  the  pulse  is  usually  at  the  same  time  small,  feeble,  and  soft.  Later  the 
heart's  action  becomes  more  and  more  enfeebled,  until  the  pulse  is  nearly  or 
quite  lost  at  the  wrist,  whilst  the  apex-beat  may  also  nearly  or  quite  disappear, 
and  the  heart-sounds  themselves  decidedly  change  their  character — the  systolic 
sound  being  greatly  weakened,  or  even  replaced  by  a  faint  blowing  murmur, 
and  the  second  sound  lost  entirely.  The  loss  of  fluid  is  shown  in  the  deeply 
sunken  orbits,  glazed  cornese,  the  pinched  expression  of  the  face,  the  wrinkled 
condition  of  the  palmar  surface  of  the  hands  and  feet — the  washer-woman's 
hands — and  the  general  emaciation,  which  often  becomes  extremely  marked. 
The  impeded  circulation  of  the  blood  is  evidenced  by  the  more  or  less  lividity, 
which  is  most  marked  around  the  eyes,  the  ears,  the  lips,  and  the  ends  of  the 
fingers.  The  surface  temperature  sensibly  falls  below  the  normal,  sometimes 
markedly  ;  on  the  contrary,  the  rectal  temperature  is  usually  considerably 
above  the  normal.  The  temperature  under  the  tongue  is  commonly  subnormal, 
and  the  tongue  itself  often  feels  cold  to  the  touch.  Whilst  the  cutaneous  sur- 
face  is  objectively  cold,  the  patient  himself  will  frequently  complain  of  intense 
internal  heat.  The  voice  becomes  weak,  hollow,  and  husky.  The  intellect 
may  be  clear  or  clouded.  Sometimes  there  is  great  restlessness  and  jactita- 
tion; at  other  times  there  may  be  entire  calm  and  hebetude  approaching  to 
stupor.  Oftentimes  cramps  in  the  extremities  and  trunk  may  be  absent  or 
mild  and  fleeting,  or  they  may  be  so  violent  as  to  cause  agonizing  pain  to  the 
patient.  In  the  early  part  of  this  period  there  is  marked  diminution  of  urine 
associated  with  albuminuria,  and  frequently,  granular  tube-casts.  Verj^  soon, 
however,  secretion  of  urine  is  completely  suppressed.  While  the  blood  is 
robbed  of  chloride  of  sodium  and  serum  by  the  exudation  into  the  intestinal 
canal,  it  is  overladen  with  urea,  which  the  kidneys  fail  to  remove,  and  there 
is  proportionately  more  of  its  salts  in  the  central  nervous  system  than  anywhere 
else  in  the  body. 

We  have  said  that  this  period  should  be  regarded  as  that  of  systemic 
intoxication.  The  specific  chemical  poison  elaborated  in  the  small  intestine 
during  the  enormous  multiplication  of  the  comma  bacillus  of  Koch,  has  at 
at  length  been  taken  up  by  the  intestinal  absorbents  or  has  entered  the  net- 
work of  intestinal  capillaries,  and  has  reached  the  general  circulation  of  the 
blood.  From  this  moment  the  scope  of  its  action  is  no  longer  localized  in 
the  small  intestine,  but  is  now  extended  throughout  the  whole  system. 
The  presence  of  this  specific  poison  in  the  blood  of  the  susceptible,  works 
changes  in  the  complexion  of  this  vital  fluid,  some  of  which  are  readily  vis- 
ible. We  have  already  spoken  of  the  relative  increase  of  the  corpuscular  ele- 
ments due  to  loss  of  fluid.  There  is,  however,  a  material  change  in  the  red 
corpuscles,  probably  due  to  the  eff"ect  of  the  special  chemical  poison  :  many  of 
the  red  corpuscles  are  much  paler  than  normal,  and  also  much  smaller ;  some 
have  been  broken  up  into  very  small  particles,  which  by  reason  of  their  form 
and  frequent  arrangement  in  pairs  and  chaplets  have  been  mistaken  for  micro- 
cocci.    The  specific  gravity  of  the  blood  is  much  increased ;  there  is  little  or 


CHOLERA  ASIATICA.  239 

no  tendency  of  the  red  corpuscles  to  adhere  together,  and  there  is  little  ten- 
dency to  the  formation  of  large  clots  when  allowed  to  stand ;  if  there  be  any 
separation  of  serum,  it  is  very  slight.  The  blood  when  drawn  from  the  veins 
is  very  dark,    almost  black  in  color  and  tarry  in  consistence. 

This  abnormality  of  the  blood  does  not,  of  course,  reach  its  height  at  once 
with  the  commencement  of  this  stage,  but  progresses  with  the  continuance  and 
severity  of  the  exudation  of  the  fluids  into  the  intestinal  canal  during  this 
period.  The  blood  becomes  so  thick  and  the  heart's  action  so  weak  that  the 
flow  in  the  veins  becomes  exceedingly  sIoav  or  seems  to  be  arrested  entirely 
toward  the  end ;  it  sometimes  will  not  flow  from  an  incision.  The  left  side 
of  the  heart  may  contain  but  little  blood,  and  the  large  arteries,  which  are 
often  spasmodically  contracted,  are  nearly  empty.  The  right  side  of  the  heart, 
on  the  contrary,  is  full  oftentimes  to  over-distention.  The  lungs  are  usually 
found,  post-mortem,  to  be  quite  pale,  bloodless,  and  retracted  well  against  the 
spinal  column.  In  the  mesentei'ies  the  arteries  are  much  contracted,  while  the 
veins  are  greatly  dilated,  and  there  is  usually  also  capillary  engorgement.  In 
fact,  this  condition  of  strong  contraction  and  emptiness  of  the  calibi'e  of  arteries, 
wide  dilatation  and  fulness  of  the  veins  and  capillaries,  is  observable  nearly 
everywhere.  There  are  often  also  small  ecchymoses,  aud  sometimes  rather 
extensive  extravasations,  particularly  at  the  mucous  surfaces.  (Edemas,  how- 
ever, are  not  to  be  met  Avith  ;  notwithstanding  the  numerous  stagnations  of  the 
blood-current  in  veins  and  capillaries,  the  flow  of  fluids  of  the  blood  into  the 
intestinal  canal  is  so  great,  and  the  consistency  of  the  blood  has  become  so 
thick,  that  everywhere  else  than  at  the  mucous  surface  of  the  intestines  the 
tendency  to  fluid  exudation  has  been  completely  arrested.  The  ecchymoses 
above  mentioned  are  more  abundantly  scattered  over  the  mucous  and  serous 
surfaces  than  elsewhere,  although  they  may  exist  even  in  the  muscular  tissue. 

The  toxic  influence  of  the  specific  chemical  poison  in  the  blood  is  pi^obably 
most  marked  upon  the  central  nervous  system  (including  the  sympathetic  gang- 
lionic system),  and  upon  the  liver  and  kidneys,  especially  the  latter.  The 
mechanical  results  of  loss  of  such  an  enormous  qauntity  of  body  fluid  may  in 
some  part  account  for  the  seriousness  and  severity  of  the  symptoms  of  this  and 
the  following  period  ;  but  doubtless  the  action  of  the  chemical  poison  in  the  blood 
upon  the  nervous  system,  the  liver,  and  the  kidneys  is  even  superior.  The  first 
onslaught  of  the  poison  upon  any  important  internal  organ  after  reaching  the 
blood  naturally  falls  upon  the  liver.  This  organ  is  generally  smaller  than 
normal,  flaccid,  and  ansemic,  and  contains  less  glycogen  than  normal.  The 
outlines  of  the  lobules  are  more  or  less  indistinct ;  the  interlobular  network  of 
blood-vessels  may  or  may  not  be  dilated  and  filled  with  blood ;  the  radiating 
cellular  trabeculpe  of  many  lobules  are  decidedly  narrowed,  while  the  inter-tra- 
becular  blood-capillaries  of  some  portions  of  acini  are  dilated  and  filled  with 
blood-corpuscles.  The  hepatic  cells  of  many  acini  are  granular  and  difficult 
to  stain.  Some  investigators  contend  that  there  is  actually  some  atrophy  of 
the  liver.  The  gall-bladder,  the  cystic  and  common  ducts  are  distended  with 
a  thin  brownish  or  greenish  fluid,  whilst  the  interlobular  biliary  network  is  not 
appreciably  altered.  Whilst  the  biliary  ducts  and  gall-bladder  are  full,  the 
intestinal  end  of  the  ductus  communis  choledochus  is  usually  practically  imper- 
meable, and  the  intestines  rarely  contain  any  bile.  The  spleen  is  contracted 
and  often  flabby.  Next  to  the  intestinal  lesions  in  cholera  the  kidneys  show 
the  greatest  pathological  changes.  The  effect  of  the  cholera  poison  in  the 
blood  falls  heavily  upon  these  eraunctories.  Granular  degeneration  of  the  se- 
cretory tubules  of  the  cortex  soon  becomes  marked,  but  is  irregularly  distri- 
buted at  first.     After  this   pathological   process  has  continued  for  some  time, 


240    AMEBIC  AN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

fatty  degeneration  of  the  tubular  epithelium  becomes  general  and  intense,  and 
associated  sometimes  with  parenchymatous  inflammation.  The  suppression  of 
urine  is  therefore  not  alone  due  to  the  mechanical  eifects  of  thickening  of  the 
blood. 

c.  The  period  of  algidity  or  collapse  may  follow  after  a  few  hours  of  con- 
tinuance of  the  period  of  serous  evacuations,  and  may  last  for  some  or  many 
hours  until  death  or  reaction  ensues.  In  this  desperate  condition  prostration 
is  extreme ;  the  voice  is  gone ;  respiration  is  very  feeble,  shallow,  and  fitful ; 
the  pulse  has  vanished  and  the  heart  almost  ceases  to  beat ;  so  also  the  nausea, 
vomiting,  and  cramj^s,  the  frequent  enormous  forcible  evacuations  of  the 
bowels,  whilst,  instead  of  the  latter,  the  contents  of  the  intestines  dribble  away 
from  the  anus,  whose  sphincter  is  inactive.  Profound  stupor  or  coma  is  the 
rule.  The  general  lividity  is  intense  ;  the  coldness  of  the  skin  is  like  that 
of  marble.  The  vital  forces  are  nearly  overwhelmed  by  the  great  losses  of 
fluid  sustained,  by  the  eflfete  substances  which  are  accumulated,  and  by  the 
special  cholera  poison.  During  this  period  the  vital  spark  flickers  very 
faintly ;  life  hangs  trembling  in  the  balance.  The  pathological  conditions 
are  essentially  those  of  the  previous  period,  intensified. 

d.  The  period  of  reaction  may  be  short  or  prolonged,  and  directly  follow 
either  of  the  three  preceding.  It  may  last  from  three  or  four  days  to  as  many 
weeks.  AY  hen  it  follows  immediately  upon  the  prodromal  period,  convalescence 
is  usually  rapid  and  short,  and  the  wonted  health  is  soon  perfectly  re-established. 
In  such  a  case  there  is,  after  all  is  over,  of  course,  great  doubt  that  the  attack 
was  choleraic  at  all.  The  finding  of  the  comma  bacilli  of  Koch  in  the 
stools  is  the  only  certain  criterion  of  what  its  true  nature  has  been.  When 
the  period  of  reaction  immediately  follows  the  period  of  serous  evacuations,  it 
is  usually  the  more  definite  the  more  serious  the  symptoms  and  pathological 
lesions  during  the  latter  period  have  been.  If  there  have  been  great  altera- 
tions of  the  mucous  membrane  of  the  intestines,  profound  general  intoxica- 
tion, with  great  destruction  of  the  red  elements  of  the  blood  and  marked  de- 
generations in  the  liver  and  kidneys,  we  may  expect  to  witness  a  more  or  less 
prolonged,  complex,  and  dangerous  period  of  reaction.  In  fact,  as  a  rule, 
more  patients  die  during  than  before  reaction,  when  the  latter  follows  immedi- 
ately the  period  of  serous  evacuations.  The  gravity  of  the  symptoms  and 
general  condition  of  the  patient  may  slowly  ameliorate  or  quickly  improve,  or 
one  set  of  alarming  symptoms  may  simply  be  substituted  by  another  set,  which, 
although  not  so  frightful  to  the  laity,  will  be  regarded  by  the  experienced  phy- 
sician as  only  a  prolongation  of  the  critical  struggle  between  the  very  evenly 
balanced  forces  of  life  and  of  death.  The  evacuations  from  the  stomach  and 
bowels  decidedly  lessen  in  frequency  and  copiousness  ;  the  stools  lose  their 
barley-water  aspect ;  the  bile  reappears  in  them,  and  they  assume  gradually 
the  common  characteristics  of  an  ordinary  diarrhoea,  sometimes  stained  with 
blood ;  or  if  the  local  destructive  efiects  of  the  cholera  poison  have  been 
drastic,  there  may  be  grafted  upon  the  diarrhoea  a  more  or  less  pronounced 
dysenteric  condition  Avith  bloody  stools  and  tenesmus.  The  characteristic  aro- 
matic sperm-like  odor  of  the  rice-water  stools  may  now  change  to  the  foul, 
stinking  odor  of  decomposition,  and  the  flatulence  which  was  absent  during 
the  proceeding  period  may  become  annoying.  The  voice  becomes  stronger, 
respiration  more  steady  and  fuller.  The  heart  gradually  regains  its  lost 
powers ;  the  pulse  begins  again  to  be  felt  at  the  wrist ;  the  surface  tempera- 
ture again  goes  toward  the  normal  and  quickly  passes  above  it ;  the  shrunken 
countenance  begins  to  discard  the  Hippocratic  expression,  the  sunken  orbits 
to  fill  up  and  the  glazed  eyes  to  brighten ;  prostration  becomes  less  marked, 


CHOLERA  ASIATIC  A.  241 

thirst  less  intense ;  the  secretion  of  urine  is  slowly  re-established,  at  first  con- 
taining much  albumin,  gi^anular  casts,  and  large  quantities  of  urea ;  appetite 
and  digestion  are  slowly  recovered  as  a  rule.  In  fortunate  cases  the  restora- 
tion to  health  and  to  the  proper  exercise  of  all  the  bodily  functions  may 
be  rapid  and  complete.  But  in  other  cases  anaemia,  due  to  the  great  injury 
to  the  elements  of  the  blood,  may  be  protracted ;  or  the  functions  of  the 
much-damaged  kidneys  may  be  slow  of  re-establishment ;  or  the  destruction 
of  intestinal  epithelium  may  leave  denuded  patches  in  the  subepithelial  layers 
of  connective  tissue,  and  thus  occasion  prolonged  irritation  and  even  serious 
derangement  of  the  processes  of  digestion,  and  at  the  same  time  furnish 
numerous  points  of  entrance  for  various  septic  micro-organisms.  In  truth, 
a  secondary  septic  fever,  as  the  result  of  systemic  invasion  in  this  manner, 
is  not  at  all  uncommon  in  this  period  :  it  is  vulgarly  called  the  typhoid  stage 
of  cholera. 

When  the  patient  passes  through  the  period  of  serous  evacuations  and 
that  of  algidity  or  collapse,  the  period  of  reaction  usually  diiFers  only  in 
degree  from  the  condition  above  described.  It  can  be  now  readily  understood 
why  almost  as  many  victims  succumb  during  the  period  of  reaction  as  during 
the  periods  of  specific  action  of  the  cholera  poison.  Even  after  convalescence 
has  been  established  impaired  health  may  persist  for  a  long  time,  evinced  by 
chronic  anaemia,  stubborn  disorders  of  the  digestive  apparatus,  and  easily  dis- 
turbed bowels.  Before  convalescence  is  fully  confirmed,  and  even  for  some 
time  afterward,  imprudences  of  diet  sometimes  precipitate  a  dangerous  relapse. 

Special  Phases  of  Cholera. — In  a  virulent  epidemic  of  cholera  the  cases 
of  very  sudden  and  violent  attacks,  which  do  not  seem  to  have  been  preceded 
either  by  a  prodromal  period  or  the  one  described  in  section  h,  are  sometimes 
numerous,  and  they  are  most  frequently  encountered  near  the  commencement 
of  the  outbreak.  These  attacks  have  been  variously  named  foudroyant,  toxic, 
asphyxic.  In  description  of  these  foudroyant  attacks  we  cannot  do  better 
than  quote  the  recent  language  of  Dr.  N.  J.  Simpson,  the  health  ofiicer  of  Cal- 
cutta :  "  On  these  occasions  the  suddenness  of  the  attack,  the  number  affected, 
and  the  virulence  of  the  disease  would  incline  one  to  think  that  the  specific 
organisms  had  already  elaborated  outside  the  human  body  a  strong  poison 
which  acted  on  the  victim  almost  immediately  after  being  swallowed.  Under 
the  most  favorable  conditions  for  the  elaboration  of  such  a  poison  there  will 
not,  as  far  as  can  be  ascertained,  be  the  usual  twelve  to  forty-eight  hours' 
period  of  incubation ;  on  the  contrary,  patients  will  be  brought  into  hospital 
in  a  dying  state,  though  taken  ill  only  a  short  time  previously  ;  some  will  die 
before  reaching  the  hospital ;  and  the  ratio  of  mortality  is  likely  to  be  75  to 
85  per  cent.  The  description  given  by  Dr.  Jamieson  in  1817  seemed  to  me 
until  some  time  ago  somewhat  exaggerated,  when  the  cases  seen  during  an 
outbreak  at  a  large  pilgrimage  convinced  me  of  the  correctness  of  Jamie- 
son's  accounts  as  applied  to  exceptional  outbreaks.  He  says :  '  Sometimes 
there  was  no  vomiting,  sometimes  no  purging,  sometimes  no  spasm  throughout, 
sometimes  all  these  symptoms  were  simultaneous,  and  the  vomiting  and  purg- 
ing took  place  together,  as  if  caused  by  sudden  contraction  of  the  alimentary 
canal  in  its  whole  extent.  In  some  rare  cases  the  virulence  of  the  disease 
was  so  powerful  as  to  prove  immediately  destructive  to  life,  as  if  the  circula- 
tion were  at  once  arrested  and  the  vital  powers  wholly  overwhelmed.  In  these 
cases  the  patient  fell  down  as  if  struck  by  lightning,  and  instantly  expired. 
Others,  again,  sank  after  making  one  or  two  feeble  efforts  to  vomit  and  draw- 
ing a  long  and  anxious  inspiration  ;  some  recovered  from  the  insensibility  pro- 
duced from  the  first  shock,  and  afterward  went  through  the  regular  course  of 

16 


242    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

the  disease.'  In  these  and  similar  cases  a  virulent  poison  is  the  best  expla- 
nation of  the  symptoms  and  apparent  absence  of  the  period  of  incubation, 
and  of  the  destructive  nature  of  the  disease."  Another  phase  of  cholera  still 
more  rarely  met  with  is  what  has  been  termed  cholera  sicca.  In  this  there  is 
no  vomiting,  no  purging,  but  the  other  symptoms  may  be  little  different  from 
those  already  described.  The  autopsy  shows,  however,  that  there  has  never- 
theless been  great  exudation  of  fluid  into  the  intestinal  canal,  for  the  latter  is 
greatly  distended  with  it  from  end  to  end. 

Special  Complications  of  Cholera. — I  have  already  spoken  of  frequent 
occurrences  of  ecchymoses,  especially  on  the  mucous  and  serous  surfaces. 
Cutaneous  petechiae  and  eruptions  are  not  uncommon  in  the  period  of  reaction  ; 
they  appear  less  frequently  during  that  of  serous  evacuations  or  algidity. 
These  eruptions,  more  often  observed  on  the  face,  neck,  and  forearms  than 
elsewhere,  are  usually  more  or  less  punctate,  the  puncta  being  slightly  elevated 
and  having  a  tendency  at  times  to  aggregate  into  irregular  groups.  These 
spots  vary  somewhat  in  color,  but  most  frequently  the  points  are  dark  or  black. 
In  some  rare  cases  the  vitality  of  the  skin  seems  to  be  in  a  degree  impaired, 
as  indicated  by  a  disposition  to  ulcerate  upon  small  provocation  ;  for  example, 
bed-sores  may  sometimes  develop  early  and  become  an  exceedingly  trouble- 
some complication.  The  cause  of  these  eruptions  is  unknown,  but  if  we  were 
to  express  a  mere  conjecture,  it  would  be  that  they  may  be  due  to  innumer- 
able minute  thrombi  and  emboli — small  clots  Avhich  have  formed  during 
stasis  of  the  blood. 

Diagnosis. — The  differential  diagnosis  of  Asiatic  cholera  by  means  of  its 
symptoms  alone  is,  during  the  absence  of  an  epidemic  of  the  disease,  one  of 
the  most  difiicult  feats  the  clinician  is  ever  called  upon  to  perform.  Indeed, 
it  is  held  by  some  of  the  most  skilful  and  renowned  clinical  diagnosticians  in 
the  Avorld  to  be  an  utter  impossibility  to  make  a  certain  diagnosis  ;  and  it  is, 
and  always  has  been,  the  common  experience  of  the  whole  Avorld  that  the 
saddest,  and  for  the  public  health  the  most  deplorable,  mistakes  are  very 
often  made  even  by  the  most  experienced.  And  yet  there  is  no  single  one  of 
the  whole  category  of  diseases  with  respect  to  which  a  mistake  in  diagnosis  of 
a  first  case  may,  and  sometimes  does,  entail  such  an  endless  series  of  incalcula- 
ble public  calamities.  There  is  not  one  of  the  symptoms,  and  of  the  groups 
of  symptoms,  met  with  in  some  period  of  an  attack  of  Asiatic  cholera,  which 
does  not  perfectly  resemble  those  of  some  disease  which  is  more  or  less 
common.  Among  these  commoner  affections  for  which  Asiatic  cholera  may  be 
mistaken  clinically  are  cholera  morbus,  arsenical  poisoning,  pernicious  inter- 
mittent fever,  and  poisoning  from  consumption  of  various  articles  of  food  in 
special  states  of  decomposition  or  fermentation. 

Of  course  during  the  prevalence  of  an  epidemic  in  a  locality,  the  physician 
of  that  place  will  wisely  regard  and  treat  every  case  presenting  the  symptoms 
common  in  Asiatic  cholera  as  an  undoubted  case,  and  will  not  hesitate  to 
handle  it  as  such ;  for  the  community  will  unquestionably  uphold  him.  It  is, 
however,  just  when  the  physician  is  most  uncertain — namely,  in  dealing  with 
those  doubtful  cases  which  precede  and  follow  the  epidemic — that  the  real 
interests  of  the  community  and  of  the  general  public  demand  the  greatest  cer- 
tainty of  diagnosis ;  but  then,  as  a  rule,  the  people  are  unwilling  to  submit  to 
restraints.  Fortunately,  through  the  discovery  of  Koch  in  1883  and  1884, 
we  now  possess  the  means  of  making  an  absolutely  certain  differential  diagnosis 
of  cholera  infectiosa  epidemica,  and  without  reliance  upon  clinical  symptoms, 
which  may  be  misleading,  or  upon  trustworthy  knowledge  of  the  previous  history 
or  relations  of  the  patient,  which  may  be  difficult  or  impossible  to  obtain.     The 


CHOLERA  ASIATIGA.  243 

presence  or  absence  in  the  stools  of  the  suspect  of  the  comma  bacillus  of  Koch 
promptly  and  definitely  settles  the  matter.  This  can  be  determined  within  forty- 
eight  hours  by  resort  to  the  microscopic  and  biological  tests.  These  tests, 
however,  should  never  be  relied  upon  when  made  by  a  tyro.  They  are  too 
difficult  of  application  to  be  trusted  to  the  inexperienced.  To  describe  here 
the  methods  of  procedure  would  therefore  be  useless,  for  the  experienced  bac- 
teriologist does  not  need  such  instruction,  whilst  the  unskilled  Avould  need 
much  more  to  be  rendered  capable.  During  times  of  great  danger  of  the 
introduction  of  Asiatic  cholera  into  a  locality  all  cases  presenting  the  symp- 
toms of  cholera  should  be  handled  as  suspicious  until  a  differential  diagnosis 
by  means  of  the  microscopic  and  biological  tests  be  made  by  a  thoroughly 
competent  and  experienced  bacteriologist. 

Prognosis. — The  outcome  of  an  attack  of  cholera  depends  very  much 
upon  what  period  of  the  seizure  medical  advice  is  had,  very  much  upon  the 
slowness  or  rapidity  with  which  grave  symptoms  appear  and  persist,  very 
much  sometimes  upon  the  period  of  the  epidemic  at  which  the  attack  happens, 
and  very  much  upon  the  constancy  of  intelligent  care  in  handling  the  case 
from  first  to  last.  Wise  and  prompt  treatment  of  the  first  stage  usually  aborts 
the  attack  almost  in  the  beginning,  and  is  followed  by  scarcely  any  mortality. 
In  the  vast  majority  of  such  cases  the  attack  never  gets  beyond  the  stage  of 
premonitory  diarrhoea,  and  convalescence  is  usually  rapid  and  complete.  The 
prognosis  of  a  seizure  which  has  passed  into  the  second  period,  or  that  of  pro- 
nounced serous  diarrhoea,  is  grave  ;  the  mortality  varies  greatly,  from  25  to  60 
per  cent,  of  attacks,  by  reason  of  the  varying  susceptibility  of  patients,  vary- 
ing doses  of  the  specific  poison,  varying  promptness,  persistency,  and  wisdom 
of  treatment.  The  prognosis  of  an  attack  of  Asiatic  cholera  in  the  period  of 
algidity  or  collapse  is  truly  desperate,  and  the  mortality  has  usually  been 
frightful,  not  infrequently  having  reached  80,  90,  and  sometimes  100  per  cent. 
The  prognosis  of  an  attack  which  has  reached  the  period  of  reaction  varies 
greatly  according  to  the  damage  which  may  have  been  done  the  intestinal  lin- 
ing, the  secretory  elements  of  the  kidneys,  the  glandular  elements  of  the  liver, 
and  the  elements  of  the  blood,  and  in  proportion  to  the  accumulations  of  effete 
material  and  of  specific  poison  in  the  blood  and  tissues.  It  is  sufficiently 
serious  to  require  careful  nursing  and  wise  medical  direction  ;  v/here  septic 
poisoning  has  been  engrafted  upon  the  cholera  attack,  it  is  often  grave. 
Speaking  generally,  the  mortality  of  epidemics  of  Asiatic  cholera  is  usually 
greatest  in  the  early  course  of  the  outbreak  in  the  locality,  and  is  limited 
almost  entirely  to  those  who  neglect  to  invoke  the  aid  of  the  physician  until 
the  attack  has  become  exceedingly  grave.  The  general  mortality  among  the 
attacked  may  vary  between  20  and  80  per  cent.,  according  to  the  virulence 
or  mildness  of  the  type  of  the  disease,  the  total  average  being  nearly  50  per 
cent.  If  the  patient  is  seen  early  and  is  promptly,  judiciously,  and  constantly 
cared  for,  the  danger  of  a  fatal  issue  is  usually  not  great. 

Treatment. — Although  the  gross  number  of  attacks  of  Asiatic  cholera 
and  the  wide  spread  of  pandemics  of  the  disease  among  civilized  nations  have 
lessened  considerably,  thanks  to  better  hygiene  and  improved  methods  of  pre- 
vention, yet  the  percentage  of  deaths  to  attacks  remains  about  the  same 
now  as  it  was  many  decades  ago,  and  is  not  very  materially  lower  under  mod- 
ern and  civilized  systems  of  therapeutics  than  it  has  been  under  antiquated 
and  semi-civilized  or  bai'barous  modes  of  management.  Knowledge  of  efficient 
methods  of  treatment  of  cholera  has  by  no  means  kept  pace  with  that  of 
the  etiology  and  prophylaxis  of  the  disease.  In  the  early  stages  of  this 
disease  the  skilful  physician  is  all  powerful ;  in  the  latter  stages  he  is  almost 


244    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

impotent.     Hence  the  paramount  advantage  of  prompt  and  judicious  medical 
treatment. 

Treatment  in  the  Premonitory  Period. — During  the  prevalence  of 
Asiatic  cholera  in  a  locality,  every  disturbance  or  derangement  of  the  ali- 
mentary canal  should  be  corrected  without  loss  of  time.  Indigestion  or 
abdominal  distress  should  receive  without  any  delay  the  careful  attention  of 
the  physician,  who  should  not  fail  to  impress  upon  his  clientele  the  urgent 
necessity  of  scrupulous  obedience  to  his  instructions.  The  first  thing  to  do  is 
to  remove  any  apparent  cause  of  the  disturbance ;  place  the  patient  upon  a 
lighter  diet,  fluids  by  preference  ;  absolutely  interdict  any  exercise  which  tends 
to  overheat  or  fatigue  ;  insist  upon  clothing  during  the  day  which  will  keep  the 
trunk  and  extremities  warm,  and,  during  the  night,  which  will  prevent  chilling 
of  the  abdomen  and  the  legs.  One  article  of  clothing  should  consist  of  a  broad 
flannel  binder  around  the  abdomen  and  loins  next  the  skin,  kept  on  day  and 
night.  The  first  appearance  of  diarrhoea  should  be  the  signal  for  active  treat- 
ment. One  or  two  stools  during  the  twenty-four  hours  more  than  the  usual  num- 
ber habitual  to  the  individual  when  in  health,  or  a  single  copious  Avatery  stool, 
should  require  the  patient  to  be  put  to  bed  at  once  and  kept  recumbent,  not  only 
during  the  continuation  of  looseness  of  the  bowels,  but  for  a  day  or  two  after  this 
condition  has  entirely  disappeared.  All  solid  food  should  be  rigidly  interdicted, 
and  nothing  but  broth,  bouillon,  or  whey,  allowed  to  be  eaten.  In  fact,  an 
approach  to  abstinence  is  far  more  desirable  than  risk  of  overfeeding.  The 
looseness  of  bowels  or  diarrhoea  must  be  arrested  as  soon  as  possible,  but  in 
doing  this  it  is  much  better  to  avoid  poAverful  astringents  and  strong  opiates  if 
it  can  be  done  without  them.  In  the  choice  of  the  remedy  it  should  be  borne 
in  mind  that  the  nature  of  the  disturbance  is  that  of  a  specific  infection  of  the 
small  intestine  by  the  comma  bacilli  of  Koch,  associated  Avith,  and  greatly 
favored  by,  a  rather  decided  alkalinity  of  the  intestinal  fluids.  The  rational 
treatment  would  therefore  seem  to  be  the  administration  of  some  combination 
of  acids,  disinfectants,  and  sedatives.  Of  the  acids  which  may  be  employed 
in  proper  doses  are  sulphuric,  hydrochloric,  lactic ;  of  the  intestinal  disin- 
fectants, naphthaline,  salol,  calomel,  salicylate  of  bismuth  ;  of  the  sedatives, 
paregoric,  Hoff'man's  anodyne.  Aromatic  sulphuric  acid  and  paregoric  in 
proper  doses  may  be  given  and  repeated  p.  r.  n.  This  may  be  alternated  or 
not  with  naphthaline  or  salol,  alone  or  in  the  same  powder  with  salicylate  of 
bismuth,  or  with  naphthaline  and  calomel  together.  It  will  be  found  in 
the  great  majority  of  cases  that  this  simple  treatment  will  prove  eifective. 
Instead  of  the  mineral  acids,  lactic  acid  is  preferred  by  many.  Dujardin- 
Beaumetz  uses — 

I^.  Lactic  acid prts.       10, 

Syrup "         20, 

Tinct.  of  citron "  2, 

Water "     1000.— M. 

Sig.     For  the  adult  three  teaspoonfuls,  with  or  without  20  drops  of  pare- 
goric added,  at  intervals  of  a  half  hour,  or  longer  as  the  case  may  require. 

As  a  drink  instead  of  water,  it  is  well  to  use  an  acid  lemonade  with  a  view 
to  lessening  the  alkalinity  or  rendering  acid,  if  possible,  the  reaction  of 
the  contents  of  the  small  intestine,  in  order  to  inhibit  the  growth  therein  of 
the  specific  microbe.  Sulphuric,  hydrochloric,  or  lactic  acid — say,  one  part  to 
the  thousand  of  sterilized  water,  sweetened — may  be  employed  for  this  pur- 
pose. 


CHOLERA  A8IATIGA.  245 

Should  the  diarrhoea  persist  or  increase  in  severity  in  spite  of  the  simple 
treatment  above  mentioned,  recourse  must  be  had  without  loss  of  time  to  more 
active  medication.  Stronger  anodynes  and  decided  astringents  are  called  for. 
Chlorodyne  may  be  used,  or  Lausedat's  drops,  as  follows : 

'Sf.  Tr.  Valerianae  sether ITLc. 

Tr.  opii TTlxx. 

Essentiae  menthse  piperit gtt.  v. 

Spts.  getheris  comp Idle. — M. 

Sig.  Five  to  eight  drops  for  a  child  of  six  years. 

Or  something  like  the  following  may  be  tried : 

!^.  Acid,  tannici  . 

Plumbi  acetat aa  gr,  iij. 

Pulv.  opii gr,  ss. 

Oleoresinge  capsici gr.  ij. — M, 

Ft.  pil.  No.  XII. 

Sig.   One  pill  every  one  to  four  hours,  |?.  r.  7i.,  at  the  age  of  six  years. 

On  the  principle  of  clearing  the  bowels  of  irritants  and  altering  the  secre- 
tions, some  begin  the  treatment  of  this  period  with  a  large  dose  of  calomel, 
followed  in  a  few  hours  by  castor  oil  combined  with  naphthaline. 

Treatment  of  the  Period  of  Serous  Diarrhcea  or  Systemic  In- 
TOXICATIOX. — Although  such  early  treatment  as  indicated  above  will,  as  a 
rule,  prove  effective  in  the  prevention  of  full  development  of  an  attack,  there 
are  some  cases  Avhich  seem  to  be  doomed,  in  spite  of  prompt  and  judicious 
attention,  to  advance  into  the  period  now  under  consideration.  Moreover,  it 
it  is  usually  not  until  this  period  that  the  physician  is  called.  The  conditions 
now  to  be  contended  with  are  those  which  have  already  been  pointed  out. 

For  the  vomiting  and  thirst  cracked  ice  and  sinapisms  to  the  epigastrium  ; 
for  the  coldness,  envelop  the  whole  person  in  hot  flannel  blankets,  with  bottles 
of  hot  water  next  the  skin,  and  immersion  in  a  hot  bath  for  fifteen  or  twenty 
minutes  at  intervals  of  two  to  four  hours  ;  for  the  cramps,  friction  by  rubbing 
with  the  palms  of  the  hands  :  if  the  pain  be  violent  it  may  be  allayed  by  inha- 
lations of  ether ;  for  the  prostration  and  restlessness,  cardiac  stimulants  and 
nervous  sedatives  ;  for  the  purging,  chiefly  intestinal  antiseptics  and  correc- 
tives;  for  the  loss  of  fluid,  hypodermatic  or  intravascular  injections  of  saline 
fluids ;  as  against  the  special  poison  in  the  intestinal  canal,  irrigation  of  the 
colon  with  large  injections  of  saline  fluids. 

Among  the  legion  of  remedies  which  have  been  tried  and  often  been  found 
wanting,  the  favorite  East  Indian  compound  called  chlorodyne  has  been  about 
as  useful  as  any.  Lausedat's  drops,  already  mentioned,  may  take  the  place  of 
chlorodyne.  The  remedies  mentioned  in  treating  of  the  prodromal  period,  es- 
pecially the  acids  and  antiseptics,  may  still  be  useful  in  the  early  part  of  the 
stage  now  under  consideration.  A  powder  which  has  been  often  used  in  former 
epidemics  to  combat  coldness,  prostration,  and  collapse  has  the  following  com- 
position : 

^i.  Bismuthi  subnitrat 3J- 

Plumbi  acetat g''-  "J- 

Camphorae g^'-  ij- 

Oleoresinge  capsici gr.  j . — M. 

Divide  in  chart.  No.  XII. 
Sig.  One  every  hour  or  two. 


246    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

Macnamara,  the  great  Anglo-East-Indian  authority  on  cholera,  says  :  "  I 
think  water,  though  urgently  demanded  by  the  patient,  should  be  refused 
(cracked  ice  is  recommended  instead).  I  would  restrict  the  opium  to  three 
grains ;  it  is  unwise  to  give  more,  although  we  are  wellnigh  certain  that  much 

of  it  has  been  vomited If  the  vomiting  is  very  severe,  a  single 

dose  of  twenty  grains  (for  the  adult)  of  calomel  will  sometimes  relieve  this 
symptom.  A  mixture  may  be  added,  each  dose  of  which  contains  two  grains 
of  acetate  of  lead  and  fifteen  drops  of  dilute  acetic  acid,  to  be  taken  every 
second  hour,  and  fifteen  drops  of  dilute  sulphuric  acid  in  water  every  alternate 
hour,  so  that  the  patient  should  take  a  draught  of  first  one  mixture  and  then 
the  other  every  hour.  In  this  way  the  alkaline  stools  become  acid,  and  perhaps 
destroy  the  cholera  organism  in  the  intestinal  canal.     However  this  may  be, 

these  acids  seem  to  be  beneficial  in  the  treatment  of  cholera I 

believe  that  alcohol   is   positively  harmful  in  any  stage  of  cholera." 

Unfortunately,  in  this  stage  of  cholera  medication  by  way  of  the  stomach 
is  always  impeded,  very  often  rendered  almost  useless,  sometimes  quite  impos- 
sible of  effecting  an  impression,  by  reason  of  the  vomiting  and  the  failure  of 
absorption  in  the  intestines.  If  the  little  that  is  not  rejected  by  the  stomach 
succeeds  in  reaching  the  intestine,  it  so  often  happens  that  none  of  it  is 
absorbed ;  powerful  drugs  may  lie  and  accumulate  in  the  latter,  to  cause  actual 
harm  when  the  stage  of  reaction  is  ushered  in,  and  with  it  restoration  of  the 
function  of  intestinal  absorption.  Neither  can  ordinary  rectal  injections  of 
medicine  be  depended  upon,  for  the  same  reason.  The  sluggishness,  sometimes 
practical  stagnation,  of  the  little  lymph  still  remaining  in  the  tissues,  after  the 
continuous  drain  of  copious  watery  evacuations  from  the  bowels,  usually  lessens, 
often  quite  nullifies,  the  customary  results  of  hypodermatic  medication.  When 
such  a  condition  arises,  as  it  unhappily  too  often  does,  what  other  resources  has 
the  physician  left  to  him?  There  are  still  three  which,  used  judiciously  and 
skilfully,  are  powerful  to  restore  marvellously — at  least  for  a  time,  sometimes 
permanently — the  suspended  functions.  I  refer  to  intestinal,  to  hypodermatic, 
and  to  intravascular  irrigation. 

Enteroelysis,  first  introduced  by  the  late  Prof.  Cantani  of  Naples  during 
the  former  cholera  epidemic  in  Italy  as  a  means  of  treating  all  stages  of  the 
disease,  consists  essentially  in  irrigating  the  rectum,  colon,  and,  if  possible, 
also  the  small  intestine,  with  large  quantities  of  a  warm,  astringent,  antiseptic, 
sedative  fluid.     The  following  is  Cantani's  formula  for  an  adult : 

I^    Boiled  water  or  infusion  of  chamomile   .    .  2  quarts. 

Tannin 1^  to  2^  drachms. 

Laudanum 30  to  50  drops. 

Powdered  gum-arabic If  ounces. 

The  temperature  of  this  mixture  when  introduced  should  be  sufficiently 
above  the  normal  to  aid  in  restoring  heat  to  the  body.  Of  course  the  quantity 
injected  should  vary  according  to  the  age  of  the  patient  and  other  circum- 
stances in  the  judgment  of  the  physician.  The  best  time  for  administration 
is  immediately  after  an  evacuation. 

Hyjiodermoclysis^  also  first  introduced  by  Prof.  Cantani  as  a  means  of 
treating  especially  the  stages  of  serous  diarrhoea  and  of  algidity  or  collapse, 
consists  essentially  in  the  introduction  hypodermatically  of  a  large  quantity 
of  warm  saline  fluid  for  the  purpose,  primarily,  of  replacing  the  fluid  lost 
through  the  intestinal  drain ;  secondarily,  of  washing  out  from  the  blood 
and  tissues  much  of  the  effete  material  and  specific  poison  which  have  accumu- 


CHOLERA  ASIATIC  A.  247 

lated  in  them.  Cantani's  formula  for  an  adult  consists  of  2  quarts  of  boiled 
water,  2J  ounces  of  pure  sodium  chloride  and  a  drachm  and  a  half  of  sodium 
carbonate.  The  quantity  to  be  injected  each  time  varies  according  to  age,  the 
apparent  amount  of  fluid  lost,  and  other  circumstances.  The  amount  for  an 
adult  is  one  to  two  and  a  half  quarts.  The  temperature  of  the  solution  when 
injected  should  be  100|-°  F.,  unless  that  of  the  rectum  be  very  low,  in  which 
case  it  has  been  sometimes  raised  as  high  as  109|°  F.  The  most  successful 
time  for  resort  to  hypodermoclysis  is  at  the  first  indications  of  insufficiency  of 
water  in  the  body,  such  as  Hippocratic  countenance,  wrinkling  or  discoloration 
of  the  skin,  cramps,  coldness,  etc. 

Intravascular  injections  of  saline  fluids,  a  procedure  as  old  as  the  history 
of  cholera  in  Europe,  has  had  a  renewed  trial  during  the  present  visitation 
of  the  disease.  Injection  into  veins  and  into  arteries  has  been  practised 
especially  at  Hamburg,  and  each  method  of  procedure  has  its  champions. 
Some  variations  in  the  constitution  and  proportions  of  the  saline  fluid  used 
occur,  but  the  following  may  be  regarded  as  a  standard :  sodium  bicarbonate 
1  part,  sodium  chloride  6  parts,  boiled  water  1000  parts.  The  temperature  of 
the  fluid  when  injected  varies  according  to  circumstances  from  100|-°  F.  to 
104°  F.,  more  frequently  the  latter.  The  quantity  administered  has  sometimes 
been  very  considerable,  averaging  for  the  adult  one  to  two  quarts.  The  injec- 
tion may  be  repeated  in  a  half  hour  to  four  hours,  as  the  condition  of  the 
patient  demands. 

Of  the  relative  advantages  and  disadvantages  of  the  hypodermatic  and 
intravascular  irrigations,  it  may  be  said  that  the  former  is  slower  and  usually 
more  permanent  in  its  action  than  is  the  latter.  There  may  occur  occasions, 
however,  in  the  treatment  of  the  algid  period,  when  the  matter  of  time  will 
decide  which  method  shall  be  tried  first.  It  seems  to  me  that  it  is  mainly  in 
rapidly-sinking  cases  in  that  period,  that  intravenous  injection  should  be  given 
the  preference,  to  be  followed  at  the  second  injection  by  hypodermoclysis.  The 
hypodermoclysis  has  the  further  advantage  of  being  far  simpler  of  application. 
Only  one  skilful  person  is  required  for  this  operation ;  indeed,  the  attendants 
can  readily  be  instructed  to  perform  it  very  safely  in  the  absence  of  the  physi- 
cian. On  the  contrary,  the  physician  requires  at  least  one  skilled  assistant 
to  safely  perform  the  intravascular  injection.  In  all  these  operations  strict 
antiseptic  or  aseptic  precautions  must  be  observed. 

For  enteroclysis  there  is  needed  a  large  fountain  syringe  with  a  long  flex- 
ible tube  with  a  cock,  to  which  a  moderately  stiff"  but  flexible  terminal  portion 
two  or  three  feet  long  is  attached.  The  tube,  quite  full  of  the  fluid,  must  be 
passed  up  into  the  colon  and  worked  along  its  interior  as  far  as  possible  ;  the 
fluid  should  be  let  flow  slowly,  avoiding  very  sudden  distention  of  the  gut, 
and  should  be  retained  as  long  as  possible. 

For  hypodermoclysis  a  fountain  syringe  with  a  long  flexible  tube,  furnished 
with  a  cock,  answers  the  purpose  ;  with  another  shorter  tube,  one  end  attached 
to  the  cock,  the  other  having  a  needle-pointed  canula,  a  little  longer,  stronger, 
and  with  a  somewhat  wider  calibre  than  the  ordinary  hypodermic  needle.  The 
tube  and  canula  are  first  perfectly  filled  with  the  fluid,  and  then  the  canula 
is  inserted  well  in  between  the  skin  and  deep  fascia  of  the  flanks,  buttocks, 
or  interscapular  region.  The  fluid  should  be  made  to  flow  slowly,  allow- 
ing fifteen  to  twenty  minutes  for  the  introduction  of  one  quart.  The  slight 
tumor  should  be  made  to  disappear,  as  it  will,  by  gentle  kneading  or 
massage. 

For  intravascular  inj  ections  of  saline  fluids  any  good  transfusion  apparatus 
suffices. 


248    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Lavage  of  the  stomach  to  stop  vomiting  is  a  most  effective  procedure,  and 
sometimes  succeeds  in  arresting  this  distressing  symptom  when  nothing  else 
will  do  it.  Indeed,  it  would  seem  to  be  a  very  useful  associate  of  enteroclysis, 
for  it  seems  that  to  clear  the  stomach  of  the  offending  rice-water  fluid  is  only 
second  in  importance  to  washing  it  out  from  the  intestine.  Boiled  water  hold- 
ing in  solution  boracic  acid  has  been  satisfactorily  used  for  this  purpose. 

Treatment  in  the  Period  of  Algidity  or  Collapse. — In  this  stage 
of  the  disease,  where  absorption  is  practically  suspended,  little  is  useful  beyond 
enteroclysis  and  hypodermoclysis  or  intravascular  injections  of  fluids,  and 
efforts  to  communicate  heat.  The  vast  majority  of  cases  in  this  stage 
die  in  spite  of  every  effort  of  the  physician,  but  there  is  certainly  more 
success  to  be  expected  of  this  mode  of  treatment  than  of  any  other  at 
present    known. 

Treatment  in  the  Period  of  Reaction. — The  treatment  in  this  stage 
is  essentially  expectant  and  symptomatic.  Each  condition  enumerated  in  the 
sections  on  Symptomatology  and  Etiology  will  suggest  to  the  experienced  the 
particular  line  to  be  folloAved.  One  of  the  most  important  things  to  avoid  is 
pointed  out  forcibly  by  Macnamara,  whom  I  can  do  no  better  than  to  quote  in 
conclusion  :  "  When  reaction  comes  on,  we  must  be  careful  not  to  fall  into  the 
error  of  over-feeding  the  patient  under  the  mistaken  idea  of  supporting  his 
strength ;  he  will  not  die  of  exhaustion  if  small  quantities  of  milk  and  arrow 
root  are  administered  frequently  for  two  or  three  days,  together  with  warm 
beef-tea  enemas.  But  enteritis  may  certainly  be  induced  if  food  beyond  the 
simplest  and  smallest  quantities  be  allowed.  The  patient  requires  rest  and 
the  most  careful  nursins;  after  a  severe  illness  like  cholera." 

Prevention. — AVhilst  the  physician  is  often  impotent  in  the  treatment  of 
cholera,  in  prevention  he  may  be,  if  he  will,  all-powerful.  It  is  not  our  pur- 
pose to  discuss  this  subject  from  the  standpoint  of  a  state  or  community;  we 
shall  consider  the  matter  solely  from  the  side  of  the  individual :  First,  what 
those  ministering  to  the  sick  should  do  to  prevent  the  spread  of  the  disease ; 
second,  what  the  individual  who  may  be  exposed  to  the  infection  should  do  to 
safeguard  himself  from  an  attack  of  cholera. 

1.  The  Duties  of  those  Attendant  upon  the  Sick. — I  wish  to  say  in  the 
beginning  that,  whilst  there  is  scarcely  any  infectious  epidemic  disease  which 
is  so  capable  as  cholera  of  working  great  injury  in  various  ways  to  the  com- 
munity, if  the  attendants  upon  the  sick  are  ignorant  or  careless  in  applying  the 
principles  of  prevention,  yet  there  is  no  such  disease  which  can  so  easily  and 
certainly  be  limited  to  those  attacked  if  only  these  principles  be  constantly  and 
scrupulously  applied.  As  I  have  said  elsewhere,  Asiatic  cholera  can  be  dwelt 
with  and  handled  with  absolute  impunity  if  only  the  proper  precautions  be 
never  once  forgotten  or  neglected.  There  is,  therefore,  not  the  slightest  danger 
in  administering  to  the  sick  if  carefulness  be  the  rigid  rule.  It  has  already 
been  pointed  out  that  it  is  only  the  evacuations  from  the  stomach  and  bowels  of  a 
person  suffering  an  attack  of  Asiatic  cholera  that  contain  the  original  infection.  To 
promptly  and  thoroughly  disinfect  these  and  everything  soiled  by  them  or  contain- 
ing them  is  to  render  the  spread  of  the  disease  from  the  person  attack  ed  impossible. 
The  evacuations  should  without  any  delay  be  treated  in  one  of  the  following 
ways :  a,  water  that  is  boiling  should  be  poured  upon  them  carefully,  so  as  not 
to  splash,  in  such  amount  that  the  volume  of  the  water  is  four  times  that  of  the 
evacuations,  or  a  strong  solution  of  potash  soap  may  be  used  in  the  same 
way ;  6,  or  fresh  milk  of  lime  (white  wash),  of  twice  the  volume  of  the 
evacuation,  should  be  poured  upon  the  latter  and  the  mixture  gently  stirred  ; 
c,  or  a  similar  quantity  of  a  freshly-prepared  solution  (5  per  cent,  strong) 


CHOLERA  ASIATICA.  249 

of  chloride  of  lime  may  be  used  in  the  same  way ;  c?,  or  a  similar  volume 
of  5  per  cent,  solution  of  carbolic  acid  may  be  thus  employed.  Which- 
ever one  of  these  means  be  chosen,  it  is  essential  that  the  vessel  be  im- 
mediately covered  from  the  flies  and  allowed  to  stand  fifteen  or  twenty  minutes 
before  emptying ;  and  it  is  also  essential  that  the  disinfected  evacuations  be 
emptied  into  a  pit  in  the  earth,  the  bottom  of  which  is  covered  with  a  layer  of 
quicklime,  and  be  covered  immediately  with  another  layer  of  the  same  mate- 
rial, care  being  taken  that  the  location  of  this  pit  does  not  jeopardize  water- 
courses, springs,  or  wells.  Clothing  or  other  textile  fabrics  soiled  by  the 
evacuations  should  be  disinfected  as  soon  as  possible.  They  should  be  at  first 
soaked  in  a  disinfectant  solution — say,  a  mixture  of  strong  potash  soap  and 
carbolic  acid  of  5  per  cent,  strength — for  an  hour  or  more,  and  then  boiled. 
It  is  better  to  burn  bedding  rather  than  attempt  its  disinfection.  The  floors 
of  the  sick-room  should  first  be  sprinkled  with  chloride  of  lime,  and  then 
mopped  over  with  a  cloth  moistened  in  a  chloride-of-lime  solution.  Any 
article  of  furniture  which  may  have  been  contaminated  should  be  carefully 
disinfected.  Finally,  it  would  be  well  to  disinfect  the  room  itself,  after  all  is 
over,  by  means  of  sulphur  fumes,  3  pounds  to  the  1000  cubic  feet  of  space,  for 
eight  to  ten  hours.  No  one  should  be  allowed  in  the  sick-room  except  the 
necessary  attendants,  who  under  no  consideration  should  eat  or  drink  in  this 
room.  The  patient  should  be  fed  from  a  set  of  dishes  which  should  be  disin- 
fected immediately  after  use,  and  kept  separate  from  those  of  the  rest  of  the 
household ;  the  remains  of  the  patient's  meal  should  be  disinfected  and 
destroyed.  After  handling  the  patient  or  anything  that  he  has  soiled,  the 
attendants  should  immediately  first  disinfect  and  then  carefully  wash  their 
hands  :  this  thorough  ablution  should  be  performed  invariably  immediately 
before  eating.  After  vomiting  or  an  evacuation  of  the  bowels  the  mouth  and 
the  parts  around  the  anus  should  be  wiped  with  a  cloth  wet  with  solution, 
1  :  2000,  of  corrosive  sublimate.  If  convalescence  supervene,  the  patient  should 
be  kept  isolated  for  a  Aveek,  and  the  stools  should  be  disinfected  during  that 
time.  If  death  occur,  the  corpse  should  at  once  be  enveloped  in  a  sheet  soaked 
with  corrosive  sublimate,  1  :  500,  and  cremated  or  buried  without  delay  or 
funeral  cortege.  Finally,  promptly  notify  health  officials  of  every  suspect  or 
known  case  of  cholera. 

2.  Individual  Precautions  for  the  Exposed. — No  water  or  milk  should 
be  used  or  consumed,  which  could  by  any  possibility  be  contaminated,  unless 
recently  boiled.  No  cold  or  uncooked  food  should  be  eaten  which  could 
possibly  become  contaminated.  Such  things  as  salads  should  be  avoided. 
Unripe  or  over-ripe  fruit  should  be  eschewed.  Alcoholic  stimulants  are  per- 
nicious. In  fact,  excesses  of  all  kinds  predispose  to  an  attack.  Regularity 
in  eating,  sleeping,  exercise,  and  all  other  habits,  contributes  to  safety.  Keep 
all  the  bodily  functions  well  regulated  ;  avoid  fatigue  and  chills.  The  use  of 
a  broad  flannel  waist-bandage  next  the  skin  day  and  night  is  beneficial  in 
guarding  against  abdominal  congestions.  Quickly  correct  the  slightest  intesti- 
nal disorder. 


DIPHTHERIA. 

By   DILLON  BROWN,   M.  D., 

New  York. 


Diphtheria  is  an  acute,  contagious,  and  infectious  disease,  the  most 
characteristic  and  constant  feature  of  which  is  a  pseudo-membranous  exu- 
date on,  or  a  superficial  necrosis  of,  a  mucous  membrane  or  some  part  of 
the  skin  which  has  been  denuded  of  its  epithelium.  Although  a  comparatively 
recent  disease  in  this  country,  it  threatens  to  be  the  scourge  of  the  large  cities. 
Less  than  a  century  ago  but  few  isolated  and  poorly-understood  cases  were 
seen,  but  the  disease  has  spread  very  rapidly  during  the  past  fifty  years,  and 
in  New  York  City  alone  the  mortality  from  diphtheria  and  croup  has  exceeded 
fifty  thousand  in  twenty-five  years.  And  this  number  does  not  include  many 
cases  which  were  reported  as  deaths  from  pneumonia,  nephritis,  heart  failure, 
etc.,  which  were  really  complications  of  diphtheria. 

There  is  no  guide  to  the  virulence  of  diphtheria.  It  is  one  of  the  most 
dreaded,  one  of  the  most  fiital,  and  one  of  the  most  common  diseases  of  child- 
hood. At  the  onset  it  is  impossible  to  say  whether  the  disease  will  be  mild  or 
malignant.  A  case  beginning  with  high  fever  and  profound  constitutional 
disturbance  may  go  on  to  a  rapid  recovery  ;  while,  on  the  other  hand,  an 
apparently  mild  case  Avill  grow  depressed  and  weak,  and  slowly  die.  Neither 
does  the  amount  nor  character  of  the  exudate  give  any  certain  prognosis. 
Indeed,  the  clinical  symptoms  vary  to  such  an  extent  that  many  mild  cases  are 
not  even  recognized  unless  some  post-diphtheritic  complication  ensues ;  but, 
although  these  mild  cases  may  be  of  small  danger  to  the  individual,  they 
are  all  diphtheria  and  all  equally  contagious,  and  may  be  the  origin  of  the 
most  malignant   ones. 

Etiology. — It  has  been  well  recognized  that  certain  cases  of  croupous 
inflammation  are  not  true  diphtheria.  This  list  includes  the  chronic  membra- 
nous exudates  seen  in  certain  forms  of  fibrinous  bronchitis,  cystitis,  enteritis, 
etc.,  the  acute  superficial  necrosis  of  the  mucous  membranes  due  to  direct 
heat,  as  a  scald,  or  an  intense  irritation  from  the  application  of  ammonia. 
However,  excluding  these,  there  remain  many  doubtful  cases ;  but  modern 
bacteriological  research  seems  to  have  solved  this  problem,  and  proven  beyond 
much  doubt  that  there  are  at  least  two  forms  of  pseudo-membranous  inflam- 
mation, the  one  a  true  diphtheria,  due  to  the  Klebs-Loeffler  bacillus,  and  the 
other,  which  may  include  several  varieties,  a  pseudo-diphtheria,  due  usually  to 
a  streptococcus. 

True  diphtheria  is  the  product  of  the  Klebs-Loefiler  bacillus,  either  alone 
or  associated  with  other  bacteria,  and  it  is  primarily  a  local  disease  with  many 
secondary  manifestations,  due  to  the  absorption  of  the  ptomaines  or  poisons 
which  result  from  the  growth  of  this  micro-organism.  Tlie  following  obser- 
vations seem  to  establish  these  propositions  as  fairly  well  proven : 

1.  This  bacillus  is  present,  usually  in  large  numbers,  in  the  false  membrane 

250 


DIPHTHERIA.  251 

of  all  typical  cases  of  infectious  diphtheria,  and  is  rarely  or  never  found  in 
other  inflammations  of  the  mucous  membrane  of  the  throat  or  in  the  healthy 
throat. 

2.  This  bacillus  is  ahvays  found  at  the  place  of  local  infection,  and  never 
found  in  the  blood  or  any  of  the  internal  organs,  even  though  they  may  be  the 
seat  of  marked  secondary  changes.  On  the  contrary,  streptococci  and  other 
bacteria  may  be  found  in  the  blood  and  internal  organs. 

3.  Pure  cultures  of  this  bacillus  when  injected  into  the  mucous  membrane 
of  susceptible  animals  produce  a  typical  diphtheritic  inflammation,  even  to 
paralyses  and  organic  lesions. 

4.  Inoculation  of  animals  "with  the  toxalbumin  of  this  bacillus  produces 
the  sepsis,  the  paralysis,  the  visceral  lesions,  and  all  the  secondary  constitu- 
tional symptoms  of  diphtheria,  without  the  membrane. 

5.  Clinically,  surface  diphtheria,  without  participation  on  the  part  of  the 
Ivmph-vessels,  is  apt  to  exhibit  little  or  no  fever ;  the  disease  does  not  run  a 
typical  course ;  one  attack  does  not  off"er  security  against  its  recurrence  in  the 
future ;  and  whenever  the  diphtheritic  infecting  agent  finds  a  foothold  on  the 
bodv — as,  for  example,  by  inoculation — it  always  excites  a  local  afi"ection  at 
the  point  of  entrance ;  and  from  this  local  infection  the  general  infection  will 
develop,  the  extent  and  rapidity  of  which  depend  upon  the  anatomical  rela- 
tions of  the  affected  parts,  their  characteristics,  and  their  power  of  absorption. 

The  hypothesis  that  diphtheria  is  at  first  a  general  disease  of  the  blood, 
with  secondary  manifestations  on  the  mucous  membranes,  is  hardly  tenable  in 
face  of  the  foregoing  facts.  The  chief  arguments  brought  forward  in  support 
of  this  theory  are  its  similarity  to  certain  of  the  infectious  diseases  ;  its  epi- 
demic occurrence  ;  the  fact  that  constitutional  symptoms  may  be  present  for 
hours  and  days  before  local  symptoms  are  discovered  ;  the  marked  susceptibility 
of  children  ;  the  great  disproportion  often  seen  betAveen  the  general  symptoms 
and  the  apparently  trifling  local  changes  ;  the  multiplicity  of  the  localizations, 
and  the  fact  that  efforts  to  conquer  the  disease  by  destroying  the  pseudo-mem- 
brane with  strong  caustics  have  been  for  the  most  part  without  result.  However, 
these  observations  simply  prove  that  diphtheria  may  be  a  general  infectious 
disease,  but  they  do  not  explain  how  this  infection  takes  place.  Neither  clin- 
ical observations  nor  post-mortem  examinations  have  ever  been  able  to  present 
enough  facts  to  settle  this  question;  but,  fortunately,  modern  bacteriological 
research,  with  inoculation  experiments  on  living  animals,  has  determined  it 
very  conclusively. 

"^Besides  true  diphtheria,  we  frequently  meet  with  an  allied  pseudo-mem- 
branous inflammation  which  cannot  be  distinguished  from  it  clinically,  except 
that  it  runs  a  milder  course.  Bacteriologically,  however,  the  Klebs-Loeffler 
bacillus  is  always  absent,  and  streptococci,  and  often  other  bacteria,  are 
found  in  great  abundance,  not  only  in  the  exudate,  but  even  in  the  blood  and 
internal  organs.  The  differential  diagnosis  is  very  important,  as  a  knowledge 
of  which  disease  we  have  to  deal  with  modifies  somewhat  the  treatment,  and 
greatly  the  prognosis. 

Not  onlv  do  we  have  a  croupous  inflammation  which  is  not  a  true  diph- 
theria, but  we  can  have  a  true  diphtheria  in  which  the  membrane  covers  so 
little  space  that  there  is  apparently  no  fibrinous  exudate.  This  was  clearly 
demonstrated  by  Jacobi  in  his  article  on  "Follicular  Amygdalitis  ;"  and  every 
observer  must  have  seen  cases  in  which  an  apparently  catarrhal  follicular 
amygdalitis  quickly  proved  itself  to  be  a  diphtheritic  one,  or,  after  recovery, 
showed  its  true  nature  by  a  characteristic  diphtheritic  sequel — a  paralysis  of 
some  muscle  or  group  of  muscles. 


252     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Accepting  the  microbic  origin  of  diphtheria,  we  must  still  take  into 
account  the  many  conditions  that  materially  modify  the  course  of  this  aft'ec- 
tion,  which  is  one  of  the  most  variable  and  uncertain  of  all  the  contagious 
diseases.  It  is  doubtful  if  a  normal  mucous  membrane  can  be  infected  by  the 
bacillus,  and  it  is  certainly  true  that  a  lesion  favors  its  development.  This 
also  applies  to  the  toxalbumin  of  the  bacterium,  large  amounts  of  which  can  be 
swallowed  without  danger  by  susceptible  animals  that  have  healthy  and  intact 
mucous  membranes. 

Age  is  ordinarily  an  important  factor  in  influencing  the  occurrence  of  the 
disease ;  and,  though  it  may  occur  at  any  time  of  life,  it  is  essentially  a  disease 
of  childhood. 

Individual  or  family  predisposition  has  some  influence.  It  occurs  by 
marked  preference  in  connection  with  those  diseases  which  produce  lesions  of 
the  mucous  membranes.  Cold  and  dampness  favor  its  occurrence,  partly  bv 
their  tendency  to  excite  catarrhal  afi'ections  and  thus  ofi"er  an  opportunity  for 
infection,  and  partly  by  the  more  favorable  conditions  for  the  growth  of  the 
bacillus  which  are  pi*esent  during  such  weather.  All  the  windows  and  other 
sources  of  ventilation  are  shut,  and  the  rooms,  especially  in  tenements,  where 
the  disease  is  most  common,  are  stifling  and  hot.  Insanitary  conditions  un- 
doubtedly favor  the  development  of  this  germ. 

Klebs-Loeffler  Bacillus. — In  the  membrane  of  true  diphtheria  this 
bacillus  is  always  found,  either  alone  or  associated  with  other  bacteria.  It  is 
rarely  or  never  found  in  the  blood  or  internal  organs,  although  the  strepto- 
coccus, which  is  often  associated  with  it,  may  appear  in  the  blood,  the 
lymphatics,  or  the  viscera.  On  the  surface  and  the  most  superficial  portions 
of  the  exudate  the  bacillus  is  found  mixed  with  numerous  other  micro- 
organisms. In  the  middle  or  deeper  portions  the  only  organisms  present  are 
the  Klebs-Loefiler  bacilli,  either  alone  or  associated  with  streptococci.  In  the 
deeper  layers  there  are  only  a  few  bacilli,  and  in  the  mucous  membrane,  as  a 
rule,  none. 

These  bacilli  are  "  moderate-sized  rods,  usually  slightly  bent,  averaging 
nearly  as  long  as  the  tubercle  bacilli,  but  twice  as  broad,  and  usually  with 
rounded  ends.  According  to  the  rapidity  of  growth,  the  soil,  and  other  con- 
ditions, the  form  and  size  of  the  micro-organisms  vary,  and  the  differences  are 
striking.  The  bacteria  are  sometimes  enveloped  in  a  more  or  less  capacious 
membrane ;  sometimes  the  contents  divide  into  a  number  of  pieces,  separated 
by  transverse  divisions ;  one  end  of  the  rod  is  frequently  thickened  like  a 
club,  or  both  ends  may  be  clubbed,  or  one  or  both  pointed.  The  bacilli  are 
immobile  and  have  no  spores.  The  best  staining  agent  is  Loeffler's  alkaline 
methyl- blue.  Some  forms  stain  uniformly,  others  in  various  irregular  ways, 
the  most  common  being  the  appearance  of  deeply-stained  granules  in  a 
slightly-stained  bacillus  or  of  darkly-stained  ends  with  a  paler  centre.  The 
bacilli  are  very  often  in  pairs,  never  in  chains ;  they  are  semi-anaerobic,  and 
thrive  at  a  somewhat  high  temperature,   20°  to  42°   C." 

"The  Loeffler  bacilli  can  be  cultivated  upon  all  the  wdinary  culture 
media,  but  grow  most  vigorously  on  a  mixture  of  blood-serum  and  nutrient 
bouillon,  as  given  by  Loeffler.  On  this,  solidified,  the  bacilli  grow  as  large, 
round,  elevated,  grayish-white  colonies,  with  the  centre  more  opaque  than  the 
somewhat  in-egular  periphery"  (Park). 

The  most  ready  method  of  detecting  this  bacillus  is  to  detach  a  small 
piece  of  membrane  and  place  it  for  five  minutes  in  a  2  per  cent,  solution  of 
boracic  acid,  then  to  draw  the  piece  of  membrane  along  the  surface  of 
sterilized  blood-serum  in  a  test-tube,  and  maintain  it  at  a  temperature  of  37° 


PLATE  IX. 


../ 


Ir, 


A.  B.  C. 

Fig.  1.— Loeffler  bacilli.    X  650.  Fig.  2. -Pseudo-bacilli.    X  650. 

Fig.  3.— Involution  forms  of  the  Loeffler  bacillus.    X  650. 

Fig.  4.— a.  Pseudo-bacillus.    B.  True  bacillus.    C.  Pseudo-bacillus. 
(Natural  size.) 


From  photographs  taken  by  Dr.  Henry  Koplik,  Carnegie  Laboratory,  New  York. 


DIPHTHERIA.  253 

G.  for  twelve  to  twenty-four  hours.  At  the  end  of  this  time,  if  the  bacilli- are 
present,  characteristic  small  white  rounded  colonies  are  visible  along  the  track 
of  inoculation.  Thev  can  then  be  stained  and  examined.  To  get  a  pure 
culture  a  second  or  third  preparation  must  be  made.  To  overcome  the  diffi- 
culty of  obtaining  serum  for  the  culture  medium,  Sakharof  suggests  the  use 
of  slices  of  hard-boiled  eggs  placed  in  sterilized  test-tubes,  and  Johnston  sug- 
gests the  use  of  hard-boiled  eggs  from  which  a  part  of  the  shell  has  been 
removed  with  ordinary  forceps,  so  that  the  shell-membrane  can  be  peeled  oif 
and  the  inoculation  made  at  that  point.  To  guard  the  culture  against  contam- 
ination, the  egg  can  be  placed  upside  down  in  a  common  egg-cup,  the  interior 
of  which  has  been  sterilized  by  allowing  a  flame  to  enter  it  for  a  second  or  two. 

The  pseudo-diphtheria  bacilli  is  a  term  applied  to  a  group  of  micro- 
organisms which  closely  resemble  the  true  diphtheria  bacilli,  both  in  appear- 
ance and  in  producing  a  pseudo-membrane,  but  they  are  without  pathogenic 
properties  in  guinea-pigs,  and  they  do  not  grow  on  gelatin  at  ordinary 
temperatures.  However,  for  bedside  diagnosis  it  is  wiser  to  consider  all  cases 
as  true  diphtheria  that  give  colonies  of  bacilli  resembling  the  Klebs-Loeffler. 

The  ptomaine,  or  poison,  produced  by  the  diphtheria  bacillus  is  of  a  proteid 
nature,  precipitated  by  alcohol  and  soluble  in  water.  When  pure,  it  is  a 
white  amorphous  mass  and  extremely,  poisonous.  It  is  not  at  all,  or  but 
little,  absorbed  by  healthy  and  intact  mucous  membranes  ;  but  when  inoculated 
into  a  susceptible  animal  it  produces  all  the  symptoms  of  a  diphtheria  without 
the  exudate. 

Mode  of  Infection  and  Propagation. — There  is  no  doubt  that  in  the 
vast  majority  of  cases  the  inoculation  takes  place  through  some  lesion  of  the 
mucous  membrane  or  of  the  skin.  Therefoi-e,  it  would  be  hard  to  over- 
estimate the  value,  as  a  prophylaxis,  of  attention  to  all  lesions,  no  matter 
how  slight,  of  the  mucous  membrane  of  the  upper  air-passages.  Every 
catarrhal  condition  should  receive  prompt  and  efficient  treatment,  and  bad 
teeth,  accumulated  secretions,  or  any  other  source  of  local  irritation  should  be 
removed  as  soon  as  possible. 

The  germ  is  usually  propagated  through  the  surrounding  air,  and  brought 
in  contact  with  the  mucous  membrane  during  respiration.  Less  frequently 
the  disease  may  be  propagated  by  the  direct  deposition  of  diphtheritic  matter 
by  inoculation  or  through  some  article  of  food.  It  has  been  known  to  have 
been  communicated  from  some  of  the  domestic  animals.  The  contagion  may 
be  spread  by  contact  with  the  person  or  clothes  of  those  suifering  from  the 
disease,  and  may  also  be  spread  by  bed-clothes,  furniture,  and  other  articles  in 
the  sick-room.  Too  much  care  cannot  be  taken  to  prevent  those  surround- 
ing the  sick  from  spreading  the  disease,  and  there  is  no  doubt  that  phys- 
icians themselves  frequently  carry  the  disease  from  one  patient  to  another. 
This  is  clearly  shown  from  the  large  number  of  cases  which  occur  in  their 
own  families. 

Incubation. — In  experimental  diphtheria  the  duration  of  the  incubation 
period  is  short,  varying  from  twelve  hours  to  three  days  ;  but  when  diphtheria 
is  contracted  in  the  usual  way — by  inhaling  air  which  contains  the  contagion 
— this  period  may  be  much  longer,  varying  from  one  day  up  to  twenty.  How- 
ever, in  the  latter  case  this  only  means  the  interval  between  exposure  and  the 
appearance  of  the  disease,  for  there  is  no  means  of  knowing  exactly  when  the 
contagion  entered  the  mucous  membrane,  and  how  long  it  had  remained  harm- 
lessly upon  it,  waiting  for  the  development  of  some  lesion  through  which  to 
infect  it.  It  is  obvious,  therefore,  that  all  observations  based  upon  the  inter- 
val between  exposure  and  the  appearance  of  the  disease  must  be  uncertain. 


254     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

This  period  also  depends  not  only  upon  the  quality  and  quantity  of  the 
infecting  material  itself,  but  also  upon  the  structure  and  texture  of  the  tissues 
and  their  power  of  resistance — a  power  which  is  often  greatl^^  modified  by  strep- 
tococci and  other  bacteria  which  may  be  associated  with  the  true  diphtheria 
bacilli.  When  the  Klebs-Loeffler  bacilli  are  implanted  upon  a  normal  mucous 
membrane,  they  do  not  grow,  but  these  associated  streptococci  produce  an 
acute  purulent  discharge,  with  redness  and  swelling.  Thus  they  prepare  the 
lesion  for  infection  by  the  Klebs-Loeffler  bacilli. 

Anatomical  Changes. — The  local  pathological  changes  of  this  disease  occur 
on  a  mucous  membrane  or  some  abraded  portion  of  the  skin.  The  changes 
found  on  the  inflamed  mucous  membrane  are  as  follows  :  The  surface  becomes 
hyperaemic  and  swollen,  and  presents  the  usual  manifestations  of  a  catarrhal 
inflammation.  After  a  short  time,  usually  a  few  hours,  it  is  covered  with  a 
whitish  or  yellowish  layer,  which  forms  the  pseudo-membrane  so  characteristic 
of  the  disease.  This  membrane  may  represent  a  fibrinous  exudate  which  can 
be  easily  peeled  from  the  surface  beneath,  or  it  may  represent  a  true  necrosis, 
so  that  the  exudate  is  an  integral  part  of  the  mucous  membrane  and  cannot 
be  separated  from  it.  Many  of  its  characteristics  depend  upon  its  anatomical 
position  and  the  type  of  epithelium  upon  which  it  is  located.  It  looks  to  the 
naked  eve  like  coagulated  fibrin,  but  under  the  microscope  it  is  seen  to  consist 
of  proliferated  epithelial  cells  held  together  by  a  fibrinous  network.  In  its 
physical  and  chemical  properties  it  closely  resembles  fibrin.  The  surface 
beneath  the  exudate  may  show  all  grades  of  inflammation,  from  a  mild  catar- 
rhal to  an  ulcerated  one.  The  false  membrane  is  found  oftenest  on  the  tonsils, 
uvula,  soft  palate,  and  back  of  the  pharynx,  the  nasal  passages,  the  larynx, 
and  trachea  ;  less  commonly  on  the  conjunctiva,  at  the  border  of  the  anus,  or 
in  the  vagina  ;  rarely  in  the  bronchi  as  a  primary  afi"ection,  but  not  uncom- 
monly as  an  extension  of  the  same  process  from  the  larynx  and  trachea ;  and 
very  rarely  in  the  oesophagus,  the  intestinal  tract,  or  the  ear. 

Besides  these  local  pathological  changes  other  organs  of  the  body  may 
become  afi"ected  as  the  result  of  the  absorption  of  the  toxall>umin. 

The  adjacent  lymph-nodes  are  swollen  and  inflamed,  but  they  rarely  become 
the  seat  of  a  suppurative  inflammation ;  the  surrounding  tissues  are  infiltrated 
with  serum  containing  scattered  pus-cells. 

The  lungs  show  areas  of  intense  congestion,  with  haemorrhages  into  their 
ti.ssue.  They  may  exhibit  oedema,  broncho-pneumonia,  catarrh,  atelectasis, 
emphysema,  ecchymoses,  and  large  infarctions ;  and  the  bronchi  may  be  lined 
with  false  membrane  as  far  as  the  smaller  branches.  These  changes,  however, 
are  mostly  observed  as  complications  of  laryngeal  diphtheria. 

The  pleura  may  be  hyperiemic  and  inflamed,  with  haemorrhages,  and  in 
many  cases  the  pleural  cavity  will  contain  an  excess  of  fluid. 

The  kidneys,  in  experimental  cases,  are  moist  and  hypernemic,  and  the 
adrenals  are  congested  and  may  be  hfemorrhagic.  Fatty  changes  occur  in  the 
epithelium  of  the  tubes  and  glomeruli,  and  hyaline  alterations  in  the  glomer- 
ular capillaries  and  in  the  smaller  arteries.  Haemorrhages,  parenchymatous 
and  interstitial  nephritis,  are  common  lesions  observed  in  the  kidneys  in  albu- 
minuric cases. 

The  spleen  and  the  liver  may  be  enlarged  and  congested,  with  haemorrhages 
into  the  capsule  and  tissue.  There  may  be  present  smaller  or  larger  masses  of 
necrotic  cells,  and  in  some  cases  there  is  a  fatty  degeneration,  and  occasionally, 
in  protracted  cases,  a  hyaline  or  a  waxy  one. 

The  heart  may  show  in  the  substance  of  the  muscle  large  and  small 
haemorrhages    and    ecchymoses.     "When    death    is    due    to    asphyxia   without 


DIPHTHERIA.  255 

general  poisoning  of  the  whole  organism,  the  muscular  substance  of  the 
heart  itself  may  be  normal ;  but  when  there  has  been  a  general  poisoning 
it  has  usually  undergone  a  granular  and  fatty  degeneration,  and  there  may  be 
other  septic  changes,  as,  for  example,  an  endocarditis. 

In  both  the  parietal  and  visceral  layers  of  the  pericardium  there  may  be 
small  and  large  haemorrhages  and  ecchymoses  ;  there  may  be  an  excess  of  fluid 
in  the  pericardial  cavity ;  and  in  rare  cases  there  may  be  an  emphysema  of 
the  pericardium  as  a  consequence  of  the  extension  of  a  subpleural  emphysema 
into  the  loose  cellular  tissue  between  the  folds  of  the  mediastinum. 

The  blood,  as  in  most  severe  forms  of  septicaemia  and  poisoning,  is  but 
slightly  coagulable,  sticky,  brown,  or  rather  livid,  and  the  blood-vessels  contain 
a  greatly  increased  number  of  leucocytes. 

The  mucous  membrane  of  the  intestinal  tract  and  of  the  bladder  may 
rarely  become  directly  infected,  and  under  such  circumstances  they  present  the 
characteristic  pseudo-membrane  and  other  changes  which  take  place  in  the 
pharynx,  etc.  However,  when  secondary  changes  occur  in  consequence  of 
general  infection,  cell-infiltration  and  haemorrhages  are  the  usual  ones,  and  in 
one  reported  case  such  extensive  haemorrhage  from  the  great  omentum  occurred 
that  a  considerable  quantity  of  free  blood  had  collected  in  the  peritoneal  cavity. 
The  layers  of  the  peritoneum  may  be  injected  and  be  the  seat  of  ecchymoses, 
and  the  peritoneal  cavity  may  contain  an  excess  of  serous  fluid. 

The  fibres  of  the  muscles  show  degenerative  changes,  and  the  thyroid  may 
be  congested  and  ecchymotic. 

The  earliest  change  in  the  brain  and  spinal  cord  is  venous  hyperaemia, 
both  in  the  vascular  linings  and  in  the  substance  itself.  Later  in  the  disease 
come  extravasations,  with  the  subsequent  softening  of  the  surrounding  tissue, 
and  finally  various  degenerative  changes.  Extravasations  into  the  substance 
of  the  spinal  nerves  have  been  seen,  as  well  as  granular  degeneration  of  the 
nerves  of  the  soft  palate  and  other  parts  that  have  suffered  from  a  diphtheritic 
paralysis. 

Ssanptoms  and  Diagnosis. — The  characteristic  feature  of  the  disease  is 
the  pseudo-membrane.  There  are  cases  of  pseudo-membranous  inflammation 
which  are  not  diphtheria ;  but,  excluding  the  chronic  cases  and  those  due  to 
great  heat,  as  a  scald,  and  to  the  application  of  an  intense  irritant,  like  am- 
monia, it  is  often  impossible  to  distinguish  between  the  true  and  the  false 
diphtheria,  except  by  a  bacteriological  examination.  The  only  positive  test  is 
the  presence  of  the  Klebs-Loeffier  bacillus,  either  alone  or  associated  with 
streptococci  or  other  bacteria.  In  a  certain  proportion  of  cases  it  is  very 
difficult  to  distinguish  between  the  true  and  the  pseudo-bacillus ;  and  in  all 
doubtful  cases,  at  least  for  the  present  or  until  inoculation  experiments  can  be 
made,  it  is  wiser  to  consider  them  as  true  diphtheria.  Clinically,  cases  of 
follicular  amygdalitis  are  frequently  diagnosticated  as  simple  catarrhal  or  puru- 
lent inflammations,  when  they  are  really  diphtheritic.  AH  such  cases  should 
be  isolated  and  treated  in  every  respect  as  true  diphtheria  until  the  diagnosis 
is  made  certain  either  by  a  bacteriological  examination  or  the  appearance  of 
new  evidence  which  will  show  the  true  nature  of  the  disease. 

The  diagnosis,  even  of  a  membranous  inflammation,  may  be  obscure  from 
its  location.  It  may  be  confined  to  the  posterior  nares,  the  larynx  and 
trachea,  or  even  the  intestine,  the  bladder,  or  other  positions  where  the  local 
changes  cannot  be  seen. 

The  constitutional  symptoms  which  are  the  result  of  the  poisoning  due  to 
the  absorption  of  the  toxalbumin  produced  by  the  .specific  bacilli  vary  greatly, 
and  depend  not  only  on  the  amount  and  rapidity  of  the  absorption,  but  also 


256     AMERICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 

upon  the  susceptibility  and  condition  of  the  patient.  In  simple  and  uncom- 
plicated cases  there  is  usually  little  or  no  fever.  The  symptoms  may  vai-y 
from  this  to  evidences  of  the  most  profound  poisoning.  The  temperature  may  be 
high  and  irregular,  the  pulse  rapid  or,  in  certain  very  fatal  cases,  abnormally 
slow.  There  is  languor  and  loss  of  appetite,  and  an  amount  of  prostration  out 
of  proportion  to  the  fever  and  the  local  inflammation;  the  skin  dry  and  hot; 
and,  according  to  circumstances,  typhoid  symptoms  may  show  themselves,  or 
there  may  be  delirium  with  great  restlessness.  Relapses  are  frequent,  and  one 
attack  does  not  protect  against  a  subsequent  one. 

The  lymph-nodes  which  are  in  anatomical  relation  with  the  local  process, 
as  well  as  their  surrounding  tissues,  may  be  swollen  and  tender,  but  they 
seldom  undergo  a  suppurative  change.  The  degree  of  enlargement  and  inflam- 
mation depends  upon  the  amount  of  absorption,  and  of  course  this  depends 
not  only  upon  the  character  of  the  local  process,  but  also  upon  its  relations 
with  the  neighboring  lymphatics. 

The  heart's  action  is  usually  rapid,  and  may  be  feeble,  during  an  attack  of 
diphtheria;  and  this  condition  often  continues  for  some  time  after  the  disap- 
pearance of  all  local  evidences  of  the  disease.  The  pulse  may  be  irregular  both 
in  force  and  rhythm.  Another  condition,  usualh'  appearing  late  in  the  disease, 
and  often  when  the  local  process  is  apparently  improving  or  has  entirely  cleared 
up,  is  for  the  feeble  pulse  to  become  progressively  slower  until  the  beats  num- 
ber less  than,  forty,  sometimes  less  than  thirty,  to  the  minute.  These  cases, 
which  are  nearly  always  fatal,  together  with  those  having  the  feeble,  rapid  pulse 
of  profound  sepsis  and  exhaustion,  may  be  classed  as  examples  of  slow  heart 
failure.  But  there  is  still  another  condition  which  usually  appears  after  all  the 
alarming  symptoms  are  gone ;  that  is,  a  sudden  failure  or  paralysis  of  the  heart. 
Endocarditis  most  frequently  involving  the  mitral  valve  may  occur,  and  is 
accompanied  by  fever,  prsBcordial  pain,  attacks  of  syncope,  a  systolic  murmur, 
and  ante-mortem  heart-clots,  which  may  become  free  and  enter  the  circulation, 
producing  the  usual  phenomena.  In  most  cases  there  is  a  rapid  destruction  of 
the  red  corpuscles  of  the  blood,  and  a  relative  increase  of  the  white  corpuscles. 
Hence  the  anaemia  which  appears  early  and  rapidly  increases  as  the  disease 
advances. 

Albuminuria  is  a  common  complication,  and  appears  usually  on  the  third 
to  sixth  day,  but  may  rarely  appear  as  early  as  the  first  day  or  as  late  as  the 
fifteenth.  The  amount  of  albumin  varies  greatly,  from  a  slight  cloudiness, 
on  boiling,  to  complete  consolidation.  The  urine  usually  appears  normal, 
but  it  may  be  scanty  and  dark,  and  in  rare  cases  dark-colored  or  smoky 
from  the  presence  of  blood.  There  may  also  be  present  in  the  sediment  gran- 
ular, hyaline,  epithelial,  and  blood  casts.  The  dui-ation  of  the  renal  complica- 
tion varies  from  a  day  or  two  to  a  week  or  two,  but  it  may  occasionally  become 
chronic.  It  is  seldom  attended  with  oedema,  but  vomiting  and  other  ur^emic 
symptoms  are  not  so  rare.  It  is  impossible  to  distinguish  between  the  albu- 
minuria of  true  and  of  false  diphtheria,  but  in  diphtheria  there  are  some 
characteristics  which  distinguish  it  from  the  same  complication  of  scarlet  fever. 

The  tonsils  are  the  most  frequent  location  of  the  disease,  and  when  confined 
to  them  it  runs  a  mild  course,  because  they  have  little  or  no  connection  with 
the  lymphatic  system,  and  they  do  not  contain  a  large  number  of  blood-vessels. 
The  chief  difiiculty  in  diagnosis  is  to  distinguish  between  a  simple  follicular 
amygdalitis  and  a  .diphtheritic  one.  The  secretion  from  a  catarrhal  amygda- 
litis may  covier  the  tonsils  with  a  coat  which  closely  resembles  pseudo-mem- 
brane, but  it  can  be  easily  washed  away  with  a  syringe,  and  in  most  cases  a 
careful  examination  will  show  its  true  character. 


DIPHTHERIA.  257 

The  pharynx,  soft  palate,  and  mouth  may  be  involved  ;  and  here  it  is  a 
more  serious  condition  than  when  confined  to  the  tonsils.  The  lymph-vessels 
are  very  numerous :  those  of  the  uvula  connect  with  the  deep  facial  glands ; 
of  the  tongue,  with  the  deep  cervical  and  the  submaxillary  glands ;  and  of  the 
floor  of  the  mouth,  with  the  submaxillary  glands.  The  differential  diagnosis 
lies  between  true  diphtheria  and  false  diphtheria,  exudates  as  the  result  of  an 
intense  heat  or  irritation,  ulcerative  and  gangrenous  stomatitis,  or  occasionally 
herpes  and  aphthge.  The  main  differential  symptoms  pointing  to  diphtheria 
are,  besides  the  history,  the  characteristic  pseudo-membrane,  the  thin,  brown- 
ish, acrid  discharge,  the  sweetish  and  musty  fetor,  the  glandular  swellings,  the 
tendency  to  haemorrhages,  the  slight  fever  and  marked  prostration,  the  albu- 
minuria, and  the  sequel  of  paralysis.  In  doubtful  cases  the  only  positive  dem- 
onstration is  the  presence  of  the  pathognomonic  bacilli. 

In  the  nares  diphtheria  is  very  serious  on  account  of  the  abundant  lymph- 
and  blood-supply,  and  the  consequent  increased  facilities  for  absorption  of  the 
poison,  and  on  account  of  the  conformation  of  the  nasal  passages,  which  inter- 
feres with  their  thorough  drainage  when  swollen  and  inflamed,  and  which 
makes  thorough  local  treatment  very  difiicult.  The  greater  supply  of  lymph- 
vessels  is  in  the  inferior  portion  of  the  nasal  cavities,  and  these  vessels  con- 
nect with  the  deep  facial  and  posterior  submaxillary  glands.  It  is  often  very 
difficult,  and  may  be  impossible,  to  see  the  pseudo-membrane  in  the  posterior 
nasal  cavities  in  children.  Theoretically,  it  is  very  simple  to  use  a  rhino- 
scope,  but  practically.it  is  quite  another  matter,  and  it  is  often  impossible  and 
usually  impracticable,  even  in  a  tractable  child.  The  symptoms  which  help 
to  a  diagnosis  are  the  thin,  acrid  discharge  more  or  less  stained  with  blood,  the 
evidence  of  nasal  obstruction,  the  enlarged  cervical  glands,  the  bad  odor  to  the 
breath,  the  tendency  to  haemorrhage,  and  the  frequent  signs  of  general  poi- 
soning. 

When  the  epiglottis,  larynx,  and  trachea  are  involved,  the  main  danger  comes 
from  the  mechanical  obstruction  to  respiration  and  the  extension  of  the  disease 
to  the  bronchi.  Constitutional  symptoms  are  usually  absent,  partly  on  account 
of  the  protection  aftorded  by  the  very  numerous  mucous  glands,  and  partly  on 
account  of  the  absence  of  lymphatic  glands  and  the  scant  supply  of  lymphatic 
vessels.  These  vessels  connect  with  the  bronchial  glands.  After  death  from 
laryngeal  diphtheria  these  glands  are  found  more  or  less  enlarged. 

The  diagnosis  by  means  of  the  laryngoscope  would  be  very  valuable  if  it 
were  practical.  In  the  vast  majority  of  cases  it  is  not  only  impossible,  but  it 
is  unnecessary  and  cruel.  There  is  undoubtedly  a  membranous  laryngitis 
which  is  not  diphtheria,  but  the  differential  diagnosis  cannot  be  made  either 
from  the  symptoms  or  the  character  of  the  membrane.  It  can  only  be  made 
by  a  bacteriological  examination,  which  will  show  the  presence  or  the  absence 
of  the  Klebs-Loeffler  bacillus. 

The  differential  diagnosis  lies  between  a  membranous  laryngitis  and  a 
catarrhal  or  a  spasmodic  one ;  and  while  this  is  not  usually  so  very  difiicult, 
certain  cases  will  present  phenomena  which  keep  the  diagnosis  obscure,  unless 
the  membrane  is  actually  seen  through  the  laryngoscope  or  is  coughed  up. 
Again,  cases  which,  in  the  beginning,  are  catarrhal  and  run  a  typical  course, 
may  later  become  infected  and  run  the  usual  course  of  a  membranous  infiam- 
mation.  Again,  confusion  may  be  caused  by  those  rather  rare  cases  in  which 
the  membranous  inflammation  begins  below  and  ascends  to  the  larynx. 

In  the  uncomplicated  cases  of  membranous  laryngitis,  excluding  the 
ascending  ones,  there  is  little  or  no  fever ;  the  onset  of  the  disease  is  gradual, 
and  it  grows  progressively  worse ;  there  is  hoarseness,  and  after  a  time  complete 
17 


258     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

aphonia ;  the  stenosis  is,  at  first,  slight  and  only  on  inspiration,  but  after 
a  while,  usually  two  to  four  days,  the  stenosis  becomes  extreme,  and  attends 
both  inspiration  and  expiration ;  the  respiration  and  the  cough,  which  in  the 
beginning  may  be  noisy  and  croupy,  gradually  become  more  husky  and  sup- 
pressed. Spasmodic  attacks  may  occur  in  connection  with  the  disease,  but 
this  is  not  a  prominent  feature  of  its  clinical  history. 

The  cases  of  ascending  diphtheria  of  the  trachea  and  larynx  are  very  fatal, 
and,  fortunately,  uncommon.  There  are  no  constitutional  symptoms,  and  the 
only  evidence  of  sickness  which  can  be  detected  is  a  slight  bronchial  or 
tracheal  catarrh,  until  the  process  reaches  the  subglottic  division  of  the  larynx 
or  the  chink  of  the  glottis,  when  laryngeal  symptoms  are  seen,  and  stenosis 
appears  and  increases  so  rapidly  that  the  patient  becomes  cyanotic  Avithin  an 
hour  or  two,  and  soon  dies  unless  immediate  relief  is  given  by  intubation  or 
tracheotomy.  Even  after  operative  interference  the  patient,  in  most  cases, 
dies  from  extension  of  the  disease  to  the  bronchi,  and  usually  within  two 
days. 

In  doubtful  cases  the  appearance  of  membrane  in  other  locations,  or  the 
existence  of  an  epidemic  of  diphtheria,  favors  the  diagnosis  of  a  membranous 
laryngitis.  If  with  this  the  temperature  is  low,  not  high  ;  the  stenosis 
increases  progressively,  not  spasmodically  ;  the  onset  is  gradual,  not  sudden ; 
the  laryngeal  symptoms  are  of  long,  not  short  duration, — the  diagnosis  of 
membranous  laryngitis  is  very  clear. 

There  are  numerous  evidences  of  stenosis  of  the  larynx  besides  the  noisy 
respiration,  as  this  latter  symptom  may  be  present  in  many  other  conditions. 
The  most  characteristic  features  of  laryngeal  obstruction  are  the  deep  reces- 
sions of  the  soft  parts  of  the  chest  in  inspiration,  the  blue  or  leaden  hue  of  the 
skin  and  mucous  membranes,  the  aphonia,  the  restlessness,  and  the  abnormal 
frequency  of  the  respirations  ;  but  none  of  these  symptoms  are  constant.  The 
soft  parts  of  the  chest-walls  may  project  and  make  the  chest  barrel-shaped  if 
the  obstruction  is  greater  on  expiration  ;  the  skin  and  mucous  membranes  may 
appear  blue  if  the  stenosis  increases  rapidly,  but  this  color  becomes  a  leaden 
white  if  the  obstruction  is  of  slow  progress ;  the  voice  may  be  clear  in  sub- 
glottic cases  ;  and  in  advanced  cases  the  restlessness  is  supplanted  by  a  con- 
dition of  stupor  from  carbon-dioxide  poisoning.  The  only  constant  and  reliable 
guide  as  to  the  presence  and  the  amount  of  laryngeal  obstruction  is  obtained 
by  auscultation  of  the  chest  and  listening  to  the  respiratory  sound.  This 
gives  an  accurate  guide  as  to  the  amount  of  air  entering  the  lungs. 

The  other  diseases  which  should  be  considered  in  making  a  diagnosis  are 
abscess  of  or  about  the  larynx,  tumors  of  the  larynx,  retropharyngeal  abscess, 
certain  cases  of  naso-pharyngeal  obstruction,  foreign  bodies  in  the  air-pas- 
sages, etc. ;  but  the  diagnosis  should  not  be  difficult  if  a  careful  examination 
is  made. 

In  the  bronchi  a  membranous  inflammation  is  rarely  or  never  primary,  but  is 
secondary  to  a  similar  one  in  the  larynx  or  trachea.  It  may  extend  to  the  finer 
bronchial  tubes,  or  even  into  the  air-cells  themselves,  and  result  in  a  broncho- 
pneumonia, with  pulmonary  collapse  or  emphysema.  Its  symptoms  are,  in 
a  case  of  laryngeal  diphtheria,  a  sudden  rise  of  temperature — often  very  high 
— rapid  respiration,  marked  dyspnoea,  and  cyanosis ;  and,  although  the  phys- 
ical signs  in  the  chest  are  often  obscure  and  masked  by  the  laryngeal  disease 
and  pulmonary  complications,  there  is  less  air  entering  the  lung  on  the  afiected 
side,  and  the  respiratory  sound  is  dry  and  "  boardy." 

Diphtheria  of  the  conjunctiva,  the  ear,  the  intestinal  tract,  the  genito- 
urinary organs,  abraded  portions  of  the  skin,  and  wounds  has  occurred,  usually 


DIPHTHERIA,  259 

as  a  secondary  process,  but  occasionally  as  a  primary  infection.  The  symptoms 
are  those  of  an  ordinary  inflammation  in  those  parts,  to  "which  are  added  the 
pseudo-membrane  and  other  characteristics  of  this  disease. 

Diphtheria  may,  of  course,  complicate  any  disease,  but  the  most  frequent 
association  is  T\"ith  scarlet  fever,  measles,  and  those  diseases  "which  present 
a  catarrhal  condition  of  the  mucous  membranes,  and  thus  favor  a  fresh  in- 
fection. 

The  skin  eruptions  -which  occur  in  diphtheria  are  septic  manifestations,  and 
may  be  of  three  kinds.  The  mildest  and  most  transient  closely  resembles  a 
scarlet-fever  rash,  but  disappears  more  rapidly  and  does  not  desquamate.  -The 
second  type  is  a  purpura  hemorrhagica,  and  is  usually  associated  "with  septic 
and  grave  forms  of  the  disease.  The  last  type,  also  seen  in  scarlet  fever, 
usually  follo"ws  a  purulent  septic  infection,  and  occurs  in  cases  "which  have  a  high 
mortality.  There  is  an  increase  of  temperature  and  the  invasion  is  gradual. 
The  eruption  appears  as  red  or  dark-pink  blotches,  "with  sharply-defined  mar- 
gins. The  color  fades  on  pressure  "with  the  finger,  but  quickly  returns.  It 
appears  first  over  the  prominent  bony  points,  such  as  the  ankles,  fimger-j  oints, 
elbo"ws,  outer  sides  of  the  feet,  etc.,  but  al"ways  has  a  tendency  to  become  gen- 
eral. Its  disappearance  is  folio-wed  by  a  profuse  desquamation,  and  usually  this 
is  quickly  folio-wed  by  a  return  of  the  eruption. 

Seq-uelse. — Besides  the  chronic  catarrh  -which  is  left  at  the  site  of  the 
pseudo-membranous  inflammation,  and  the  anaemia,  the  most  frequent  and  char- 
acteristic sequel  of  diphtheria  is  paralysis,  -which  develops  from  one  to  five 
-weeks  after  all  evidence  of  the  acute  disease  has  gone,  though  it  may  make  its 
appearance  during  the  course  of  the  primary  affection.  It  is  a  true  multiple, 
peripheral  neuritis,  and  resembles  very  closely,  both  clinically  and  pathologic- 
ally, the  neuritis  of  alcohol,  lead,  and  other  poisons.  The  duration  of  the 
paralysis  usually  varies  from  t"wo  to  six  "weeks;  it  may  last  several  months,  and 
in  exceptional  cases  has  persisted  for  years.  It  is  more  frequent  in  adults  than 
in  children,  and  the  severity  of  the  original  disease  seems  to  oflFer  no  guide  as 
to  the  severity  of  the  paralysis  or  the  probability  of  its  appearance.  Recovery 
usually  takes  place,  and.  "ohile  the  location  and  the  order  of  involvement  diff"er 
greatly,  the  course  is  usually  as  follo"ws:  The  soft  palate  and  pharyngeal 
muscles,  giving  a  nasal  tone  to  the  voice  and  a  tendency  to  regurgitation  of 
food  through  the  nose  during  deglutition;  the  muscles  of  the  tongue,  lips, 
and  face;  the  ocular  muscles,  as  sho"wn  by  strabismus  and  disturbances  of 
vision;  the  lo"wer  extremities;  the  upper  extremities;  the  larynx,  recognized 
by  modifications  in  the  character  of  the  voice  or  by  obstruction,  usually  on 
inspiration;  the  muscles  of  the  neck,  "with  inability  to  control  the  position  of 
the  head;  the  muscles  of  the  trunk,  "with  loss  of  po"n'er  over  the  body;  the 
intercostal  muscles,  the  diaphragm  and  other  muscles  of  respiration,  "with  inter- 
ference "with  their  function  ;  the  heart,  usually  fatal,  but  may  not  be;  the  "^^'alls 
and  the  sphincter  of  the  intestines  or  bladder.  There  has  also  been  observed 
paralysis  of  the  special  senses,  giving  temporary  amaurosis,  deafness,  and  im- 
pairment of  taste  and  smell. 

The  paralysis  of  diphtheria  may  be  divided  into  t-wo  classes;  first,  a  true 
multiple  neuritis,  -with  loss  of  tendon  reflexes  as  the  result  of  poisoning  by  the 
toxalbumin;  and  second,  other  types  of  paralysis,  as  a  result  of  haemorrhages 
or  degenerative  changes  in  the  brain  or  spinal  cord.  The  first  type  occurs 
only  in  true  diphtheria ;  the  second  may  occur  in  true  or  false  diphtheria  or  as 
a  result  of  many  other  septic  conditions. 

Prognosis. — The  prognosis  is  al"ways  better  "when  the  Klebs-Loeffler  bacillus 
is  absent.      In  159  observations  on  cases  of  pseudo-membranous  inflammation 


260     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

made  by  Park  at  the  Willard  Parker  Hospital  of  New  York,  the  Loeffler 
bacillus  was  found  in  54  cases,  and  in  the  other  cases  streptococci  were  the 
most  abundant  bacteria,  and  often  the  only  ones.  The  mortality  in  true 
diphtheria  was  46^  per  cent. ;  in  pseudo-diphtheria,  5§  per  cent.  ;  intubation 
in  diphtheria,  71J  per  cent.  ;  intubation  in  pseudo-diphtheria,  28J  per  cent.  ; 
adults  in  diphtheria,   36  per  cent.  ;  adults  in  pseudo-diphtheria,  2  per  cent. 

The  prognosis  varies,  not  only  according  to  the  age  and  condition  of  the 
patient,  to  the  symptoms,  and  to  the  anatomical  location  of  the  disease,  but 
also  according  to  the  character  of  the  prevailing  epidemic.  The  danger  is 
greater  the  larger  the  surface  involved  and  the  more  the  exudate  approaches  a 
septic  or  gangrenous  type,  as  shown  by  broken-down  masses  of  exudation,  the 
sweetish  foul  odor  from  the  mouth,  the  yellowish  or  brownish  secretion  from 
the  mouth  and  nose,  which  is  both  fetid  and  acrid,  and  the  swelling  and  tender- 
ness of  the  lymphatic  nodes  and  the  surrounding  cellular  tissue.  However,  the 
prognosis  must  always  be  a  guarded  one,  since  the  subsequent  course  of  the 
disease  can  never  be  predicted ;  and  even  after  it  has  apparently  terminated  in 
recovery  a  relapse  may  take  place,  the  infection  may  extend  to  the  larynx  or 
nose,  or  sudden  death  may  result  from  paralysis  of  the  heart.  Another  class  of 
cases  result  in  death,  after  all  local  manifestations  of  the  disease  have  disap- 
peared, from  a  slow  exhaustion.  Such  a  condition  might  be  called  diphtheritic 
marasmus,  the  chief  characteristic  of  which  is  the  distaste  for  all  food  and  the 
progressive  and  extreme  emaciation. 

The  prognosis  in  nasal  cases  is  more  serious,  for  reasons  already  given,  while 
in  laryngeal  cases  the  prognosis  is  very  grave  from  the  great  danger  of 
asphyxia ;  and,  even  if  this  be  overcome,  from  the  ease  and  frequency  with 
which  the  membranous  inflammation  extends  into  the  bronchi. 

Unfavorable  prognostic  signs  are  pallor,  prostration,  vomiting,  haemor- 
rhages, marked  weakness  of  the  pulse,  with  excessive  rapidity  or  slowness, 
fetor,  purpura  haemorrhagica  and  septic  blotches  on  the  skin,  persistent  high 
fever,  restlessness,  delirium,  and  anorexia.  The  importance  of  albuminuria 
depends  upon  its  character  and  the  gravity  of  the  symptoms  which  are  asso- 
ciated with  it.  Diphtheritic  paralysis  usually  ends  in  recovery,  and  is  danger- 
ous only  when  it  involves  the  heart  or  the  muscles  of  respiration  or  degluti- 
tion ;  and  even  in  these  cases  its  danger  depends  upon  its  degree. 

Prophylaxis. — The  first  requisite,  after  the  appearance  of  the  disease,  is 
complete  isolation  of  the  patient,  either  in  a  hospital  devoted  to  contagious 
diseases  or  in  a  separate  room  in  the  house,  preferably  on  the  top  floor,  and 
containing  as  little  furniture  as  possible.  Separate  dishes  and  other  utensils 
should  be  kept  for  the  sick-room,  and  everything  that  it  is  necessary  to  return 
to  other  parts  of  the  house  should  be  thoroughly  disinfected  before  it  leaves  the 
room.  All  discharges  should  be  received  in  vessels  containing  a  strong  solu- 
tion of  copperas  or  corrosive  sublimate.  The  clothing,  towels,  etc.  should  be 
put  in  a  solution  of  sulphate  of  zinc  (4  ounces)  and  common  salt  (2  ounces)  in 
boiling  water  (1  gallon).  Water-closets,  privies,  etc.  should  be  liberally 
treated  with  copperas  solution  (IJ  pounds  to  the  gallon).  During  the  con- 
tinuance of  the  disease  it  is  of  great  service  to  keep  the  room  filled  with  some 
antiseptic  vapor,  as  carbolic  acid,  eucalyptus,  or  turpentine  ;  but  I  have  found 
that  most  good  in  preventing  the  spread  of  the  disease  is  obtained  by  sub- 
liming fifteen  to  thirty  grains  of  calomel  in  the  room  every  hour.  After  recovery 
the  patient  should  be  thoroughly  cleansed  and  disinfected,  and  dressed  in  clothes 
that  have  not  been  exposed  to  infection.  In  any  event,  as  much  as  possible  of 
the  exposed  clothing,  furniture,  etc.  should  be  destroyed,  and  the  rest  thoroughly 
disinfected,  either  by  the  methods  previously  described  or  by  naphtha  or  super- 


DIPHTHERIA.  261 

heated  steam.  The  walls,  bed,  and  furniture  should  be  washed  with  a  strong 
solution  of  corrosive  sublimate,  and  then,  after  closing  the  room  tightly,  sul- 
phur should  be  burned  in  it  in  the  presence  of  an  excess  of  moisture — about 
three  pounds  of  sulphur  to  every  thousand  cubic  feet  of  air-space.  After  this 
it  is  well  to  advise  that  four  to  eight  ounces  of  calomel  be  sublimed.  Other 
members  of  the  family  should  be  kept  from  school  and  church  ;  they  should  be 
removed  to  a  different  house  if  possible,  away  from  the  infection,  and  their 
naso-pharyngeal  cavities  and  teeth  should  be  kept  clean  by  means  of  antiseptic 
washes,  sprays,  and  gargles.  At  all  times,  and  especially  during  an  epidemic 
or  after  exposure  to  it,  the  mucous  membrane  of  the  respiratory  tract  should  be 
kept  in  as  healthy  a  condition  as  possible  by  keeping  it  clean  and  free  of  lesions. 

The  physician  should  protect  his  clothing  as  much  as  possible  on  entering 
the  sick-room  by  a  linen  gown,  and  before  seeing  another  patient,  especially  a 
child,  all  parts  exposed  to  the  infection  should  be  thoroughly  aired ;  or,  better 
still,  he  should  disinfect  himself  and  put  on  fresh  clothes,  leaving  the  dis- 
carded ones  exposed  to  the  open  air  or  to  the  fumes  of  subliming  mercury. 

One  of  the  chief  causes  of  the  spread  of  diphtheria  in  New  York  City  is 
the  laxness,  and  almost  criminal  carelessness,  of  the  authorities  in  our  dis- 
pensaries for  the  poor.  It  is  almost  a  daily  occurrence  in  the  large  dispensa- 
ries for  a  contagious  case  to  be  packed  in  a  small,  hot  room  with  a  number  of 
other  children,  most  of  them  ill  and  in  good  condition  to  contract  the  infec- 
tion. 

Treatment. — There  is  no  disease  in  which  a  greater  variety  of  treatment 
has  been  recommended — from  the  expectant,  which  lets  the  patient  absolutely 
alone,  to  the  active  treatment,  which  requires  him  to  be  disturbed  every  few 
minutes.  It  is  impossible  to  lay  down  any  routine  plan :  we  have  no  specific 
for  the  disease,  and  each  case  should  be  treated  on  general  principles  and 
according  to  its  individual  indications.  The  general  condition  and  strength 
of  the  patient  should  be  improved  as  much  as  possible.  There  should  be 
plenty  of  sunlight  and  fresh  air  in  the  sick-room,  which  should  be  kept  at 
a  uniform  temperature  of  about  70°  F.  The  clothes  and  bed-linen  should 
be  kept  clean  and  pure  by  frequent  changing.  The  skin  should  be  kept  in 
good  condition,  and  special  care  should  be  taken  of  the  digestion  and  nourish- 
ment. Great  stress  should  be  given  in  advising  the  recumbent  position  and 
avoiding  all  exertion,  but,  of  course,  this  is  often  impossible  in  children. 

Internal  Treatment. — Alcohol  and  food  are  of  the  greatest  value,  and  too 
much  stress  cannot  be  laid  on  the  importance  of  their  proper  use.  The  diet 
should,  as  a  rule,  be  a  liquid  one,  and  consist  of  such  food  as  is  easily  digested. 
Cows'  milk,  pure  and  fresh,  is  undoubtedly  the  best,  but  to  aid  digestion  or  to 
prevent  souring  and  other  fermentative  changes  it  may  be  peptonized,  or  lime- 
water  or  an  antiseptic  may  be  added  to  it.  To  give  variety  to  the  diet  or  to 
meet  special  indications  other  wholesome  and  nourishing  articles  may  be 
included,  as  beef  juice,  eggs,  etc.  The  food  should  always  be  given  at  regular 
intervals,  about  once  every  three  or  four  hours,  and  in  definite  quantities.  It 
is  always  harmful  to  compel  a  child  to  take  more  food  than  it  can  digest,  and 
any  drug  Avhich  interferes  with  the  proper  digestion  and  assimilation  of  the 
food  is  positively  harmful,  and  its  use  should  be  avoided. 

Alcohol,  as  brandy,  whiskey,  champagne,  wine,  or  in  some  other  form, 
should  be  given  rather  freely  from  the  beginning,  and  there  is  more  danger 
from  giving  too  little  than  too  much.  A  three-year-old  child  can  take  from  one 
to  ten  ounces  of  whiskey  in  twenty-four  hours,  and  in  bad  septic  cases  this 
amount  may  be  greatly  increased  with  advantage.  Other  valuable  stimulants 
are  carbonate  of  ammonium,  camphor,  musk,  strychnia,  digitalis,  and  the  large 


262    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDBEN. 

number  of  heart  stimulants  and  tonics ;  but  alcohol,  in  one  of  its  many  forms, 
is  by  far  the  best  and  safest. 

The  remedies  which  are  given  internally  in  the  treatment  of  diphtheria 
make  a  long  list,  but  most  of  them  are  of  doubtful  value,  and  many  of  them 
interfere  with  the  digestion  or  do  positive  harm  in  other  ways.  Tincture  of 
the  chloride  of  iron  is  the  most  popular  one.  Locally  it  is  a  powerful  astring- 
ent and  antiseptic,  but  internally  it  seems  to  me  that  the  theoretical  benefit 
which  it  produces  is,  in  many  cases,  more  than  counterbalanced  by  the  diges- 
tive disturbances  which  follow  its  use. 

Chlorate  of  potassium  has  an  excellent  effect  in  healing  lesions  of  the 
mucous  membranes,  but  internally,  especially  in  large  doses,  it  is  positively 
dangerous,  not  only  by  its  irritating  effects  on  the  stomach  and  intestines,  but 
also  by  its  dangerous  action  on  the  kidneys  and  heart. 

The  mercurials,  especially  the  corrosive  and  the  mild  chloride,  are  undoubt- 
edly valuable,  but  most  of  "the  good  resulting  from  their  use  is  obtained  from 
their  local  effect  on  the  pharynx,  and  their  local  effect  in  the  digestive  tract  by 
preventing  fermentation.  The  corrosive  sublimate  should  be  used  in  large  and 
frequent  doses,  and  always  well  diluted. 

Turpentine,  chloride*^  of  ammonium,  iodide  of  potassium,  antimony,  the 
salicylates,  bromine,  benzoate  of  sodium,  balsam  of  copaiba,  cubeb,  quinine, 
pilocarpine,  and  many  other  drugs  are  enthusiastically  advised  by  different 
writers ;  but  in  the  light  of  recent  knowledge  of  this  disease  it  is  difficult  to 
understand  how  any  benefit  could  be  obtained  by  their  internal  adminis- 
tration. 

High  fever  should  be  reduced  by  sponging  and  baths,  and  the  antipyretic 
drugs,  antipyrine,  acetanilid,  phenacetin,  etc.,  should  be  avoided,  because 
they  all  increase  the  depression  of  the  weak  and  degenerated  heart.  The  bath, 
if  used,  should  not  be  cold,  but  begun  at  95°  F.  and  gradually  reduced  to 
80°,  or  even  70°  in  bad  septic  cases.  Stimulants  internally,  hot  applications 
to  the  extremities,  and  a  warm  sponge-bath  are  valuable  in  overcoming  any 
bad  effects  of  an  over-cold  bath.  However,  it  is  seldom  wise  to  reduce  the 
temperature  of  the  bath  below  70°  F.,  and  the  best  antipyretic  effects  are 
obtained  in  this  manner.  The  patient  should  remain  in  the  bath  until  the 
temperature,  taken  in  the  rectum,  begins  to  fall,  Avhen  he  should  be  imme- 
diately removed  and  put  to  bed.  In  laryngeal  cases,  and  in  cases  with  enlarged 
and  tender  lymphatic  glands,  cold  applications,  and  even  the  ice-bag,  often 
seem  to  be  of  benefit  to  the  local  process. 

Exhaustion,  reflex  vomiting,  collapse,  diarrhoea,  haemorrhages,  and  other 
complications  should  be  treated  symptomatically  and  promptly ;  but  their 
appearance  can  often  be  prevented,  and  every  effort  should  be  made  to  attain 
this  end.  For  exhaustion  and  collapse  alcohol  in  large  doses,  both  by  mouth 
and  under  the  skin,  is  the  best  remedy,  but  digitalis,  nitro-glycerin,  strych- 
nine, camphor,  and  musk  are  useful.  In  the  rapid  heart  failure  of  diphtheria, 
with  an  irregular  and  fluttering  pulse,  nothing  is  equal  to  a  moderately  large 
dose  of  morphine,  given  hypodermatically.  It  is  a  powerful  stimulant,  and 
quiets  and  steadies  the  heart.  For  the  reflex  vomiting  there  is  nothing  more 
satisfactory  than  the  oil  of  wormwood,  given  as  follows : 

I^.   Olei  absinthii gtt.  j  to  ij. 

Sodii  bicarbonatis 3j. 

Aquse  menthre  piperit?e ad  fsiv. — M. 

Sig.   One  teaspoonful  for  a  child  three  years  old,  every  half  hour  until 
the  vomitinor  ceases.      Shake  well  before  using. 


DIPHTHERIA.  263 

When  the  vomiting  is  due  to  uraemia  or  to  irritation  of  the  stomach  other 
appropriate  measures  should  be  taken.  For  the  diarrhoea,  when  due  to  local 
irritation  in  the  bowels,  give  an  active  cathartic,  by  preference  calomel  or 
castor  oil,  to  remove  from  the  digestive  tract  the  cause  of  the  irritation,  and 
follow  this  by  an  antiseptic  to  prevent  further  fermentation.  The  following 
answers  very  well : 

~Sf.  Hydrargyri  chloridi  corrosivi gi"-  j* 

Bismuthi  subnitratis 3iv. 

Aquas  anisi f^iv. — M. 

Sig.   One  teaspoonful  in  water  every  two  hours  until  the  discharges  are 
black  and  lose  their  fetor.     Shake  well. 

In  severe  haemorrhages,  especially  from  the  nose,  it  may  be  necessary  to 
apply  local  astringents  or  even  to  plug  the  nares  with  cotton.  However,  this 
should  be  avoided  when  possible,  and  many  cases,  being  caused  by  an  irregular 
and  weak  heart  or  a  passive  congestion  from  a  weak  right  ventricle,  can  be 
stopped  by  the  use  of  alcohol,  digitalis,  or  nitro-glycerin,  according  to  the 
indications. 

Local  Treatment. — It  must  be  acknowledged  that  the  best  and  most  sat- 
isfactory results  in  diphtheria  are  obtained  by  local  treatment.  The  chief 
points  to  be  considered  in  deciding  upon  a  plan  of  treatment  are — 

1.  The  7nost  convenient  method  of  ap2)lying  the  medication — by  spray, 
irrigation,  insufflation,  gargle,  inhalation  in  the  form  of  vapor,  or  by  direct 
application  with  a  swab.  This  will  vary  according  to  the  medication  employed 
and  the  location  of  the  disease.  For  naso-pharyngeal  cases  the  most  satisfac- 
tory and  thorough  method  is  by  irrigation  with  a  fountain  syringe.  Through 
the  nostrils  the  whole  naso-pharyngeal  cavity  can  be  most  thoroughly  cleansed, 
and  with  less  difficulty  than  by  any  other  method.  The  child  should  be  kept 
in  a  horizontal  position  when  possible,  and  a  rubber  sheet  arranged  to  catch 
the  discharge.  At  each  irrigation  it  is  necessary  to  use  enough  of  the  solution 
to  thoroughly  clean  the  naso-pharynx — about  one  pint.  This  should  be  done 
every  two  hours,  and  in  all  cases  often  enough  to  thoroughly  clean  the  diseased 
surface  and  bring  the  germicide  in  direct  contact  with  it.  In  adults  it  is  very 
satisfactory  to  use  the  irrigation  through  the  mouth.  In  children  this  is  often 
impracticable,  but,  when  necessary,  pass  the  nozzle  of  the  syringe  back  be- 
tween the  teeth  and  cheek,  so  that  the  stream  will  enter  the  pharynx  behind 
the  last  molar  tooth.  If  the  child  be  intractable  and  exhaust  himself  to  a  dan- 
gerous degree  by  fighting  against  the  treatment,  it  may  become  necessary  to 
clean  the  surface  by  giving  internally  plenty  of  water,  either  alone  or  with  a 
weak  antiseptic  or  a  mild  alkali,  and  applying  the  germicide  by  inhalation  in 
the  form  of  vapor,  either  by  the  sublimation  of  fifteen  to  forty  grains  of  calo- 
mel every  hour  or  two,  or  by  keeping  the  air  of  the  room  saturated  with  steam 
which  is  impregnated  with  turpentine  or  some  of  the  volatile  antiseptics.  The 
following  is  an  excellent  combination  : 

I^.  Acidi  carbolici fij. 

Olei  eucalypti fsij. 

Spts.  terebinthinse fiviij. — M. 

Sig.  Add  a  tablespoonful  every  half  hour  to  about  a  quart  of  water, 
which  is  kept  simmering  over  a  flame. 

In  laryngeal   or  bronchial  cases,  although  an  application  may  be  made 


264     AMERICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

directly  to  the  larynx  with  a  swab,  the  only  satisfactory  method  is  by  means 
of  the  inhalation  of  a  medicated  vapor. 

The  spray,  while  of  value,  usually  does  not  go  beyond  the  oral  cavity,  and 
seldom  or  never  reaches  the  posterior  pharynx.  Through  the  nose  it  does 
better  service.  The  swab,  except  in  very  careful  and  experienced  hands,  is 
liable  to  be  too  harsh  and  tear  off  membrane,  thus  opening  up  fresh  avenues 
for  infection ;  and  in  the  grave  cases,  the  nasal  ones,  it  is  almost  useless.  The 
use  of  the  2arsrle  is  limited  to  adults  and  older  children,  it  is  not  thorough,  and 
it  tires  the  patient  very  quickly. 

2.  The  medication  to  he  employed.  There  are  two  indications  to  be  met : 
(a)  the  clearing  away  of  debris  and  dead  tissue,  which  may  be  the  cause  of 
much  fetor  and  secondary  septic  complications,  and  which  may  also  prevent 
the  germicide  from  reaching  the  bacilli ;  and  {b)  the  destruction  of  the  living 
bacilli  and  other  bacteria  which  are  producing  the  disease.  A  third  indication 
would  be  to  neutralize  or  to  destroy  any  of  the  unabsorbed  toxalbumin  which 
may  be  present.  With  our  present  knowledge  of  the  properties  of  this  poison 
it  would  be  difficult  to  decide  upon  any  practical  rules,  but  we  may  be  sure 
that  its  mechanical  removal  by  irrigation  is  of  value.  We  know  that  it  is 
taken  up  very  slowly  from  the  infected  tissues,  often  giving  symptoms  of  fresh 
absorption  after  all  the  bacilli  have  disappeared ;  therefore  the  importance  of 
keeping  the  surface  of  the  mucous  membrane  clean  after  all  evidence  of  the 
disease  has  gone. 

(a)  The  most  efficient  drug  for  the  removal  of  broken-down  membrane, 
dead  tissue,  pus.  and  other  debris  is  the  peroxide  of  hydrogen,  although  it  has 
apparently  no  destructive  effect  on  the  living  bacilli.  For  this  purpose  it  is 
certainly  superior  to  any  other  means,  although  there  are  some  preparations 
which  are  of  great  value  as  adjuncts — e.  g.  a  saturated  solution  of  borax  in 
hot  water,  and  the  solvents,  like  pepsin,  trypsin,  and  papayotin.  The  ordinary 
fifteen-volume  solution  of  peroxide  should  be  used,  either  in  full  strength  or 
diluted  with  lime-water,  which  removes  some  of  its  acrid  and  irritating  quali- 
ties without  impairing  its  efficiency.  It  should  be  used  freely,  and  in  most 
cases  a  mixture  of  one  part  of  the  ordinary  fifteen-volume  solution  with  two  or 
three  parts  of  lime-water  is  effective.  The  best  method  to  apply  it  is  by  irriga- 
tion with  a  fountain  syringe,  using  about  half  a  pint  each  time,  and  often  enough 
to  keep  the  diseased  surfaces  clean.  There  are  several  objections  to  its  use.  One 
is  the  difficulty  of  obtaining  a  fresh  and  active  solution.  This  objection  has  been, 
in  a  great  measure,  overcome  by  Squibb  of  Brooklyn,  who  has  made  it  possible 
to  freshly  prepare  this  solution  at  the  time  of  use.  A  serious  objection  to 
Squibb's  method  is  the  long  time  required  to  prepare  the  solution.  How- 
ever, it  is  ahvays  well  to  test  the  activity  of  the  solution  before  depending  upon 
it.  Another  objection,  and  an  important  one,  is  its  irritating  effect  upon  the 
mucous  membrane.  It  causes  pain.  and.  as  a  result,  objections  to  its  use  on 
the  part  of  the  patient ;  it  also  produces  fresh  lesions  in  the  healthy  mucous 
membrane,  thus  offering  new  places  for  infection.  In  my  early  experience 
with  the  drug,  these  objections  and  the  greatly  increased  number  of  cases  in 
which  the  diphtheritic  process  extended  to  the  buccal  mucous  membrane,  the 
gums,  the  tongue,  and  lips,  seemed  to  make  its  use  of  very  doubtful  value,  and 
probably  harmful.  However,  these  faults  can  be  obviated  in  a  great  degree 
bv  dilutins  the  solution  with  an  alkaline  water,  and.  after  its  use,  bv  irrifratino; 
the  same  surface  with  a  saturated  solution  of  borax  in  hot  water.  If  it  is 
desirable  to  use  the  solution  of  peroxide  without  diluting  it,  neutralize  the 
excess  of  acid  with  an  alkali. 


DIPHTHERIA.  265 

(J)  To  destroy  the  bacilli  almost  every  caustic,  astringent,  digestive  fer- 
ment, essential  oil,  and  germicide  has  been  lauded,  and  brilliant  results  claimed 
for  each.  Unfortunately,  most  of  these  reports  are  not  based  upon  enough 
observations  to  be  of  much  value ;  and  it  is  apparently  not  recognized  that 
nearly  every  case  of  tonsillar,  most  cases  of  pharyngeal,  and  many  cases  of 
naso-pharyngeal  diphtheria  recover  under  any  kind  of  treatment. 

Of  all  the  germicides,  the  mercurials  seem  to  have  the  most  destructive 
effect  on  the  Klebs-Loeffler  bacillus,  and  carbolic  acid,  either  alone  or  combined 
with  eucalyptus  and  turpentine,  on  the  streptococci  and  other  bacteria  which 
produce  the  false  diphtheria.  As  it  is  often  so  difficult  to  distinguish  between 
them — and,  in  fact,  both  forms  are  so  frequently  combined — it  is  better  to  use 
locally  both  the  carbolic  acid  and  some  mercurial  preparation.  Therefore, 
always  keep  the  room  moderately  filled  with  steam  that  is  impregnated  with 
the  mixture  of  carbolic  acid,  eucalyptus,  and  turpentine.  In  naso-pharyngeal 
cases,  after  the  thorough  cleansing  of  the  surface  with  the  peroxide  and  the 
borax  solution,  use  in  the  cavity  a  solution  of  bichloride  of  mercury,  1 :  1000, 
either  by  irrigation,  with  a  swab,  or  by  spray.  No  metallic  utensils  should 
come  in  contact  with  the  mercury  solution,  as  it  corrodes  them.  If,  for  any 
reason,  it  is  impossible  to  use  the  irrigation  or  spray,  the  local  effect  of  the  mer- 
cury may  be  obtained  by  subliming  the  mild  chloride  and  allowing  the  child  to 
inhale  the  fumes. 

In  laryngeal  cases  dependence  must  be  placed  upon  inhalation,  as  it  is  im- 
practicable and  dangerous  to  use  the  laryngeal  applicator.  The  inhalation 
most  destructive  to  the  Klebs-Loeffler  bacillus  is  the  fumes  obtained  by  sub- 
liming calomel.  The  child  should  be  well  wrapped  up,  so  that  only  the  face  is 
free,  thus  exposing  the  least  possible  surface  of  the  skin  to  the  action  of  the 
mercury.  It  should  then  be  placed  in  an  ordinary  croup-tent,  and  the  calomel 
sublimed  in  such  a  manner  as  to  fill  it  with  the  fumes.  The  best  apparatus  for 
this  purpose  is  the  ordinary  steam-spray,  in  which  the  boiler  is  replaced  by  a 
strip  of  tin  upon  which  the  calomel  is  put.  Another  good  arrangement  is  to 
put  a  small  alcohol  lamp  in  the  bottom  of  an  ordinary  chamber,  and  cover  it 
with  a  pie-pan  or  strip  of  metal  to  hold  the  powder.  The  same  end  may 
be  attained  with  a  hot  stove-lid,  a  shovel  of  red-hot  coals,  and  in  other  ways. 
According  to  circumstances,  fifteen  to  forty  grains  of  calomel  should  be  burned 
in  this  manner  every  one,  two,  or  three  hours.  It  is  not  necessary  to  wake  the 
child  for  treatment,  and  if  the  smoke  causes  much  coughing  and  irritation,  sub- 
lime it  less  rapidly  by  lowering  the  flame  of  the  lamp.  It  usually  takes  about 
ten  minutes  to  sublime  fifteen  grains,  and  if  care  be  taken  to  obtain  pure  calo- 
mel, or,  better  yet,  calomel  which  has  been  recently  sublimed  and  recondensed, 
the  irritation  from  the  fumes  is  usually  very  slight.  This  treatment  does  good 
not  only  by  its  local  effect  in  the  larynx,  but  by  keeping  the  bronchi  protected, 
and  thus  preventing  the  most  common  and  fatal  complication  of  laryngeal  diph- 
theria— the  extension  of  the  disease  to  the  bronchi.  This  treatment,  which 
was  first  suggested  by  Corbin  of  Brooklyn,  is  not  only  of  great  valueu  after 
operative  interference,  by  preventing  the  extension  of  the  disease  to  the  bron- 
chi, but  its  early  use  will  in  many  cases  obviate  the  necessity  of  an  intubation 
or  a  tracheotomy.  Besides  this,  it  keeps  the  sick-room  disinfected  and  helps 
to  prevent  the  spread  of  the  disease.  The  attendant  should  be  cautioned  to 
inhale  the  vapor  as  little  as  possible,  as  it  is  surprising  how  frequently  the  nurse 
becomes  salivated  and  how  seldom  the  patient  is  at  all  affected.  However,  this 
treatment  seems  to  have  a  depressing  effect  on  some  patients,  although  there  are 
seldom  any  other  evidences  of  mercurialization  ;  but  it  should  be  remembered 
that  in  infants  and  young  children  mercury  is  not  liable  to  produce  salivation 


266     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

as  in  adults.     Its  effects  are  shown  rather  by  marked  anaemia  and  depression, 
with  signs  of  irritation  of  the  intestines  and  the  kidneys. 

The  operative  treatment  of  diphtheria  will  be  considered  elsewhere,  but  the 
followino;  suggestion  may  be  of  value  in  overcoming  one  of  the  most  serious 
complications  that  arises — namely,  loose  membrane  in  the  trachea  or  bronchi. 
Its  removal  by  aspiration,  by  tubes  of  large  calibre,  and  by  numerous  kinds  of 
forceps  has  been  attempted,'  but  with  little  or  no  satisfaction.  The  most  suc- 
cessful method  in  my  own  practice  is  to  insert  a  small  laryngeal  applicator,  the 
cotton  on  which  is  covered  with  a  very  sticky  substance  like  Canada  balsam. 
Upon  its  withdrawal  more  or  less  of  the  membrane  remains  adherent  to  it, 
and  after  several  trials  and  in  many  cases  the  loose  membrane  is  all  brought 
out. 

Antitoxin. — In  discussing  the  value  of  any  treatment  for  diphtheria  it 
is  necessary  to  consider  this  disease  separately  as  it  involves  the  larynx 
and  as  it  involves  the  naso-pharynx.  For  all  therapeutical  purposes  we 
have  practically  two  distinct  diseases,  although  the  cause  may  be  the  same. 
In  the  laryngeal  type  the  danger  is  from  asphyxia,  either  from  laryn- 
geal obstruction  or,  when  this  is  overcome,  from  an  extension  of  the  mem- 
branous inflammation  to  the  smaller  bronchi ;  and  the  danger  from  sep- 
sis is  not  great,  because  of  the  meagre  lymphatic  supply  in  this  region 
and  the  small  area  of  the  surface  from  which  absorption  of  toxins  can 
take  place. 

On  the  other  hand,  in  naso-pharyngeal  diphtheria  the  danger  from 
mechanical  obstruction  is  slight,  and  the  fatal  cases  are,  almost  Avithout 
exception,  the  result  of  the  absorption  of  poisons  through  the  abundant 
lymph-  and  blood-supply.  This  is  especially  true  of  the  nasal  cases,  as  in 
this  region  not  only  is  the  blood-  and  lymph-supply  very  abundant,  but  it 
is  almost  impossible  to  obtain  good  drainage  when  the  nasal  mucous  mem- 
brane and  the  turbinated  bones  are  swollen. 

Again,  in  laryngeal  cases  the  disease  is  rarely  the  result  of  a  mixed  infec- 
tion, but  naso-pharyngeal  diphtheria,  as  we  see  it  in  practice  and  not  in  the 
laboratory,  is  frequently  due  to  a  mixed  infection.  The  importance  of  this 
from  a  therapeutical  point  of  view  is  evident  when  we  consider  the  difference 
between  infection  by  Klebs-Lciffler  bacilli  and  by  streptococci.  The  point  is 
that  in  streptococcus  infection  the  germ  itself  finds  its  way  into  the  blood 
and  viscera,  but  this  is  rarely  true  of  the  bacillus  in  Klebs-Lofller  infection. 
In  one  case  you  have  a  toxin  only  to  fight,  and  in  the  other  you  have  both 
the  germ  and  its  toxin. 

Although  we  admit  that  there  are  many  unsolved  therapeutical  problems 
in  connection  with  the  antitoxin  treatment  of  naso-pltaryngeal  diphtheria, 
there  can  be  no  doubt  of  its  almost  specific  value  in  the  larij7igeal  form  of 
this  disease.  The  laboratory  proof  is  absolutely  convincing  as  far  as  it  goes 
— namelv,  that  the  serum  in  proper  doses  is  a  specific  for  preventing  the 
harm  which  follows  the  absox'ption  of  the  toxin  of  the  Klebs-L5ffler  bacillus. 
The  clinical  results  confirm  this  conclusion. 

I  can  do  nothing  stronger  to  uphold  this  position  than  to  give  a  short 
analysis  of  the  cases  of  laryngeal  diphtheria  which  I  have  seen  during  the 
past  twelve  years.  I  have  arranged  them  from  September  to  September, 
so  that  the  cases  of  each  winter  will  be  kept  together.  With  but  few 
exceptions  they  have  been  seen  in  council  with  other  physicians,  and,  since 
the  antitoxin  days,  the  diagnosis  has  been  confirmed  in  nearly  every  case 
by  a  bacteriological  examination  by  the  New  York  or  Brooklyn  Board  of 
Health. 


Sept. 

,  1886, 

(( 

1887, 

<c 

1888, 

a 

1889, 

ii 

1890, 

a 

1891, 

a 

1892, 

li 

1893, 

(I 

1894, 

11 

1895, 

(C 

1896, 

442  cases ; 

intubation 

295     " 

59     " 

50    " 

no    " 

45     " 

"      " 

18     " 

a        ii 

DIPHTHERIA.  267 

Intubation  Cases. 

No.  Recovered. 

July,  1885,  to  September,  1886,     37 7  =  18.9  per  cent. 

-         ---  "  1887,     65 15  =  23.0 

"  1888,     89 28  =  31.4 

1889,     95 31  =  32.6 

"  1890,     63 19  =  30.1         " 

"  1891,     63 23  =  36.5        "  Began  calomel 

"  1892,  117 40  =  34.1         "  sublimations. 

«  1893,     84 32  =  38.0         " 

1894,     76 29  =  38.1        " 

,,  ,„„.    (  13  with  antitoxin    .    5=38.4         " 

^^^^'144  without     "_      .20  =  45.4 
,,  Toni?   [27  with  antitoxin   .  17  =  62.9         " 

^^9^'i    3  without     "  .    0=       0         " 

.      .,       ,  o„_   f  19  with  antitoxin    .  18  =  94.7         " 
to     April,     189^1    1  without     "        ^_0=_0 

Total 796 284=35.6 

The  following  table  shows  the  results  with  and  without  calomel  sublima- 
tions in  all  cases  of  laryngeal  diphtheria  up  to  September,  1894,  or  the 
beginning  of  the  antitoxin  treatment,  and  the  results  since  the  antitoxin 
was  used : 

no  calomel  sublimations  ;     121  recovered  =   27.3  per  cent, 
with  "  123         "         =   41.6 

"    antitoxin;  40         "         =   67.8 

no  calomel  sublimations;     all  recovered  =  100 
with  "  "  =100 

"     antitoxin;  "  =100 

38  died  before  my  arrival. 
23  refused  operation  and  died. 
21  died  of  sepsis  with  only  slight  obstruction. 
991  cases. 

It  is  interesting  to  note  the  steady  improvement  in  results  as  our  know- 
ledge of  the  technique  of  intubation  increased,  and  as  we  learned  from  experi- 
ence to  overcome,  with  greater  success,  the  dangers  and  accidents  of  intuba- 
tion. The  marked  improvement  after  calomel  sublimations  were  used,  and 
the  still  greater  success  after  antitoxin,  are  noteworthy.  This  benefit  is  seen 
not  only  in  the  larger  number  of  recoveries  after  operation,  but  in  the  in- 
creased percentage  of  cases  Avhich  recovered  without  an  operation.     Thus  of 

492  cases,  no  sublimations,  50  recovered  without  operation  =  10.1  per  cent. 
340      "      with         "  45  "  "  =13.2 

77      "         "     antitoxin,     18  '•  "  =23.3         " 

Of  course  even  this  underestimated  the  good  results,  for  the  percentage  of 
cases  under  calomel  sublimations  or  the  antitoxin  treatment  Avhich  recover 
without  operation  is  very  much  larger.  Since  the  introduction  of  antitoxin 
many  cases  recover  and  are  never  seen  by  the  consultant  which  in  former 
years  would  have  undoubtedly  come  under  his  notice. 

The  apparently  bad  results  after  the  use  of  antitoxin  from  September, 
1894,  to  September,  1895,  were  probably  due  to  two  causes — inferior  anti- 
toxic serums  and  insufficient  doses.  A  careful  consideration  of  the  cases 
during  this  period  fails  to  show  any  marked  difference  in  severity  between 
those  that  received  and  those  that  did  not  receive  antitoxin. 

Treatment  of  Sequels. — The  treatment  of  the  sequels  and  the  albu- 
minuria of  diphtheria  requires  a  few  words.  The  albuminuria  of  this  disease 
seems  to  be  very  little  affected  by  treatment.     The  best  that  can  be  done  is  to 


268    AMEBIC  AN  TEXT-BOOK  OF  DISEASES  OF  CHILDBEN. 

put  the  patient  on  a  proper  diet,  compel  the  skin  and  the  intestinal  tract  to  do 
the  work  of  the  kidneys  as  much  as  possible,  and  to  give  a  diuretic  mixture — 
e.  g.  the  infusion  of  digitalis  Avith  acetate  of  potassium.  In  bad  septic  cases 
the  tincture  of  the  chloride  of  iron  seems  to  be  useful ;  but  marked  diminu- 
tion of  urine,  especially  anuria,  with  a  large  amount  of  albumin,  seems  to  be 
unaffected  by  any  treatment,  and  usually  ends  fatally. 

The  anaemia  should  be  treated  by  improving  the  nutrition  and  general  con- 
dition in  every  possible  way,  and  giving  an  iron  mixture  internally,  a  most 
satisfactory  one  being — 

'Sf.  Tr.  ferri  chloridi f.5iij  to  xij. 

Glycerini fsj- 

AqufB ad  f^iv. — M. 

Sig. — Teaspoonful  three  times  daily,  in  water,  through  a  glass  tube. 

The  chronic  catarrh  left  after  the  disappearance  of  the  pseudo-membrane 
should  receive  prompt  and  efficient  treatment.  In  most  cases  the  local  appli- 
cation, continued  for  some  time,  of  a  weak  solution  of  nitrate  of  silver  will  be 
all  that  is  needed.  But  there  are  cases  which  may  require  operative  interfer- 
ence and  special  treatment;  and  this  treatment  is  discussed  at  another  place 
in  this  work. 

The  natural  tendency  of  the  post-diphtheritic  paralysis  is  to  recovery.  This 
is  aided  by  every  means  which  tends  to  increase  the  nutrition  and  improve  the 
general  condition.  Therefore,  good  hygienic  surroundings,  plenty  of  easily- 
digested  and  nourishing  food,  iron,  quinine,  strychnine,  and  other  tonics,  are 
indicated.  Strychnine,  either  hypodermatically  or  by  mouth,  seems  to  affect 
most  beneficially  the  paralyzed  muscles,  one-sixtieth  to  one-thirtieth  of  a 
grain  being  given  in  twenty-four  hours.  Besides  this,  the  careful  use  of  mas- 
sage and  electricity  does  good  service  in  assisting  the  nutrition  and  circulation 
of  the  affected  muscles  until  the  nerve-lesion  gets  well. 

Synopsis  of  Treatment. — In  brief,  the  treatment  of  diphtheria  may  be 
summarized  as  follows: 

1.  Put  the  patient  in  the  best  hygienic  surroundings,  with  plenty  of  fresh 
air  and  sunlight.  Keep  the  room  at  a  uniform  temperature  of  about  70°  F., 
and  give  him  an  abundance  of  clean  linen  and  bed-clothes.  In  protracted 
cases  transfer  the  patient  to  a  fresh  room  that  has  been  thoroughly  aired  and 
not  exposed  to  the  disease,  as  many  cases  are  undoubtedly  liable  to  rein- 
fection. 

2.  Keep  up  the  strength  and  nutrition  of  the  patient  with  plenty  of  stimu- 
lants and  easily-digested  and  nourishing  food. 

3.  Avoid  all  internal  medication  unless  clearly  indicated.  The  bichloride 
of  mercury  is  useful,  and  in  certain  septic  cases  the  tincture  of  the  chloride  of 
iron.     The  chlorate  of  potassium  is  dangerous. 

4.  Remove  all  broken-down  membrane,  pus,  and  other  debris  by  irrigation 
of  the  diseased  surface  with  a  fifteen-volume  solution  of  peroxide  of  hydrogen, 
diluted  with  lime-water. 

5.  To  destroy  the  bacilli  after  the  surface  has  been  cleaned  apply  a  solution 
of  bichloride  of  mercury,  1 :  1000,  either  by  irrigation  or  spray,  and  keep  the 
room  saturated  with  the  vapor  from  a  mixture  of  carbolic  acid,  turpentine,  and 
eucalyptus.  When  it  is  impracticable  to  use  the  spray  or  irrigation,  either  from 
the  location  of  the  disease  or  the  impossibility  of  managing  the  child,  the  best 
substitute  is  to  make  the  patient  inhale  the  fumes  obtained  by  subliming 
calomel. 


DIPHTHERIA.  269 

6.  The  treatment  of  the  albuminuria  is  very  unsatisfactory ;  in  septic 
cases  the  tincture  of  the  chloride  of  iron,  in  addition  to  the  digitalis  and 
acetate  of  potassium,  gives  the  best  results. 

7.  The  sequelge  should  be  treated  according  to  indications — the  anaemia 
with  iron  and  general  tonics ;  the  chronic  catarrh  by  the  application  of  weak 
solutions  of  nitrate  of  silver ;  and  the  paralysis  by  strychnine,  massage,  elec- 
tricity, and  general  tonics. 

8.  Recent  studies  in  immunity  have  given  us  a  knowledge  of  an  antitoxin 
which  neutralizes  or  destroys  the  toxalbumin  of  the  diphtheric  bacillus.  The 
following  are  the  excellent  rules  for  its  use  recommended  by  the  American 
Pediatric  Society  at  its  meeting  in  1897  : 

Antitoxin  should  be  given  at  the  earliest  possible  moment  in  all  cases  of 
suspected  diphtheria. 

Quality. — Of  the  products  on  the  market  some  have,  by  test,  been  found 
to  contain  one-half  to  one-third  the  antitoxin  units  stated  on  the  label.  Select 
the  most  concentrated  strength  of  an  absolutely  reliable  preparation. 

Dosage. — All  cases  of  laryngeal  diphtheria,  the  patient  being  two  years 
of  age  or  over,  should  receive  as  follows : 

First  dose — 2000  units  at  the  earliest  possible  moment. 

Second  dose — 2000  units  twelve  to  eighteen  hours  after  the  first  dose  if 
there  is  no  improvement  in  symptoms. 

Third  dose — 2000  units  twenty-four  hours  after  the  second  dose  if  there 
is  still  no  improvement  in  symptoms. 

Patients  under  two  years  of  age  should  receive  1000  to  1500  units,  the 
doses  to  be  repeated  as  above. 


TUBERCULOSIS, 

By  WILLIAM  OSLER,  M.  D., 
Baltimore. 


I.  General  Etiology  and  Morbid  Anatomy. 

(a)  Incidence  of  Tuberculosis  in  Infancy  and  Childhood. — Altkough 
it  has  long  been  known  that,  in  the  quaint  language  of  Sir  Thomas  Browne, 
"consumptive  and  tabid  roots  sprout  early,"  the  appreciation  of  the  wide- 
spread prevalence  of  tuberculosis  in  the  early  periods  of  life  is  due  to  recent 
observations.  Extremely  rare  in  the  new-born  and  uncommon  in  the  first  three 
months  of  life,  the  cases  increase  rapidly  throughout  the  latter  half  of  the  first 
year  and  in  the  second  year.  In  the  creche  of  the  Hopital  Tenon  of  Paris,  in 
the  year  1890,  it  is  stated  that  more  than  21  per  cent,  of  the  babies  died  of 
tuberculosis.  Of  2576  autopsies  on  infants  made  at  Kiel,  Boltz  found  424 
cases  of  tuberculosis.  The  following  table  gives  the  proportions  at  different 
ages: 


Infants  born  dead  .    . 

From  0  to    4  weeks  . 
"      5  "  10      "      . 
"      3  "    5  months 
«      6  "  12       " 
"      1  "    2  years   . 


.  0.0  per  100 
.  0.0  " 
.  0.0  " 
.  8.6  " 
.  18.3  " 
.  26.8    " 


From 


2  to    3  years 

.  33.0  per  100 

3  "    4      " 

.  29.6    "      " 

4  "     5      " 

.  31.8    "      " 

5  "  10      " 

.  34.3    "      " 

0  "  15      " 

.  30.1    "      " 

The  statistics  of  the  late  Professor  Parrot  embraced  219  cases  in  children 
under  three  years.     Of  these  there  were — 

From  1  day  to  3  months 23 

"      3  to    6  months 35 

"      6  "  12       "  .    .    .    .    : 53    • 

giving  a  total  of  111  under  one  year  of  age,  and  from  one  to  two  years,  108. 

Of  500  autopsies  in  children  at  the  Munich  Pathological  Institute,  MUller 
found  tuberculosis  in  150.  Of  527  infants  dead  in  hospital  of  various  diseases, 
tubercles  were  present  in  314. 

A  set  of  combined  autopsies  on  2230  children  gave  753  tuberculous  and 
1407  non-tuberculous.     The  ages  of  the  tuberculous  cases  are  thus  grouped : 

From  birth  to  1  month 10 

Up  to  2}  years 138 

From    3  to    5  years 255 

"       6  "  10     "        226 

"     11  "  15     "        124 

270 


TUBERCULOSIS.  271 

Analogous  statistics  are  not,  to  my  knowledge,  available  in  this  country, 
but  the  observations  of  Northrup  at  the  New  York  Foundling  Asylum  show, 
at  any  rate,  that  the  disease  must  prevail  quite  as  extensively.  From  the  third 
to  the  fifteenth  year  tuberculosis  is  also  very  frequent,  and  its  manifestations 
in  the  glands,  skin,  and  bones  contribute  a  very  considerable  percentage  of  all 
cases  in  the  out-patient  departments  of  hospitals  and  in  the  special  infirmaries 
for  children's  diseases. 

The  mortality,  highest  in  the  first  year,  sinks  rapidly  throughout  childhood, 
to  rise  after  puberty.  Thus  of  10,000  living,  there  die(U.  S.  Census,  1870)  of 
tuberculosis  in  the  first  year  18.5;  in  the  second,  10.5;  in  the  third,  5.9;  from 
the  third  to  the  fifth,  2.9;  from  the  fifth  to  the  tenth,  2;  from  the  tenth  to 
the  fifteenth,  3.3.  The  Kiel  mortality  statistics  (Heller)  also  show  this  in  a 
striking  manner:  of  10,000  living,  there  died  in  the  first  year  245;  in  the  sec- 
ond, 114;  in  the  third,  76;  from  the  third  to  the  fifth,  34;  from  the  fifth  to 
the  tenth,  14 ;  from  the  tenth  to  the  fifteenth,  16. 

{h)  The  Bacillus  Tuberculosis. — It  is  acknowledged  by  those  most 
capable  of  expressing  an  opinion  that  the  essential  cause  of  tuberculosis  is  the 
organism  discovered  by  Koch.  The  bacillus  is  a  short,  fine  rod  from  1  to  5  // 
in  length,  and  usually  a  little  curved.  In  the  sputum  and  in  tuberculous 
tissue  the  bacilli  are  often  in  little  clumps,  or  two  lie  crosswise  at  an  acute 
angle. 

For  demonstrating  the  bacilli  in  sputa  the  following  method  will  be  found 
satisfactory :  The  thicker  and  more  purulent  parts  of  the  sputum  are  picked  out 
with  a  small  sharp-pointed  forceps  and  spread  over  the  cover-glass,  which  is 
allowed  to  dry  in  the  air  and  then  passed  three  or  four  times  through  the 
flame.  A  few  drops  of  Ziehl's  solution  of  fuchsin — namely,  distilled  water 
100  crranis,  carbolic-acid  crystal  5  g-rams,  alcohol  10  ^rams,  fuchsin  1  gram — 
are  placed  upon  the  cover-glass,  which  is  held  over  the  flame  until  it  begins  to 
boil.  The  glass  is  then  washed  in  water,  and  a  few  drops  of  Gabbet-Ernst's 
solution — namely,  methylene  blue  1  to  2  grams,  25  per  cent,  sulphuric  acid 
100  grams — are  placed  upon  the  glass  and  allowed  to  remain  there  for  about  a 
minute.  The  glass  is  then  washed  in  water,  and  mounted  either  in  water  or, 
after  drying  between  filter-paper,  in  oil  or  balsam.  The  tubercle  bacilli  are 
stained  red,  while  the  nuclei  of  the  cells  and  any  other  bacteria  are  stained  blue. 

In  sections  the  following  method  is  pursued  at  the  Pathological  Laboratory 
of  the  Johns  Hopkins  Hospital:  The  tissues  should  be  hardened  in  absolute 
alcohol  and  imbedded  in  celloidin.  After  the  sections  have  been  cut,  the  cel- 
loidin  should  be  removed  either  with  oil  of  cloves  or  with  absolute  alcohol  and 
ether.  After  this  they  are  passed  through  strong  alcohol  (to  remove  the  oil  or 
ether),  and  then  placed  in  water  previous  to  staining.  The  most  satisfactory  dye 
is  the  carbol-fuchsin  solution  of  Ziehl.  The  sections  are  left  for  two  hours  at  a 
temperature  of  60°  C.  (or,  if  this  be  inconvenient,  they  may  be  stained  for  six 
or  eight  hours  in  the  thermostat  at  37°  C,  or  for  twenty-four  hours  at  the  room 
temperature).  The  tissue-elements  and  the  bacilli  are  thus  stained  deeply  in 
the  fuchsin.  A  good  decolorization  solution  is  the  ordinary  acid  alcohol  of  the 
laboratory  (acid,  hydrochloric.  1,  aq.  destill.  30,  alcohol  70).  The  decolorizing 
process  must  be  carefully  watched,  as  too  much  of  the  dye  may  be  easily 
extracted,  the  tubercle  bacilli  along  with  the  tissue-elements  losing  their  stain. 
It  is  best  to  remove  the  sections  from  the  acid  alcohol  while  they  still  retain  a 
decided  pink  tint.  A  counter-stain  is  then  used,  the  most  desirable  being  a  2 
per  cent,  aqueous  solution  of  methylene  blue.  This  removes  all  remaining  fuch- 
sin color  from  the  tissue-elements  and  stains  them  a  delicate  blue.     The  tuber- 


TUBEBCULOSIS.  273 

material  into  the  anterior  chamber  of  the  eye  of  the  rabbit,  as  used  by  Cohn- 
heim.  The  development  of  the  tubercles,  at  first  a  local  process,  may  be 
watched  in  the  iris.  There  is  afterward  generalization,  and  the  animal  dies 
emaciated.  In  some  instances  in  the  rabbit  and  guinea-pig  the  lesion  produced 
is  entirely  local  and  the  animal  recovers.  If  a  culture  of  tubercle  bacilli  is 
injected  into  the  veins,  the  animal  dies,  as  a  rule,  in  a  shorter  time,  with  the 
development  of  miliary  granulations,  particularly  in  the  liver  and  in  the  spleen. 
If  a  larger  quantity  be  injected,  the  animal  may  die  of  a  profound  infection 
before  the  tubercles  become  visible  to  the  naked  eye. 

The  transmission  by  inhalation  is  more  diiBcult  in  animals,  and  the  results 
of  causing  animals  to  breathe  air  charged  with  tubercle  bacilli  are  discordant, 
but  in  some  instances  undoubted  pulmonary  infection  and  general  tuberculosis 
have  followed.'  Experimental  infection  through  the  digestive  passages  has 
also  been  demonstrated,  particularly  in  the  feeding  of  animals  with  the  milk 
of  tuberculous  cows. 

(2)  Hereditary  Transmission. — Current  opinion  on  this  point  may  be  ex- 
pressed as  follows  :  While  in  a  few  rare  cases  tuberculosis  is  transmitted  directly 
from  parent  to  offspring,  in  the  great  majority  of  all  cases  the  heredity  does  not 
relate  to  the  transmission  of  the  seed  itself,  but  of  a  disposition  of  body,  a 
type  of  tissue-soil  favorable  to  the  development  of  the  disease  in  case  of  acci- 
dental infection. 

Congenital  tuberculosis  has  been  observed  in  some  six  or  eight  cases.  In 
the  case  of  Chai-rin  there  was  generalized  tuberculosis  in  a  foetus  seven  and  a 
half  months  old,  the  mother  of  which  died  of  phthisis.  In  Berti's  case  the 
child,  born  at  term  of  a  phthisical  mother,  died  on  the  ninth  day,  and  two  small 
cavities  were  found  at  the  posterior  border  of  the  lower  lobe  of  the  right  lung, 
which  were  shown  microscopically  to  be  tuberculous.  In  Merkel's  case  the 
tuberculous  mother  died  two  days  after  confinement.  The  child  had  tuber- 
culosis of  the  palate  and  an  abscess  of  the  left  trochanter  major.  In  Jacob i's 
case  the  foetus,  born  at  the  seventh  month,  had  miliary  granulations  in  the 
liver,  peritoneum,  spleen,  and  right  pleura.  In  the  case  described  by  Sabour- 
aud  the  child  born  of  a  tuberculous  mother  died  on  the  eleventh  day.  The 
liver  and  spleen  were  tuberculous. 

In  all  of  the  cases  reported  it  was  direct  maternal  heredity.  The  mode  of 
transmission  is  not  at  all  certain,  but  it  is  probably  transmission  through  the 
placenta.  Tuberculosis  of  the  placenta  is  very  rare.  Lehman  has  recently 
reported  an  instance  in  a  woman  aged  twenty-nine  dead  of  acute  tuberculosis  in 
the  eighth  or  ninth  month  of  pregnancy.  The  foetus  was  not  affected,  but  on 
both  surfaces  of  the  placenta  there  were  a  fcAV  grayish  nodules,  Avhich  showed 
the  characteristic  structure  of  tubercle,  with  bacilli.  It  has  been  shown  also 
that  the  placenta  of  a  tuberculous  woman  proved  infective  ;  and,  indeed,  it  is 
stated  that  the  amniotic  fluid  of  a  tuberculous  subject  may  produce  the  disease 
in  a  guinea-pig. 

There  are  several  experiments  (Landouzy  and  Martin,  Birch-Hirschfeld,  and 
Armanni),  which  indicate  that  the  virus  may  be  present  in  the  foetus  without 
the  presence  of  actual  tubercles,  since  they  found  that  portions  of  the  viscera 
of  foetuses  born  of  tuberculous  mothers  Avere  infective  to  guinea-pigs. 

A  modified  view  of  this  direct  heredity  is  advocated  by  Baumgarten,  who 
holds  that  the  virus  is  directly  transmitted,  but  remains  latent,  and  does  not 
develop  until  some  time  after  birth.  In  support  of  this  he  quotes  the  large 
number  of  cases  of  tuberculosis  in  the  early  months,  the  figures  illustrating 
which  have  already  been  given.  He  also  lays  great  stress  upon  the  occurrence 
of  tuberculosis  in  the  bones  and  the  joints  of  children,  regions  to  which  the 

18 


274    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

bacilli  would  not  be  likely  to  be  conveyed  in  accidental  infection.  This  post- 
natal development  he  regards  as  analogous  to  syphilis  hereditaria  tarda,  and  he 
suggests  that  the  actively  growing  tissues  of  the  child  restrain  or  inhibit  the 
development  of  the  germs. 

There  is  no  evidence  to  show  that  a  tuberculous  father  can  directly  trans- 
mit the  disease.  The  experimental  evidence  is  also  negative.  Gartner  (whose 
recent  article  on  "Heredity  in  Tuberculosis"  is  the  most  important  contribu- 
tion made  to  the  subject  of  late  years)  found  that  in  rabbits  and  guinea-pigs, 
with  artificially  induced  tuberculosis  of  the  testes,  and  whose  semen  contained 
bacilli,  the  embryos  were  never  infected.  On  the  other  hand,  of  65  female 
guinea-pigs  which  had  consorted  with  the  tuberculous  bucks,  5  presented  genital 
tuberculosis,  and  of  59  female  rabbits  under  similar  conditions  11  became 
infected. 

In  support  of  the  view  that  tuberculosis  is  hereditary  great  stress  is  laid 
naturally  on  the  frequency  with  which  a  history  of  the  disease  is  met  with  in 
the  parents.  The  estimates  of  various  authors  on  this  point  vary  from  10  to 
50  per  cent.  Of  427  cases  at  the  Johns  Hopkins  Hospital,  there  were  only  53 
in  which  the  mother  was  aifected,  52  in  which  the  father  had  had  tuberculosis, 
and  105  in  which  sister  or  brother  had  had  the  disease.  The  fact  that  the 
children  and  relatives  of  tuberculous  individuals  are  more  directly  exposed  to 
contagion  than  other  individuals  renders  it  difficult,  as  Fagge  remarks,  to  draw 
a  clear  line  between  heredity  and  accidental  infection. 

(3)  Inoculation. — This  is  not  very  common  in  man,  as  the  skin  does  not  offer 
a  very  suitable  soil  for  the  development  of  the  tubercle  bacilli.  This  mode  of 
infection  is,  however,  seen  in  persons  whose  occupations  bring  them  in  contact 
with  dead  bodies  and  animal  products.  Demonstrators  of  anatomy  are  particu- 
larly subject  to  a  local  tubercle  on  the  finger  or  back  of  the  hand — the  so- 
called  post-mortem  wart,  verruca  necrogenica,  the  "lichen"  tubercle  of  the 
Germans.  Only  in  very  exceptional  instances  is  this  followed  by  serious  results. 
Cases  have  been  reported  of  infection  from  the  bite  of  a  tuberculous  patient, 
inoculation  from  a  cut  by  a  broken  spit-cup  and  the  puncture  of  a  hypoder- 
mic needle.  There  is  no  reliable  observation  of  the  transmission  of  tubercu- 
losis by  vaccination.  In  the  performance  of  the  rite  of  circumcision  children 
have  been  inoculated,  the  infection  in  these  cases  being  associated  with  disease 
in  the  operator,  and  occurs  in  connection  with  the  habit  of  cleansing  the  wound 
by  suction. 

(4)  Transmission  hy  Inhalation. — The  expired  air  of  tuberculous  patients 
is  harmless,  but  the  sputa,  dried  and  widely  diffused  in  the  form  of  dust,  con- 
stitute one  important  medium  of  transmission  in  the  disease.  The  investi- 
gations of  Cornet  have  shown  the  greater  infectiveness  of  the  dust  of  localities 
frequented  by  patients  with  pulmonary  tuberculosis.  The  frequency  with  which 
the  disease  is  met  with  in  the  lungs  and  in  the  bronchial  glands  finds  here  its 
explanation. 

In  institutions  the  residents  of  which  are  restricted  in  the  matter  of  fresh 
air  and  exercise,  as  in  jails  and  convents,  the  death-rate  from  tuberculosis  is 
very  much  higher  than  in  the  general  population.  Cornet  found  that  in  some 
of  the  religious  communities  more  than  three-fourths  of  the  deaths  were  due  to 
this  disease.  The  mortality  in  prisons  from  tuberculosis  is  from  40  to  50  per 
cent.,  while  in  the  general  community  it  is  not  more  than  15  per  cent.  Flick 
has  brought  forward  evidence  to  show  that  the  distribution  of  tuberculosis  in 
one  of  the  wards  of  the  city  of  Philadelphia  is  more  particularly  with  certain 
houses  in  which  individuals  have  died  of  this  disease.  There  are  also  some 
striking  local  epidemics  of  tuberculosis:  thus  Marfan  gives  an  instance  of  a 


TUBERCULOSIS.  '        275 

place  confined  and  badly  ventilated,  occupied  by  twenty-two  employees,  who 
were  joined  in  1878  by  two  consumptives,  who  for  several  years  coughed  and 
spat  about  the  floor  indiscriminately.  The  employees  arrived  at  an  early  hour 
and  breathed  the  air  charged  with  the  dust  raised  by  the  morning  cleanino-. 
Between  1884  and  1889  thirteen  of  these  persons  fell  victims  to  tuberculosis. 

Against  these  facts,  however,  are  the  statements  that  at  hospitals  for  con- 
sumptives, as  at  Brompton,  in  London,  the  doctors  and  nurses  are  rarely 
attacked.  Dettweiler  claims  that  at  his  institution  in  Falkenstein  no  case  of 
tuberculosis  has  been  contracted.  On  the  other  hand,  Marfan  states  that  in 
the  Paris  hospitals  tuberculosis  is  extremely  frequent  in  the  attendants  and 
decimates  the  lay  contingent.  At  the  Hospital  Necker  half  of  the  attendants 
are  attacked  with  phthisis,  and  he  notes  as  a  significant  fact  that  it  is  particu- 
larly the  attendants  in  the  medical  wards. 

The  danger  is  enhanced  when  the  contact  is  particularly  intimate,  as  between 
a  tuberculous  mother  and  her  child  or  between  man  and  wife.  In  the  latter 
case  there  are  figures  which  indicate  that  contagion  is  not  at  all  infrequent. 

(5)  Transmission  hy  the  Food. — Experiments  have  shown  that  infection 
may  be  communicated  by  ingestion  of  tuberculous  material,  and  one  of  the 
most  important  problems  relates  to  infection  with  the  milk  of  tuberculous  cows. 
Experimentally,  it  has  been  conclusively  demonstrated  that  such  milk  is  infec- 
tive, even  when  the  disease  is  localized  in  the  lungs  of  the  animal,  and  that 
it  is  not  necessary  that  the  udder  should  be  diseased.  Ernst  has  shown  that 
the  bacilli  may  be  present  in  the  milk  when  there  is  no  tuberculous  mammitis. 
The  danger  of  infection  from  this  source  in  children  is  very  urgent,  and  system- 
atic sanitary  inspection  should  be  made  of  the  cows,  and,  if  necessary,  inocu- 
lation experiments  made  with  the  milk. 

The  percentage  of  tuberculous  animals  in  the  dairy-stables  of  our  cities 
is  very  much  larger  than  has  been  supposed.  The  figures  in  this  country 
for  large  numbers  are  not  available.  It  has  been  stated  that  from  10  to  15 
per  cent,  of  the  dairy  stock  in  the  Eastern  States  is  tuberculous.  This  is 
probably  a  low  estimate. 

The  virulence  is  retained  in  the  cream  and  in  the  butter.  Other  conditions 
than  the  presence  of  the  bacilli  in  the  milk  are  probably  necessary  for  infection, 
and,  fortunately,  all  children  who  drink  tuberculous  milk  do  not  become  con- 
taminated. In  some  instances  the  gastric  juice  may  destroy  the  bacilli;  in 
others,  conditions  of  the  tissues  may  not  be  favorable  to  the  development 
of  the  seed.  Experimentally  it  has  been  shown  that  lesion  of  the  intes- 
tines itself  is  not  necessary,  and  infection  of  the  mesenteric  glands  may  take 
place  through  a  normal  mucosa.  Possibly  the  great  frec[uency  of  mesenteric 
tuberculosis  in  children  finds  here  its  explanation.  In  127  cases  of  fatal  tuber- 
culosis in  children  noted  by  Woodhead  these  glands  were  involved  in  100.  It 
is  not  definitely  determined  whether  the  milk  of  a  tuberculous  woman  is  viru- 
lent. 

Infection  by  meat  is  probably  very  much  more  rare.  When  the  tuberculosis 
is  generalized  in  the  internal  organs  the  flesh  should  be  confiscated.  The  viru- 
lence, however,  is  only  marked  when  the  disease  is  very  extensive.  It  has 
been  shown  that  the  flesh  of  tuberculous  subjects  is  infective  to  guinea-pigs. 
Nocard,  however,  in  a  series  of  experiments  found  that  the  juices  of  the  muscle 
of  twenty-one  cases  with  general  tuberculosis,  when  injected  into  the  perito- 
neum of  guinea-pigs,  only  once  produced  tuberculosis. 

(cZ)  CoxDiTiONS  INFLUENCING  INFECTION. — (1)  Greneral. — These,  dealing 
specially  with  the  environment  of  individuals,  explain  in  a  great  measure  the 


276    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

frequency  of  the  disease  in  certain  localities.  Thus  one  of  the  most  important 
is  residence  in  the  large  centres  in  which  many  people  are  crowded  together. 
The  death-rate  from  tuberculosis  is  very  much  higher  in  towns  than  in  the 
country,  and  a  very  considerable  share  of  the  high  infant  mortality  of  cities  is  to 
be  attributed  to  it.  Not  only  is  the  air  of  the  large  towns  less  pure,  but  the 
chances  are  very  much  greater  that  the  dust,  blown  in  all  directions,  has  with 
it  the  germs  of  the  disease.  The  inhalation  of  impure  air  in  certain  occu- 
pations, which  in  adults  is  an  important  predisposing  factor  in  pulmonary  tuber- 
culosis, does  not  prevail  to  any  special  extent  in  children.  Climate  in  itself 
does  not  influence  the  conditions  materially,  but,  as  a  rule,  the  disease  is  more 
common  in  the  temperate  regions,  largely  because  in  these  are  found  the  largest 
collection  of  human  beings.  Soil  and  locality  have  an  important  influence, 
cold  and  dampness  increasing  the  personal  liability  by  favoring  the  develop- 
ment of  catarrhal  aff"ections.  There  are  fewer  cases  of  tuberculosis  and  fewer 
foci  of  infection  in  regions  such  as  the  Alps  and  in  elevated  plateaux  as  in 
Mexico,  but  altitude  itself  does  not  confer  immunity,  and  there  are  many 
mountainous  regions  in  which  the  inhabitants  are  much  affected  by  tuberculosis. 

More  important  than  these  are  the  factors  relating  to  personal  environment, 
as  of  the  dwellings.  The  constant  breathing  of  a  vitiated  air,  as  in  the  small 
crowded  rooms  in  the  tenements  and  narrow  alleys  of  our  large  cities,  and  the 
absence  of  sunlight,  are  two  of  the  most  important  predisposing  elements  in 
tuberculosis  in  children.  These  influence  infection  in  two  ways :  first,  by 
favoring  the  distribution  of  the  bacilli  ;  and,  second,  by  lowering  the  nutrition 
of  the  individual  and  leading  to  conditions  favoring  the  entrance  of  the  bacilli 
to,  or  their  development  in,  the  body. 

(2)  Individual  Predisposition. — From  the  time  of  Hippocrates  it  has  been 
thought  that  there  was  a  certain  conformation  of  body  which  rendered  an  indi- 
vidual more  prone  to  the  disease.  His  words  are  :  "  The  form  of  body  peculiar 
to  subjects  of  phthisical  complaints  was  the  smooth,  the  whitish,  that  resem- 
bling the  lentil ;  the  reddish,  the  blue-eyed,  the  leuco-phlegmatic  ;  and  that  with 
the  scapulffi  having  the  appearance  of  wings."  In  children  it  may  be  said  that 
the  build  and  type  such  as  here  described  is  certainly  more  prone  to  tuber- 
culous aff'ections.  Two  types  of  conformation  have  long  been  recognized  as 
predisposing  in  some  way  to  infection ;  the  tuberculous^  with  bright  eyes,  oval 
face,  thin  skin,  and  long  thin  bones,  and  the  scrofulous,  with  a  heavy  figure, 
thick  lips  and  hands,  opaque  skin,  and  large  thick  bones.  But,  as  in  adults, 
well-developed,  healthy  infants  and  children  may  become  subject  to  the  disease. 
In  addition  to  the  conformation  of  the  chest,  the  respiratory  capacity,  the  rela- 
tion between  the  volume  of  the  lung  and  of  the  heart,  a  relatively  small  heart 
with  narrow  arteries,  and  a  pulmonary  artery  relatively  wider  than  the  aorta 
(Beneke),  and  relatively  large-sized  viscera,  have  all  been  brought  forward  as 
causes  predisposing  to  tuberculosis. 

Among  others  which  may  be  mentioned  is  race :  the  negro  seems  more 
liable  to  the  disease  than  the  white  races,  and  it  is  stated  that  the  Hebrews 
possess  a  relative  immunity. 

More  important  in  children  are  the  local  conditions  influencing  infection. 
Acute  and  chronic  catarrhal  troubles  of  the  throat  and  upper  air-passages,  and 
of  the  lunor,  undoubtedlv  favor  infection,  either  by  allowincr  the  freer  entrance 
of  the  germs  or  by  weakening  the  powers  of  resistance.  The  infectious  diseases, 
particularly  whooping-cough,  measles,  and  influenza,  act  probably  in  this  way, 
while  small-pox,  typhoid  fever,  and  syphilis  influence  the  conditions  rather  by 
reducing  the  power  of  resistance.  In  institutions  the  frequency  with  which 
tuberculosis  follows  the  infectious  disorders  is  very  striking. 


TUBERCULOSIS.  277 

Of  local  affections  of  the  lungs  which  predispose  to  tuberculosis,  hgemoptysis, 
which  was  regarded  as  an  important  cause,  is  now  thought  to  be  an  indication 
rather  of  the  existence  of  the  disease.  Such  disorders  as  dilatation  of  the 
bronchi  and  pleurisy  also  heighten  the  liability  to  infection,  though  in  the 
latter  case  many  of  the  instances  believed  to  be  simple  are  in  reality  from  the 
outset  tuberculous. 

The  subjects  of  congenital  or  acquired  contraction  of  the  orifice  of  the 
pulmonary  artery  usually,  as  is  well  known,  die  of  tuberculosis.  Prior  to  the 
development  of  the  disease  many  subjects  show  a  marked  angemia,  and  unques- 
tionably chlorosis  offers  favoring  conditions  for  the  development  of  this  affection. 
Diseases  of  the  sttimach  and  intestines,  particularly  chronic  entero-colitis,  in- 
crease the  susceptibility  to  infection. 

Blows  and  contusions  favor  in  some  way  the  development  of  tuberculosis, 
particularly  in  children,  in  whom  spinal  caries  and  hip  disease  may  follow 
an  injury ;  less  often  does  trauma  play  any  part  in  pulmonary  tuberculosis. 
Here,  too,  may  be  mentioned  the  favoring  influence  of  operation :  resection  of 
a  tuberculous  joint  is  occasionally  followed  by  an  acute  infection. 

"With  reference  to  infection  and  the  conditions  which  influence  it  the  follow- 
ing may  be  stated : 

(a)  In  a  few  cases  the  disease  is  directly  transmitted  from  the  mother,  and 
appears  in  the  child  at  birth. 

(5)  The  primary  tuberculosis  of  the  bones,  joints,  kidney,  spleen,  liver,  etc. 
of  early  youth  is  very  possibly  associated  with  a  foetal  hsematogenous  infection 
(Baumgarten,  Gartner). 

(c)  Direct  paternal  transmission  has  not  been  proved,  and  experimental  evi- 
dence is  stronglv  against  it. 

{d)  In  a  large  proportion  of  cases  the  infection  is  post-foetal — through  the 
lungs,  intestines,  or  skin. 

(e)  Heredity  influences  the  soil.  All  are  tubercuUzahle,  to  use  a  French 
expression,  and  very  many  of  us  actually  become  infected.  Whether  or  not  the 
seed  develops  depends,  firstly,  upon  the  character  of  the  tissue-soil ;  and 
secondly,  upon  the  existence  of  special  favoring  circumstances. 

(/)  Immunity,  a  relative  condition,  enjoyed  chiefly  in  consequence  of 
inherited  tissue-resistance,  is  lessened  by  all  circumstances  which  depress  nutri- 
tion, such  as  bad  air.  bad  food,  and  imperfect  hygienic  surroundings.  Kext  to 
the  germ,  a  vulnerability  of  tissue,  however  brought  about,  whether  congenital 
or  acquired,  is  the  most  important  factor  in  the  etiology  of  the  disease. 

(3)  The  Relations  of  Tuberculosis  and  Scrofula. — The  lesions  known  as  scrof- 
ulous are  tuberculous,  and  due  to  the  development  of  the  bacillus  tuberculosis, 
so  that  the  term  scrofula  is  now  almost,  and  may  well  be  entirely,  abandoned. 
Though  the  so-called  scrofulous  lesions  of  glands  and  bones  and  skin  are  bacillary 
in  orig-in,  vet  it  has  been  shown  that  their  virulence  is  not  so  extreme  as  that 
of  the  tuberculous  products  in  the  viscera,  the  latter,  according  to  Arloing, 
killing,  when  injected,  both  guinea-pigs  and  rabbits,  the  former  only  guinea- 
pigs.  This  corresponds  with  the  more  protracted  course  and  the  more  favorable 
termination  of  the  so-called  scrofulous  affections.  It  has  been  suggested  that 
the  scrofulo-tuberculous  manifestations  are  caused  by  an  attenuated  virus.  An 
attempt  has  been  made  by  writers,  particularly  Marfan,  to  show  that  the  scrofulo- 
tuberculous  lesions,  when  recovered  from,  confer  a  sort  of  immunity  to  pulmo- 
nary tuberculosis,  but  the  evidence  for  this  is  not  yet  very  strong. 

(e)  ANATOMICAL  Changes  produced  by  the  Tubercle  Bacilli. — The 
lesions  induced  by  the  bacilli  are  in  the  form  of  small  nodules  which,  fused 


278    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

together,  may  form  large  infiltrated  areas,  so  that  a  distinction  is  often  made 
between  the  nodular  and  the  diffusely  infiltrated  varieties.  The  studies  of 
Baumgarten  and  others  have  enabled  us  to  follow  accurately  the  primary 
changes  induced  by  the  bacillus.     These  are — 

(1)  The  mutiplication  of  the  fixed  tissue-elements  by  a  process  of  karyokine- 
sis.  The  cells  of  the  vascular  epithelium,  of  the  ordinary  epithelium,  and  of 
the  connective  tissue  proliferate,  and  gradually  there  is  produced  from  them  the 
large,  rounded,  cuboidal,  or  polygonal  cells  with  vesicular  nuclei — the  so-called 
epithelioid  cells — inside  some  of  which  the  bacilli  are  seen.  This  reaction  of 
the  fixed  elements  of  the  tissue  would  appear  to  be  the  primary  effect. 

(2)  Leucocytes,  chiefly  polynuclear,  migrate,  and  accumulate  about  the 
focus  of  infection.  These  form  the  lymphoid  cells  which  were  formerly  thought 
to  be  so  characteristic  of  the  tubercle.  They  do  not,  however,  undergo  sub- 
division. Some  believe  that  they  attack  and  destroy  the  bacilli.  There  would 
appear  to  be  successive  invasions  of  leucocytes  at  the  focus  of  irritation,  and 
many  of  them  undergo  rapid  destruction.  It  is  stated,  too,  that  later,  as  the 
little  tubercle  grows,  the  leucocytes  which  surround  it  are  of  the  mononuclear 
form,  or  lymphocytes,  and  that  these  persist  and  do  not  undergo  the  rapid 
degeneration  of  the  polynuclear  forms. 

(3)  A  reticulum  of  fibres  is  formed  in  the  tubercle  by  the  fibrillation  and 
rarefaction  of  the  connective-tissue  matrix,  most  apparent,  as  a  rule,  at  the 
margins  of  the  growth. 

(4)  In  some,  but  not  in  all,  tubercles  giant-cells  are  formed  by  an  increase 
in  the  protoplasm  and  in  the  nuclei  of  an  individual  cell,  or  possibly  by  the 
fusion  of  several  cells.  The  bacilli  are  usually,  but  not  always,  seen  in  the 
giant-cells.  There  seems  indeed  to  be  an  antagonism  between  the  number  and 
virulence  of  the  bacilli  and  the  giant-cells:  thus  in  joint  and  gland  tuberculosis 
and  in  lupus,  in  which  the  former  are  scanty,  the  latter  are  abundant;  while  in 
miliary  tubercles,  and,  as  a  rule,  in  all  lesions  in  which  the  bacilli  are  abundant, 
the  giant-cells  are  scanty. 

The  tuberculous  nodule  thus  formed  may  undergo  necrosis  and  caseation, 
or  may  gradually  be  converted  into  a  connective-tissue  mass.  Caseation  begins 
at  the  central  part  of  the  growth,  and  appears  to  be  owing  to  the  direct  action 
of  the  bacilli.  The  cells  undergo  coagulation  necrosis,  lose  their  outline,  be- 
come irregular,  and  are  finally  converted  into  a  homogeneous,  structureless 
material  in  which  the  cells  are  no  longer  distinguishable,  and  which  no  longer 
takes  the  stain.  As  this  process  extends  involving  several  nodular  tubercles, 
they  are  gradually  converted  into  uniforni  yellowish-gray  masses.  No  blood- 
vessels are  found  in  the  central  portion,  but  the  bacilli  are  usually  abundant. 
By  the  union  of  many  of  the  nodular  tubercles  large  masses  may  be  formed 
which  may  undergo  either  (1)  softening  or  liquefaction  with  the  formation  of 
cavities;  (2)  fibroid  limitation,  leading  ultimately  to  encapsulation;  (3)  in  the 
older  caseous  masses,  particularly  when  encapsulated,  lime  salts  may  be  deposited 
(calcification) ;  and  (4)  sclerosis.  There  is  necrosis  of  the  tissue-elements  in  the 
centre,  gradual  hyaline  transformation,  with  great  increase  in  the  fibrous  reti- 
culum, so  that  the  tubercle  is  ultimately  converted  into  a  firm,  hard  structure. 
Sometimes  increase  in  the  fibrillation  and  caseation  go  on  together,  with  the 
production  of  fibro-caseous  tubercle. 

Diffuse  Infiltrated  Tubercle. — It  was  formerly  thought  that  the  products  of 
any  simple  inflammation  might  become  caseous,  and  the  identity  of  the  caseous 
pneumonia  and  of  scrofulous  lesions  with  tubercle,  which  Morton  (1685)  main- 
tained, and  which  Laennec  laid  down  as  a  fundamental  proposition,  was  for  a 
long  time  disputed,  particularly  by  Virchow.     Now,  the  researches  of  Koch 


TUBEBGULOSIS.  279 

have  demonstrated  that  these  infiltrated  caseous  lesions  are  definitely  tuber- 
culous. 

Infiltrated  tubercle  results  from  the  fusion  of  many  small  nodular  foci,  too 
small  sometimes  to  be  visible  to  the  naked  eye.  Histologically,  however — in 
the  lungs,  for  instance — they  may  be  seen  to  be  composed  of  scattered  centres 
surrounded  by  zones  in  which  the  air-cells  are  filled  with  leucocytes  and  the 
products  of  the  proliferation  of  the  alveolar  epithelium.  Under  the  influence 
of  the  bacilli  caseation  takes  place,  usually  in  small  groups  of  lobules,  but 
occasionally  in  an  entire  lobe,  or  it  may  be  throughout  the  greater  part  of  a 
lung.  There  is  really  no  essential  difference  between  the  nodular  and  the  infil- 
trated tubercle. 

Secondary  inflammatory  processes  accompany  the  growth  and  development 
of  tubercle:  (1)  The  exudation  of  leucocytes  and  serum  about  the  primary 
growth  is  in  reality  an  inflammation,  which  varies  with  varying  conditions,  and 
which  may  be  limited  or  very  extensive.  For  example,  about  the  tubercles  in 
the  lungs  there  is  always  inflammation  of  the  alveoli  with  infiltration  and  pro- 
liferation of  the  connective-tissue  elements  of  the  septa,  and  changes  in  the 
blood-  and  lymph-vessels. 

(2)  The  bacilli  themselves  may  induce  suppuration,  as  in  joint  and  bone 
tuberculosis ;  experimentally,  the  products  of  the  growth  of  the  tubercle  bacilli, 
particularly  Koch's  tuberculin,  produce  an  active  suppuration.  In  tubercu- 
losis of  the  lungs,  as  well  as  in  other  regions,  the  suppuration  is  largely  the 
result  of  a  mixed  infection,  and  is  due  to  pus-organisms. 

(3)  A  slow,  reactive  inflammation  occurs  about  many  tubercles,  resulting 
in  the  formation  of  a  cicatricial  connective  tissue,  limiting  and  restricting  their 
growth,  and  constituting,  in  reality,  the  important  conservative  and  healing  ele- 
ment in  the  disease. 

n.  Generalized  Forms  of  Tuberculosis. 

(1)  Acute  Miliary  Tuberculosis. 

Forms  of  tuberculous  infection  running  a  rapid  course  are  decidedly  more 
common  in  infants  and  children  than  in  adults.  Practically,  there  is  always  a 
focus  of  local  disease  in  a  bronchial  or  mesenteric  gland,  a  joint,  or  on  the  skin, 
or  in  superficial  lymph-glands.  In  a  few  rare  instances  a  miliary  tuberculosis  is 
encountered  in  which  caseous  foci  cannot  be  discovered.  The  picture  may  be 
either  that  of  an  acute  infection  without  definite  local  manifestations,  or  of  an 
intense  infection  with  pronounced  symptoms  pointing  to  involvement  of  the 
meninges  of  the  brain,  the  lungs,  or  the  serous  membranes.  In  children  there 
is  no  hard-and-fast  line  to  be  drawn  between  the  acute  forms  in  which  miliary 
granulations  occur  throughout  all  the  organs,  and  in  which  the  clinical  course 
is  from  three  to  six  or  eight  weeks,  and  forms  in  which  throughout  the  various 
organs  there  are  coarser,  larger  grayish-yellow  tubercles,  and  in  which  the 
clinical  course  is  of  more  subacute  character,  lasting  from  eight  to  twelve  or 
even  sixteen  weeks.  As  in  the  adult,  the  cases  maybe  divided  for  convenience" 
into  three  groups,  as  the  symptoms  are  those  of  a  general  infection,  simulating 
very  often  typhoid  fever,  or  those  of  an  acute  meningitis  or  of  an  acute  aff"ec- 
tion  of  the  lungs.  These  cerebral,  general,  and  pulmonary  types  cover  a  major- 
ity of  the  cases.  There  may  be  mentioned,  in  addition,  an  acute  affection, 
occurring  in  children  the  subjects  of  a  local  tuberculous  process,  in  which,  with 
the  symptoms  of  a  profound  infection,  there  is  no  general  miliary  tuberculosis. 
This  form,  which  has  been  described  by  several  French  writers  as  the  fievre 


280    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

infectieuse  tuberculeuse  suraigue,  is  not  generally  recognized,  but  the  cases 
described  by  Landouzy  and  others  presented  quite  minor  tuberculous  lesions 
of  the  lungs  or  of  other  organs,  with  the  clinical  symptoms  of  very  intense 
infection,  the  severity  of  which  Avas  out  of  all  proportion  to  the  local  lesion  and 
to  the  number  of  miliary  granulations  found  throughout  the  body.  It  is  thought 
to  be  due  to  the  action  of  the  tuberculous  toxines. 

The  acute  tuberculous  meningitis  will  be  described  separately.  We  shall 
here  speak  only  of  the  typhoid  and  of  the  pulmonary  types. 

Typhoid  Type. — The  onset  is  usually  insidious,  and  commonly  there  has 
been  an  indisposition  or  slight  cough,  but  prior  to  the  fever  the  child  may 
have  been  in  good  health.  The  fever  is  noticed  in  the  afternoon  or  evening, 
and  Avith  it  there  is  loss  of  appetite,  and  the  child  loses  in  weight  and  is  list- 
less and  not  inclined  to  play.  A  bronchial  cough  is  by  no  means  uncommon, 
but  it  is  to  be  remembered  that  the  disease  may  set  in  quite  abruptly  in  a  child 
believed  to  be  in  good  health.  AVithin  a  week,  or  even  earlier,  the  child  takes 
to  bed,  and  the  symptoms  of  an  infection  are  well  pronounced.  The  tongue  is 
white  and  furred.  The  abdomen  is  distended,  sometimes  painful  on  pressure, 
and  there  may  be  diarrhoea.  The  spleen  is  usually  enlarged,  and  can  be  readily 
felt.  The  liver  may  be  also  distinctly  swollen.  The  gastro-intestinal  trouble 
with  the  continued  fever  may  be  strongly  suggestive  of  typhoid  fever,  but  rose- 
spots  are  not  detected.  There  are  usually  some  sj^mptoms  pointing  to  the 
involvement  of  the  bronchi  or  the  lungs,  and  the  respirations  are  hurried,  only, 
however,  in  proportion  to  the  fever,  and  the  physical  signs  indicate  rather  a 
catarrh  of  the  larger  than  of  the  smaller  tubes ;  thei'e  is  no  dulness.  There 
are  headache,  delirium,  particularly  at  night,  and  sometimes  marked  hyper- 
aesthesia  of  the  skin.  Albuminuria  is  often  present,  and  there  may  be  com- 
plete suppression  of  urine.  The  fever  varies  greatly  in  intensity,  but  usually  has 
not  the  regularity  of  typhoid,  and  the  daily  exacerbations  are  more  marked.  It 
may  rise  to  104°  and  105  °  F.  On  the  other  hand,  there  are  cases  in  which  the 
fever  is  moderate,  not  more  than  101°  or  102°,  and  very  rarely  there  may  be 
no  fever.  There  are  also  instances  in  which  there  have  been  rigors  through- 
out the  course  of  the  disease.  The  condition  of  the  child  becomes  aggravated, 
and  with  a  dry  tongue,  delirium,  unconsciousness,  distended  abdomen,  and 
swollen  spleen,  the  similarity  to  typhoid  fever  is  very  close.  The  course  is  ex- 
tremely variable,  and  while  death  may  occur  at  the  end  of  the  second  or  begin- 
ning of  the  third  week,  in  other  cases  the  disease  is  prolonged  to  five  or  six 
weeks.  In  the  more  protracted  cases  definite  local  signs  are  met  with  ;  thus, 
with  an  increase  in  the  dyspnoea  and  cough  bronchitis  of  the  smaller  tubes  is 
found,  and  patches  of  consolidation  at  the  bases,  so  that  aeration  is  very  defec- 
tive. The  eruption  of  tubercles  on  the  meninges  may  intensify  the  cerebral 
manifestations,  and  there  may  be  from  the  outset  severe  headache,  with  a  gradual 
and  progi-essive  coma,  dilated  pupils,  and  sometimes  strabismus. 

Pulmonary  Type. — The  clinical  features  are  of  an  intense  capillary  bron- 
chitis (broncho-pneumonia).  This,  the  more  common  variety,  is  very  often 
mistaken  at  its  onset,  and  even  throughout  the  course,  for  simple  broncho- 
pneumonia. The  onset  may  be  abrupt,  and  even  with  a  chill,  but,  as  a  rule,  the 
child  has  been  failing  in  health  or  is  at  the  time  convalescing  from  some  acute 
illness  or  is  the  subject  of  an  acute  naso-pharyngeal  catarrh.  The  fever  is  high, 
and  may  reach  from  103°  to  105°;  the  pulse  is  rapid,  from  130  to  140. 
The  respiratory  symptoms  are  marked.  At  first  the  shortness  of  breath  is  slight 
and  proportionate  to  the  fever,  but  gradually  it  increases,  and  the  respii'ations 
may  be  from  60  to  70  per  minute.  The  cough  is  frequent,  dry,  and  very 
troublesome.    As  the  dyspnoea  becomes  more  marked  the  color  of  the  face  changes, 


TUBEBCUL0SI8.  281 

and  there  is  slight  cyanosis.  Though  the  fever  is  high  and  the  symptoms  grave, 
there  are  rarely  severe  cerebral  manifestations.  There  may  be  slight  diar- 
rhoea, but  the  abdomen  is  not  specially  distended  ;  the  spleen  is  easily  pal- 
pable. The  whole  clinical  picture  is  that  of  an  acute  broncho-pneumonia.  The 
physical  examination  shows  hurried  respiration,  and  there  may  be  retraction  of 
the  lower  zone  of  the  thorax  ;  the  percussion  note  is  clear,  even  hyperresonant, 
and  auscultation  at  first  shows  signs  of  a  general  bronchial  catarrh,  chiefly  of 
the  smaller  tubes.  Subsequently,  as  the  case  progresses,  there  are  areas  in 
which  the  resonance  is  higher  in  pitch  or  even  tympanitic,  and  in  places  distinct 
blowing  breathing  may  be  heard,  or  even  the  signs  suggestive  of  cavity. 

The  course  of  the  disease  in  this  type  is  much  more  rapid,  and  the  child 
may  die  at  the  end  of  a  week,  or  even  earlier,  with  the  signs  of  an  acute  suf- 
focative catarrh — more  commonly  in  from  ten  to  twelve  or  fourteen  days,  usually 
from  a  progressively  advancing  asphyxia. 

Diagnosis. — The  diagnosis  of  acute  tuberculosis  in  children  may  be  very 
easy  or  beset  with  the  greatest  difficulties.  The  family  history  should  be  taken 
into  account ;  the  surroundings  of  the  case,  particularly  whether  there  have 
been  instances  of  tuberculosis  in  the  same  house  or  occupying  the  same  room. 
Much  more  important  is  the  previous  history  and  personal  condition  of  the 
patient.  Inquiries  should  be  made  about  whooping-cough  and  measles, 
diseases  not  infrequently  followed  by  acute  tuberculosis.  Sometimes  a  history 
of  failing  health  or  of  protracted  catarrh  may  be  obtained.  The  most  evident 
cases  are  those  in  Avhich  there  are  signs  of  local  glandular  or  bone  tuberculosis. 
Sometimes  the  acute  affection  follows  an  operation  on  the  tuberculous  glands  of 
the  neck  or  the  opening  of  a  joint  abscess,  or  even  of  a  so-called  cold  abscess, 
or,  in  very  rare  instances,  the  tapping  of  a  pleural  effusion.  In  the  typhoid 
type,  when  the  features  are  well  developed,  the  simulation  of  ordinary  enteric 
fever  may  be  extremely  close.  Here,  if  from  the  outset  a  careful  temperature 
record  be  kept,  it  will  usually  be  found  that  the  fever  is  much  more  irregular 
in  tuberculosis,  and  early  in  the  disease  there  may  be  quite  marked  morning 
remissions.  As  noted  before,  in  a  few  instances  the  temperature  may  be  Ioav, 
even  subnormal,  in  the  morning.  The  general  features  of  infection  are  much  the 
same  in  both  diseases.  The  absence  of  typhoid  rash,  unless  it  is  there,  which  is 
usually  present  in  children,  and  very  distinctive,  is  a  most  important  nega- 
tive sign.  Expectoration  is  rarely  obtained,  but  should  the  child  vomit,  sputa 
should  be  looked  for  in  the  vomitus,  since  it  sometimes  happens  that  an  acute 
miliary  tuberculosis  takes  its  origin  in  a  small  focus  of  disease  in  one  lung,  from 
which  tubercle  bacilli  may  reach  the  sputum. 

The  examination  of  the  urine  is  important,  but  Ehrlich's  reaction  is  pres- 
ent as  frequently  in  acute  tuberculosis  as  in  typhoid  fever.  Pus  in  the  urine 
should  be  carefully  examined  for  bacilli,  since  instances  of  general  infection 
have  resulted  from  urogenital  tuberculosis. 

The  profound  infection  associated  with  malignant  endocarditis  may  simulate 
that  of  acute  tuberculosis.  The  special  heart-signs,  if  present,  and  embolic 
features,  would  be  important  distinguishing  marks.  The  diagnosis  of  the 
catarrhal  or  broncho-pneumonic  type  will  be  more  fully  considered  when  speak- 
ing of  the  acute  tuberculous  broncho-pneumonia  of  infants. 

Prognosis. — The  prognosis  is  always  unfavorable.  Here,  however,  may 
be  mentioned  a  type  of  acute  tuberculosis  recognized  by  Empis,  Landouzy,  and 
others,  which  they  call  typlio-tuherculose  or  typho-hacillose,  and  which  may 
be  either  the  first  manifestation  of  the  invasion  of  the  organism  with  the  bacilli 
or  the  expression  of  an  acute,  but  aborted,  tuberculosis,  following  some  local 
tuberculous  process.     The  clinical  aspect  is  really  that  of  typhoid  fever,  and 


282    A3fEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  temperature  curve  would  not  appear  to  give  any  definite  criterion.  Unless, 
in  fact,  there  is  some  local  tuberculous  focus,  I  do  not  see  how  this  form  can  be 
recognized,  and  many  of  the  cases  reported  by  Aviragnet  in  his  monograph  are 
not  at  all  convincing.  That  there  may  be,  however,  either  early  in  a  tuber- 
culosis, or  as  a  secondary  event  in  a  local  process,  an  infection  of  the  system 
with  the  toxines  is  extremely  likely.  In  adults  it  is  not  very  uncommon  to 
find  a  tuberculous  focus  completely  overlooked  in  a  general  infection  believed 
to  be  t^^phoid  fever,  and  in  which  the  secondary  development  of  miliary  granu- 
lations seems  scarcely  sufficient  to  account  for  all  the  symptoms. 

(2)  Chronic  Diffuse  Tuberculosis. 

This,  one  of  the  most  common  forms  of  tuberculosis  in  children,  is  charac- 
terized anatomically  by  the  gradual  development  of  tubercles  in  many  ditferent 
parts  of  the  body  :  they  are  not,  however,  the  miliary  granulations  of  the  acute 
tuberculosis,  but  coarse,  grayish-yellow  tuberculous  masses,  varying  in  size  from 
a  pea  to  a  walnut.  In  the  lungs,  for  instance,  there  are  caseous  tubercles  of  all 
sizes,  areas  of  caseous  broncho-pneumonia,  some  of  which  have  undergone 
softening;  but  cavities  are  not  common  except  in  children  above  four  or  five. 
The  bronchial  glands  are  often  greatly  enlarged  and  caseous,  and  sometimes 
present  abscesses.  The  abdominal  organs  show  extensive  tuberculosis.  The 
spleen  is  greatly  enlarged,  and  on  section  presents  numerous  grayish-yellow 
tuberculous  masses,  varying  in  size  from  2  to  10  mm.  The  liver  is  enlarged 
and  may  show  miliary  tubercles  on  the  capsule,  but  in  many  instances  there 
are  coarser  yellowish-gray  masses  which  have  developed  about  the  bile-capil- 
laries, and  which,  having  softened  in  the  centre,  present  a  yellowish-green  bile- 
stained  pus.  The  small  intestines  may  show  tuberculous  ulceration  to  a  greater 
or  less  extent.  The  mesenteric  glands  are  usually  enlarged  and  caseous. 
The  kidneys  may  show  coarse  tubercles,  sometimes  an  intense  tuberculous  pye- 
litis. In  the  brain  there  may  be  either  an  acute  terminal  meningitis  or  there 
are  coarse  tuberculous  nodules  scattered  throughout  the  substance,  particularly 
in  the  cerebellum.  The  chronic  diffuse  tuberculosis  is  much  more  frequent  in 
infants  than  in  children  above  the  age  of  two.  The  symptoms  are  those  of  a 
progressive  enfeeblement  of  the  nutrition,  as  a  rule  without  fever,  and  with 
manifestations  in  different  organs  varying  with  the  degree  of  tuberculization. 
The  affection  may  set  in  acutely  as  a  bronchitis  or  a  broncho-pneumonia,  the 
symptoms  of  which  gradually  subside.  Very  often  the  condition  follows  whoop- 
ing-cough, measles,  or  acute  gastro-intestinal  catarrh.  Less  frequently  it  is 
insidious,  and  the  child  presents  simply  progressive  failure  in  health.  The 
appearance  of  the  child  is  that  of  marked  cachexia.  It  is  thin ;  the  skin  is  loose 
and  pale,  sometimes  covered  with  fine  scales,  and  occasionally  pigmented.  The 
eyes  are  large,  and  the  expression  often  bright  and  animated.  The  thorax  is 
thin,  the  ribs  readily  noted,  and  there  may  or  may  not  be  the  signs  of  coexist- 
ing rickets.  The  abdomen  is  usually  tumefied,  and  both  the  liver  and  spleen 
are  enlarged.  When  the  abdominal  features  are  marked,  the  clinical  picture 
is  that  really  of  some  cases  formerly  described  as  tabes  mesenterica.  The 
superficial  glands  may  be  enlarged  and  hard.  Cough  may  be  present,  usually 
dry,  and  very  rarely  there  is  dyspnoea.  The  physical  signs  thoroughout  the 
lungs  are  either  dulness  in  the  interscapular  regions  or  scattered  areas  of  defec- 
tive resonance  with  bronchial  rales  and  blowing  breathing.  The  appetite  is 
poor,  the  digestion  feeble,  vomiting  is  frequent,  and  diarrhoea  is  common.  Not 
only  may  there  be  no  fever,  but  the  temperature  may  even  be  subnormal. 
Death  usually  results  from  some  complication,  either  a  secondary  invasion  of 
pneumococci  or  streptococci,  or  an  acute  meningitis. 


TUBEBCULOSIS.  283 

The  diagnosis  may  present  difficulties  if  one  does  not  constantly  bear  in 
mind,  in  the  first  place,  the  frequency  of  tuberculosis  in  infants,  particularly 
in  institutions ;  and,  secondly,  the  fact  that  this  diffuse  form,  which  is  very 
common,  may  pursue  its  course  without  fever,  and  only  perhaps  toward  the 
close  show  signs  of  active  disease,  now  of  the  meninges,  now  of  the  lungs,  or, 
again,  of  the  intestines.  This  cachexia  of  the  chronic  diffuse  tuberculosis  of 
infants  must  be  distinguished  from  that  of  rickets,  of  chronic  gastro-intestinal 
catarrh,  and  of  syphilis.  In  rickets  the  changes  in  the  bones  and  cartilages, 
in  athrepsia  the  marked  gastro-intestinal  disturbance,  and  the,  as  a  rule,  more 
enfeebled  and  senile  look  of  the  child,  serve  as  distinguishing  features.  The 
absence  of  enlargement  of  the  spleen  and  liver  or  of  the  lymph-glands  is  an 
important  negative  sign.  A  greater  difficulty  exists  in  distinguishing  some  of 
the  cases  of  profound  syphilitic  cachexia,  as  here  the  superficial  glands  may  be 
enlarged  and  the  spleen  and  liver  hypertrophied ;  but,  on  the  other  hand,  the 
history,  the  facies,  the  skin-rashes,  rhagades,  and,  above  all,  the  prompt 
improvement  under  antisyphilitic  treatment,  are  important  points  of  differen- 
tiation. 

m.  Localized  Tuberculosis. 

(1)  Tuberculosis  of  the  Lymph-glands. 

[a)  Tuberculous  Polyadenitis. — The  lymphatic  system  may  be  the  chief 
seat  of  the  disease,  and  the  glands,  internal  and  external,  or  the  lymph-sacs 
(serous  surfaces),  may  present  advanced  tuberculosis  without  much  involvement 
of  the  viscera  or  other  parts.  This  is  more  often  the  case  than  we  have  here- 
tofore supposed.  In  some  instances  of  general  tuberculous  infection  in  young 
children  there  may  be  what  Legroux  calls  micro-poly  adenopathy,  which  in 
doubtful  cases  may  give  an  important  diagnostic  hint.  More  recently  Lesage 
and  Pascal  have  described  cases  in  children  in  which  there  was  progressive 
involvement  of  the  lymphatic  glands,  usually  at  first  those  of  the  groin,  then 
those  of  the  axilla,  and  lastly  the  cervical  and  internal  groups.  They  regard 
the  affection  in  some  of  the  cases  as  due  to  cutaneous  tuberculosis;  in  others 
they  believe  the  disease  to  be  congenital.  The  symptoms  of  this  form  of  gen- 
eralized enlargement  of  the  superficial  lymph-glands  are  progressive  cachexia 
without  much  fever  and  without  signs  of  disease  of  the  lungs  or  of  the  abdom- 
inal organs,  and  frequently  a  ravenous  appetite. 

The  cases  must  be  carefully  distinguished  from  the  general  slight  enlarge- 
ment of  the  lymph-glands  in  syphilis,  and  from  the  rare  cases  of  Hodgkin's 
disease  in  children,  in  which,  however,  the  enlargement  is  much  greater  and 
the  involvement  of  one  group  is  generally  much  more  marked.  It  must  not 
be  supposed,  however,  that  every  case  of  general  moderate  enlargement  of  the 
superficial  lymph-glands  in  children  is  due  either  to  tuberculosis,  syphilis,  or 
Hodgkin's  disease.  Following  the  infectious  fevers,  and  associated  with  chronic 
catarrh  of  the  upper  air-passages,  I  have  seen  on  more  than  one  occasion 
enlargement  of  the  glands  of  the  neck,  of  the  groin,  and  of  the  axillae — 
a  condition  of  the  superficial  lymph-apparatus  comparable  to  the  swelling 
of  the  Peyer's  follicles  and  of  the  mesenteric  glands  found  so  frequently  in 
children  dead  of  one  of  the  infectious  diseases,  or,  in  fact,  of  any  prolonged 
illness. 

(h)  Cervical  Adenitis. — The  drainage-areas  of  the  lymphatic  glands  of 
the  neck  embrace  the  superficial  and  deep  structures  of  the  head  and  neck . 


284    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  most  important  groups  are  the  superficial  cervical,  beneath  the  platysma, 
which  drains  the  side  of  the  head  and  neck  and  face  and  external  ear,  and  the 
deep  cervical  along  the  carotid  sheath,  which  drains  the  mouth,  the  tonsils, 
palate,  pharynx,  and  larynx.  In  addition  there  are  the  submaxillary  and 
suprahyoid  groups  draining  the  lower  gums,  the  front  of  the  mouth  and  tongue, 
and  the  chin  and  lower  lips. 

Tuberculous  adenitis  of  the  glands  of  the  neck,  so  extrelnely  common,  which 
fortunately  often  remains  a  local  and  curable  affection,  was  regarded  as  one 
of  the  most  typical  and  characteristic  manifestations  of  scrofula.  Cornet's  obser- 
vations upon  the  presence  of  tubercle  bacilli  in  the  dust  of  cities  and  of  rooms 
show  how  widely  spread  the  virus  is,  and  how  liable  we  are  in  crowded  cities 
to  inhale,  and  even  to  swallow,  bacilli  with  the  dust.  Whether  the  bacilli 
are  capable  of  passing  through  the  healthy  mucous  membrane  is  perhaps  doubt- 
ful, though  there  are  experiments  which  would  seem  to  prove  the  liability  of 
infection  through  the  healthy  mucous  membrane  of  the  intestines.  More  prob- 
ably the  slight  catarrhal  troubles  about  the  naso-pharynx,  so  frequent  in  chil- 
dren, open,  as  one  may  say,  the  portals  and  allow  the  bacilli  to  reach  the  lymph- 
glands.  Preliminary  irritation  and  enlargement  of  the  glands  in  eczema  of  the 
scalp  and  in  sore  throat  in  children  may  weaken  the  powers  of  resistance. 
Here,  no  doubt,  if  the  tissue-soil  be  unfavorable,  they  may  exert  no  influence 
whatever,  but  with  that  vulnerability  of  tissue,  regarded  by  former  writers  as 
the  characteristic  feature  of  scrofula,  the  bacilli  find  a  suitable  nidus,  and  a 
local  tuberculosis  is  the  result — a  process  characterized  usually  by  extreme 
chronicity. 

The  glands  may  enlarge  rapidly  at  first  and  become  soft  and  painful ;  more 
commonly,  they  swell  slowly,  and  can  be  felt  as  firm  rounded  masses  freely 
movable  beneath  the  skin.  They  may  gradually  subside  and  undergo  spon- 
taneous healing.  In  other  instances  the  glands  increase,  areas  of  softening  are 
found,  the  process  involves  the  skin  overlying  the  gland,  which  becomes  red, 
and  finally  ulcerates,  discharging  a  cheesy  matter  and  a  thin  watery  sero-pus. 
The  sore  thus  left  is  very  indolent,  does  not  tend  to  heal ;  the  skin  about  it  is 
livid  and  undermined.  Many  of  the  glands  may  suppurate  in  this  way,  and 
when  healing  ultimately  takes  place  the  sides  of  the  neck  are  disfigured  by 
irregular,  unsightly  scars.  In  the  neck  of  young  or  old  these  are  usually  a 
certain  sign  of  healed  tuberculosis. 

It  is  to  be  borne  in  mind  that  involvement  of  the  cervical  glands  may  be 
due  to  extension  of  tuberculous  processes  from  the  axillary  glands  or  even  from 
carious  cervical  vertebrae.  When  the  glands  are  large  and  growing  actively 
there  is  fever ;  death  very  rarely  follows,  and  even  aggravated  cases  in  children 
may  recover.  In  some  instances  the  general  nutrition  is  very  slightly  disturbed. 
Tuberculous  adenitis  of  the  cervical  or  axillary  groups  may  precede  the  devel- 
opment of  tuberculosis  of  the  pleura  or  of  the  lung. 

((?)  Tracheo-bronchial  glands. — Within  the  thorax  the  groups  of  lymph- 
glands  are  of  great  importance.  The  sternal  are  placed  along  the  course  of  the 
internal  mammary  vessels;  the  intercostal  along  the  heads  of  the  ribs,  and 
sometimes  extending  outward;  the  anterior  mediastinal  group  between  the 
lower  part  of  the  sternum  and  the  pericardium ;  the  cardiac  group  in  the  inter- 
pleural s^ace  about  the  arch  of  the  aorta;  and,  lastly,  the  tracheal  glands  on 
either  side  of  the  windpipe,  and  the  bronchial  proper,  continuous  with  them, 
which  surround  the  main  bronchi  and  pass  deeply  in  the  hilus  of  the  lung. 
There  are  also  glands  in  the  posterior  mediastinum  along  the  thoracic  aorta 
and  oesophagus.     Tuberculosis  of  the  tracheo-bronchial  glands  is  extremely 


TUBERCULOSIS.  285 

common.  Observations  of  Loomis  (Jr.)  show  even  that  in  apparently  normal 
glands  bacilli  may  be  present  and  the  gland-tissue  infective.  Certainly  in  a 
very  large  proportion  of  all  cases  of  tuberculosis  in  children  it  would  appear 
that  the  first  infection  was  in  these  structures,  while  common  experience  shows, 
contrary  to  the  so-called  law  formulated  by  Parrot,  that  the  glands  may  be 
involved  without  any  local  lesion  in  the  lungs.  Of  125  cases  examined  by 
Northrup,  the  bronchial  glands  were  tuberculous  in  every  case ;  42  had  cheesy 
masses  in  the  bronchial  lymph-nodes  only,  with  recent  tubercles  in  the  lungs 
and  elsewhere ;  in  13,  it  was  limited  to  the  bronchial  glands  alone.  The  glands 
may  present  gray  miliary  tubercles,  large,  unpigmented,  cheesy  areas,  foci 
of  softening  with  suppuration,  or  old  calcified  masses.  In  the  long-standing 
cases  there  is  much  sclerosis  and  pigmentation.  The  diiferent  groups  may  be 
very  differently  involved;  thus  the  tracheal  may  be  much  affected  without 
great  involvement  of  the  bronchial  nodes  proper.  More  commonly  all  the 
glands  are  involved,  and  very  often  those  deep  in  the  hilus  of  the  lung  form 
large  caseous  masses  uniformly  surrounding  the  main  bronchus  and  its  divisions, 
and  penetrating  deeply  between  the  lobes  of  the  lung.  When  the  glands  sup- 
purate the  abscesses  may  perforate  in  different  directions.  The  effects  of  these 
enlarged  glands  are  very  varied,  and  for  full  details  the  reader  is  referred  to  the 
elaborate  section  in  the  Traite  of  Barthez  and  Sanne  (tome  3).  It  is  suf- 
ficient here  to  say  that  there  are  instances  on  record  of  compression  of  the 
superior  cava,  of  the  pulmonary  artery,  and  of  the  azygos  vein.  The  trachea 
and  bronchi,  though  often  flattened,  are  rarely  seriously  compressed.  The 
pneumogastric  nerve  may  be  involved,  particularly  the  recurrent  laryngeal 
branch.  More  important,  really,  are  the  perforations  of  the  enlarged  and 
softened  glands  into  the  bronchi  or  trachea,  or  a  sort  of  secondary  cyst  may  be 
formed  between  the  lung  and  the  softened  bronchial  gland.  Perforations  of  the 
vessels  are  much  less  common,  but  the  pulmonary  artery  has  been  opened.  Per- 
foration of  the  oesophagus  has  been  described  in  several  cases.  One  of  the 
most  serious  effects  is  infection  of  the  lung  or  pleura  by  the  caseous  glands 
situated  deep  along  the  bronchi.  The  infection  may,  as  is  often  clearly  seen, 
be  by  direct  contact,  and  it  may  be  difficult  to  determine  in  some  sections  where 
the  caseous  bronchial  gland  terminates  and  the  pulmonary  tissue  begins.  In 
other  instances  it  takes  place  along  the  root  of  the  lung,  and  is  subpleural. 
Among  rarer  sequences  may  be  mentioned  diverticula  of  the  oesophagus  follow- 
ing adhesion  of  an  enlarged  gland  and  its  subsequent  retraction,  and,  in  the 
case  of  the  anterior  mediastinal  and  aortic  groups,  the  frequent  association  of 
tuberculous  adenopathy  and  pericarditis,  either  by  contact  or  by  rupture  of  a 
softened  gland  into  the  pericardium. 

Symptoms. — In  the  great  majority  of  instances  there  are  no  indications 
whatever,  and  even  in  enormous  enlargement  pressure-signs  may  not  have  been 
present.  Authors  differ  extremely  in  their  views  on  this  point.  Many  hold, 
and  I  think  correctly,  that  the  manifestations,  as  a  rule,  are  very  slight.  Com- 
pression of  the  veins  leading  to  dropsy,  dilatations  of  the  veins  causing  cyano- 
sis, and  haemorrhages  are  referred  to  by  Barthez  and  Sannd.  Alterations  in 
the  character  of  the  heart-sounds  and  attacks  of  paroxysmal  dyspnoea  are  des- 
cribed by  the  same  writers.  The  latter  come  on  suddenly,  often  at  regular 
hours,  frequently  in  the  afternoon,  and  there  is  extreme  oppression  with  rapid 
breathing,  cyanosis,  and  cold  sweats,  almost  like  an  attack  of  severe  croup. 
These  paroxysms  may  succeed  each  other,  and  they  have  been  ascribed  not  so 
much  to  pressure  at  the  bifurcation  of  the  trachea  as  to  compression  of  the  vagi, 
causing  in  this  way  laryngeal  spasm.  More  definite,  undoubtedly,  is  the  com- 
pression of  one  or  other  bronchus,  causing  feeble  breathing  on  the  side  most 


286    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

affected,  with  sibilant  and  fine  rales.  Usually,  however,  when  the  glands  are 
very  much  enlarged  the  lung  is  also  involved,  and  it  may  be  difficult  to  say  how 
far  the  alterations  are  due  to  the  changes  in  it.  Still  less  reliable  is  the  infor- 
mation obtained  on  percussion,  for  the  dulness  in  the  upper  part  of  the  sternum 
and  in  the  interscapular  spaces  is,  when  present,  by  no  means  a  positive  sign. 
The  thymus  may  cause  sternal  flatness  on  percussion;  and  behind,  unless  the 
glands  are  enormously  enlarged  and  the  child  very  thin,  it  is  difiicult  to  deter- 
mine any  special  modification  of  the  resonance  in  the  interscapular  space 
between  the  first  and  third  dorsal  vertebrae. 

{d)  Mesenteric  Glands  (Tabes  Mesenterica). — The  glands  involved 
are  those  of  the  mesentery  and  the  gastro-hepatic  omentum  and  the  chain 
of  retroperitoneal  glands  along  the  aorta ;  more  rarely  those  of  the  pelvis. 
Tuberculous  disease  of  these  glands  is  extremely  common ;  thus  of  127  cases 
of  fatal  tuberculosis  in  children,  noted  by  Woodhead,  these  structures  were  in- 
volved in  100,  while  Ashby  states  that  of  103  consecutive  post-mortems  on 
children  dying  of  tuberculosis,  in  62  there  was  tuberculous  ulceration  of  the 
intestines;  in  71,  cheesy  mesenteric  glands;  in  55,  both  ulcers  and  cheesy 
glands ;  in  7,  tuberculous  ulcers  without  involvement  of  the  glands ;  and  in 
16,  cheesy  glands  without  ulcers.  Of  144  children  in  which  the  mesenteric 
glands  were  tuberculous,  only  44  showed  neither  ulcerations  nor  tubercles  in 
the  intestines  (Barthez  and  Sann^). 

In  a  great  many  instances  the  condition  is  found  accidentally  in  children 
who  have  died  of  other  diseases.  Unquestionably,  as  is  indicated  by  these 
figures,  the  infection  in  many  of  these  cases  is  primary  in  the  glands.  Lesion 
of  the  intestines  is  not  necessary.  Some  experiments  have  shown  that  the 
bacilli  may  gain  entrance  through  a  healthy  mucosa.  A  special  interest  relates 
to  the  possibility  of  infection  by  the  bacilli  in  milk,  more  particularly  as  it  is 
well  known  that  in  animals  experimentally  fed  with  infected  milk  primary 
tuberculosis  of  the  intestines,  with  extensive  disease  of  the  mesenteric  glands, 
has  been  produced.  The  question  will  be  referred  to  again  on  the  subject  of 
primary  tuberculosis  of  the  intestines.      The  cases  fall  into  four  groups : 

(1)  Very  slight  tuberculous  affection  of  a  few  glands  (which  may  be  the 
only  ones),  met  with  accidentally  in  children  who  have  died  of  various  dis- 
orders. 

(2)  In  the  chronic  generalized  tuberculosis,  in  both  the  acute  and  chronic 
pulmonary  tuberculosis,  and  in  the  more  chronic  forms  of  tuberculosis  of 
any  of  the  organs  in  children,  the  mesenteric  glands  may  be  found  enlarged 
and  caseous.  There  are  instances,  too,  in  which  the  affection  of  the  mesen- 
teric and  retroperitoneal  glands  with  those  of  the  thorax  constitutes  the  chief 
lesion. 

In  both  these  groups  the  disease  of  the  glands  does  not  necessarily  cause 
any  symptoms  pointing  to  abdominal  disorder. 

(3)  In  a  third  gi'oup  there  are  signs  of  chronic  intestinal  catarrh  or  ulcer- 
ation and  very  marked  disturbance  in  the  general  nutrition.  These  cases 
are  seen  chiefly  in  children  between  the  ages  of  eighteen  months  and  five 
years.  The  abdomen  is  distended,  tympanitic,  usually  a  little  painful  on  deep 
pressure,  but  no  nodules  are  felt.  The  diarrhoea  is  the  most  troublesome  symp- 
tom ;  the  stools  are  frequent,  brownish  or  yellow-brown  in  color,  containing 
mucus,  not  often  blood.  The  diarrhoea  is  variable,  and  may  sometimes  persist 
for  several  weeks.  There  is  usually  slight  fever,  but  the  general  wasting  and 
debility  are  the  most  characteristic  features.  The  name  tabes  mesenterica  is 
often  applied  to  this  condition.     The  course  is  chronic  and  may  extend  over  a 


TUBEBCULOSIS.  287 

year  or  two,  leading  to  the  most  extreme  emaciation.  It  is  sometimes  very 
difficult  to  determine  whether  actual  tuberculous  disease  of  the  bowel  is  present 
or  not,  as  a  chronic  intestinal  catarrh  may  lead  to  just  such  a  condition  of 
extreme  debility  and  wasting.  In  the  diagnosis  of  these  cases  much  stress  can 
be  laid  upon  the  presence  or  absence  of  tubercles  in  other  parts. 

(4)  And,  lastly,  there  are  cases  in  which  with  ulceration  of  the  intestines 
the  mesenteric  glands  are  greatly  enlarged,  and  in  addition  the  peritoneum  is 
involved.  Here  the  diarrhoea,  the  slight  fever,  the  malnutrition,  and  progres- 
sive wasting  are  as  in  the  previous  group ;  additional  symptoms  are  associated 
with  disease  of  the  peritoneum,  in  which  nodular  masses  may  be  felt,  and  there 
may  be  considerable  ascites.  These  cases  will  be  referred  to  more  particularly 
under  Peritoneal  Tuberculosis. 


(2)   Tuberculosis  of  the  Intestines  and  of  the  Abdominal  Organs. 

{d)  Tuberculosis  of  the  bowels. — The  small  intestine  is  most  frequently 
involved ;  thus,  of  141  children  presenting  tuberculous  ulcerations  in  the 
gastro-intestinal  canal  (Barthez  and  Sann^),  in  134  the  small  intestine  was 
involved ;  in  60,  the  large  intestine ;  in  71,  the  small  intestine  alone.  It  is 
remarkable,  considering  the  comparative  rarity  in  the  adult  of  tuberculous  dis- 
ease of  the  stomach,  that  in  this  series  it  should  have  been  met  with  in  21 
cases.  That  tuberculosis  may  originate  in  the  alimentary  canal  is  shown 
experimentally  by  the  feeding  of  guinea-pigs  with  cultures  of  the  bacillus  and 
the  feeding  of  calves  and  pigs  with  the  milk  of  tuberculous  animals.  There  are 
now  many  series  of  cases  demonstrating  the  facility  with  which  animals  may  be 
infected  through  this  latter  source.  That  the  intestinal  lesion  may  be  primary 
in  children  is  acknowledged.  The  comparatively  large  number  of  children  with 
caseous  foci  in  the  mesenteric  glands  is  very  suggestive.  On  the  other  hand, 
instances  of  primary  intestinal  tuberculosis  are  not  very  common. 

In  a  great  majority  of  the  cases  the  tuberculous  lesions  are  part  of  a 
general  infection,  and  are  undoubtedly  secondary.  The  ulcers  are  situated 
chiefly  in  the  ileum,  involving  the  solitary  and  agminated  follicles  of  Peyer.  The 
tubercles  may  be  seen  as  small  granulations  in  the  submucosa ;  sometimes  the 
whole  ileum  may  present  a  remarkable  appearance  from  the  grayish-yellow 
nodular  tubercles,  the  size  of  split  peas,  occupying  the  submucosa  and  the 
mucous  membranes.  The  caseation  and  necrosis  lead  to  ulceration,  which  may 
be  very  extensive,  involving  at  first  Peyer's  patches,  but  ultimately  extending 
beyond  their  limits.  The  tuberculous  ulcer  has  the  following  characters :  It 
is  "  transverse  to  the  long  axis,  rarely  ovoid,  often  irregular  in  outline ;  the 
edges  and  base  are  infiltrated,  often  caseous  ;  the  submucosa  and  muscularis 
are  also  involved  in  the  tuberculous  process ;  and,  lastly,  colonies  of  young 
tubercles  or  well-marked  lymphangitis  may  be  seen  on  the  serosa." 

Primary  tuberculosis  of  the  bowel  is,  as  stated,  rare;  but  in  children  with 
extensive  ulceration  in  the  ileum  and  very  slight  lesions  of  other  parts  the  dis- 
ease may  be  regarded  as  primary ;  thus  in  a  child  aged  nine  who  was  admitted 
to  my  wards  with  dropsy  and  emaciation  after  an  illness  of  six  months'  duration, 
there  were  only  a  few  small  foci  in  the  lungs,  while  the  intestines  showed  most 
extensive  disease.  About  50  cm.  below  the  duodenum  there  was  a  large 
circling  ulcer,  the  edges  of  which  were  undermined,  the  bases  irregular  and 
worm-eaten,  and  containing  necrotic,  grayish  material.  The  peritoneum  over 
it  was  thick  and  opaque.  Throughout  the  whole  of  the  ileum  there  was  a  series 
of  these  girdling  ulcers  at  varying  intervals.     The  caecum  presented  a  very 


288    A3fEBICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 

large,  deep  ulcer,  while  the  mesenteric  attachment  about  the  ileum  formed  a 
large  tumor-mass  from  the  extent  of  the  involvement  of  the  glands.  The 
peritoneum  presented  scattered  tubercles  and  the  mesenteric  glands  were  enor- 
mously enlarged. 

In  a  few  instances  tuberculous  disease  of  the  bowels  extends  from  a  chronic 
tuberculous  peritonitis  in  which  the  coils  of  the  intestine  become  matted  toge- 
ther, caseous  and  suppurating  foci  develop  between  the  folds,  and  perforation 
may  occur  in  several  places. 

Symptoms. — The  symptoms  of  intestinal  tuberculosis  are  very  varied.  The 
most  common  indication  is  a  persistent  diarrhoea.  It  is  not  always,  however, 
proportionate  to  the  extent  of  the  ulceration,  and  large  ulcers  in  the  ileum  may 
exist  with  constipation.  When  the  ulceration  is  extensive  in  the  large  intestine 
the  diarrhoea  is  usually  profuse  and  obstinate.  The  mode  of  onset  is  variable. 
In  a  few  instances  of  general  tuberculosis  there  is  diarrhoea  from  the  start.  In 
a  large  number  of  cases  the  existence  of  intestinal  complication  is  not  suspected 
until  the  signs  of  disease  in  other  organs  are  well  marked ;  and  in  perhaps  a 
majority  of  the  secondary  cases  the  diarrhoea  is  rather  an  event  of  the  latter 
part  of  the  illness.  Of  other  symptoms,  haemorrhage  may  occur,  or  peritonitis 
from  extension — a  condition  not  very  uncommon,  and  often  associated  with 
disease  of  the  mesenteric  glands.  The  abdomen  in  these  cases  is  usually 
enlarged  and  painful,  and  the  nodular  masses  may  be  felt.  In  a  few  instances 
there  are  gastric  symptoms,  which  do  not  necessarily  indicate  ulceration  in  the 
stomach,  but  there  may  be  loss  of  appetite  and  occasional  vomiting,  and  there 
are  instances  on  record  of  profuse  hsematemesis  or  melgena  from  erosion  of 
an  artery. 

The  outlook  is  unfavorable,  and  death  may  be  caused  by  the  severity  of 
the  intestinal  symptoms,  or  more  rarely  by  the  accidents,  such  as  perfoi-ation  or 
haemorrhage. 

Recognition  is  rarely  difficult,  except  in  the  primary  cases,  Avhich  are 
regarded  at  first  as  simple  entero-colitis.  Usually,  however,  Avhen  well  es- 
tablished, the  diagnosis  is  easy,  particularly  when  other  organs  become  in- 
volved. In  suspected  cases  the  stools  should  be  carefully  examined  for  tubercle 
bacilli. 

(h)  Tuberculosis  of  Liver. — In  all  cases  of  acute  miliary  tuberculosis 
granulations  are  found  in  this  organ  ;  sometimes  they  are  extremely  minute 
and  are  only  detected  microscopically.  The  liver  is  usually  somewhat  enlarged, 
pale,  and  fatty.  In  more  chronic  cases,  particularly  the  diffuse  generalized 
tuberculosis  of  young  children,  the  tubercles  may  attain  considerable  size  and 
develop  about  the  finer  bile-ducts.  They  undergo  rapid  softening,  and  give  a 
very  remarkable  appearance  to  the  liver,  which  is  in  extreme  cases  almost 
honeycombed  with  tuberculous  abscesses,  varying  in  size  from  a  pea  to  a  marble  ; 
the  pus  is  usually  bile-stained. 

Occasionally  large,  coarse,  caseous  masses  are  found  forming  irregular 
tumors,  most  frequently  in  association  Avith  perihepatitis  or  tuberculous  peri- 
tonitis. The  so-called  tuberculous  cirrhosis  of  the  liver  does  not,  I  believe, 
occur  in  children,  though  there  may  be  in  chronic  cases  of  tuberculosis  a 
marked  increase  in  the  connective  tissue  of  the  organ. 

((?)  Tuberculous  Peritonitis. — Tuberculosis  is  one  of  the  most  common 
causes  of  peritonitis  in  children.  It  is  more  common  about  the  eighth  and  tenth 
years,  and  attacks  boys  more  frequently  than  girls ;  thus  of  86  cases  analyzed 
by  Barthez  and  Sannd,  there  Avere  from 


TUBERCULOSIS.  289 

1  to  2|  yrs 11  cases. 

3  to  51    "       26      " 

6  to  101    "       40      " 

11  to  15"    "       9      " 

The  ratio  of  frequency  in  children  may  be  gathered  from  the  large  statis- 
tics of  Aldibert,  who  found  in  326  cases  of  tuberculous  peritonitis,  52  in  chil- 
dren. As  in  the  adult,  the  disease  may  be  primary,  but  in  a  majority  of  the 
cases  it  is  secondary  to  tuberculosis  of  the  intestines,  mesenteric  glands,  or 
of  the  genitalia. 

Morbid  Anatomy. — Tubercles  in  the  peritoneum  are  not  infrequently  met 
with  in  the  bodies  of  children  dead  of  tuberculosis.  Ashby  noted  them  38 
times  in  105  post-mortems  on  tuberculous  children.  They  occur  either  as  (1) 
the  gray  granulations  with  or  without  exudation,  serous  or  sero-fibrinous. 
Sometimes  the  entire  peritoneum  is  found  studded  with  (2)  firm,  hard,  fibrin- 
ous tubercles  surrounded  by  a  pigmented  and  firm  connective  tissue.  In  both 
of  these  varieties  the  process  may  be  latent,  and  the  condition  is  met  Avith  acci- 
dentally post-mortem.  More  frequently  (3)  when  symptoms  have  been  present, 
the  tubercles  are  in  the  form  of  caseous  nodules,  yellow-gray  in  color,  often 
forming  flattened  tuberculous  plaques.  The  exudate  is  purulent  or  sero- 
purulent,  the  coils  of  intestines  are  much  matted  together,  and  between 
them  there  may  be  large  caseous  masses.  It  may  be  impossible  to  separate  the 
coils,  and  in  advanced  cases  extensive  ulceration  occurs,  with  multiple  perfora- 
tion of  the  intestine.  There  are  three  anatomical  points  of  special  interest  in 
these  cases :  First,  the  efi"usion  may  be  sacculated  and  form  a  definite  tumor  ; 
sometimes  the  process  is  confined  to  the  cavity  of  the  lesser  peritoneum ;  in 
other  cases  it  is  in  the  pelvis,  less  frequently  in  the  middle  portion.  The  cysts 
may  be  multi-  or  mono-locular. 

Second,  there  are  cases  in  which  occlusion  of  the  intestine  has  resulted, 
sometimes  from  compression  of  the  coils  by  the  large  caseous  masses  ;  more 
frequently  by  the  binds  of  connective  tissue  in  the  healing  of  the  process. 
Alclibert  has  found  five  instances  of  this  sort  in  children. 

Lastly — and  much  more  frequently  in  children  than  in  adults — there  is  peri- 
umbilical suppuration.  The  intensity  of  the  inflammation  is  in  the  central 
portion  of  the  abdominal  cavity,  adhesions  take  place,  and  a  definite  cyst  is 
formed,  usually  purulent,  which  projects  at  the  umbilicus,  and  often  opens 
spontaneously,  leaving  a  fistula,  sometimes  stercoral,  which  persists  for  months 
but  may  ultimately  heal. 

Symptoms.— The  symptoms  of  tuberculous  peritonitis  are  extremely 
varied,  and  it  is  very  difiicult  to  give  a  clear  and  definite  picture  of  the  disease. 
For  convenience  three  clinical  types  may  be  considered  : 

(1)  The  Ascitic  Form. — The  symptoms  may  come  on  acutely  with  a  difiuse 
eruption  of  miliary  tubercles.  So  abrupt  is  the  onset  that  cases  have  been 
mistaken  for  acute  enteritis,  or  even  for  acute  obstruction  or  hernia.  More 
frequently  the  onset  is  subacute,  and  ascites  gradually  develops.  Fever  of  some 
degree,  indigestion,  and  diarrhoea  are  present,  and  there  may  be  abdominal 
pain  ;  but  in  many  instances  the  process  is  latent,  and  the  enlarging  abdomen 
is  the  symptom  for  which  the  physician  is  consulted.  The  effusion,  indeed,  may 
proceed  to  considerable  degree  Avithout  fever,  and  with  no  symptoms  other  than 
those  of  gradually-failing  health  and  progressive  emaciation.  Intestinal  dis- 
order occurs  in  some  instances,  diarrhoea,  colicky  pains,  or  often  attacks  of 
diarrhoea  alternating  with  constipation.  The  local  symptoms  are  by  no  means 
characteristic.     The  abdomen  is  distended,  the  skin  thin,  the  superficial  veins 

19 


290    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

enlarged.  Percussion  gives  dulness  in  the  flanks,  which  is  movable,  resonance 
in  the  umbilical  region,  and  there  is  a  well-marked  fluctuation  wave.  Palpa- 
tion may  be  entirely  negative  ;  no  nodular  masses  are  felt.  The  liver  and  spleen 
are  not  often  enlarged.  It  may  be  extremely  difficult,  or  quite  impossible, 
unless  there  are  tuberculous  lesions  in  other  regions,  to  speak  definitely  of 
the  nature  of  the  gradually-developing  ascites.  The  clinical  picture  is  very 
similar,  indeed,  to  that  of  the  cases  of  ascites  from  cirrhosis,  and  an  identical 
condition  is  met  with  in  the  rare  cases  of  simple  chronic  peritonitis  in  children. 
The  ascites  may  demand  tapping,  but  the  fluid  reaccumulates  rapidly.  The 
exudate  may  be  encysted,  forming  a  prominent  tumor  in  the  epigastric  or 
umbilical  regions  (in  which  case  the  eff"usion  is  probably  within  the  lesser  peri- 
toneum), or  it  may  be  situated  in  the  pelvis  or  in  the  flank,  and  simulate  very 
closely  cystic  ovarian  disease.  This  form  is  not  very  uncommon  in  children, 
and  very  good  results  have  folloAved  operation ;  of  nine  instances  in  the  litera- 
ture, all  recovered.  This  asaitic  form,  developing  slowly,  and  ultimately 
presenting  the  picture  of  a  chronic  ascites  or  an  encapsulated  exudate,  is  by 
far  the  most  favorable  variety,  and  cases  may  recover  spontaneously  or  after 
operation. 

(2)  The  ulcerative  form  is  much  more  serious.  The  peritoneum  here  con- 
tains larger  caseous  masses  which  break  down,  and  there  is  a  diff'use  purulent 
peritonitis.  The  coils  of  intestines  are  matted  together,  nodular  tuberculous 
masses  develop  on  the  parietal  and  visceral  layers,  the  glands  are  greatly  en- 
larged, and  in  protracted  cases  extensive  ulcerations  occur.  The  onset  in  this 
form  is  usually  gradual,  but  the  abdominal  symptoms  are  pronounced.  The 
child  complains  of  colicky  pains,  diarrhoea,  and  chronic  indigestion.  The 
abdomen  is  enlarged  and  painful.  The  condition  on  examination  may  be  entirely 
different  from  that  of  the  ascitic  form.  The  outline  is  often  symmetrical,  not 
flattened  in  the  flanks  ;  nodular  projections  may  sometimes  be  seen  beneath  the 
skin.  Unless  there  is  a  very  extensive  purulent  eff"usion  there  is  no  movable 
dulness.  There  is  a  flat  tympany  or  there  are  alternating  areas  of  resonance 
and  dulness.  On  palpation  there  is  a  boggy,  doughy  feel,  and  nodular  masses 
may  be  felt  in  diff'erent  regions.  The  liver  and  spleen  may  both  be  enlarged. 
In  this  suppurative  form  the  eff"usion  may  be  general,  or  it  may  be  encysted 
either  in  the  upper  abdominal  region  or  in  the  pelvis.  One  form  of  this  encysted 
suppurative  variety  requires  special  consideration — namely  : 

Periumhilical  Tuberculous  Abscess. — This  is  seen  most  frequently  in  chil- 
dren, and  is  in  reality  a  localized  suppurative  peritonitis,  which  points  at  the 
navel  and  frequently  opens  and  discharges.  The  condition  is  almost  constantly 
tuberculous  in  the  child.  There  may  be  a  fistula  discharging  pus  for  weeks  or 
months,  and  recovery  may  ultimately  take  place.  In  other  instances  the  fistula 
communicates  with  the  bowel.  In  the  case  of  a  colored  child,  aged  five, 
operated  upon  by  my  colleague.  Dr.  Halsted,  there  was  distention  of  the  abdo- 
men, marked  protrusion  of  the  umbilicus,  and  here  a  spontaneous  opening  dis- 
charging yellowish  material  for  months.  Then  the  opening  healed  and  the 
condition  of  the  child  improved.  At  the  time  of  the  operation  there  was  a 
large,  prominent,  cone-shaped,  umbilical  tumor.  The  child  died  some  time  after 
the  operation ;  creamy  pus  was  found  between  the  intestinal  coils,  and  there 
were  many  tuberculous  ulcers  in  the  intestines.  There  was  an  extensive 
caseous  salpingitis. 

There  are  instances  also  of  perihepatic  tuberculous  abscesses. 

(3)  Chronic  Adhesive  or  Dry  Tuberculous  Peritonitis. — In  a  very  consider- 
able number  of  all  cases  of  tuberculous  peritonitis  there  is  little  or  no  serous 
or  purulent  exudate,  but  the  tubercles  are  surrounded  with  a  fibrinous  lymph 


TUBERCULOSIS.  291 

and  they  tend  I'apidly  to  cicatrize.  The  growing  tubercles  may  not  have  caused 
any  symptoms,  and  the  condition  is  found  accidentally  post-mortem,  and  in 
adults  has  often  been  met  with  in  exploratory  laparotomies  for  various  condi- 
tions. In  long-standing  cases  the  tubercles  are  hard,  firm,  often  surrounded 
by  deeply  pigmented  fibroid  adhesions.  In  some  of  these  instances  the  tuber- 
culosis of  the  peritoneum  is  localized ;  thus  it  has  been  found  in  a  hernial  sac 
alone,  or  in  the  region  of  the  caecum  and  appendix,  or  on  the  epiploon.  There 
are  instances  in  which  this  membrane  has  been  gradually  curled  and  rolled 
until  it  forms  a  ridge-like  tumor  lying  across  the  upper  portion  of  the  abdomen. 
This  chronic  adhesive  form  is  not  so  frequent  in  children  as  in  adults.  The 
symptoms  are  very  indefinite.  The  abdomen  is  usually  distended  and  tym- 
panitic, everywhere  resonant,  sometimes  distinctly  painful  on  pressure.  In 
protracted  cases  the  omentum  may  be  felt  as  a  firm  ridge  in  the  upper  portion 
of  the  abdomen.  The  general  symptoms  are  very  variable.  There  may  be 
wasting  and  cachexia,  sometimes  with  marked  fever,  though  these  chronic 
adhesive  forms  are  not  infrequently  afebrile  throughout,  or  the  temperature, 
indeed,  may  be  subnormal.  With  the  exception  of  the  colicky  pains  there 
may  be  no  symptoms  directly  from  the  peritoneum,  but  the  cases  are  very  often 
complicated  with  tubercles  in  other  parts,  and  the  mesenteric  glands  or  the 
lungs  may  be  extensively  diseased.  These  are  cases  in  which  spontaneous 
recovery  is  not  infrequent. 

Diagnosis. — A  gradually  developing -ascites  in  a  young  child  with  moderate 
fever  is  in  itself  very  suggestive  of  peritoneal  tuberculosis.  Doubtless  very 
many  of  the  cases  of  simple  ascites  with  recovery  belong  to  this  disease. 

The  condition  is  to  be  distinguished  from  ascites  due  to  disease  of  the  liver 
and  from  chronic  simple  peritonitis.  Cirrhosis  of  the  liver,  syphilitic  or  sim- 
ple, is  a  rare  disease  in  children.  The  local  symptoms  may  give  us  no  clue, 
but  after  withdrawal  of  the  fluid  the  liver  in  a  cirrhotic  case  may  be  felt  to  be 
unusually  hard,  and  perhaps  small,  and  possibly,  when  due  to  syphilis,  irregu- 
lar. The  general  symptoms  are  more  important.  In  cirrhosis  there  is  more 
frequently  a  slight  jaundice.  The  fever  and  gastro-intestinal  symptoms  are 
not  so  marked.  An  encysted  exudate  is  always  in  favor  of  tuberculosis.  A 
simple  chronic  peritonitis,  though  rare,  occurs  in  children,  and,  even  after  the 
exploratory  laparotomy,  the  diagnosis  may  not  be  clear,  inasmuch  as  there  may 
be  small  nodular  fibroid  bodies  scattered  over  the  membranes.  It  is  very 
important  in  these  cases  to  have  a  careful  microscopical  examination  made,  in 
order  to  determine  the  presence  of  bacilli,  or,  if  the  nodules  are  very  firm  and 
fibroid,  the  experimental  test  should  be  made.  It  is  quite  possible  that  some 
instances  of  reported  recovery  in  peritoneal,  tuberculosis  after  laparotomy  may 
have  been  instances  of  this  chronic  simple  peritonitis  with  fibroid  nodules. 
The  ulcerative  form  with  suppuration  and  the  development  of  nodular  masses 
in  the  peritoneum  with  fever  and  a  marked  cachexia,  rarely  offers  the  slightest 
difiiculty  in  diagnosis.  It  is  to  be  remembered,  of  course,  that  the  suppurative 
forms  also  may  be  encysted,  and  the  periumbilical  abscess  with  umbilical 
fistula,  simple  or  stercoral,  is  almost  constantly  tuberculous. 

Prognosis. — The  prognosis  is  often  good,  particularly  in  the  ascitic  and 
chronic  adhesive  varieties.  Many  instances,  no  doubt,  in  which  the  ascites 
has  gradually  disappeared  have  been  tuberculous,  and  even  in  the  ulcerative 
variety,  when  the  abscess  has  discharged  at  the  navel,  recovery  has  followed. 
The  operation  of  incision  and  drainage  has  certainly  favored  recovery  in  a  con- 
siderable number  of  cases. 

Treatment. — The  general  treatment  of  tuberculosis  will  be  discussed  at 
the  end  of  the  section ;  here  reference  will  be  made  more  particularly  to  incis- 


292    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ion  and  drainage  in  tuberculous  peritonitis.  The  results  which  have  been 
obtained  are  exceedingly  satisfactory,  even  if  we  suppose,  as  is  probable, 
that  many  cases  relapse  and  are  not  fully  healed  at  the  time  of  reporting. 
The  figures  given  in  the  monograph  of  Aldibert  are  extremely  interesting:  in 
the  ascitic  form,  of  32  instances  in  which  laparotomy  was  performed,  there 
were  3  deaths  and  29  recoveries,  4  of  which  had  persisted  for  more  than  one 
year.  This  demonstrates  the  impunity  with  which  the  abdominal  cavity  may 
be  opened,  and  the  large  percentage,  at  any  rate,  of  those  which  are  benefited 
immediately  by  the  operation.  In  the  chronic  adhesive  form  an  operation  is  really 
not  indicated,  as  in  the  majority  of  the  instances  the  tuberculosis  is  in  pro- 
cess of  healing,  but  there  are  cases  in  which  pain,  associated  with  the  adhesions, 
has  been  relieved  by  an  exploratory  incision.  In  the  ulcerative  variety,  when 
generalized,  the  results  have  not  been  so  satisfactory,  but  many  instances  with 
an  encysted  purulent  fluid  have  been  opened  and  drained  successfully.  The 
drainage  favors  the  process  of  cicatrization  in  the  tubercle,  lessens  the  tendency 
to  effusion,  and  exerts  a  favorable  influence  on  the  whole  process.  Of  the  52 
cases  in  children  in  which  laparotomy  was  performed,  there  were  45  recoveries 
and  7  deaths.  Of  these  45,  9  had  persisted  for  more  than  a  year,  and  2  for 
more  than  two  years  (Aldibert). 

(3)  Tuberculosis  of  the  Lungs. 

In  speaking  of  acute  miliary  tuberculosis  and  of  chronic  diffuse  tuberculosis 
we  have  considered  affections  in  which  the  lungs  are  almost  constantly  involved 
— in  the  one  case  the  seat  of  miliary  granules  ;  in  the  other  of  larger,  coarse, 
grayish-yellow  tubercles.  We  shall  speak  in  this  section  more  particularly  of 
those  forms  in  Avhich  the  lungs  are  so  involved,  that  the  clinical  features  are 
those  of  an  acute  or  of  a  chronic  pulmonary  disease.  Two  groups  of  cases  may 
be  recognized :  the  acute  tuberculous  broncho-pneumonia,  and  the  chronic 
ulcerative  form,  the  first  corresponding  to  the  acute  galloping  phthisis,  and 
the  other  to  the  chronic  phthisis,  or,  as  Ave  call  it  now,  chronic  pulmonary 
tuberculosis. 

{a)  Acute  Tuberculous  Broncho-pneumonia. — In  infants  and  children 
we  very  rarely  see  pulmonary  tuberculosis  set  in  Avith  the  clinical  picture  of 
an  acute  lobar  pneumonia.  Personally,  I  never  remember  to  have  met  with  an 
instance,  such  as  is  not  very  rare  in  adults,  in  which  the  tuberculosis  came  on 
abruptly,  and  at  first  ran  the  course  of  an  ordinary  lobar  pneumonia,  with  pain 
in  the  side,  high  fever,  and  rapid  consolidation  of  an  entire  lobe.  Such  cases 
are,  however,  on  record,  and  it  is  only  the  absence  of  the  crisis,  the  persistence 
of  the  local  signs,  the  gradual  softening,  and  the  development  of  hectic  and 
progressive  debility  Avhich  lead  to  a  revision  of  the  diagnosis.  It  is  to  be 
remembered  that  Avhile  clinically  the  physical  signs  may  be  those  of  a  lobar 
affection,  anatomically  it  is  clearly  seen  that  many  groups  of  lobules  are 
involved,  separated  by  strands  of  air-containing  or  collapsed  lung-tissue.  These 
pseudo-lohar  cases  are  almost  impossible  to  differentiate  during  life. 

Tuberculous  bi'oncho-pneumonia  is  common  in  children  from  the  sixth 
month  to  the  fifth  year.  A  large  proportion  of  the  cases  occur  after  the  sec- 
ond year. 

The  disease  is  most  common  in  children  in  institutions,  in  those  debilitat'Cd 
by  previous  illnesses,  and  more  particularly  in  convalescents  from  one  of  the 
infectious  diseases — measles,  whooping-cough,  scarlet  fever,  or  diphtheria.  It 
is  most  frequent  perhaps  after  measles  and  whooping-cough.  Its  sequence  in 
the  latter  disease  has  been  common  knowledge  in  the  profession  since  the  days 


TUBERCULOSIS.  293 

of  Willis,  whose  axiom,  "  Tussis  convulsiva  vestibulum  tabis,"  has  been  quoted 
through  two  centuries.  Children  the  subject  of  chronic  naso-pharyngeal 
catarrh  and  tonsillitis,  and  mouth-breathers  seem  more  prone  to  the  affection. 
But  it  is  to  be  remembered  that  it  may  develop  in  perfectly  healthy,  well- 
nourished  children. 

And  lastly,  like  miliary  tuberculosis,  it  may  be  a  terminal  process  in  cases 
in  which  local  tuberculous  disease  exists  in  other  parts — the  skin,  bones,  lymph- 
glands,  or  the  urogenital  tract. 

Morbid  Anatomy. — The  condition  varies  considerably  with  the  inten- 
sity and  duration  of  the  process.  The  lungs  may  be  voluminous  and  crepitant, 
with  firm  and  nodular  masses  scattered  throughout  the  lobes.  On  section  these 
are  seen  to  be  peribronchial  nodules  ranging  in  size  from  a  pea  to  a  walnut. 
Some  of  the  more  recent  are  reddish  in  color  ;  the  older  are  grayish-yellow, 
with,  perhaps,  central  softening.  Many  of  these  peribronchial  nodules  are 
seen  to  be  composed  of  aggregations  of  tubercles  undergoing  caseation.  In 
the  very  acute  cases  the  process  is  more  extensive  in  the  upper  lobes  or  central 
portion  of  the  lungs,  certain  parts  of  which  may  be  almost  solid  and  scarcely 
contain  any  air.  The  consolidation  may  indeed  look  uniform,  but  on  section 
it  is  noted  that  the  process  is  not  actually  diffuse,  as  in  a  lobar  pneumonia,  but 
the  general  consolidation  has  arisen  from  the  involvement  of  a  very  large  num- 
ber of  the  lobules,  groups  of  which  are  separated  by  strands  of  reddish  col- 
lapsed tissue.  The  consolidated  areas  have  undergone  caseation,  and  may  in 
places  have  softened,  forming  cavities.  The  older  the  process  the  more  exten- 
sive usually  are  the  areas  of  caseation.  Though  primarily  tuberculous,  many 
of  these  cases  show  a  mixed  infection,  and  there  may  be  areas  of  simple 
broncho-pneumonia  due  to  streptococci,  staphylococci,  or  pneumococci.  The 
pleura  may  show  many  nodules  or  a  fresh,  fibrinous  exudate,  sometimes  a  sero- 
fibrinous or  even  purulent  exudate.  The  bronchial  and  tracheal  glands  are 
enlarged,  tumefied,  and  studded  with  tubercles  or  uniformly  caseous,  not  infre- 
quently having  softened  to  form  definite  abscess.  The  glands  at  the  hilus 
may  be  greatly  enlarged  and  extend  deeply  between  the  lobes,  and  in  some  in- 
stances there  would  appear  even  to  be  an  invasion  of  the  lung-tissue  from  these 
deeply-placed  large  caseous  glands.  The  other  organs  may  present  a  few 
scattered  tubercles  or  there  may  be  a  generalized  miliary  tuberculosis. 

As  in  other  forms  of  broncho-pneumonia,  the  essential  lesion  is  a  bron- 
chitis and  peribronchitis  excited  by  the  tubercle  bacilli,  with  inflammation 
of  the  contiguous  air-cells,  which  become  filled  with  epithelial  products,  the 
so-called  catarrhal  alveolitis.  The  accompanying  phenomena  of  atelectasis  and 
emphysema  occur  just  as  in  simple  broncho-pneumonia,  and  the  distinguishing 
features  are  the  caseation  and  necrosis  with  the  presence  of  the  bacilli. 

Much  discussion  has  taken  place  upon  the  relation  of  broncho-pneumonia 
to  tuberculosis,  and  some  French  observers  have  maintained  that  in  many 
instances  the  form  following  measles  and  diphtheria,  and  which  anatomically 
looks  simple  in  character,  is  in  reality  tuberculous  and  due  to  the  bacilli.  It 
may  be  difiicult  sometimes  to  determine  whether  a  given  patch  of  broncho- 
pneumonia is  tuberculous  or  not,  but  as  a  rule,  macroscopically,  there  will  be 
seen  small  tubercles  or  areas  of  caseation,  while  in  stained  sections  the  bacilli 
are  readily  demonstrable.  The  simple  broncho-pneumonia  in  some  cases  pre- 
cedes the  tuberculous,  particularly  after  measles,  scarlet  fever,  diphtheria,  and 
whooping-cough.  In  institutions  it  is  by  no  means  uncommon  to  meet  with  cases 
in  which  broncho-pneumonia  has  gradually  subsided,  and  then  symptoms  have 
developed  pointing  to  fresh  invasion,  and  ultimately  death  follows  with  the 
lesions  of  an  acute,  recent,  tuberculous  broncho-pneumonia.      Sometimes  the 


294    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

infection  is  less  intense,  and  a  subacute  or  chronic  pulmonary  tuberculosis  is 
established.  In  cases  of  tuberculosis  consecutive  to  broncho-pneumonia  we 
find  the  lesions  of  two  sorts :  simple,  inflammatory,  non-tuberculous,  such  as 
peribronchial  suppuration,  dilatation  of  the  bronchi,  lesions  of  the  alveolar  epi- 
thelium, and  peribronchial  and  peri-alveolar  sclerosis ;  then,  in  addition,  there 
are  the  ti'ue  tuberculous  processes,  peribronchial  nodules,  tuberculous  infiltra- 
tion, and  caseous  areas  (Mosny). 

In  other  instances  the  tuberculosis  precedes  the  broncho -pneumonia. 
This  is  met  with  particularly  in  children  the  subject  of  latent  tuberculosis,  in 
whom,  following  one  of  the  infectious  diseases,  a  simple  broncho-pneumonia 
develops.  According  to  Mosny,  the  lesions  may  be  seen  as  an  alveolitis 
surrounding  the  tuberculous  peribronchial  nodules,  or  foci  of  simple  and  tuber- 
culous broncho-pneumonia  occur  scattered  throughout  the  apices  of  the  lung. 
It  is  a  broncho-pneumonia  dependent  upon  pneumococci  or  streptococci  invading 
a  lung  already  the  seat  of  local  tuberculosis. 

Symptoins. — Clinically,  tuberculous  broncho-pneumonia  scarcely  differs  in 
any  feature  from  the  simple  form.  The  onset  may  be  acute  in  a  previously  healthy 
child,  but  more  frequently  the  disease  sets  in  during  convalescence  from  one  of  the 
infectious  diseases.  In  the  tuberculous  form  the  fever  is  sometimes  not  so  high 
and  not  so  persistent,  showing  more  variations  throughout  the  day.  Cough  and 
dyspnoea  are  prominent  symptoms.  The  physical  signs  are  those  of  broncho- 
pneumonia. The  localization  of  the  lesion  is  more  commonly  at  the  apices  of 
the  lung,  where  there  may  be  signs  of  consolidation  with  fine  crepitant  and  sub- 
crepitant  rales.  There  are  no  physical  signs  of  any  moment  in  differentiating 
a  simple  from  a  tuberculous  broncho-pneumonia,  and  indeed  even  the  local- 
ization of  the  disease  at  the  apex,  upon  which  so  much  stress  is  laid,  is  not  of 
very  much  value,  since  we  frequently  find  in  young  children  a  tuberculous 
process  beginning  at  the  base  or  in  the  central  portions  of  the  lung.  In  the 
course  of  the  disease,  however,  indications  of  great  value  develop ;  thus  toward 
the  end  of  the  second  week  there  are  more  marked  oscillations  in  temperature, 
often  with  profuse  sweats.  The  child  emaciates  rapidly,  and  there  may  some- 
times develop  signs  indicating  softening.  In  the  acute  cases  the  duration  is 
from  three  to  five  weeks.  Throughout  the  course  of  the  disease  there  may  be 
no  single  indication  of  much  value  in  definitely  determining  the  nature,  and  we 
often  have  to  depend  more  on  the  general  features  of  the  case.  Careful  inqui- 
ries should  be  made  as  to  heredity  ;  also  the  personal  history  immediately 
preceding  the  onset.  Sometimes  important  information  may  be  gathered  by  a 
systematic  examination  of  the  child.  There  may  be  a  tuberculous  adenitis, 
local  bone  disease,  or  a  tuberculous  testis.  Simple  broncho-pneumonia  tends 
as  a  rule  to  recovery ;  in  exceptional  cases,  however,  it  becomes  subacute,  and 
ultimately  chronic.  In  the  more  subacute  and  chronic  cases  tuberculous 
broncho-pneumonia  may  present  large  areas  of  caseation,  which  give  the 
physical  signs  of  consolidation,  perhaps  of  an  entire  lobe.  In  such  instances 
softening  and  the  signs  of  cavity  not  infrequently  develop,  and  give  very 
definite  indications  of  the  nature  of  the  process.  As  the  little  patients  rarely 
expectorate,  examination  for  bacilli  can  seldom  be  made.  Sometimes,  if 
vomiting  occurs,  portions  of  mucus  may  be  picked  out,  and  important  evi- 
dence in  this  way  obtained. 

{h)  Chronic  Pulmonary  Tuberculosis.  —  In  infants  and  very  young 
children  we  find  the  lungs  either  involved  in  a  generalized  tuberculosis  or  the 
seat  of  an  acute  tuberculous   broncho-pneumonia.     After  the  sixth   or  eighth 


TUBERCULOSIS.  295 

year  cases  are  not  very  uncommon  in  which  the  picture  resembles  that  of 
chronic  tuberculosis  pulmonum  of  the  adult. 

Morbid  Anatomy. — The  lesions  are  similar  to  those  met  with  in  the  tuber- 
culosis of  adults — miliary  tubercles,  peribronchial  nodules,  caseous  blocks, 
areas  of  softening  and  of  fibroid  induration,  and  cavities  of  various  sizes.  We 
do  not  see  so  frequently  the  invasion  of  the  lung  from  the  apex  downward. 
The  chief  seat  of  disease  may  be  in  the  central  portion  of  the  lung,  or  even  at 
the  base.  As  already  mentioned  in  speaking  of  tuberculosis  of  the  lymph- 
glands,  the  groups  along  the  trachea  and  about  the  bronchi  may  be  greatly 
enlarged  and  caseous,  forming  on  section  a  very  striking  feature  in  the  chronic 
pulmonary  tuberculosis  of  children.  Indeed,  in  some  instances  the  process 
seems  to  spread  directly  from  the  deeply-placed  glands  in  the  hilus  of  the  lung, 
which  may  be  enormously  enlarged,  uniformly  caseous,  and  the  organ  may  be 
directly  invaded  from  them.  Large  areas  of  caseous  pneumonia  are  not  uncom- 
mon, and  often  present  foci  of  softening.  Small  cavities  are  by  no  means  infre- 
quent in  chronic  pulmonary  tuberculosis  of  children,  but  very  large  excavations 
are  rare ;  thus  in  the  265  cases  noted  by  Barthez  and  Sann^  there  were  77 
cases  with  excavation,  chiefly,  too,  in  the  upper  lobes.  In  the  analysis  by 
Leroux  of  the  cases  of  the  late  Professor  Parrot,  in  219  children  under  two 
years  of  age  there  were  57  instances  in  which  cavities  existed.  In  5  of  these 
the  children  were  under  three  months.  In  long-standing  cases  hard,  firm, 
fibrous  tubercles  are  found,  and  sometimes  cretaceous  nodules.  The  primary 
lesion  in  a  great  majority  of  instances  is  a  tuberculous  broncho-pneumonia, 
taking  its  origin  in  the  smaller  bronchioles,  leading  to  peribronchial  nodules 
and  subsequent  peribronchial  alveolitis. 

Symptoms. — The  general  symptomatology  of  chronic  pulmonary  tuber- 
culosis in  the  child  is  similar  in  essential  details  to  that  of  the  adult,  but  pre- 
sents, however,  as  might  be  expected,  certain  peculiarities.  The  onset  is  gener- 
ally more  abrupt,  and  the  first  symptoms  may  be  those  of  a  broncho-pneumonia 
at  the  apex.  The  child  may  have  been  in  failing  health  or  come  of  a  markedly 
tuberculous  stock,  or  there  may  have  been  local  glandular  or  bone  disease. 
Occasionally  failing  health,  with  repeated  attacks  of  chills  and  fever,  may  arouse 
the  suspicion  of  malaria,  but  this  mode  of  onset  is  not  so  frequent  as  in  adults. 
Some  cases  follow  a  protracted  naso-pharyngeal  catarrh  with  recurring  bron- 
chitis. Progressive  failure  in  health  and  strength,  cough  and  fever,  are  the 
first  symptoms  to  attract  attention.  There  is  loss  of  appetite,  but  rarely  the 
extreme  anorexia  which  we  find  in  some  cases  of  pulmonary  tuberculosis  in 
older  subjects.  Cough  is  rarely  absent  among  the  initial  symptoms,  and,  with 
variations,  persists.  It  is  short  and  dry  at  first,  subsequently  looser.  It  may 
be  distributed  equally  throughout  the  day  or  is  most  troublesome  at  night,  and 
paroxysms  of  coughing  may  return  at  fixed  hours,  so  that  the  case  may  be  mis- 
taken at  first  for  whooping-cough  ;  but  there  is  never  the  noisy  crowing  inspira- 
tion. Expectoration  is  absent  in  very  young  children.  Children  above  the 
age  of  ten  can  often  be  taught  to  expectorate.  The  sputum  is  mucoid  at  first, 
with  grayish-yellow  streaks  ;  sometimes  it  is  more  sero-mucoid,  and  in  the  later 
stages  more  definitely  purulent.  Haemoptysis  may  be  said  to  be  infrequent  in 
children  under  ten.  Certainly  it  is  very  rare  at  the  onset.  It  is  usually  small 
in  amount.  The  terminal  haemoptysis,  common  in  the  adult,  but  rare  in  chil- 
dren, results  from  the  rupture  of  an  aneurism  in  a  small  cavity  or  erosion  of  a 
branch  of  the  pulmonary  artery.  The  fever  of  onset  and  during  the  early 
periods  is  remittent,  the  daily  excursions  slight — a  range  between  102°  and 
104°  is  common.  Subsequently,  when  the  disease  is  more  extensive  and  soft- 
ening has  taken  place  with  the  formation  of  cavities,  the  temperature  is  more 


296    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

hectic  in  character,  and  the  morning  observation  may  be  normal  or  subnormal, 
while  in  the  evening  the  thermometer  may  register  103.5°  or  104°,  or  even 
higher.  Chills  are  not  very  common.  Drenching  sweats  are  frequent,  par- 
ticularly toward  the  close.  Dyspnoea  may  be  present  at  the  onset  and  during 
the  early  stages,  and  may  be  due  in  part  to  the  fever,  sometimes  to  the  presence 
of  a  diffuse  bronchitis.  Marked  increase  in  the  respirations,  with  cyanosis, 
indicates  very  rapid  progress  in  the  disease.  In  protracted  cases,  just  as  in  the 
adult,  there  may  be  very  extensive  destruction  of  the  lung  without  the  slightest 
dyspnoea.  The  child  may  complain  of  pains  in  the  chest,  usually  associated 
with  pleurisy.  In  a  majority  of  instances  the  disease  is  painless  throughout 
its  course.  Qvisling  states  that  an  early  sign  is  tenderness  on  percussion  of 
the  affected  side,  or  on  pressure  in  the  intercostal  spaces,  particularly  in  the 
first  space  at  the  apex. 

Progressive  weakness  and  wasting  are  very  pronounced  symptoms,  and 
there  is  usually  progressive  pallor.  Frequently  the  abdominal  viscera  become 
involved,  and  there  is  diarrhoea  due  to  tuberculous  ulceration,  and  the  liver 
and  spleen  may  become  enlarged.  The  urine  does  not  often  show  changes,  but 
as  the  disease  progresses  albumin  is  common  and  a  secondary  nephritis  may 
develop.  A  child  may  come  under  observation  with  general  anasarca,  due 
partly  to  the  anaemia,  partly  to  the  renal  condition,  and  the  pulmonary  tubercu- 
losis may  be  entirely  overlooked. 

Physical  Sig-ns. — Inspection  frequently  shows  in  advanced  cases  an 
extremely  thin  chest,  with  marked  intercostal  spaces.  Deformities  due  to 
mouth-breathing  or  to  rickets  are  not  uncommon.  On  the  affected  side  the 
respiratory  movement  may  be  decidedly  less  marked,  or  the  clavicle  may  stand 
out  prominently ;  or  there  may  be  subclavicular  depression  at  the  affected  apex — 
a  sign  usually  of  a  chronic  process.  In  very  long-standing  cases  with  much 
fibroid  change  there  may  be  flattening  of  the  affected  side,  with  depression 
of  the  shoulder. 

By  palpatio7i  one  appreciates  any  differences  in  expansion  on  the  two  sides, 
and  the  differences  in  the  tactile  fremitus,  and  it  may  be  of  value  in  eliciting 
painful  points. 

Percussion. — In  the  early  condition,  when  the  tubercles  are  scattered  or  the 
areas  of  broncho-pneumonia  are  limited,  there  may  be  no  change  in  the  per- 
cussion note.  Indeed,  the  emphysema  about  the  affected  areas  may  cause  slight 
hyper-resonance  over  the  part  affected.  Extensive  involvement  at  one  apex 
usually  gives  loss  of  resonance  beneath  the  clavicle,  which  may  amount  to  dul- 
ness  and  is  accompanied  with  marked  increase  in  the  resistance.  Absolute 
flatness  is  rarely  met  with.  Skoda's  resonance,  the  flat  tympany,  is  not  fre- 
quent. The  cracked-pot  sound  has  very  little  value  in  children,  as  it  may 
sometimes  be  elicited  in  a  thin-walled  healthy  subject. 

Auscultation  may  give  only  the  signs  of  bronchial  catarrh,  piping  rales 
and  moist  sounds,  but  when  there  is  definite  dulness  there  is  usually  change 
in  the  character  of  the  respiratory  sounds,  which  have  lost  their  vesicular  cha- 
racter and  are  harsh,  broncho-vesicular,  or  definitely  bronchial.  Sometimes 
with  defective  resonance  there  is  enfeeblement  of  the  respiratory  murmur, 
with  prolongation  of  expiration.  The  auscultatory  phenomena  are  often  very 
deceptive.  Diffuse  bronchitis  may  lead  us  to  suppose  that  there  is  much  greater 
involvement  of  the  lung  than  in  reality  exists.  In  very  young  infants  signs  of 
cavity  are  rarely  present,  but  in  older  children  in  advanced  cases,  with  hectic 
and  emaciation,  the  metallic  splashing  or  amphoric  quality  of  the  rales,  with 
the  loud  cavernous  breath-sounds,  leaves  no  doubt  as  to  the  existence  of  a 
vomica.     In  children,  more  frequently  than  in  adults,  we  are  deceived  by  the 


TUBERCULOSIS.  297 

so-called  pseudo-cavernous  signs.  Over  an  area  of  slightly  defective  resonance 
or  of  positive  dulness  inspiration  and  expiration  are  cavernous,  the  rales  large 
and  resonant,  and  the  whispered  voice  may  be  conveyed  intensely  to  the  ear. 
In  acute  cases  with  high  fever  one  is  not  so  apt  to  be  deceived  ;  these  signs  are 
also  met  with  in  broncho-pneumonia  and  in  pleurisies. 

Course. — The  course  of  chronic  pulmonary  tuberculosis  is  more  rapid  in 
children  than  in  adults,  and  a  majority  of  cases  die  in  from  six  to  twelve  months. 
The  disease  is  marked,  now  by  intervals  of  improvement,  in  which  the  fever 
lessens  and  the  severity  of  the  symptoms  subsides,  now  by  aggravation  of  the 
local  and  constitutional  condition,  sometimes  with  attacks  in  which  the  fever  and 
dysjmoea  increase,  and  the  child  may  become  quite  cyanotic.  Some  of  these 
intercurrent  attacks  simulate  closely  acute  tuberculosis,  but  often  pass  away  at 
the  end  of  a  week  or  ten  days.  In  the  chronic  cases  they  probably  indicate 
the  invasion  of  other  portions  of  the  lung. 

Occasionally,  in  a  case  of  chronic  pulmonary  tuberculosis  extensive  fibroid 
substitution  takes  phice,  with  gradual  retraction  of  the  affected  side,  depression 
of  the  shoulder,  and  all  the  signs  of  so-called  fibroid  phthisis.  Usually  in  such 
instances  there  is  dulness  at  the  base  and  side  with  modified  resonance,  and 
cavernous  signs  at  the  apex.  When  involving  the  left  lung,  the  heart  is  drawn 
ovei%  and  there  may  be  a  very  extensive  cardiac  pulsation  from  the  second  to 
the  fifth  interspaces.  A  child  may  gradually  regain  a  fair  measure  of  health 
and  for  years  live  a  tolerably  comfortable  life,  troubled  only  by  one  or  two 
spells  of  coughing  through  the  day.  There  may  be  dyspnoea  on  exertion,  and 
gradually  the  terminal  phalanges  become  clubbed.  Hemoptysis  is  rare,  but 
occasionally  terminates  the  case. 

Diagnosis. — Progressive  emaciation  with  hectic  and  cough  in  a  child  should 
always  arouse  the  suspicion  of  chronic  pulmonary  tuberculosis.  In  the  early 
stages  the  condition  is  usually  that  of  tuberculous  broncho-pneumonia.  Care- 
ful and  repeated  physical  examination  may  be  necessary  to  establish  the  diag- 
nosis, and  one  should  take  into  consideration  carefully  the  condition  of  the 
other  organs.  The  position  of  the  physical  signs  at  the  apex  or  central  portions 
of  the  lung,  the  increased  fremitus,  the  moist  sounds,  are  all  suggestive,  and 
frequently  one  may  trace  the  progressive  character  of  the  lesion.  The  disease 
most  frequently  confounded  is  empyema,  but  here  the  movable  dulness.  the 
bulging  of  the  intercostal  spaces,  and  the  absence  of  fremitus  are  valuable 
points. 

Auscultation  is  an  extremely  fallacious  guide,  and  in  several  instances  the 
persistence  of  a  loud,  almost  cavernous,  respiratory  murmur  at  the  base  has  led 
the  practitioner  astray.  When  in  doubt  the  exploratory  needle  should  be  freely 
used  for  the  purpose  of  diagnosis.  The  differentiation  of  chronic  simple  broncho- 
pneumonia sometimes  gives  a  great  deal  of  trouble,  and  the  time  element  alone 
may  determine  whether  we  have  to  do  with  a  tuberculous  process  or  not.  These 
are  the  very  instances  in  which  any  fragments  of  sputum  should  be  carefully 
sought  for  and  examined.  In  a  paroxysm  of  coughing  the  child  may  bring 
up  a  mouthful  of  food,  and  with  it  the  expectoration,  which  should  be  carefully 
picked  out  and  examined  for  tubercle  bacilli. 

Prognosis. — The  prognosis  in  a  large  majority  of  the  cases  is  bad.  particu- 
larly when  hectic  is  established  and  there  is  disorganization  of  one  lung.  On 
the  other  hand,  when  cases  are  seen  early  and  placed  under  suitable  conditions 
recovery  may  take  place.  The  large  number  of  individuals  whose  lungs  and 
bronchial  glands  present  traces  of  old  tuberculous  pi'ocesses  shows  how  con- 
siderable a  proportion  of  all  those  who  are  infected  must  survive.  We  do  not 
see  many  cases  of  chronic  pulmonary  tuberculosis  in  children  between  the  ages 


298    A3fERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  six  and  fifteen,  for  the  reason,  no  doubt,  that  the  tuberculous  broncho- 
pneumonia is  so  often  an  acute  process,  carrying  off  the  victim  before  it  has 
assumed  the  characters  of  a  chronic  affection. 

(4)  Tuberculosis  of  the  Pleura. 

This  is  usually  secondary  to  existing  disease  in  the  lung  or  in  the  bronchial 
glands.  A  certain  number  of  acute  serofibrinous  pleurisies  in  children  may 
be,  as  in  the  adult,  due  to  tuberculosis :  but  the  cases,  as  a  rule,  run  a  favor- 
able course,  and  unless  the  child  has  definite  manifestations  of  tuberculosis  in 
other  parts  the  assumption  in  any  given  case  is  of  course  purely  gratuitous. 
Purulent  pleurisies  in  children  are  most  commonly  associated  with  lobar  or 
broncho-pneumonia,  but  in  a  certain  proportion  of  the  cases  the  process  is  tuber- 
culous. The  disease  is  usually  latent,  and  failing  health,  pallor,  and  shortness 
of  breath  are  the  symptoms  for  which  relief  is  sought.  The  general  symptom- 
atology and  diagnosis  of  tuberculous  pleurisy  are  practically  those  of  the  simple 
forms  which  are  elsewhere  considered. 

(5)  Tuberculous  Pericarditis. 

This  is  by  no  means  rare  in  children,  and  cases  have  been  reported  in 
infants  under  a  year.  In  65  cases  collected  from  the  literature  by  Brackman, 
19  were  in  children.  The  disease  is  associated  in  almost  all  instances  with 
tuberculosis  of  the  mediastinal  or  bronchial  glands.  An  enlarged  and  softened 
gland  may  perforate  the  pericardium  and  produce  an  acute  sero-fibrinous  or 
suppurative  inflammation;  and  no  doubt  a  considerable  number  of  all  the  cases 
of  so-called  idiopathic  suppurative  pericarditis  have  been  due  to  this  cause. 
The  tuberculous  process  may  slowly  invade  the  pericardium  from  the  medias- 
tinal glands,  and  produce  a  chronic  adhesive  pericarditis,  leading  to  great 
thickening  of  the  membranes  and  gradual  hypertrophy  of  the  heart.  The 
patient  may  die  with  all  the  symptoms  of  cardiac  dropsy. 

(6)  Uro-genital  Tuberculosis. 

{a)  Tuberculosis  of  the  Kidneys. — As  part  of  a  general  diffuse  tuber- 
culosis these  organs  are  very  frequently  affected — more  commonly,  indeed,  than 
in  adults.  Usually  there  are  scattered  gray  tubercles  or  coarse  yellow^  nodules 
in  the  cortical  substance.  Sometimes,  however,  the  lesion  is  primary,  and  one 
or  other  kidney  is  extensively  diseased.  The  affection  in  these  cases  appears 
to  begin  in  the  papillae  and  calices,  gradually  invades  the  substance,  and  may 
ultimately  destroy  the  entire  organ,  converting  it  into  a  series  of  excavations 
containing  a  cheesy  material.  When  confined  to  one  kidney,  this  (known  as 
the  serofulous  kidney)  is  sometimes  met  with  in  children,  the  other  kidney  being 
healthy  and  greatly  enlarged.  When  there  is  extensive  tuberculous  pyelo- 
nephritis there  is  often  pain  over  the  kidney;  the  urine  contains  pus,  very 
rarely  blood.  Irregular  fever  and  chills  are  common.  Frequent  micturition 
may  lead  to  the  diagnosis  of  cystitis,  with  Avhich,  of  course,  it  is  frequently 
associated;  but  it  is  to  be  borne  in  mind  that  in  connection  Avith  either  calcu- 
lous or  tuberculous  pyelitis  frequent  micturition  may  be  a  marked  symptom. 
Sometimes  the  tuberculous  organ  is  large  enough  in  a  child  to  be  palpable. 
Tuberculosis  rarely  produces  so  extensive  pyonephrosis  as  that  due  to  stone. 

The  diagnosis  can  rarely  be  made  from  calculous  pyelo-nephritis  except  by 
the  detection  of  bacilli  in  the  urine. 


TUBEBCUL  0SI8.  299 

Tuberculosis  of  the  ureters  and  bladder,  very  rare  as  a  primary  affection, 
is  nearly  always  secondary  to  disease  of  the  pelvis  of  the  kidney,  sometimes  to 
disease  of  the  prostate. 

(h)  Tuberculosis  of  the  Testis. — Disseminated  miliary  tubercles  may  be 
present  in  the  testicles,  but  primary  tuberculosis  of  these  organs  is  not  at  all 
rare  in  children.  Dreschfeld  has  reported  an  instance  of  congenital  tubercu- 
losis of  the  testis.  Many  cases  have  been  reported  of  late  years.  Of  20  cases 
by  Jullien,  6  were  under  one  year,  and  6  between  one  and  two  years.  Both 
organs  may  be  affected.  The  disease  most  commonly  develops  in  the  tunica 
albuginea  or  in  the  epididymis,  and  may  lead  to  the  formation  of  hard  circum- 
scribed tumors.  In  other  instances  the  process  may  be  more  diffuse.  When 
the  nodular  masses  are  large  the  testis  may  have  a  dumb-bell  or  double  outline 
from  enlargement  of  the  epididymis.  It  is  a  serious  affection  in  children, 
usually  associated  with  tuberculous  disease  in  other  parts.  Its  existence  should 
always  be  borne  in  mind,  as  in  obscure  abdominal  or  thoracic  affections  the 
presence  of  nodular  masses  in  the  testicles  is  of  great  help  in  diagnosis.  The 
lesion  may  gradually  heal.  The  cheesy  masses  may  break  down  and  suppurate, 
and,  forming  adhesions  to  the  skin,  the  pus  discharges,  and  the  organ  may 
become  much  enlarged — the  condition  formerly  known  as  strumous  orchitis. 

(c)  Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus. — 
These  parts  are  rarely  affected  primarily  in  children.  It  is  not  very  uncom- 
mon in  generalized  tuberculosis  to  find,  even  in  infants,  a  double  salpingitis. 

IV.  Prophylaxis. 

While  the  possibility  of  inherited  transmission  from  an  infected  mother 
cannot  be  denied,  we  have  to  face  the  fact  that  in  a  large  proportion  of  all  cases 
of  tuberculosis  the  infection  is  at  the  gateways  of  the  body — namely,  in  the 
bronchial  and  mesenteric  lymph-glands — and  we  have  here  a  clue  to  the  two 
chief  sources  of  danger. 

To  ensure  freedom  from  contamination  through  the  air  the  greatest  care 
should  be  taken  to  prevent  tuberculous  patients  spitting  about  in  a  careless 
manner.  Every  part  of  the  expectoration  should  be  carefully  collected  and 
boiled,  and  the  patient's  handkerchiefs  should  be  thrown  into  boiling  water. 
The  liability  of  children  to  infection  from  this  source  is  very  much  greater  than 
that  of  adults,  possibly  on  account  of  the  intimate  relations  which  the  child 
has  to  the  members  of  the  family,  more  particularly  the  mother  should  she 
happen  to  be  diseased.  The  habit  of  young  infants,  as  they  creep  about,  of 
putting  everything  in  their  mouths  enhances  greatly  the  liability  to  con- 
tamination. 

The  second  danger  to  be  avoided  in  children  is  the  use  of  milk  from  tuber- 
culous animals.  Experiments  have  shown  the  readiness  with  which  young 
pigs  and  calves  become  infected  when  fed  on  the  milk  of  tuberculous  cows. 
We  have,  unfortunately,  no  reason  to  believe  that  children  are  less  susceptible 
than  calves.  Fortunately,  the  health  authorities  have  at  last  awakened  to  the 
importance  of  careful  inspection  of  dairy  herds.  The  safeguard  lies  in  the  use 
of  boiled  milk,  unless  the  source  is  known  to  be  free  from  all  possibility  of 
contamination.  The  infection  through  meat  is  probably  a  very  slight  danger 
in  a  community. 

Individual  prophylaxis  is  of  almost  equal  importance.  A  child  born  of 
delicate  parents  or  in  a  family  in  which  tuberculosis  has  prevailed  should  be 
reared  with  the  greatest  care.  Very  special  pains  should  be  taken  to  guard  it 
against  catarrhal  affections  of  all  sorts,  particularly  of  the  nose  and  throat,  and 


300   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

on  the  first  indication  of  mouth-breathing  a  thorough  examination  of  the  naso- 
pharynx should  be  made  and  any  adenoid  vegetations  removed ;  and  if  the 
tonsils  are  at  all  enlarged,  it  is  better  to  have  them  cut  out.  The  child  should 
live  in  the  open  air  as  much  as  possible,  and  the  nursery  should  be  thoroughly 
ventilated,  more  particularly  at  night.  The  meals  should  be  at  regular  hours, 
the  food  plain  and  nutritious.  Every  encouragement  should  be  given  to  take 
fats,  and  milk  and  cream  should  be  used  freely.  It  is  a  good  practice  for 
the  mother  to  sponge  the  throat  and  neck  of  the  child  night  and  morning 
with  cold  water. 

The  trifling  ailments  should  be  carefully  watched.  The  convalescence  from 
measles,  scarlet  fever,  diphtheria,  and  whooping-cough  should  be  specially 
guarded.  As  the  child  grows  older  a  systematically  regulated  exercise  or  course 
of  pulmonary  gymnastics  may  be  taken. 

V.  Treatment. 

Fortunately,  a  very  large  proportion  of  all  cases  of  tuberculosis  recover. 
Many  instances  of  adenitis  and  disease  of  the  bones  heal  spontaneously. 
Even  in  pulmonary  tuberculosis  it  is  remarkable  how  often  we  find  post 
mortem  evidences  of  healed  lesions,  the  percentage  in  some  series  being  as 
high  as  38.  In  fact,  one  may  say  that  in  a  very  large  number  of  all  cases 
in  which  the  bacilli  find  a  lodgment  in  the  glands  and  in  the  solid  organs, 
the  conditions  not  being  favorable,  the  growth  remains  local  and  tends  to  heal 
spontaneously.  The  essential  point  in  the  treatment  of  tuberculosis  is  the  main- 
tenance of  nutrition  at  the  highest  possible  grade.  To  aid  in  this  three  meas- 
ures are  to  be  practised  : 

First :  A  life  in  the  fresh  air  and  sunshine.  The  importance  of  environ- 
ment is  well  shown  in  Trudeau's  experiments  with  inoculated  rabbits.  Those 
confined  in  a  damp,  dark  place  succumbed  rapidly  ;  those  allowed  to  run 
wild  recovered  or  showed  very  slight  lesions.  By  far  the  most  important 
single  element  in  the  treatment  of  tuberculosis  of  all  forms  is  the  constant  inhal- 
ation of  fresh  air.  The  good  effects  obtained  at  Gobersdorf,  Falkenstein,  Saranac 
Lake,  Davos,  and  Colorado  are  due  primarily  to  the  fact  that  the  patients  live 
a  life  in  the  0|>en  air  and  sunshine.  Even  in  cities  much  can  be  done  by  insist- 
ing upon  open  windows  night  and  day,  except,  of  course,  in  the  very  inclement 
seasons.  It  is  an  easy  matter  to  protect  the  patient  from  draughts,  and  neither 
fever,  cough,  nor  night-sweats  contraindicate  in  any  way  fresh  air.  This  is  in 
reality  the  very  essence  of  the  climatic  treatment  of  tuberculosis  ;  that  other 
considerations,  such  as  moisture,  barometric  pressure,  temperature,  etc.,  are 
secondary  is  Avell  shown  by  the  fact  that  cases  of  various  types  of  tuberculosis 
recover  completeh'^  at  places  so  diametrically  opposite  as  Colorado  Springs  and 
Torquay.  The  regions  of  high  altitudes  Avith  low  barometric  pressure  are  cer- 
tainly more  stimulating,  and,  according  to  Jaccoud,  are  better  for  cases  of  early 
pulmonary  tuberculosis.  Cases  of  bone  and  gland  tuberculosis  do  remarkably 
well  at  the  Adirondacks  and  in  Colorado.  The  level  regions  with  low  barometric 
pressux-e,  such  as  Riviera,  Florida,  and  Southern  California,  are  reputed  to  be 
more  sedative  in  their  action  and  better  for  tuberculosis  in  the  more  advanced 
grades  and  with  high  fever. 

The  second  important  measure  is  feeding,  and  the  outlook  in  any  case,  par- 
ticularly of  pulmonary  tuberculosis,  depends  very  much  upon  the  stability  of  the 
digestive  poAvers.  In  no  way  does  the  open-air  treatment  do  more  good  than 
in  improving  the  appetite  and  digestion.  A  highly  nitrogenized  diet,  consist- 
ing of  broths,  eggs,  milk,  and  meat,  should  be  taken.     In  children  the  milk 


TUBERCULOSIS.  301 

diet  is  particularly  to  be  commended  while  fever  persists.  Raw  meats  scraped, 
various  meat  extracts,  and  peptones  may  be  used  when  the  digestion  is  feeble. 
In  tuberculous  children  it  is  sometimes  extremely  difficult  to  manage  the  diet, 
and  many  patients  have  an  aversion  to  the  very  articles  of  food  which  seem 
best  adapted.     Gavage  can  rarely  be  resorted  to  with  any  advantage  in  them. 

Third,  the  use  of  such  remedies  as  cod-liver  oil,  hypophosphites,  and 
arsenic,  which  improve  the  general  nutrition.  Other  measures  are  frictions, 
rubbing,  and  bathing,  all  of  which  stimulate  and  improve  the  general  metab- 
olism. 

Treatment  directed  to  the  Tuberculous  Processes. — The  specific  treatment 
by  the  tuberculin  of  Koch,  which  consists  of  a  glycerine  extract  of  the  cultures 
of  tubercle  bacilli,  has  been  practically  abandoned,  though  the  good  results 
obtained  in  the  hands  of  Trudeau  and  others  with  Hunter's  modification 
raise  the  hope  that  something  yet  may  be  accomplished  by  its  use.  Anti- 
bacillary  medication  is  as  yet  unknown,  and  the  introduction  of  various  anti- 
septic agents  by  inhalation,  subcutaneously,  or  directly  into  the  local  lesion  has 
not  been  followed  by  very  brilliant  results.  The  direct  action  of  iodoform 
on  local  tuberculosis  is  of  great  interest,  and  the  remarkable  eff'ects  in  joint 
tuberculosis  should  encourage  a  more  widespread  use  in  other  forms  of  the 
disease.  Creasote  is  a  remedy  which  is  believed  to  have  a  beneficial  action  on 
the  tuberculous  processes.  It  probably  has  no  definite  antibacillary  action, 
though  it  is  stated  to  influence  powerfully  the  secondary  and  associated  infec- 
tions so  common  in  tuberculosis.  It  seems  rather  to  act  as  a  general  nutritive 
stimulant,  improving  the  appetite,  .diminishing  the  fever,  and  promoting  tissue- 
metabolism  and,  according  to  some,  sclerotic  processes.  It  is  probably  at 
present  more  widely  used  than  any  other  single  remedy.  It  has  been  a  favo- 
rite with  some  practitioners  for  many  years,  and  its  reintroduction  has  been 
due  to  the  powerful  advocacy  of  Sommerbrodt,  Bouchard,  and  others.  It 
should  be  given  in  large  and  increasing  doses,  beginning  in  young  children 
with  a  minim  three  times  a  day,  and  increasing  to  five  or  even  ten  minims.  It 
may  be  given  in  perles,  or  in  pills  or  in  mixture ;  in  the  latter  a  convenient 
way  is  with  tincture  of  gentian,  alcohol,  and  sherry.  As  a  rule,  it  is  well  borne 
by  the  mouth.  It  may  also  be  given  in  the  form  of  inhalations,  the  so-called 
vapor  creasoti  consisting  of  creasote,  80  minims,  light  carbonate  of  magnesium, 
30  grains,  water  to  one  ounce  ;  a  teaspoonful  in  a  pint  of  water  at  140°.  Inha- 
lations with  this  are  strongly  recommended.  Intrapulmonary  or  intratracheal 
injections  of  creasote  in  oil  have  been  practised.  The  active  principle  of  it, 
guaiacol,  has  been  much  used,  both  by  the  mouth  and  hypodermatically.  Given 
in  solution,  it  may  be  made  up  with  tincture  of  gentian,  rectified  spirits,  and 
sherry.  Hypodermatically,  it  is  used  with  sterilized  olive  oil,  5  per  cent, 
solution ;  1  or  2  per  cent,  iodoform  may  be  employed  with  it,  and  1  cc.  of  the 
mixture  injected,  gradually  increasing  to  3  cc.  or  even  4  cc.  One  rarely 
sees  bad  eff'ects  from  creasote :  the  beneficial  results  are  most  marked  in  indi- 
viduals who  can  take  large  quantities  and  who  can  enjoy  the  associated 
action  of  fresh  air  and  a  good  diet.  Creasote  without  these  accessories  is  not 
of  very  great  service,  as  witnessed  in  ordinary  hospital  practice.  Patients  are 
remarkably  tolerant  of  it,  and  one  rarely  sees  any  ill  effects.  Other  balsamic 
substances,  such  as  eucalyptol,  terebene,  terebinthine,  thymol,  and  menthol, 
have  been  recommended. 

Symptomatic  Treatment. — In  this  we  shall  refer  more  particularly  to  pul- 
monary tuberculosis. 

The  fever  of  tuberculosis  is  serious  and  obstinate.  It  will  be  found  in  the 
early  stages  that  the  combination  of  rest  with  fresh  air  is  the  most  beneficial. 


302    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  child  may  be  "wrapped  up  and  taken  into  the  fresh  air  for  the  greater  part 
of  the  day.  We  have  no  thoroughly  satisfactory  medicinal  means  for  reducing 
the  temperature.  Antipyrine,  antifebrin,  and  acetanilide,  if  used  at  all,  must 
be  given  with  great  care.  Quinine  and  salicylic  acid  are  still  used  by  many 
practitioners.  When  the  temperature  is  persistently  high  in  the  early  stages 
of  tuberculous  broncho-pneumonia,  cold  in  various  forms  will  probably  be  the 
most  efficient  measure,  and  by  careful  sponging  the  temperature  may  be  reduced 
several  degrees.  The  most  satisfactory  antipyretic  is  found  in  the  fresh  air, 
more  particularly  the  change  to  a  resort  such  as  the  Adirondacks  or  Colorado. 

In  the  chronic  pulmonary  tuberculosis  of  children,  when  the  fever  is  of  a 
hectic  type,  sweating  is  a  very  troublesome  and  disagreeable  symptom,  for  which 
atropine,  aromatic  sulphuric  acid,  and  tincture  of  nux  vomica  may  be  used.  In 
young  children  great  care  should  be  taken  to  prevent  the  chilling  of  the  body 
after  a  profuse  night-sweat.  For  the  cough,  if  troublesome  at  night,  paregoric 
or  small  doses  of  Dover's  powder  may  be  used.  Codeine  or,  in  extreme  cases, 
small  doses  of  morphine  may  be  given.  Where  there  is  marked  tenderness  on 
the  chest  or  pleuritic  complications  the  cough  is  sometimes  relieved  by  mild 
counter-irritation  or  the  application  of  a  warm  poultice.  Inhalation  of  terebene 
and  oil  of  eucalyptus  may  sometimes  diminish  the  profuse  expectoration. 

Haemoptysis  in  the  pulmonary  tuberculosis  of  young  children  is  usually  a 
terminal  and  fatal  symptom,   quickly  beyond  treatment. 

The  diarrhoea  may  demand  very  careful  regulation  of  the  diet,  and  if  pro- 
fuse the  acetate  of  lead,  alone  or  with  opium,  may  be  used.  Preparations  of 
tannin  and  gallic  acid  are  also  beneficial.  In  all  tuberculous  processes  there  is 
a  more  or  less  marked  tendency  to  anaemia,  and  many  patients  improve  quickly 
under  the  administration  of  iron.  Careful  attention  should  be  paid  to  the 
gastric  symptoms.  If  the  digestion  is  pooi',  dilute  hydrochloric  acid  may  be 
used,  and  if  heartburn  and  pain  be  present  some  time  after  eating,  the  carbo- 
nate of  sodium  or  the  alkaline  mineral  waters. 


MALARIAL  FEVER. 

By  W.  S.  THAYER,  M.  D., 

Baltimore. 


Synonyms. — Intermittent  fever  ;  Swamp  or  Marsh  fever ;  Paludism  or 
Paludal  fever ;  Fever  and  ague  ;  Chills  and  fever. 

The  term  "malaria,"  which  has  been  applied  in  a  general  way  to  a  variety 
of  febrile  and  non-febrile  processes,  must  now  be  limited  to  a  certain  definite 
class  of  febrile  affections  which  we  know  to  have  a  specific  infectious  origin. 
The  specific  micro-organisms  which  are  the  cause  of  these  processes  belong  to 
the  class  of  protozoa  and  inhabit  the  blood  of  the  infected  individual. 

Etiology  and  Pathology. — The  geographical  distribution  of  the  malarial 
fevers  is  a  point  of  considerable  interest,  particularly  inasmuch  as  it  is  not 
entirely  constant.  In  Europe,  France,  Germany,  and  England  are  compara- 
tively free  from  malarial  fever,  while  in  Southern  Russia  and  Italy  the  disease 
is  very  frequent.  In  many  parts  of  Africa  and  India  some  of  the  severest 
forms  of  malaria  are  seen.  In  this  country  there  are  various  localities  in  which 
malaria  is  endemic,  particularly  in  certain  regions  in  the  Southern  States,  in 
Louisiana,  Mississippi,  Arkansas,  and  Texas.  In  the  low,  marshy  lands  along 
the  coast  throughout  the  Southern  and  Central  States  there  are  many  places 
in  which  malarial  fevers  are  common.  In  parts  of  New  England  malaria  also 
occurs,  particularly  in  the  Connecticut  Valley,  while  of  late  a  considerable 
number  of  cases  has  been  seen  along  the  course  of  the  Charles  River  in 
Massachusetts.  In  New  York  City  the  disease  is  rare,  though  certain  low- 
lying  districts  in  the  neighborhood  give  rise  to  a  number  of  cases.  In  Phila- 
delphia the  disease  is  perhaps  more  frequently  seen,  but  most  of  the  cases  in 
that  city  come  from  outlying  districts.  In  parts  of  Baltimore  also  malarial 
fever  occurs,  though  a  great  majority  of  the  cases  come  from  the  districts  bor- 
dering on  Chesapeake  Bay.  In  the  Western  States  malaria  is  less  common,  but 
in  certain  parts  about  the  Great  Lakes  it  is  more  or  less  prevalent. 

A  very  interesting  point  in  connection  with  the  geographical  distribution 
of  malarial  fever  is  the  manner  in  which  the  disease  wanders  from  one  region 
to  another,  diminishing  greatly  in  intensity  or  almost  dying  out  in  a  district 
where  it  has  formerly  been  endemic,  and  developing  perhaps  in  a  region  where 
it  has  been  for  many  years  an  unknown  disease.  An  instance  of  this  is  the 
appearance  during  the  last  five  or  six  years  of  malarial  fever  along  the  basin 
of  the  Charles  River  in  Massachusetts,  where  it  had  been  for  many  years 
unknown.  Again,  in  districts  in  which  malarial  fever  has  for  years  been 
endemic  there  seem  to  be  cycles  in  which  the  intensity  of  the  process  increases 
and  diminishes. 

Malarial  fever  is  particularly  prevalent  in  low,  swampy,  and  badly-drained 
districts,  and  especially  in  areas  which  are  rich  in  vegetable  matter  and  have 

303 


304    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

been  allovred  to  fall  out  of  cultivation.  It  is  much  more  prevalent  in  tropical 
or  semitropical  regions,  and  is  more  severe  in  climates  where  the  moisture  is 
considerable.  It  has  been  thought  that  winds  have  possibly  some  connection 
with  the  carrying  of  the  contagion  ;  for  instance,  in  some  malarial  districts  the 
residents  on  one  side  of  a  stream  may  be  relatively  free  from  the  disease,  while 
those  upon  the  other  side,  toward  which  the  prevailing  winds  blow,  may  suffer 
considerably.  The  danger  of  contracting  malarial  fever  is  apparently  greater 
among  those  living  in  the  lower  stories  of  a  house  than  in  the  upper. 

In  temperate  climates  the  frequency  of  the  malarial  fevers  varies  greatly 
with  the  seasons.  The  majority  of  cases  occurs  in  the  late  summer  and  fall, 
though  a  certain  number  develops  in  the  spring  and  early  summer,  while  in 
the  winter  it  is  very  rare.  In  tropical  climates,  where  the  disease  occurs  all 
the  year  round,  the  greater  number  of  cases  is  seen  in  the  fall  and  spring 
months. 

The  Specific  Micro-organism. — All  our  accurate  knowledge  of  the  causal 
element  of  malarial  fever  dates  from  the  discoveries  of  Laveran  in  1880. 
While  studying  malarial  fever  in  Algiers,  Laveran  discovered  certain  pig- 
mented bodies  in  the  blood  of  affected  individuals.  These  bodies  had  long 
been  observed  by  others,  and  by  some  accurately  described,  and  even  pictured, 
but,  while  the  older  observers  considered  them  to  be  altered  blood-corpuscles, 
Laveran  recognized  them  as  parasites,  and  asserted  that  they  were  the  definite 
exciting  agent  of  malarial  fever.  These  discoveries  have  been  confirmed  by 
numerous  other  observers  in  Italy,  the  United  States,  Russia.  Germany,  and 
India.  In  this  country  Councilman,  Abbott,  Osier,  James,  and  Dock  have 
made  valuable  observations.  Laveran  and  his  school  have  published  careful 
and  accurate  descriptions  of  the  different  forms  of  the  parasite,  which  may  be 
seen  in  the  blood,  but  they  assert  that  they  are  unable  to  associate  any  definite 
types  of  organism  with  distinct  types  of  fever.  From  the  observations  which 
have  been  made,  however,  by  the  numerous  Italian  observers,  led  by  Golgi, 
there  can  be  to-day  little  doubt  that  certain  definite  types  of  the  organism  are 
associated  with  certain  definite  types  of  fever. 

In  this  country,  as  in  Italy,  there  are  several  main  types  of  fever : 

(1)  The  milder  forms  of  intermittent  fever,  which  form  the  great  majority 
of.  the  cases  in  the  spring  and  early  summer,  but  which  occur  at  all  malarial 
seasons :  (a)  tertian  and  double  tertian  (quotidian)  fever ;  (b)  quartan  fever, 
with  its  combinations. 

(2)  The  more  severe,  often  more  or  less  irregular,  fevers  which  occur  here, 
as  in  Italy,  more  commonly  in  the  later  summer  and  fall — the  festivo-autumnal 
fevers  of  the  Italians,  the  tropical  malaria  of  the  Germans.  This  type  of 
fever  includes  the  so-called  remittent  malarial  fevers  as  well  as  most  of  the 
cases  of  pernicious  malaria  and  of  the  malarial  cachexise.  Some  of  the  Italian 
observers  have  attempted  to  divide  these  fevers,  again,  into  (c)  quotidian  fever, 
and  (rZ)  malignant  tertian  fever.  In  this  country,  however,  we  see  probably 
only  the  quotidian  type.  "With  each  of  these  types  of  fever  is  associated  a  dis- 
tinct type  of  the  specific  micro-organism. 

(a)  The  Parasite  of  Tertian  Fever. — Golgi  was  the  first  observer  who 
accurately  described  and  differentiated  the  organisms  of  the  tertian  and  of  the 
quartan  forms  of  malarial  fever,  and  his  admirable  observations  have  remained 
practically  unassailed.  If  we  examine  the  blood  from  a  case  of  tertian  fever 
just  after  the  paroxysm,  we  find  in  certain  of  the  red  blood-corpuscles  small 
round,  colorless  bodies  (Fig.  1,  ^'  -•  ^)  which  appear  to  have  a  slight  depres- 
sion in  the  centre,  and  when  stained  in  dried  specimens  show  a  paler  central 
area  with  a  darker  periphery.     These  bodies,  examined  in  the  fresh  specimen, 


MALARIAL    FEVER.  305 

show  active  amoeboid  movements.  A  few  hours  later  the  organism  will  be 
found  to  have  increased  somewhat  in  size,  and  to  contain  a  few  fine  brownish 
pigment-granules  which  dance  actively  under  the  eye  (Fig.  1,  *),  the  motion 
probably  being  due  to  undulatory  movements  in  the  protoplasm.  On  the 
day  between  the  paroxysms  the  bodies  will  be  found  to  have  about  half 
filled  the  red  corpuscle  (Fig.  1,  ^).  They  are  still  actively  amoeboid,  and 
the  number  of  pigment-granules  has  considerably  increased.  The  red  cor- 
puscle at  this  stage  will  be  seen  to  be  a  trifle  larger  than  its  unaffected 
neighbors,  and  to  be  considerably  decolorized.     On  the  day  of  the  paroxysm 

Fig.  1. 


%^ 


•s,. 


■:7 


12 


o 


1^^ 


%T^       "m^        O         A 


The  Parasite  of  Tertian  Intermittent  Fever  (drawings  made  from  the  blood  of  patients  in  the  Johns  Hop- 
kins Hospital,  with  the  camera  lucida.  Winekel,  1-14  oil  immers.  lens,  4  eye-piece) :  1,  2,  3,  hyaline 
intracellular  amceboid  bodies,  seen  during  the  febrile  stage  of  the  paroxysm ;  4,  6,  half-grown  bodies 
seen  on  the  day  between  paroxysms  ;  6,  the  same,  further  advanced ;  7,  full-grown  body  seen  during 
the  paroxysm ;  8,  segmenting  body  seen  during  the  paroxysm  ;  traces  of  the  red  corpuscle  still  seen 
about  the  organism  ;  9, 10,  segmenting  border  further  advanced ;  11, 12,  extracellular  pigmented  bodies, 
regenerative  forms ;  13,  flagellate  body  (somewhat  diagrammatic,  not  drawn  with  the  camera  lucida). 

the  organism  has  entirely  filled  and  almost  destroyed  the  red  blood-corpuscle, 
which  is  represented  only  by  a  faint  pale  rim  about  the  full-grown  parasite, 
if  indeed  it  has  not  entirely  disappeared  (Fig.  1,  '^).  The  pigment-granules 
may  show  at  this  stage  a  very  active  motion,  but  the  amoeboid  movements 
of  the  organism  as  a  whole  are  but  little  marked.  At  the  time  of  the 
paroxysm  an  interesting  change  takes  place ;  the  pigment  gathers  together 
in  a  more  or  less  solid  clump,  usually  in  the  centre  of  the  organism,  while  the 
rest  of  the  protoplasm  looks  somewhat  granular  and  shows  a  suggestion  of 

20 


306    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

lines  radiating  outward  from  the  centre  (Fig.  1,  *).  This  appearance  gradu- 
ally changes,  the  lines  becoming  more  distinct  (Fig.  1,  ^),  until  finally  we  see 
the  central  clump  of  pigment  surrounded  by  from  fifteen  to  twenty  small  ovoid 
or  round  gliste'ning  segments,  each  one  having  a  central  more  refractive  spot, 
and  resembling  strongly  the  hyaline  bodies  which  Ave  see  immediately  following 
the  chill  (Fig.  1,  i*').  This  segmentation  of  the  organism  is  always  coincident 
with  the  paroxysm,  and  the  presence  in  the  blood  of  a  segmenting  body  is  a 
sure  indication  that  the  paroxysm  is  present,  or  is  about  to  occur.  Immedi- 
ately following  the  paroxysm  fresh  hyaline  bodies  appear  in  the  red  corpuscles. 
Though  the  invasion  of  the  corpuscles  by  these  fresh  segments  has  never  been 
actually  observed,  the  evidence  that  this  occurs  is  so  strong  that  we  can  safely 
accept  it  as  a  fact.  Besides  these  forms  we  see  not  infrequently  small  or  large 
extra-cellular  pigmented  bodies ;  that  is,  organisms  resembling  exactly  those 
within  the  red  blood-corpuscles,  excepting  that  they  are  free  in  the  blood-cur- 
rent (Fig.  1,  11'  i2^_  These  may  be  seen  at  times  to  break  up  into  several 
smaller  bodies,  while  at  other  times  they  may  show  a  long,  tail-like,  non-motile 
process,  containing  sometimes  a  few  pigment-granules.  They  are  probably 
organisms  which  have  escaped  from  the  red  corpuscles,  or  full-grown  bodies 
which  have  broken  up ;  they  are  considered  to  be  degenerative  forms.  At 
times  also  we  find  the  so-called  flagellate  bodies.  Their  development  from  the 
pigmented  organism  may  indeed  be  observed,  the  pigment  of  the  full-grown 
body  becoming  very  actively  motile,  then  collecting  in  the  centre  of  the 
organism,  w^hile  several  long,  thread-like  flagella  burst  out  of  the  body  and 
move  actively  about  among  the  surrounding  corpuscles  (Fig.  1,  i^).  Some- 
times we  may  see  one  of  these  flagella  which  has  broken  away  from  the  organ- 
ism and  is  moving  rapidly  through  the  field.  This  is  also  thought  by  the 
Italians  to  be  a  degenerative  process.  The  characteristics  of  this  form  of 
organism,  which  is  observed  in  tertian  fever  alone,  are  so  marked  that  with  a 
little  study  of  the  parasite  one  can  make  a  definite  diagnosis  of  the  type  of 
fever  from  an  examination  of  the  blood  alone. 

(h)  The  Parasite  of  Quartan  Fever. — Quartan  fever  is  not  at  all  common 
in  this  country,  but  in  the  few  cases  which  the  writer  has  observed  the 
organisms  difier  distinctly  from  the  tertian  parasite,  and  show  accurately  the 
characteristics  described  by  Golgi.  Here  the  first  stage  of  the  organism  is 
similar  to  that  observed  in  tertian  fever,  excepting  that  the  amoeboid  move- 

FiG.  2. 


>^A  ^  0.0  §^ 

The  Parasite  of  Quartan  fever  (drawings  mainly  after  Marchiafava,  Bignami,  and  Mannaberg):  1, 
hyaline  amoeboid  intracellular  body ;  2,  3,  4,  further  stages  in  the  growth  of  the  body ;  5,  full-grown 
form  ;  6,  7,  segmenting  bodies. 

ments  are  not  so  active.     As  the  body  develops  the  rods  and  clumps  of  pig- 
ment are  larger  and  darker  than  those  in  tertian  fever,  while  the  amoeboid 


MALABIAL    FEVER.  307 

movement  of  the  organism  is  relatively  slight.  The  full-grown  forms  are 
materiallT  smaller  than  in  tertian  fever,  while  the  red  blood-corpuscle,  instead 
of  being  expanded  and  decolorized,  appears  at  times  shrunken  about  the  bodv, 
and  of  a  somewhat  deeper  old-brass  color  (^lessingfarbe).  In  segmentation  the 
organism  divides  into  from  six  to  ten  diiferent  parts  instead  of  twenty  or  thirty, 
as  in  the  tertian  form  (Fig.  2,  ^'^). 

(e)  The  Organisms  of  the  ^stivo-autiumial  Fevers. — The  organisms  asso- 
ciated with  the  aestivo-autumnal  fevers  have  been  carefully  studied,  but  much 
remains  to  be  done,  particularly  in  this  country.  There  is  some  difference 
of  opinion  as  to  whether  there  are  not  two  types  of  organism  associated  vt^ith 
these  fevers.  Some  Italian  observers  divide  them  into  the  quotidian  and  the 
malignant  tertian  organisms.  The  differences  made  out  by  the  Italians  are, 
however,  very  slight,  and  have  not  been  observed  in  this  country.  In  the 
first  place,  we  see  just  after  the  paroxysm  small  hyaline  bodies  which  may 
or  may  not  be  actively  amoeboid ;  these  can  sometimes  be  distinguished 
from  those  appearing  in  the  initial  stage  of  either  tertian  or  quartan  fever, 
in  that  they  are  generally  somewhat  smaller  and  have  oftentimes  a  charac- 
teristic ring-like  appearance  (Fig.  3,  '^"^).  In  the  early  stages — during  the 
first  week,  for  instance — of  an  attack  of  this  form  of  fever  we  may  see  only 
the  hyaline,  unpigmented  forms,  but  commonly,  if  we  observe  carefully,  we 
may  see,  some  time  after  the  exacerbation  of  temperature,  shortly  before  the 
beginning  of  another,  bodies  which  are  a  trifle  larger  than  these  smallest  hvaline 
forms,  and  which  contain  one  or  two  very  minute  pigment-granules  lying  near 
the  periphery  (Fig.  3,  3-  4^_     J^g^;  before  or  during  the  paroxysm  we  may  see 

Fig.  3. 


Parasites  seen  in  .Estivo-autumnal  Fever— tropical  malaria.  CDrawn  with  the  camera  lucida  from  the  blood 
of  patients  in  the  Johns  Hopkins  Hospital ;  Winckel,  1-14  oil  immersion  lens,  4  eye-piece.) :  1,  2,  3,  hya- 
line, ring-like  amceboid  bodies  seen  in  the  blood  toward  the  end  of  the  paroxysm  ;  4,  the  same  further 
developed ;  5,  6,  disc-  and  ring-shaped  bodies  with  one  or  two  small  pigment -granules,  seen  shortly 
before  a  paroxysm  ;  7,  full-grown  body  with  central  pigment-granules,  seen  during  paroxysm ;  8,  full- 
grown  body  with  central  active  pigment-corpuscle  crumpled  and  shrunken :  9-12,  crescentic  and 
ovoid  bodies  with  coarse  central  pigment.  9  and  11  show  remains  of  the  corpuscle  (from  a  ease  of 
chronic  malaria  with  normal  temperature). 

bodies  with  a  small  central  clump  of  motile  or  non-motile  pigment-granules 
lying  usually  in  cells  which  are  more  or  less  shrunken  and  crumpled,  and  of  a 
deeper  color  than  the   normal  corpuscles  (Messingfarbe).      These  bodies  are 


308    A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

generally  not  half  as  large  as  the  red  corpuscle  (Fig.  3,  ^'  ^j.  After  the  first 
week  or  ten  days  of  the  disease,  or  after  treatment  has  been  begun,  Ave  see, 
however,  certain  very  characteristic  and  easily  recognizable  forms  Avhich  are 
only  seen  with  this  type  of  fever.  These  are,  first,  round  or  ovoid  bodies 
about  the  size  of  a  red  blood-corpuscle,  a  little  smaller  or  a  little  larger,  Avith 
clear,  rather  highly  refractive,  Avaxy-looking  protoplasm,  and  coarse  dark  pig- 
ment-granules, Avhich  are  usually  collected  in  a  ring  or  a  mass  in  the  centre  of 
the  organism  (Fig.  3,  ^'  i  ^'  i^).  The  granules  are  usually  very  slightly  motile. 
At  one  side  of  the  body  Ave  often  see  a  small  bib-like  attachment  Avhich  may 
shoAV  a  slightly  yellowish  color.  On  examination  this  proves  to  be  the  remains 
of  the  red  blood-corpuscle  in  Avhich  the  oi'ganism  has  developed.  In  association 
Avith  these  are  seen  crescentic  bodies  (Fig.  3,  ^  i),  the  protoplasm  of  Avhich  shoAvs 
the  same  characteristics  as  that  in  the  forms  above  described,  Avhile  the  pigment 
is  collected  in  the  middle  in  a  similar  ring  or  bunch,  and  is  but  slightly  motile. 
On  the  concave  side  of  these  crescents  one  may  also  often  see  a  bib-like  attach- 
ment, just  as  in  the  ovoid  forms.  At  times  during  the  examination  of  the  fresh 
specimen  Ave  may  see  the  change  from  an  ovoid  body  into  a  crescent  take  place. 
The  development  of  these  forms  from  the  hyaline  bodies  can  be  folloAved  out 
on  careful  observation.  They  are  thought  by  some  to  be  a  resting  stage  of 
the  organism.  Segmenting  bodies  are  almost  never  seen  in  the  circulating 
blood  of  this  form  of  malarial  fever,  though  the  presence  of  the  round  intra- 
cellular bodies  Avith  central  pigment  is  a  sure  sign  that  segmentation  is  going 
on  elscAvhere.  It  has  been  found  by  the  Italians  that  after  the  accumu- 
lation of  a  few  pigment-granules  the  organisms  seek  the  internal  organs, 
where  segmentation  takes  place.  The  bodies  are  still  small  and  contained 
within  the  red  corpuscle.  The  pigment  gathers  in  the  centre,  as  in  the  other 
types  of  segmentation,  Avhile  the  segments  are  very  small  and  rarely  more  than 
tAvelve  in  number.  During  the  paroxysm  Ave  may  see  large  numbers  of  leuco- 
cytes containing  pigment  granules  and  clumps  A\-hich  are  probably  the  remains 
of  sesrmenting  organisms.  Flagellate  bodies  mav  be  observed  here  as  in  the 
tertian  and  quartan  fevers,  but  only  when  ovoid  and  crescentic  pigmented  bodies 
are  present.  They  may  be  seen  to  develop  from  the  round  bodies  Avith  central 
pigment. 

Careful  studies  concerning  the  morphological  characteristics  of  the  malarial 
parasite  have  shown  that  it  belongs  to  the  class  of  Protozoa,  and  is  possessed 
of  a  nucleus  coiitaining  one  or  more  nucleoli.  At  the  time  of  sporullation  this 
nucleus  divides — according  to  some  directly,  according  to  others  by  karyokinesis. 

Pathological  Anatomy. — In  the  acutely  fatal  cases  of  malarial  fever 
(pernicious  malaria)  certain  fairly  characteristic  changes  are  found  in  the 
various  organs. 

The  hrain  may  shoAV  fcAv  changes.  At  times,  hoAvever,  there  may  be  a 
slight  subpial  cedema,  Avitli  hyperaemia  of  the  cerebral  substance  and  per- 
haps punctate  haemorrhages.  Melanosis  may  be  entirely  absent.  Micro- 
scopically, hoAvever,  the  changes  are  most  characteristic.  The  cerebral  capil- 
laries are  croAvded  Avith  malarial  parasites,  Avhich  may  be  in  all  stages  of 
development,  though  generally  one  of  tlie^e  phases  is  most  marked.  At  times 
the  organisms  may  not  be  so  numerous,  but  free  clumps  of  pigment  may  be 
found,  and  large  endothelial  cells  and  leucocytes  containing  pigment-clumps 
and  red  corpuscles.  There  is  usually  a  marked  granular  and  fatty  degen- 
eration of  the  endothelium  of  the  vessels,  a  change  upon  Avhich  the  punc- 
tate haemorrhages  may  depend.  These  lesions  are  particularly  marked  in  the 
comatose  forms  of  pernicious  malaria.  In  other  forms  the  cerebral  lesions 
may  be  much  less  marked. 


MALARIAL    FEVER.  309 

The  spleen  is  always  enlarged :  the  capsule  is  tense ;  the  parenchyma  is 
cyanotic,  of  a  slaty -gray  color,  and  almost  diffluent.  In  some  cases  of  acute 
malaria  death  may  occur  from  rupture  of  a  greatly  enlarged  spleen.  The  pulp 
contains  enormous  numbers  of  red  blood-corpuscles,  many  of  which  contain 
parasites.  It  also  contains  numerous  large  white  elements  rich  in  protoplasm, 
containing  usually  a  single  bladder-like  nucleus,  and  at  times  coarse  granula- 
tions. These  elements  are  usually  laden  with  pigment,  which  at  times  has  the 
same  arrangement  as  it  does  in  the  body  of  the  parasite  itself.  Sometimes 
these  cells  may  contain  the  entire  red  corpuscle  with  the  organism.  There 
may  be  free  pigment  in  the  intercellular  spaces  of  the  pulp.  The  small 
mononuclear  elements  and  the  lymphocytes  of  the  follicles  never  contain  pig- 
ment. The  capillaries  are  usually  filled  with  the  plasmodia,  while  the  splenic 
veins  show  relatively  few,  though  they  ahvays  contain  large  cells  enclosing  pig- 
ment or  the  remains  of  red  blood-corpuscles. 

The  liver  has  usually  a  slaty-gray  color.  There  is  always  cloudy  swelling, 
while  microscopically  small  areas  of  necrosis  have  been  described  by  Guar- 
nieri.  The  capillaries  are  filled  with  leucocytes  which  contain  numerous  pig- 
mented bodies.  Relatively  few  plasmodia  are  found  in  the  blood-corpuscles  in 
the  vessels.  Numerous  liver-cells  are  found  containing  clumps  of  hgematin 
and  altered  red  corpuscles — a  condition  similar  to  that  which  has  been  found 
in  pernicious  anaemia,  which,  as  Bignami  suggests,  may  explain  the  polycholia 
which  is  commonly  found  in  subjects  who  have  died  of  pernicious  malaria.  On 
this  probably  depends  the  icteroid  hue  in  severe  malaria. 

The  lungs  show  in  their  capillaries  numerous  cells  containing  pigment-clumps 
and  well-preserved  parasites,  though  it  is  unusual  to  find  pigment  in  the  endo- 
thelial cells,  in  the  capillaries,  and  smaller  veins.  In  the  areas  of  broncho- 
pneumonia which  may  occur,  polynuclear  leucocytes  are  chiefly  found,  while  the 
large  pigmented  cells  take  no  part  apparently  in  the  active  inflammatory  process. 

The  vessels  of  the  kidneys  contain  relatively  few  organisms.  The  glomeruli 
may  be  considerably  pigmented.  There  may  be  marked  degeneration  of  the 
epithelium  of  the  capsules,  and  at  times  changes  in  the  parenchyma,  especially 
areas  of  necrosis  of  the  epithelium  of  the  convoluted  tubules.  The  other  viscera 
show  no  especially  characteristic  changes  excepting  at  times  the  melanosis. 

In  the  more  chronic  forms  of  malaria  and  in  malarial  cachexia  the 
anaemia  is  usually  particularly  marked.  The  spleen  is  always  enlarged  and 
very  firm.  There  is  a  marked  thickening  of  the  capsule,  which  is  often  adher- 
ent to  the  neighboring  tissue.  On  section  the  spleen  is  generally  of  a  dark 
brownish-gray  color,  the  fibrous  tissue  throughout  the  organ  being  greatly 
thickened.  The  liver  is  considerably  enlarged,  and  usually  has  a  grayish- 
brown  or  slaty  color.  Microscopically,  Kupfer's  cells  and  the  perivascular 
tissue  may  contain  much  pigment.  At  times  there  is  a  considerable  increase 
in  the  connective  tissue.  The  kidneys  show  no  particular  characteristic  changes, 
though  there  may  be  considerable  pigmentation  :  the  pigment  is  most  marked 
about  the  blood-vessels  and  the  Malpighian  bodies,  and  sometimes  in  the 
region  of  the  convoluted  tubules.  There  are  no  characteristic  changes  in  the 
other  organs,  excepting  the  slaty-grayish  pigmentation. 

Symptoms. — As  may  be  gleaned  from  what  has  already  been  said  con- 
cerning the  specific  organisms,  malarial  fever  occurs  in  several  main  types  : 
(1)  The  milder  intermittent  fevers,  which  form  the  majority  of  all  cases  in  the 
more  temperate  climates,  and  occur  in  the  warmer  climates  more  commonly  in 
the  spring  and  early  summer :  (a)  Tertian  intermittent  fever  and  its  combi- 
nations ;  (h)  Quartan  intermittent  fever  and  its  combinations.  (2)  The  more 
irregular,  sestivo-autumnal  fevers,  which  usually  show  quotidian  paroxysms. 


310    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Tertian  Intermittent 
Fever. — This   is   by  f;ir   the 
commonest    form    of    malarial 
fever  in  this  country,  and  with 
the    quartan    fever   forms    the 
mildest  type  of  the  disease.     It 
is  the  type  of  the  intermittent 
fever  of  the  spring  and  early 
summer,  though  it  may  be  seen 
at  any  time  of  year.     It  shows 
often  no  particular  tendency  to 
increase  in  severity,  while    in 
many  instances,  under  proper 
care    and    change    of   climate, 
spontaneous  recover}^  may  oc- 
cur.    It  depends,  as  we  have 
seen,  upon  the  invasion  of  the 
blood   by  an    organism  which 
passes  through  its  cycle  of  ex- 
istence   in    forty-eight    hours. 
The    febrile    paroxysms   occur 
Avhen   these    parasites    have 
reached  their  full  development 
and  begin  segmentation.   These 
periods  occur  with  considerable 
regularity  at  intervals  of  forty- 
eight  hours  one  from  another. 
In    older   children   the  parox- 
ysms may  usually  be   divided 
into   three   stages :    first,    the 
chill;  secondly,  ih.e  fever  ;  and 
thirdly,    the    siveating.      The 
child,  who  may  have  been  feel- 
ing fairly  well  beforehand,  be- 
comes   suddenly    uneasy,   may 
begin  to  yawn,  or  may  have  an 
attack  of  vomiting  or  diarrhoea, 
which    is    followed    or    accom- 
panied by  a  well-marked  rigor, 
associated    Avith    cyanosis    and 
coldness    of    the    extremities. 
The  temperature  rises  to  a  con- 
siderable   height,    possibly    to 
108°  F.     This  stage  lasts  for 
a  varying  time,  from  ten  min- 
utes to  an  hour.     As  the  chill 
ceases  the  patient  passes  into  a 
stage  in  Avhich  there  is  marked 
flushing  of  the  skin,  with  great 
heat  and  dryness.     The  child 
complains  bitterly  of  thirst  and 
headache,  and  is  usually  very  fretful.     There  may  be,  as  in  the  first  stage, 
renewed  attacks  of  vomiting  or  diarrhoea.     This  stage,  after  lasting  for  a  vari- 


Fig.  4. 

f  |g   s   g   s   1   s   s   s 

o      S       o      o       o 

'Z^~ 

I   M 

~t 

4  />* 

T 

6  pit 

'^^ 

a  PA 

v-'V 

OPA 

L                    rl                     ■ 

III* 

] 

?  >n. 

'     "t 

f  IM 

Qr" 

6  IH 

""«^ 

6  l-A 

-^>,, 

/on 

// 1« 

~ — -< 

>^ 

12  HO  fl/ 

;• 

1   'M 

^- 

2  'H 

^j'" 

3  '14 

^■^ 

«  ?* 

c 

g  'M 

:  2 

10  "M 

J                   : 

Z  It 

s 

4  l« 

5 

6  m 

K 

8  <fl 

^ . 

10  ih 

-  N 

IZ«'  1 

? 

2  PM 

t 

4  '/« 

6  ?^ 

a  ?1 

^* 

\0  'M 

2  IK 

\  ~ 

4  lA 

6  'A 

\  ^ 

8  <M 

1     ^^  —  —  ■_  ^ 

To** 

"■  ■ 

-~^ 

n  M 

,  ^ 

(J  m  in 

<« 

^  « 

»'' 

1    'H 

m  —  ^ 

2   'M 

>  '' 

4IIM 

'  z. 

6  m 

^^^ 

8  m 

^ 

10  'M. 

-*  "^ 

2I« 

X 

4  1^ 

\ 

6  IM 

5 

8  0" 

101* 

w 

12  tlo^n 

», 

t 

s  m 

l 

4  •« 

: 

6  'M 

^^ 

8  ?« 

::      :^^^:-  _ 

ID'M 

==      =3=     ==  ===  :  : 

Z  in 

^^ 

4«> 

_      3 

6  1* 

■'>« 

8  U 

*.,^  ^ 

9  01  " 

""■-•.  ^ 

10  At 

II  <J> 

«  «  " 

^ 

/  PM 

^r--" 

Z  P* 

W^ 

3  f* 

-         i'^ 

4  P* 

t 

6  />« 

7 

8  PH 

::::::  :  ;^::::::::, 

WPM 

==-=___2^ _- 

Z  »* 

A 

4  W 

X^ 

6  W 

\- 

8«* 

\ 

III* 

I 

12  Hi  <n 

it 

2  'M 

\ 

4  •« 

3 

b'» 

t 

BPM 

SS'gsgSiSggSSSSi 

o       • 

c   5    s    s    s    g.   s    £    ?.    s    t;    §    S    S    2 

I 

Tertian  Fever. 


MALABIAL    FEVER. 


311 


able  length  of  time,  from  half  an  hour  to  three  or  four  hours,  is  followed  by 
profuse  sweating,  the  temperature  falling  within  an  hour  or  two  to  a  normal  or 
even  a  subnormal  point.  With  the  sweating  the  child  may  seem  exhausted  and 
weak,  but  shortly  afterward  appears  again  perfectly  well. 

Such  an  attack  as  this  differs  but  little  from  the  intermittent  fever  of 
adults,  and  indeed  above  the  age  of  six  the  differences  are  very  slight.  Under 
this  age,  however,  there  are  marked  differences  in  the  paroxysm.  Very  com- 
monly in  young  children  both  the  first  and  the  third  stages,  those  of  the  chill 
and  sweating,  are  absent.  The  first  stage  is  then  generally  represented  by  a 
slight  restlessness,  the  face  looks  pinched,  the  eyes  sunken,  the  finger-tips  and 
toes  may  become  cyanotic  and  cold,  while  the  child  may  yawn  or  stretch  itself. 
Oftentimes  there  is  nausea  or  vomiting,  and  possibly  diarrhoea.  This  may  be 
the  only  manifestation  of  the  first  stage,  though  it  may  be  followed  by  slight  or 
severe  nervous  symptoms.  These  begin  usually  with  a  slight  spasmodic 
twitching  of  the  eyelids  or  of  the  extremities,  and  may  go  on  to  general  convul- 
sions. The  chill  in  the  adult  is  very  often  represented  in  the  young  child  by 
the  convulsion — a  fact  which  is  as  true  in  all  other  acute  febrile  processes  as  in 
malarial  fever.  This  stage  lasts  usually  for  a  short  time,  not  more  than  an 
hour  or  so.  The  temperature  rises  rapidly,  possibly  to  108°  F. ;  then  comes 
the  period  of  fever,  during  which  the  child  is  much  flushed,  is  restless, 
thirsty  and  fretful,  while,  as  has  been  already  said,  various  gastro-intestinal 
disturbances  may  occur.  The  fever  remains  at  its  height  for  an  hour  or  two  ; 
afterward  there  is  a  gradual  fall  of  temperature,  unaccompanied  by  sweating. 
In  many  instances,  besides  the  slight  coldness  of  the  hands  and  blueness 

Fig.  5. 


■T.n,p       •'■■-■■ 

.07  Si=  -;:S=  =tE=i|i.  HI=  =  =  =tl---  ^-::I  =  =  =  -tS^IjI-';!- 

S   =                                     ■=                                                                   *                                                                  2 

infi      <i;cM-*«!!t<oS~'M'»<oooS!|<M'»-o<DSS!ca'a-u)a)S!!'M*'OioS2;Mxl-ioc[)2£lcM-r 

1 

^           \            \\ 

\\          \            w 

JiL.t                _L    .                      tt 

.03       X>'                       \X                          ^^ 

j                 -  ^-                  ^  :: 

.oa     i     -                      ..                     Jt 

X                -t-      A.--                       \- 

«>'■  4P   -       T  ^--             i 

^    t                   f 

::          :       ':            :       ^:: 

\r     -^^^\r^-       r-^^^-^\f 

S8        __    E_         |__      :     ^_| r s^,___ 

97      I                ->.^                ^                     t^         -+       +           ^                4-      + 

L_ 

Double  Tertian  (quotidian  fever). 

of  the  finger-tips,  and  a  somewhat  pinched  expression  of  the  face  in  the 
first  stage,  the  first  and  the  third  stages  of  the  attack  may  be  entirely 
lacking. 

Pure  tertian  fever  is  rare  in  children,  as  the  process  is  almost  always  a 
double  infection;  that  is,  the  blood  contains  two  sets  of  organisms,  which 
attain  maturity  on  alternate  days,  and  give  rise  to  quotidian  paroxysms.     If, 


312    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

as  is  unusual,  the  case  is  one  of  pure  tertian  fever,  the  child  may  seem  per- 
fectly well  on  the  day  between  the  attacks. 

Physical  examination  during  the  very  first  attack  may  reveal  little  or 
nothing,  but  usually'  by  that  time,  and  always  after  one  or  two  paroxysms,  an 
enlarged  spleen  may  be  made  out.  If  a  child  has  had  more  than  two  supposed 
malarial  paroxysms  and  the  spleen  is  not  distinctly  enlarged,  we  have  almost 
sufficient  evidence  to  put  aside  the  diagnosis  of  malarial  fever.  Herpes 
labialis  is  a  very  common  accompaniment.  Anaemia  is  usually  noticeable  if 
the  process  has  lasted  for  any  length  of  time.  The  discovery  of  the  specific 
organism  in  the  blood  is  the  one  diagnostic  point.  The  paroxysm  in  tertian 
malarial  fever  may  last  altogether  from  twelve  to  fifteen  hours,  though  com- 
monly it  is  much  shorter,  the  first  stage  lasting  from  ten  minutes  to  an  hour, 
the  second  stage  from  an  hour  to  three  or  four  hours,  and  the  third  stacje  a 
varying  length  of  time.  As  the  length  of  time  which  the  tertian  organism 
requires  to  attain  its  full  growth  is  almost  exactly  forty-eight  hours,  the 
attacks  dependent  upon  one  group  of  parasites  occur  almost  regularly  forty- 
eight  hours  apart,  though  in  some  instances  we  may  find  a  tendency  to  antici- 
pation or  to  retardation  in  the  attacks.  This  point  can  only  be  determined  by 
observation,  so  that  one  cannot  definitely  prophesy  the  hour  at  which  an 
attack  will  occur  until  he  has  seen  several  paroxysms.  It  is  easy  to  see  that 
in  the  quotidian  cases,  which  depend  upon  the  presence  of  a  double  infection, 
the  chills  on  the  alternate  days  may  occur  at  diff"erent  hours,  one  group  of 
organisms  segmenting  perhaps  at  ten  o'clock,  and  the  other  at  two.  Usually, 
however,  these  diff"erences  are  slight.  Not  infrequently  we  find  the  history 
of  tertian  attacks  at  first,  and  later  on  dailj'^  attacks  of  fever.  The  common- 
est time  for  the  paroxysm  in  tertian  fever  is  in  the  early  part  of  the  day, 
between  eight  in  the  morning  and  two  in  the  afternoon,  though  they  may 
occur  at  all  hours  either  of  the  day  or  night.  Irregularities  in  the  course  of 
the  fever,  no  matter  what  the  type  may  be,  are  much  commoner  in  children 
than  in  adults. 

Quartan  Fever. — This  form  of  fever  is  rarely  observed  in  this  country. 
Out  of  about  500  cases  of  malaria  treated  at  the  Johns  Hopkins  Hospital  in 
four  years,  it  only  occurred  tAvice.  Here  the  length  of  time  required  for 
the  development  of  the  organism  is  seven ty-tAvo  hours,  and  the  paroxysms 
occur  every  fourth  day.  The  nature  of  the  paroxysm  does  not  differ  from 
that  observed  in  tertian  fever.  As  one  may  easily  see,  complex  attacks  of 
fever  may  arise  from  a  double  or  triple  infection  Avith  quartan  organisms.  Thus 
we  may  have  a  daily  paroxysm  due  to  a  quartan  infection,  or.  on  the  other 
hand,  paroxysms  on  two  days  in  succession,  Avith  one  day  intermission,  a  triple 
or  a  double  infection.  The  diagnosis  of  quartan  fever  may  be  made  by  a 
skilled  observer  from  one  examination  of  the  blood  by  the  discovery  of  the 
characteristic  quartan  organism. 

The  ^sTivo-AUTiTMNAL  Fevers.  "Tropical  Malaria."  "Febris 
Irregularis." — The  malaria  occurring  in  the  late  summer  and  fall  is  often  of 
a  much  more  severe  type  than  that  occurring  in  the  spring,  and,  as  has  been 
shown  by  the  Italian  observers,  most  of  these  cases  are  due  to  a  different 
type  of  the  specific  organism.  It  is- in  the  later  summer  and  fall  that  Ave  see 
most  of  the  cases  of  apparently  irregular  fever,  and  the  so-called  remittent 
malarial  fever.  The  typical  malarial  cachexia,  Avhile  it  may  folloAv  any  foi'm 
of  intermittent  fever,  usually  results  from  this  type  of  malaria.  Most  of  the 
pernicious  foi'ms  also  come  under  this  heading. 

The  So-called  Irregular  Remittent  Fevers. — The  recent  Italian 
observers,  asserting  that  there  is  in  reality  no  actual  irregularity,  divide  these 


3IALABIAL    FEVER. 


313 


fevers  into  the  quotidian,  in  which  a  daily  paroxysm  occurs,  and  the  tertian,  in 
which  the  paroxysm  occurs  on  every  other  day ;  but  in  both  instances  there  is 
a  greater  tendency  to  irregularity  in  the  time  required  for  the  development  of 
each  brood  of  organisms.  On  the  one  hand,  there  is  often  a  very  marked 
tendency  for  the  paroxysms  to  anticipate  one  another,  or  there  may  be  a 
retardation,  while  again  the  attacks  do  not  present  themselves  in  so  clean-cut 
and  regular  a  form  as  in  the  spring  fevers.  They  may  be  much  lengthened 
out,  so  that  one  attack  may  follow  another  without  the  temperature  ever 
actually  reaching  a  normal  point.     Most  of  the  cases  of  this  type  of  fever  seen 

Fig.  6. 


'•jemj, 

- 

r- 

~ 

- 

1 

1 1 

r 

T 

i  1 

~J~ 

"" 

"* 



1 

ji 

1  I 

Z| 

1 

•=] 

1 

1 

^ 

C3| 

i 

1 

J 

lj_ 

° 

s. 

-- 

.-  ^ 

£ 

= 

i 

° 

£ 

=  5 

:  "^! ' 

= 

J 1  - 

= 

.1^. 

=1= 

= 

= 

M 

=  1  =  |: 

:  ?U  '.s 

j:  s 

s;e 

E  £ 

o 

1 

^ 

z 

^ 

■  ■ 

2. 

i    i 

"* '    i"- 

""  "" 

**  °- 

*    "^j 

"^ 

1    n" 

* 

■o 

m 

ii 

!^ 

tvl 

* 

j> 

<o 

o  c 

1   N 

•r 

■o 

<o 

s 

s; 

OJ 

* 

■n 

to 

1    og 

■J- 

O 

<D 

s 

~ 

■^ 

«- 

J),a>!=|J 

•tsi 

■^1  j>ia) 

2!~    -IT 

-olaii!: 

:  vm-ii 

<0   (D 

toco 

"i""! 

1 

i 

i  ■■ 

'■■   i 

1  J 

1 

1 

-^T^ 

i 

' 

T* 

r\ 

1 

I 

J 

i 

\ 

(^ 

\ 

> 

/ 

V 

\ 

/ 

i 

r^ 

'^H 

\ 

f 

i 

V 

' 

[ 

tor 

\ 

A 

/ 

\ 

1 

; 

1 

fs 

V 

V 

1  1 

JOO 

l\ 

\ 

/ 

V 

,1 

\i 

1 

\ 

/ 

•^ 

i    J 

■SB 

1 

V 

V 

r 

^ 

^ 

A« 

•  '] 

'A\ 

i 

1 

^, 

■* 

i 

V 

s 

1 

\ 

f 

1 

:    !■ 

V^ 

~ 

'~ 

^ 

r 

y> 

=t 

~" 

J 



1       ■ 

^^ 

' 

p — 

V 

\ 

1  ! 

97 

i 

I 

s 

\!fJ 

' 

~^ 

95 

Temp 

_L 



L 

L 

L 

L 

- 

_^ 

_ 

._ 

_ 

_ 

1 

1 

-lEstivo-autumnal  fever.   (Quotidian.) 


in  this  country  show  a  distinct  daily  paroxysm ;  it  is  doubtful  whether  we  see  in 
America  the  "-malignant  tertian  fever"  of  the  Italians.  The  attacks  may  differ 
little  from  those  in  the  ordinary  tertian  form,  excepting  that  they  are  often  more 
severe  and  of  a  somewhat  longer  duration,  so  that  the  afebrile  periods  are  shorter 
or  even  absent.  On  the  other  hand,  the  onset  may  be  very  gradual,  with  daily 
exacerbations  of  temperature,  accompanied  by  restlessness,  flushing,  often 
vomiting  or  diarrhoea,  and  headache,  but  without  chills  or  perhaps  even  SAveating. 
The  attacks  may  be  prolonged  and  run  into  one  another,  so  that  a  remittent 
temperature  results.  There  is  often  delirium  or  droAvsiness  and  somnolence ; 
the  spleen  is  always  enlarged.  In  this  condition  the  diagnosis  from  typhoid  fever 
or  meningitis  may  be  impossible  without  an  examination  of  the  blood.  Such 
cases  as  this,  however,  do  not  generally  go  on  to  recovery  without  treatment,  but 
tend  to  become  pernicious,  the  paroxysms  increasing  in  severity  till  death. 

Malarial  Cachexia. — The  fever  in  some  instances  may  never  rise  as  high 
as  it  does  in  the  paroxysms  of  tertian  fever,  nor  may  the  immediate  symptoms 
of  the  paroxysm  be  as  striking,  and  the  attention  of  the  phj^sician  is  often 
called  to  the  patient  for  the  first  time  when  the  stage  of  malarial  cachexia  has 
been  reached.  The  child  may  then  show  a  pitiful  appearance.  It  is  pale,  of 
a  sallow,  parchment-like  color,  and  often  much  emaciated.  The  skin  is  dry, 
the  face  has  a  drawn,  pinched  look,  the  eyes  are  sunken ;  there  may  be  marked 
symptoms  on  the  part  of  the  digestive  tract,  frequent  attacks  of  vomiting  and 


314    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

diarrhoea.  The  fever  may  stand  in  the  background.  Indeed,  in  some  of  these 
cases  there  may  be  for  weeks  rehitively  little  fever.  The  spleen  is  always 
enlarged.  Malarial  cachexia  does  not  exist  in  children  without  an  enlarged 
spleen.  In  all  instances,  no  matter  Avhether  our  attention  is  called  to  the  child 
on  account  of  the  fever  or  of  the  gastro-intestinal  derangement,  an  examination 
of  the  blood  will  show  the  organisms,  usually  those  characteristic  of  the  sestivo- 
autumnal  or  tropical  malarial  fever,  the  small  hyaline  bodies,  and  the  pig- 
mented crescents  and  ovoid  forms.  Malarial  cachexia  may  follow  all  forms  of 
the  disease,  and  not  infrequently  is  seen  in  improperly  treated  cases  of  tertian 
fever  or  in  those  Avho  have  been  subject  to  repeated  attacks,  but  it  is  much  more 
commonly  seen  in  this  type  of  fever. 

Pernicious  Malarial  Fever. — It  is  in  the  sestivo-autumnal  fevers  that 
we  see  more  commonly  the  pernicious  forms  of  malaria,  though  these  are  rare 
in  temperate  climates.  In  these  cases  a  previously  healthy  child  may  begin  to 
show  a  slight  restlessness,  with  a  pinched  expression  of  the  ftice  and  some  blue- 
ness  of  the  extremities.  An  attack  of  vomiting  or  diarrhoea  may  occur,  which 
may  be  followed  suddenly  by  severe  convulsions  and  a  very  rapid  rise  in  tem- 
perature, which  may  be  as  high  as  108°.  The  convulsions  may  continue  or 
the  child  may  pass  into  a  dull,  comatose  condition,  the  pupils  being  fixed  and 
possibly  irregular ;  in  this  condition  it  may  remain  until  death  ensues.  In 
some  instances  the  whole  attack  may  be  represented  by  a  condition  of  coma 
with  collapse,  possibly  with  little  or  no  rise  in  temperature.  These  severe 
attacks  are  rare  in  this  country,  and  it  is  not  at  all  improbalde  that  in  regions 
in  which  severe  malarial  fever  prevails  many  non-malarial  attacks  are  ascribed 
to  this  disease.  The  definite  diagnosis  can  only  be  made  by  the  discovery  of 
the  parasite  in  the  blood.  Some  of  the  most  severe  of  these  attacks  are  prob- 
ably due  to  the  infection  with  several  groups  of  the  organisms  at  once,  so  that 
segmentation  is  going  on  continuously. 

Affections  of  Other  Viscera  sometimes  Associated  with  Mala- 
rial Fever. — Resjnratory  Apparatus. — In  all  forms  of  malarial  fever  bron- 
chitis is  a  common  complication,  as  it  is,  indeed,  with  any  acute  febrile  affec- 
tion. This  is  particularly  true  in  children.  The  appearance  of  a  profuse 
coryza  in  the  absence  of  the  sweating  stage  has  been  noted. 

Alime7itary  Tract. — In  almost  all  cases  of  malarial  fever  in  children  symp- 
toms are  present  on  the  part  of  the  stomach  and  intestines.  Vomiting  in  the 
first  and  second  stages  of  the  paroxysm  is  extremely  common,  while  diarrhoeas 
are  also  very  frequently  seen  in  all  forms  of  malaria,  particularly  in  the  more 
remittent  forms  and  in  the  chronic  cachexia,  where  it  is  probably  generally  due 
to  a  secondary  infection  to  which  the  debilitated  child  is  more  readily  subject. 
Little  is  to  be  noticed  on  the  part  of  the  circulation. 

Kidneys. — Slight  albuminuria  may  often  be  observed,  and  in  rare  instances 
hsematuria  occurs.  Malarial  hoematuria  is  generally  considered  a  grave  symptom. 
It  is  probably,  however,  a  rare  condition,  except  in  districts  where  the  severest 
forms  of  the  disease  are  common.  Many  of  the  so-called  malarial  haematurias 
are  due  to  other  causes. 

The  literature  of  malarial  fever  contains  numerous  references  to  "malarial 
pneumonia,"  "malarial  bronchitis,"  "malarial  neuralgia,"  "malarial  diar- 
rhoeas," and  the  like,  most  of  which,  in  the  light  of  our  present  knowledge, 
have  probably  little  or  no  connection  with  malarial  fever.  It  is  easy  to 
understand  that  the  child  debilitated  by  a  severe  malarial  fever  may  more 
readily  fall  a  victim  to  a  variety  of  other  diseases.  In  this  way  probably  the 
gastro-intestinal  and  bronchial  disturbances  so  commonly  observed  are  to  be 
explained.     That  there  is  any  such  thing,  for  instance,  as  a  specific  malarial 


MALABIAL    FEVER.  315 

pneumonia  is  wholly  out  of  the  question.  The  chills  which  may  occur  sometimes 
with  some  regularity  in  the  course  of  many  of  the  specific  fevers  are  commonly 
attributed  to  a  malarious  influence.  These  inferences  are  for  the  most  part 
unjustifiable.  In  rare  instances  a  patient  who  is  subject  to  an  acute  or  chronic 
malaria  may  develop  typhoid  fever  at  the  same  time,  or  the  converse  may  occur, 
but  these  instances  are  few  and  far  between,  and  the  great  majority  of  instances 
of  chills  occurring  in  typhoid  fever  have  no  connection  whatever  with  malaria. 
Pneumonia  may  develop  during  the  course  of  a  malarial  attack,  but  it  is  due 
in  these  cases  to  its  specific  cause.  The  examination  of  the  blood  is  our  one 
safe  clue  to  the  explanation  of  such  complications. 

Diagnosis. —  The  Milder  Tertian  and  Quotidian  [double  tertian)  Fevers. — 
The  diagnosis  of  malarial  fever  in  children  may  be  made,  in  the  first  place,  from 
the  character  and  periodicity  of  the  attacks ;  secondly,  from  the  enlargement  of 
the  spleen,  which  is  always  present  after  the  first  or  second  attacks;  and  thirdly, 
by  the  presence  of  the  malarial  organism  in  the  blood.  In  some  instances  there 
may  be  relatively  few  parasites,  but  the  careful  examination  of  several  fresh 
specimens  of  the  blood  will  always  reveal  the  organism  if  present.  Even  in 
the  absence  of  definite  data  with  regard  to  the  attacks,  the  diagnosis  may  be 
made  by  the  type  of  organism  found.  The  commonest  type,  as  has  been  said, 
is  the  double  tertian,  quotidian  fever. 

The  commonest  condition  with  which  malarial  fever  is  confounded  is 
tuberculosis  in  its  various  forms  ;  the  hectic  evening  temperature  is  often 
ascribed  to  malaria.  Most  pediatrists  may,  I  fancy,  remember  more  than  one 
instance  where  after  a  diagnosis  of  malarial  fever  evidences  of  pulmonary, 
abdominal,  or  even  glandular  tuberculosis  have  developed.  The  absence  of 
definite  signs  of  tuberculosis,  the  splenic  enlargement,  and  the  anaemia,  which 
may  be  marked,  speak  in  favor  of  the  malarial  nature  of  the  affection,  while 
the  absence  of  malarial  organisms  in  several  specimens  of  fresh  blood,  even  in 
the  presence  of  marked  febrile  paroxysms,  is  a  sure  sign  of  the  absence  of 
malarial  fever. 

The  same  rules  of  diagnosis  apply  to  quartan  fever.  The  characteristic 
organism  of  that  type  will  be  found  on  examining  the  blood. 

^stivo-autwnnal  Fevers. — It  is  the  more  irregular  and  remittent  fevers 
and  the  malarial  cachexiae  which  give  the  most  tl'ouble  to  the  diagnostician. 
The  regularly  intermittent  fever  may  not  here  give  us  our  clue  to  the 
diagnosis.  On  the  other  hand,  the  presence  of  a  considerable  anaemia  in 
association  with  a  markedly  enlarged  spleen,  which  is  always  present  in  this 
form  of  fever,  will  lead  us  to  suspect  the  proper  diagnosis,  which  will  be  con- 
firmed by  the  discovery  of  the  small  ring-like  hyaline  intracellular  organisms, 
and,  if  the  case  has  lasted  a  week  or  more,  the  ovoid  and  crescentic  pigmented 
bodies  in  the  blood.  This  form  of  fever  may  often  be  confounded  with  tuber- 
culosis. It  may  also  simulate  very  closely,  from  the  physical  exa(mination 
alone,  leukaemia  or  the  anaemia  infantilis  pseudo-leukaemica  of  Von  Jaksch. 
In  some  instances  where  the  paroxysms  tend  to  run  into  one  another  and  pro- 
duce a  more  or  less  remittent  fever,  the  differentiation  of  the  process  from  fever 
may  be  impossible  from  the  physical  examination  alone.  The  frequent  herpes, 
the  large  size  and  prominence  of  the  spleen,  as  well  as  the  rapidly  developing 
anaemia,  may  be  suggestive,  but  here,  as  elsewhere,  the  examination  of  the 
blood  alone  gives  us  our  certain  diagnosis.  In  the  absence  of  an  examination 
of  the  blood,  the  chronic  cachexiae  may  be  considered  to  be  the  result  of  the 
concomitant  gastro-intestinal  derangements  or  of  the  bronchitis,  while  in  many 
instances  the  atrophy,  the  dyspepsia,  and  the  diarrhoea  may  be  found  to  depend 
upon  the  presence  of  the  malarial  organisms  in  the  blood.     In  the  cases  of 


316    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

severe  pernicious  malarial  fever  the  examination  of  the  blood  is  also  our  only 
safe  clue  to  a  diagnosis. 

Methods  of  Examination  of  the  Blood. — The  examination  is  best 
made  with  fresh  specimens.  The  lobe  of  the  ear  is  punctured  with  a  sharp, 
spear-pointed  lancet;  a  very  small  cut  is  all  that  is  necessary.  This  may  be 
done  behind  the  back  without  the  child  seeing  the  instrument,  so  that  it  may 
not  be  alarmed,  while  if  the  instrument  is  sharp  the  process  is  almost  painless. 
In  some  instances  it  may  be  done  while  the  child  is  asleep,  Avithout  even 
awakening  it.  After  wiping  away  the  first  drop  or  two  of  blood,  a  perfectly 
clean  cover-glass  is  brought  into  contact  with  the  tip  of  a  small  drop  of  blood, 
and  allowed  to  fall  immediately  upon  a  freshly-cleaned  slide.  If  the  slide  and 
cover-glass  have  been  washed  in  alcohol  just  before  using  and  are  perfectly 
clean,  the  drop  of  blood  will  spread  out  regularly  under  the  glass,  and  the 
corpuscles  may  be  seen  lying  side  by  side  free  from  crenation  or  any  other 
artificial  changes.  Pressure  on  the  cover-glass  may  spoil  the  specimen.  It  is 
best  to  hold  the  cover-glass  in  a  forceps  in  order  to  avoid  any  injury  to  the  cor- 
puscles from  the  moisture  of  the  hand.  The  specimen  is  then  examined  at  best 
with  a  ^  oil-emersion  lens,  and  a  2,  3,  or  4  eye-piece.  A  4  eye-piece  with  an 
8  objective,  or  a  Zeiss  E  or  F,  will  answer  the  purpose  well,  though  an  oil- 
emersion  lens  is  clearer  and  better.  In  this  manner  all  forms  of  the  organism 
may  be  seen  Avhile  yet  alive.  When  it  is  impossible  to  examine  the  fresh  spec- 
imen, dried  and  stained  specimens  may  be  used.  A  small  drop  of  blood  is 
taken  upon  one  cover-glass,  which  is  then  allowed  to  fall  upon  the  second  glass. 
The  drop  immediately  spreads  out,  and  the  two  glasses  are  separated  by  being 
gently  drawn  apart.  These  specimens  are  allowed  to  dry  in  the  air.  They 
may  be  kept  for  almost  any  length  of  time  before  examining.  There  are 
numerous  different  methods  for  preparing  and  staining  the  specimen.  As 
satisfactory  a  method  as  any  is  to  place  the  glass  in  a  solution  of  absolute 
alcohol  and  ether,  equal  quantities,  for  a  half  to  one  hour,  or  the  spec- 
imens may  be  heated  for  from  one  to  two  hours  at  100°-120°  C.  The 
specimen  may  then  be  stained  in  a  concentrated  aqueous  solution  of  methylene 
blue  for  about  a  minute,  washed  in  water,  dried  between  filter-paper,  mounted 
in  balsam  or  oil,  and  examined.  The  red  corpuscles  remain  unstained.  Only 
the  nuclei  of  the  leucocytes,  the  malarial  organisms,  and  occasional  blood- 
platelets  take  up  the  blue  coloring.  In  case  a  double  stain  is  desired,  one 
may  make  use  of  two  solutions:  Solution  1.  Eosin  1  part;  70  per  cent, 
alcohol  100  parts  ;  Solution  2.  Saturated  aqueous  solution  of  methylene  blue. 
After  preparing  the  specimen  in  absolute  alcohol  and  ether  as  before,  place 
it  in  Solution  1  for  from  fifteen  seconds  to  half  a  minute,  wash  in  water, 
dry  between  filter-paper ;  place  it  then  in  Solution  2,  which  has  been 
diluted  one-half  with  water,  letting  it  stain  for  from  one  half  to  one  minute ; 
wash  in  water,  and  dry.  By  this  method  the  red  corpuscles  and  the  eosinophilic 
granules  in  the  leucocytes  are  stained  red  by  the  eosin,  while  the  nuclei  of  the 
leucocytes  and  the  malarial  parasites  are  stained  blue. 

Good  results  may  be  obtained  by  Romanowsky's  method  :  saturated  aqueous 
solution  of  methylene  blue,  1  part,  i  per  cent,  aqueous  solution  of  eosin  2  parts. 
Do  not  shake  or  filter  the  mixture.  Place  the  specimen  (heated  as  above)  in 
this  mixture  for  two  to  three  hours,  and  then  in  Avater  for  one  to  two  hours,  and 
dry.  The  parasites  are  stained  blue.  In  this  manner  any  practitioner  who  pos- 
sesses a  microscope  may,  without  much  labor,  make  the  diagnosis  of  malarial 
fever.  The  examination  of  the  fresh  specimens  will  probably  be  found  to  be 
more  satisfactory,  and  the  observer  who  studies  only  stained  specimens  must 
beware  of  certain  mistakes  which  one  who  is  not  familiar  with  the  examination  of 


MALARIAL    FEVER.  317 

the  blood  may  readily  make,  such  as  the  confusion  of  the  blood-plates,  the 
hgematoblasts  of  Hayem,  with  the  malarial  parasite — a  mistake  which  certain 
good  observers  have  recently  made. 

Course  and  Prognosis. — Excepting  in  the  acute  pernicious  cases  the  prog- 
nosis in  malarial  fever  is  good,  provided  the  case  is  recognized  and  properly 
treated. 

If  untreated  the  fever  may  take  one  of  three  courses  : 

(1)  Mild  cases  may  go  on  to  spontaneous  recovery  ; 

(2)  The  paroxysms  may  gradually  diminish  in  intensity,  the  fever  becoming 
less  marked,  Avhile  grave  angemia  develops,  and  the  patient  passes  into  the  con- 
dition of  chronic  cachexia ; 

(3)  The  paroxysms  may  increase  in  severity,  assuming  finally  a  pernicious 
type. 

Treatment. — Prophylaxis. — In  a  malarial  district  certain  prophylactic 
measures  should  be  taken  with  children  as  well  as  with  adults.  The  child 
should  be  kept  in  the  house  after  sundown  and  should  be  carefully  kept  away 
from  those  regions  in  which  experience  has  shown  that  malaria  is  present. 
Sleepincr  on  the  ground  floor  of  houses  in  malarious  districts  should  be 
avoided. 

Medicinally.,  we  possess  in  quinine  one  of  the  few  specific  drugs  which  are 
at  the  command  of  the  physician.  In  almost  all  cases  of  malarial  fever  we  may 
expect  with  confidence  a  complete  recovery  after  the  use  of  quinine.  There  is 
only  one  form  of  malarial  fever,  and  that  rarely  seen  in  this  country,  the  acute 
pernicious  malaria,  in  which  we  cannot  entirely  rely  upon  this  drug.  In  the 
milder  forms  of  the  disease,  the  tertian  and  quartan  fevers  and  their  combina- 
tions, small  doses  of  quinine  are  rapidly  efficacious.  One  or  two  grains  of 
quinine  (.065-.  13),  three  times  a  day  in  children  under  six  years  of  age,  will 
be  followed  by  the  rapid  disappearance  of  all  symptoms.  The  best  time  to 
administer  a  single  larger  dose  of  quinine  is  immediately  after  a  paroxysm. 
In  the  more  chronic  and  irregular  forms,  Avhich  are  so  apt  to  occur  in  the  later 
summer  or  fall,  the  forms  in  which  the  smaller  organisms  are  found,  much 
longer  treatment  and  larger  doses  of  quinine  may  be  required.  Ordinarily, 
however,  doses  larger  than  two  or  three  grains  (0.13-0.2)  three  times  a  day  are 
not  required  under  five  or  six  years  of  age.  Relatively  large  doses  of  quinine 
may,  however,  be  well  borne,  and  in  cases  of  pernicious  malaria  must  be  admin- 
istered. Ferreiera  states  that  he  has  given  doses  as  large  as  15  grains  in  infants 
under  one  year  of  age  without  noticing  ill  effects  ! 

In  pernicious  cases  the  quinine  must  generally  be  administered  hypoder- 
matically.  A  good  preparation  is  the  muriate  of  quinine  and  urea.  In  ordinary 
cases  it  is  probably  better  to  give  smaller  doses  several  times  a  day  than  it  is 
to  give  one  large  dose  with  the  idea  of  "breaking  up"  the  fever.  In  some 
children  it  is  very  difficult  to  administer  quinine  by  the  mouth,  on  account  of 
the  difficulty  in  disguising  the  taste,  and  because  in  some  cases  it  is  constantly 
vomited.  In  some  cases  in  infants  the  drug  is  with  difficulty  retained.  Here 
small  doses  should  be  given  and  often  repeated.  In  these  instances  it  may  be 
administered  by  the  rectum ;  the  dose  under  these  circumstances  should  be 
about  double  that  by  the  mouth.  The  administration  of  quinine  through 
the  skin  by  means  of  ointments  is  probably  of  little  value.  In  cases  of  the 
more  chronic  ^estivo-autumnal  forms  of  malaria,  associated  with  crescent  organ- 
isms in  the  blood,  the  treatment  by  quinine  may  have  to  be  continued  for  a 
considerable  length  of  time.  The  crescents  may  be  found  in  the  blood  for 
months.  The  fever,  however,  if  the  case  is  truly  one  of  malaria,  will  surely 
yield  to  the  treatment  after  a  few  days.     Much  has  been  written  about  those 


318    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

forms  of  malaria  both  in  children  and  adults  which  do  not  yield  to  quinine. 
These  cases  are  probably  not  true  malarial  fever,  as  examination  of  the  blood 
will  show.  Few  cases  of  fever  in  this  country  do  not  yield  within  a  few  days 
to  treatment  by  quinine.  By  this  it  is  not  said  that  relapses  may  not  occur ; 
they  are  frequent  in  cases  where  the  treatment  has  been  continued  too  short  a 
time.  In  some  of  the  acute  forms  of  fever,  and  more  particularly  in  the  more 
chronic  forms  and  in  the  malarial  cachexia,  the  anaemia  and  various  gastro- 
intestinal disturbances  may  also  demand  our  attention.  In  most  instances, 
with  proper  attention  to  the  diet,  the  gastro-intestinal  symptoms  will  disappear 
after  the  disappearance  of  the  fever.  The  anaemia,  however,  may  require 
extended  treatment  with  various  preparations  of  iron,  and  even  in  the  severe 
cases  with  arsenic,  which  is  particularly  well  borne  by  children.  The  adminis- 
tration of  arsenic,  which  is  common  in  chronic  malaria,  has  its  chief  value 
in  its  effect  on  the  anoemia.  Various  other  drugs  have  been  tried  in  malarial 
fever,  some  of  which  have  some  influence  on  the  attacks.  The  most  important 
of  these  are  preparations  of  eucalyptus  and,  of  late,  methylene  blue.  None, 
however,   approach  quinine  in  efiicacy. 

One  attack  of  malarial  fever  does  not,  unfortunately,  render  the  patient 
immune.  On  the  other  hand,  he  seems,  if  anything,  to  be  more  readily  subject 
to  fresh  attacks,  and  in  some  instances  these  attacks  may  be  so  frequent  and 
prolonged  that  a  removal  of  the  child  to  a  proper  climate  is  necessary. 


PART    IV. 
GENERAL  DISEASES  NOT  INFECTIOUS 


RACHITIS. 

By  J.  LEWIS  SMITH,  M.  D., 

New  York. 


Rachitis  is  a  constitutional  disease,  but  its  most  conspicuous  anatomical 
characters  pertain  to  the  osseous  system.  The  gross  nutritive  changes  which  it 
produces  in  the  bones  and  cartilages,  causing  deformities,  are  well  known  to 
physicians  and  the  laity.  In  addition  to  these  anatomical  changes  in  the 
skeleton,  typical  cases  exhibit  a  lack  of  tonicity  with  stretching  of  the  liga- 
ments, causing  the  knock-knee  and  flat-foot;  weakness  of  the  muscles,  resem- 
bling paralysis  and  sometimes  mistaken  for  it  in  severe  cases  ;  reflex  irritability, 
rendering  rachitic  patients  liable  to  laryngismus  and  tetany  ;  undue  perspi- 
ration ;  anaemia  and  proneness  to  catarrhal  inflammation  ;  and  certain  anatomi- 
cal changes  in  the  spleen  and  liver  in  aggravated  forms  of  the  disease.  These 
many  and  divers  anatomical  and  functional  characters  indicate  the  constitutional 
or  general  nature  of  rachitis.  Therefore  theories  which  restrict  rachitis  to 
the  osseous  system  are  inadequate  and  erroneous. 

Rachitis  is  probably  an  ancient  disease.  It  is  said  that  an  old  statue  of 
^sop,  who  was  thrown  from  a  precipice  by  the  indignant  Delphians  564  years 
before  Christ,  exhibited  rachitic  deformities ;  and  Hippocrates,  born  460  years 
before  Christ,  is  believed  to  have  alluded  to  it  in  his  treatise  on  the  Articu- 
lations. 

Occasionally  expressions  in  the  works  of  Celsus  and  Galen  in  the  second 
century  of  the  Christian  era  have  led  writers  on  rickets  to  believe  that  they 
also  had  observed  the  deformities  produced  by  this  disease.  But  rickets  was 
first  investigated  in  a  scientific  manner  by  Whistler,  Glisson,  and  their  contem- 
poraries in  the  middle  of  the  seventeenth  century.  During  the  last  few  years 
many  excellent  monographs  have  been  written  on  this  malady,  and  its  causa- 
tion, pathology,  and  treatment  are  better  understood  than  formerly. 

Frequency. — Rachitis  is  a  widespread  disease,  but  it  is  comparatively 
infrequent  in  rural  localities,  where  families  enjoy  the  hygienic  requirements 
of  pure  air,  sunlight,  and  a  plentiful  diet  of  good  quality.  It  is  most  common 
in  crowded  and  badly-fed  families  in  city  tenement-houses,  where  antihygienic 
conditions  prevail. 

Mild  cases  of  rickets,  not  manifested  by  any  prominent  signs  or  symptoms, 
are  often  overlooked,  so  that  the  physician  is  not  summoned,  or,  if  he  be  sum- 
moned and  have  not  given  particular  attention  to  this  disease,  he,  in  not  a  few 
instances,  does  not  detect  its  presence.  In  the  absence  of  deformity,  which 
occurs  later,  the  fretfulness,  tenderness  of  surface,  and  perspirations  are  likely 

319 


320     AMERICAN   TEXT-BOOK   OF   DISEASES    OF    CHILDREN. 

to  be  attributed  to  other  causes  tban  the  correct  one.  Hence,  according  to  my 
observations,  rachitis  is  more  common  in  its  mihler  forms  in  the  asylums  and 
dispensaries  and  in  the  tenement-houses  of  New  York,  and  probably  in  other 
American  cities,  than  is  commonly  believed  by  the  laity,  and  even  by  physi- 
cians who  have  given  little  attention  to  the  disease.  A  few  years  since  in  one 
of  the  New  York  asylums  my  attention  was  directed  to  a  rachitic  child  in  whom 
the  anatomical  characters  of  rachitis  had  become  so  pronounced  that  they 
attracted  the  attention  of  the  nurses.  Prompted  by  the  occurrence  of  this  case, 
which  had  developed  during  my  attendance  in  the  asylum,  I  made  an  exami- 
nation of  all  the  infants,  and  found,  what  I  had  previously  not  suspected,  that 
about  one  in  nine  presented  unmistakable  signs  of  rachitis,  though  in  a  mild 
form  and  for  the  most  part  in  its  commencement.  The  late  Dr.  John  S.  Parry 
of  Philadelphia  stated  that  at  least  28  per  cent,  of  the  children  between  the 
ages  of  one  month  and  five  years  who  came  under  his  observation  in  the  Phila- 
delphia Hospital,  during  the  three  years  preceding  the  publication  of  his  paper 
in  1872,  were  rachitic.  According  to  Dr.  Gee,  whose  observations  were,  how- 
ever, made  as  far  back  as  1867  and  1868,  of  the  patients  under  the  age  of  two 
years  in  the  London  Hospital  for  Sick  Children,  30.3  per  cent,  were  rachitic; 
and  Ritter  von  Rittershain,  whose  observations  were  also  made  several  years 
ago,  stated  that  of  1623  out-door  patients  under  the  age  of  five  years  brought 
to  the  Clinique  at  Prague,  504,  or  31.1  per  cent.,  manifested  this  disease. 
Recently  Prof.  Henoch  of  the  University  of  Berlin  has  stated  that  he  had  seen 
many  thousand  cases  of  rachitis,  and  he  adds  that  its  spread  in  the  large 
cities  of  Northern  and  Middle  Europe  is  enormous.  He  states  that  his  obser- 
vations in  regard  to  the  frequency  of  rachitis  in  dispensary  practice  correspond 
with  those  of  Ritter,  as  many  as  31  per  cent,  being  rachitic.  In  Manchester 
also,  with  its  large  number  of  operatives,  Ritchie's  statistics  show  that  of  728 
out-door  patients  219  were  rachitic.  The  curator  of  the  New  York  Found- 
ling Asylum  for  the  last  ten  years  informs  me  that  he  believes,  without  the 
accuracy  of  statistics,  that  as  many  as  20  per  cent  of  the  cadavers  examined 
by  him  in  the  dead-house  have  presented  the  anatomical  characters  of  rachitis, 
usually  in  a  mild  form. 

The  recent  large  emigration  from  Europe  of  destitute  families,  living  from 
choice  or  necessity  in  filth  and  degradation,  who  for  the  most  part  remain  in 
the  cities,  occupy  small,  dark,  and  dirty  apartments,  and  whose  food  is  of  the 
poorest  quality  and  often  insufficient,  greatly  increases  the  number  of  rachitic 
children  in  New  York  and  probably  in  other  American  cities.  In  the  out- 
door department  of  Bellevue,  to  which  many  thousand  immigrants  from  the 
lowest  class  of  European  society  carry  their  sick  children  for  treatment, 
rachitis  is  not  infrequent ;  and  the  fact  has  been  observed  in  this  institution 
that  a  larger  proportion  of  severe  cases  attended  by  marked  deformities  occur 
in  the  Italian  families  than  in  those  from  other  parts  of  Europe.  In  families 
of  American  parentage  it  is  generally  admitted  that  rachitis  is  more  prevalent 
in  the  negro  than  in  the  white  race. 

Although  this  disease  occurs  most  frequently  in  the  families  of  the  destitute 
and  poorly  fed,  nevertheless  children  of  well-to-do  families  occasionally  suffer 
from  it,  even  in  an  aggravated  form,  in  consequence,  I  think,  usually  of  igno- 
rance on  the  part  of  parents  in  regard  to  the  dietetic  requirements  of  young 
children.  Merei,  in  his  treatise  on  the  Disorders  of  Infantile  Development 
(London,  1850),  states  that  in  Manchester,  where  his  observations  were  made, 
one  child  in  every  five  in  comfortable  circumstances  presented  rachitic  symp- 
toms. In  the  United  States  rachitis  is  rare  in  well-to-do  fjimilies,  who  provide 
sufficient  and  suitable  diet  for  their  children  and  have  a  proper  regard  for  sani- 


RACHITIS. 


321 


tary  requirements.     When  it  does  occur  in  such,  it  is  due  usually,  I  think, 
to  improper  feeding.     But  this  cause  Avill  be  discussed  in  another  place. 

Diagnosis. — In  preparing  statistics  relating  to  rachitis  it  is  obviously 
important  that  the  diagnosis  of  mild  and  incipient  cases  should  be  clear  and 
unmistakable.  What  symptoms  and  anatomical  characters  indicate  rachitis  ? 
The  fact  that  an  infant  has  reached  its  ninth  month  without  a  tooth  is  regarded 
by  Sir  William  Jenner  as  a  reliable  sign  of  rachitis.  In  order  to  determine  to 
what  extent  dentition  is  retarded  by  rachitis — and  retarded  dentition  may  be 
considered  a  sign  of  rachitis — Dr.  H.  E..  Purdy,  physician  to  the  Out-door 
Department  of  Bellevue  Hospital,  made  the  following  observations ; 


Table  I. — Shoioing  at  what  Age  WO  Infants  exhibiting  no  Signs  of  Rac-hitis 
cut  the  First  Tooth — cases  consecutive. 


3  cut  first  tooth  at  2  months. 


28  cut  first  tooth  at    8  months. 


14   " 

<          u         u    3 

16    " 

'       "       "   4 

20   " 

'       "       "   5 

24   " 

'       "       "   6 

37    " 

'       "       •"   7 

20   " 

"     9 

14   " 

"  10 

15   " 

"  11 

8   " 

"  12 

1    " 

"  13 

Of  these,  132  were  wet-nursed,  68  bottle-fed. 

Table  II. — Shoiving  at  what  Age  50  Infants  exhibiting  one  or  more  Rachitic 
Symptoms  cut  the  First  Tooth — cases  consecutive  (18  wet-nursed,  32 
bottle-fed). 


2  cut  first  tooth  at  4  months. 

2  "      "        "      "  5 

3  "     "        "      "  6        " 
2    "      "        "      "  7 


5  cut  first  tooth  at  8  months. 

6  "      "        "      "     9       " 

7  "      "        "      "  11 

5    "      "        "      "  12       " 


6  cut  first  tooth  at  13  months. 
3    "      "        "      "  14       " 
1    "      "        "      "  16       " 
1    "      "        "      "  18       " 


Table  III. —  Thirty  Infants  tvithout  Teeth,  but  with  pronotmced  Rachitic 
Symptoms.  (In  all  these  cases  the  rachitic  rosary,  enlarged  subcutaneous 
veins,  profuse  perspirations,  abdominal  distenjtion,  and  enlarged  joints  were 
present.  Bottle-fed,  21 ;  wet-nursed,  9.  Age  at  which  they  cut  the  first 
tooth.) 


6  at  7  months. 

1  at  10  months. 

2  at  13  months. 

10  "  8 

4  "   11        " 

2  "   14 

1  "   9 

3  "   12        " 

1   "   15 

It  is  evident  from  these  interesting  statistics  that  dentition  delayed  until 
the  ninth,  or  even  the  tenth  or  eleventh  month,  is  not  a  certain  sign  of  rachitis, 
but  slow  teething  is  common  in  the  rachitic,  and  therefore  it  aids  in  the  diag- 
nosis.    It  is  one  of  the  diagnostic  signs. 

In  order  to  determine  whether  rachitis  incipient  or  of  a  mild  form  be  present, 
all  the  signs  which  characterize  it  should  be  considered — the  fretfulness,  free 
perspiration  upon  the  head,  neck,  face,  and  chest,  the  tenderness  of  surface, 
anaemia  and  general  deterioration  of  health,  delayed  dentition,  swelling  of  the 
joints,  craniotabes,  bending  of  the  long  bones,  rachitic  rosary,  misshapen  head, 
prominent  frontal  and  parietal  bones,  deformity  of  the  thorax  with  depression 
of  the  ribs,  projecting  or  misshapen  sternum  and  prominent  abdomen,  with 
Harrison's  groove.  All  these  signs  and  symptoms  must  be  considered  before 
making  a  diagnosis  in  incipient  or  mild  rachitis.  In  order  to  determine 
the  diagnostic  value  of  enlargement  of  the  costo-chondral  articulations,  "the 
rachitic  rosary,"  in  three  of  the  New  York  institutions  I  have  examined  these 
joints  in  children  supposed  to  be  healthy  or  suffering  from  other  ailments  than 

21 


322    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


rachitis.  In  many  young  children  believed  to  be  healthy  these  joints  are  not 
appreciable  on  palpation.  In  others  a  slight  prominence  can  be  felt  in  one  or 
more  joints.  In  order  that  the  beading  of  these  articulations  be  sufficient  to 
indicate  rachitis,  it  should,  I  think,  be  plainly  detected  by  the  fingers  in  most 
of  these  articulations.  Less  than  this  I  Avould  not  regard  as  sufficient  evidence 
of  this  disease. 

Age  of  Occurrence. — Rachitis  is,  with  few  exceptions,  a  disease  of  infancy. 
A  large  majority  of  the  cases  occur  before  the  age  of  three  years.  Now  and 
then  it  occurs  in  the  foetus,  producing  deformities  such  as  are  present  in  typical 
cases.  In  the  Kinderspital  Museum  at  Prague  is  a  specimen  of  foetal  rachitis 
described  by  Ritter.  Ilink  and  Winkler  also  relate  foetal  cases,  and  Virchow 
alludes  to  a  specimen  in  the  Wlirzburg  Museum  which  exhibits  such  deformities 
as  characterize  rachitis.  Bednar  even  regards  foetal  rachitis  as  not  uncommon 
(Hillier,  Parry).  In  the  Wood  Museum  of  Bellevue  Hospital  is  a  skeleton  which 
is  probably  similar  to  those  in  the  Prague  and  Wlirzburg  museums.  It  shows 
in  a  striking  manner  the  deformities  of  congenital  rachitis.  The  case  occurred 
in  my  practice,  and  the  dissection  was  made  by  Prof.  Francis  Delafield.  The 
infiint,  born  at  term,  died  a  few  hours  after  birth  from  atelectasis,  apparently  pro- 
duced by  the  lateral  depression  of  the  ribs  and  contracted  state  of  the  thorax. 
The  parents  were  hard-working  English  people,  whose  mode  of  life  and  sur- 
roundings were  such  as  are  known  to  conduce  to  rachitis.  They  were  free 
from  syphilitic  taint.     The  accompanying  wood-cut  represents  this  skeleton. 

The  following  remarkable  case  of  supposed  foetal  rachitis  was  related  to  me 
by  Dr.  Heitzmann,  whose  interesting  experiments  will  presently  be  detailed : 
A  woman  who  had  frequently  inhaled  the  vapor  of  lactic 
Fio.  1.  acid  each  day  for  many  months,  as  she  was  employed  to  feed 

animals  with  this  agent,  gave  birth  to  an  infant  at  term  which 
died  immediately  after  it  was  born.  It  exhibited  the  signs 
of  congenital  rachitis  in  a  high  degree.  The  skull-bones 
were  completely  absent ;  in  the  cartilages  of  the  bones  of 
the  extremities  and  in  those  of  the  ribs  there  were  scanty 
depositions  of  lime  salts  and  numerous  infarctions.  The  death 
of  the  child  was  evidently  due  to  the  absence  of  the  skull- 
bones,  inasmuch  as  the  pressure  upon  the  head  occurring 
during  birth  had  caused  cerebral  haemorrhage.  The  organs 
of  the  chest  and  abdomen  were  fully  developed  and  normal. 
In  the  Neiv  York  Journal  of  Obstetrics  for  Nov.,  1870, 
Dr.  A.  Jacobi  also  published  the  description  of  a  case  of 
congenital  rachitic  craniotabes. 

Enlargement  of  the  costo-chondral  articulations,  known 
as  the  rachitic  rosary,  has  been  observed,  though  rarely,  in 
infants  only  a  few  weeks  old.  Dr.  Parry  saw  it  as  early  as 
the  sixth  week  after  birth,  and  Dr.  Lee  at  the  third  or  fourth 
week.  The  significance  of  this  enlargement  as  a  sign  of 
rachitis  we  have  treated  of  elsewhere.  We  have  stated  that 
Congenital  Rachitis,  with  few  exceptions  rachitis  begins  before  the  close  of  the 
third  year.  Though  first  detected  and  diagnosticated  at  a 
later  date,  it  will  ordinarily  be  ascertained,  on  inquiry,  that  its  symptoms  had 
an  earlier  beginning.  Still,  according  to  certain  observers,  it  may  have  a  con- 
siderably later  commencement.  Glisson,  Portal,  and  Tripier  state  that  they 
have  seen  it  commence  in  children  who  were  well  on  toward  the  age  of  puberty. 
Sir  William  Jenner  says  that  he  has  seen  children  of  seven  and  eight  years 
who  were  only  beginning  to  suffer  from  rachitis. 


RACHITIS.  323 

The  following  are  the  aggregate  statistics  of  Bruennische,  Von  Eittershain, 

and  Ritsche  relating  to  the  age  at  which  rachitis  occurs  : 

No.  of  Cases. 

During  the  first  half  year 99 

"    second  half  of  first  vear 259 


year 


342 


"  .  "   third  year 134 

"    "   fourth  vear 31 

"         "      fifth  year 17 

Between  the  fifth  and  ninth  years 21 

Aggregate 903 

Etiology. — Inheritance. — Some  patients  with  rachitis  appear  to  have 
inherited  a  predisposition  to  it.  Feeble  digestion  and  defective  assimilation 
in  the  infant — which  are,  as  we  will  see,  important  factors  in  producing  the 
rachitic  state — are  often  traceable  to  disease  or  cachexia  of  one  or  both  parents. 
Among  the  parental  causes  may  be  mentioned  poverty,  hardships,  and  defect- 
ive nutrition  of  either  parent ;  age  of  father  and  exhausting  discharges  of  the 
mother,  such  as  purulent,  hsemorrhoidal,  or  uterine  fluxes.  The  offspring  of  a 
tubercular,  syphilitic,  or  otherwise  enfeebled  parent  is  more  likely  to  become 
rachitic  than  is  one  of  healthy  and  robust  ancestry.  We  will  especially  empha- 
size the  syphilitic  dyscrasia  in  either  parent  as  a  potent  cause,  but  M.  T.  Parrot, 
in  his  thesis  published  in  1872,  evidently  went  too  far  in  attempting  to  show 
that  congenital  syphilis  is  the  common  cause  of  rachitis.  Most  rachitic  cases 
are  entirely  free  from  the  syphilitic  taint,  and  a  large  proportion  of  the  chil- 
dren who  have  inherited  the  syphilitic  dyscrasia  do  not  exhibit  any  signs  of 
rachitis. 

Antikygienic  Conditions.  —  In  the  damp,  dark,  filthy,  and  overcrowded 
tenement-houses  of  the  city,  rickets  occurs  most  frequently  and  in  its  severest 
forms.  There  can  be  no  doubt  that  general  mal-hygiene  is  a  potent  factor  in 
causing  this  disease,  and  that  it  sometimes  produces  it  in  those  who  have  inher- 
ited good  constitutions.  On  the  other  hand,  many  children  with  healthy  parent- 
age and  vigorous  ai  birth,  reduced  by  poverty  to  a  life  of  squalor  and  privation, 
do  not  become  rachitic. 

IFood. — Of  the  antihygienic  conditions  which  give  rise  to  rachitis,  the  most 
common  and  potent  appears  to  be  the  use  of  food  not  sufficiently  nutritious,  or, 
if  nutritious,  not  suited  to  the  age  and  digestive  powers  of  the  child.  The  use 
of  thin  and  poor  breast-milk  and  artificial  food  of  poor  quality  or  not  suitable 
for  the  stage  of  growth  and  development  is  a  common  cause  of  rachitis.  Those 
children  who  have  been  prematurely  weaned,  and  who  have  been  given  a  food 
which  is  not  a  proper  substitute  for  the  natural  aliment,  and  those  too  long  wet- 
nursed  by  scantily-fed  and  poorly -nourished  mothers,  and  not  allowed  the  addi- 
tional aliment  which  they  require,  are  especially  liable  to  this  disease.  Those 
children  whose  digestive  power  is  feeble,  from  whatever  cause,  are  more  likely 
to  become  rachitic  than  those  who  in  a  state  of  robust  health  have  a  hearty 
digestion.  Hence  we  meet  with  rickets  as  a  sequel  of  various  protracted  and 
exhausting  maladies  during  infancy. 

I  might  relate  cases  of  rachitis  occurring  during  the  use  of  certain  of  the 
popular  proprietary  or  commercial  foods.  I  have  examined  the  analyses  of 
these  foods  made  by  Prof.  Leeds  in  order  to  determine  what  ingredient  is  lack- 
ing, and  they  are  found  to  contain  a  considerably  smaller  percentage  of  fat  than 
occurs  in  human  milk.  Too  little  fat  in  the  food  may,  as  Cheadle  observes, 
be  one  of  the  chief  dietetic  causes  of  rachitis.  Infants  suckled  by  healthy 
mothers  or  wet-nurses  who  have  an  abundance  of  milk,  of  good  quality,  do  not 
become  rachitic  as  long  as  their  nutriment  is  derived  from  this  source.     But 


324    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

those  prematurely  weaned  and  given  a  diet  deficient  in  nutritive  properties,  and 
those  who  are  allowed  the  promiscuous  food  of  the  table  or  have  largely  a  fari- 
naceous diet  during  the  first  and  second  years,  when  the  food  should  be  chiefly 
milk,  are  especially  liable  to  become  rachitic. 

It  is  an  interesting  fact,  and  one  that  throws  light  on  the  dietetic  cause  of 
rachitis,  that  it  does  not  occur  in  Japan.  Physicians  who  have  had  abundant 
opportunities  to  observe  the  diseases  of  the  Japanese  state  that  they  have  never 
seen  or  heard  of  a  case  among  them.  M.  Remy,  in  his  Notes  Medicales  sur 
le  Japon,  says  that  the  Japanese  women  have  a  remarkable  abundance  of  milk, 
and  that  they  suckle  their  young  until  the  age  of  five  or  six  years,  but  their 
children  are  also  given  artificial  food  after  the  first  year.  Remy's  explanation 
of  the  immunity  of  the  Japanese  from  rachitis  is  as  follows:  "The  Japanese 
have  always  eaten  plentifully  of  fats  and  oil  of  fishes,  the  blubber  of  the 

whale,   the  eel   and  loach   especially The  universal  use  of  the  food 

under  notice  from  the  time  of  ancient  Buddhist  flesh-prohibition,  but  espe- 
cially the  consumption  of  fish  by  the  lactating  Avomen,  together  with  the  fish 
given  to  the  children  as  supplementary  feeding,  which  at  that  time  is  allowed 
them  by  Japanese  tradition,  are,  in  my  opinion,  main  causes  of  the  non-exist- 
ence of  rachitis  in  Japan." 

Observations  on  the  feeding  of  animals  have  also  aided  in  the  elucidation 
of  the  causation  of  rachitis.  Gu^rin  gave  certain  puppies  a  diet  of  meat  four 
or  five  months,  and  they  became  markedly  rachitic,  while  other  puppies  of  the 
same  litter,  suckled  by  their  mother,  remained  well.  At  a  meeting  of  the 
section  of  Diseases  of  Children  of  the  British  Medical  Association,  held  in 
August,  1888,  Dr.  W.  B.  Cheadle  read  an  instructive  paper  on  rachitis,  in 
which  he  said  that  the  results  of  feeding  young  animals  in  the  Zoological  Gar- 
dens strongly  support  the  view  that  a  deficiency  of  animal  fats  and  earthy  salts 
are  the  most  efficient  agents  in  producing  rickets.  He  states  that  in  the  Zoo- 
logical Gardens  the  young  monkeys  taken  from  their  mothers  and  fed  with  a 
vegetable  diet,  chiefly  fruits,  became  rachitic.  Such  diet  is  destitute  of  animal 
fat,  and  is  deficient  in  proteids  and  earthy  salts.  Two  young  bears  were  fed 
with  rice  biscuits,  and  occasionally  with  lean  meat,  which  they  licked,  but  rarely 
ate.  Fat,  proteids,  and  lime  salts  were  practically  excluded  from  their  food. 
The  bears  died  of  extreme  rickets  while  still  young.  Cheadle  also  states  that 
more  than  twenty  litters  of  lions  had  died  successively  of  rachitis,  and  the 
n^xt  brood  were  fed  with  cod-liver  oil,  pulverized  bones,  and  milk.  In  three 
months  all  signs  of  rickets  had  disappeared.  The  addition  of  fat  and  bone- 
salts  caused  the  change,  and  after  eighteen  months,  when  the  last  observa- 
tions were  made,  the  brood  of  young  lions  were  strong  and  healthy.  They  had 
received  in  every  respect  the  same  treatment  as  the  litters  that  had  perished, 
except  as  regards  the  diet.  The  latter  had  been  fed  with  the  carcasses  of  old 
horses,  which  are  destitute  of  fit  and  whose  bones  resisted  the  lions'  teeth. 

The  theory  that  lactic  acid  is  the  causal  agent  in  rachitis  has  been  strongly 
advocated  by  Dr.  C.  Heitzmann,  formerly  of  Vienna,  but  now  of  New  York. 
He  administered  lactic  acid  by  mouth  and  subcutaneous  injection  to  five  dogs, 
seven  cats,  two  rabbits,  and  one  squirrel.  The  lactic  acid  administered  to  the 
dogs  and  cats,  with  "restricted  administration  of  calcareous  food,"  produced 
the  characteristic  enlargement  of  the  epiphyses,  and  finally  the  "  curvatures 
of  the  bones  of  the  extremities."  After  four  or  five  months  of  administration 
of  lactic  acid  the  long  bones  were  very  flexible,  and  repeated  inflammations 
of  the  conjunctiva,  bronchi,  stomach,  and  intestines  had  occurred. 

But  in  many  cases  of  rachitis  there  is  no  evidence  of  an  excess  of  lactic 
acid,  and  an  objection  to  the  lactic-acid  theory  apparently  valid  is  that  lactic 


RACHITIS.  325 

acid,  produced  by  imperfect  digestion,  would  unite  with  a  base,  either  the 
soda  or  potash  in  the  blood,  which  is  always  alkaline,  before  it  reached  the 
osseous  system.  The  more  the  causation  of  rachitis  is  elucidated  by  observa- 
tions on  man  and  experiments  on  animals,  the  stronger  is  the  evidence  that 
its  chief  cause  is  dietetic — that  there  is  a  failure  to  receive  or  to  digest  and 
assimilate  certain  important  substances  in  the  food,  particularly  the  fat,  phos- 
phate of  lime,  and  proteids.  The  deprivation  of  these  alimentary  substances 
produces  the  rachitic  dyscrasia,  which  is  manifested  by  malnutrition  in  many 
tissues.  Of  course  general  antihygienic  conditions,  which  lower  the  vitality, 
may,  as  we  have  stated  elsewhere,  be  a  factor  in  causing  rachitis. 

Pathology. — Distinguished  pathologists  and  clinical  observers  who  have 
investigated  rachitis,  and  Avhose  investigations  have  been  chiefly,  if  not  entirely, 
restricted  to  the  osseous  system,  have  regarded  this  disease  as  an  inflammation 
aifecting  the  bones  and  cartilages.  Among  those  who  have  expressed  this 
opinion  may  be  mentioned  Virchow  and  Niemeyer.  Niemeyer  says :  "  It  seems 
to  me  that  the  most  probable  hypothesis  regarding  the  cause  of  rachitis  is  that 
which  refers  it  to  inflammation  of  the  epiphyseal  cartilages  and  periosteum." 
The  increased  vascularity  of  the  periosteum,  the  proliferation  of  periosteum 
and  cartilage,  the  tenderness  and  pain  on  motion,  and  the  elevation  of  tem- 
perature in  acute  forms  of  the  disease,  indicate  inflammation  rather  than  any 
other  recognized  pathological  state.  If  the  rachitic  disease  of  the  osseous 
system  be  regarded  as  an  inflammation,  it  obviously  presents  a  subacute  or 
chronic  character,  like  cirrhosis  and  certain  forms  of  chronic  nephritis,  in 
which  proliferation  of  connective  tissue  and  sclerosis  occur.  The  eburnation, 
instead  of  normal  ossification,  which  terminates  the  rachitic  process,  might  be 
considered  an  osteosclerosis.  Moreover,  the  thickening,  hypergemia,  and  infil- 
tration of  the  periosteum,  exudation  and  formation  of  new  vessels  in  the  peri- 
osteum and  underlying  cartilaginous  and  osseous  tissues,  are  conformable  with 
the  theory  of  the  inflammatory  nature  of  rachitis.  On  .the  other  hand,  some 
of  the  structural  changes  in  the  soft  tissues  in  rachitis  Avhich  are  described  in 
this  paper  are  not  such  as  ordinarily  result  from  inflammatory  processes.  Bill- 
roth, seeing  the  difficulties  in  the  way  of  the  inflammatory  theory,  wrote  of 
rachitis  that  it  "  cannot  be  exactly  classed  among  the  chronic  inflammations, 
although  nearest  related  to  this  process."  It  seems  most  in  consonance  with 
the  facts  to  regard  rachitis  as  •  a  constitutional  or  general  disease,  a  dyscrasia 
aff'ecting  the  nutrition  of  various  tissues  of  the  body,  and  producing  disease  in 
the  osseous  system  which  is  either  inflammatory  or  closely  allied  to  inflammation. 

Changes  in  the  Soft  Tissues. — We  have  stated  that  although  the  con- 
spicuous lesions  of  rachitis  pertain  to  the  skeleton,  the  soft  tissues  are  also 
more  or  less  implicated,  as  might  be  expected,  since  the  disease  is  systemic  in 
its  nature.  The  skin  in  mild  cases  is  but  little  involved,  but  as  a  rule  the  per- 
spiration of  the  rachitic  is  excessive  from  the  head,  face,  neck,  and  chest. 
This  may  occur  before  changes  are  observed  in  the  skeleton.  Pyrexia  is  in 
some  patients  absent  or  slight,  but  catarrhs  of  the  mucous  surfaces  are  common, 
and  these  are  likely  to  give  rise  to  some  elevation  of  temperature.  The  fever 
that  frequently  accompanies  severe  cases  may  sometimes  result  from  the  disease 
of  the  skeleton.  In  protracted  and  severe  cases  the  patients  become  mark- 
edly anaemic,  but  in  recent  and  mild  cases  the  pallor  may  be  so  slight  as  not  to 
attract  attention.  Emaciation  is  not  pronounced,  as  a  rule,  in  the  rachitic, 
but  in  certain  patients  the  muscles  throughout  the  system  become  shrunken 
and  flabby,  partly  perhaps  in  consequence  of  the  gastro-intestinal  disorder, 
indigestion,  and  malnutrition,  partly  perhaps  from  want  of  use,  for  the  rachitic 
are  likely  to  be  passive. 


326    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Mucous  Membranes. — Rachitis,  as  we  have  stated  above,  increases  the 
liability  to  catarrh  of  the  mucous  surfaces.  Writers  on  this  disease  have 
remarked  the  frequent  occurrence  of  bronchitis,  broncho-pneumonia,  entero- 
colitis, and  conjunctivitis. 

Ligaments. — The  ligaments  become  relaxed  and  flabby,  giving  unusual 
mobility  to  the  joints  and  unsteadiness  to  the  movements.  The  fibrous  bands 
which  unite  the  vertebrae,  as  well  as  the  ligaments  of  the  extremities,  participate 
in  the  relaxation.  Talipes  valgus  and  knock-knee  are  especially  likely  to  occur 
in  rickets  as  a  result  of  the  relaxation  of  ligaments,  even  when  the  bones  are 
but  slightly  involved.  Kyphosis,  lordosis,  and  scoliosis — backward,  forward, 
and  lateral  curvatures  of  the  spine — also  result  from  relaxation  of  the  liga- 
ments, aided  by  the  softening  and  change  in  shape  of  vertebrse  and  of  the 
intervertebral  cartilages. 

The  Spleen  and  Liver. — The  spleen  is  sometimes  enlarged,  as  ascer- 
tained by  palpation  and  percussion.  Ritter  von  Rittershain  found  this  organ 
decidedly  enlarged  in  10  out  of  35  cases  which  he  examined  after  death.  The 
enlargement  is  the  result  of  cellular  proliferation,  common  in  diseases  which 
are  attended  by  a  dyscrasia.  In  a  recent  very  anaemic  and  fatal  case  of  rachitis 
in  the  New  York  Foundling  Asylum  the  spleen  extended  below  the  level  of 
the  umbilicus.  But  in  many  cases  of  rachitis,  even  when  profound,  splenic 
enlargement  is  slight  or  is  not  appreciable. 

The  liver  in  many  patients  undergoes  no  perceptible  change,  except  that  it 
is  carried  dowuAvard  by  the  lateral  depression  of  the  ribs.  It  is  occasionally 
enlarged  from  fatty  infiltration,  but  no  special  significance  attaches  to  this,  for 
fatty  liver  is  common  in  various  forms  of  disease  attended  by  innutrition  and 
wasting.  It  is  common  in  tuberculosis  and  in  protracted  intestinal  catarrh,  and 
its  pathological  significance  appears  to  be  the  same  in  these  various  diseases. 
There  can  be  no  doubt  that  Sir  William  Jenner  errs  when  he  states  that  albu- 
minoid infiltration  of  the  liver  is  common  in  rachitis.  Parry,  Gee,  Dickinson, 
and  Senator  agree  that  it  is  rare,  and  that  Avhen  it  does  occur  it  is  a  coincidence. 

In  the  discussion  of  rickets  at  the  meeting  of  the  British  Medical  Asso- 
ciation in  August,  1888,  Dr.  Ranke  of  Munich  said  that,  according  to  the 
records  of  34  post-mortem  examinations  of  rachitic  cases  in  Virchow's  Patho- 
logical Institute  between  1872  and  1880,  13  exhibited  changes  in  the  liver, 
mostly  parenchymatous  fatty  infiltration  with  increase  of  volume.  In  the  34 
cases  the  spleen  was  recorded  enlarged  in  9  and  small  in  2.  In  the  remaining 
23  cases  the  size  and  appearance  of  the  spleen  were  probably  normal,  or  some 
mention  would  have  been  made  of  it.  Dr.  Ranke  also  consulted  the  records 
of  the  Munich  Pathological  Institute  under  Professor  Bollinger,  and  in  9  of 
25  post-mortem  examinations  of  rachitic  cases  more  or  less  enlargement  of  the 
liver  was  recorded.  We  may  therefore  infer  from  these  carefully  conducted 
examinations  that  enlargement  and  structural  changes  of  the  liver  and  spleen 
only  occasionally  occur  in  rachitis — that  in  the  majority  of  cases  this  disease 
runs  its  course  without  any  notable  alteration  in  these  organs.  My  own 
observations  lead  me  to  believe  that  hypertrophy  of  the  spleen,  and  probably 
also  of  the  liver,  occurs  chiefiy  in  decidedly  anaemic  subjects. 

The  Abdomen  is  Protuberant  from  various  causes.  The  lateral  depres- 
sion of  the  thoracic  walls  causes  the  liver  and  spleen  to  descend  a  little  lower 
in  the  abdominal  cavity  than  natural,  producing  at  the  base  of  the  chest 
anteriorly  Harrison's  groove,  which  is  transverse  and  corresponds  with  the 
insertion  of  the  diaphragm.  The  enlargement  of  the  liver  and  spleen,  the 
feeble  tonicity  of  the  intestinal  muscular  fibres,  and  consequent  distention 
of  the  intestines  with  gas,  and  the  rachitic  shortening  of  the  spinal  column, 


BACHITI8.  327 

which  causes  approximation  of  the  ribs  and  pelvis,  necessarily  produce  abdom- 
inal protuberance. 

The  Kidneys  and  Urine. — Observations  thus  far  have  not  detected  any 
structural  change  or  disease  of  the  kidneys  attributable  to  rachitis,  except  that 
this  organ  is  enlarged  in  some  cases.  Moreover,  the  records  of  the  urine  are 
so  conflicting  that  more  exact  and  more  numerous  examinations  of  this  excre- 
tion are  required  before  any  positive  statement  can  be  made  in  reference  to  its 
composition.  Dr.  C.  H.  Flagge  has  seen  two  cases  in  which  there  were  large 
quantities  of  uric  acid  in  the  urine.  Ephraim  also  mentions  an  increased  elimi- 
nation of  uric  acid  up  to  18  per  cent.  Ephraim  likewise,  as  well  as  Marchand 
and  Lehmann,  state  that  there  is  an  increase  of  phosphate  of  lime  and  the 
occurrence  of  lactic  acid  in  the  urine. 

Brain  and  Spinal  Cord.  —  It  is  not  improbable  that  the  symptoms  of 
rachitis  which  are  referable  to  the  nervous  system,  such  as  laryngismus  strid- 
ulus, tetany,  convulsions,  and  weakness  or  paralysis  of  the  extremities,  may 
be  largely  due  to  the  pressure  exerted  in  places  upon  the  cerebro-spinal  axis 
by  its  bony  covering.  Hence  we  will  postpone  their  consideration  until  we 
have  described  the  changes  produced  by  rachitis  in  the  osseous  system. 

Changes  in  the  Osseous  System. — A  knowledge  of  the  normal  anat- 
omy and  normal  development  of  the  osseous  system  will  enable  us  to  better 
understand  the  changes  which  occur  in  this  system  in  disease,  and  especially, 
which  concerns  us  at  present,  in  rachitis.  Hence  we  will  give  a  brief  rdsum^ 
of  the  anatomy  of  the  skeleton  in  health  before  we  consider  the  changes  pro- 
duced in  it  by  rachitis. 

Osseous  System  in  Health. — In  health  and  when  fully  developed,  bone 
consists  of  animal  matter  (chiefly  gelatin)  and  earthy  salts,  in  the  proportion, 
by  Aveight,  of  about  one  part  of  the  former  to  two  of  the  latter.  The  following 
is  the  analysis,  which  may  be  regarded  as  approximately  correct,  of  healthy 
human  bone  of  the  adult: 

Animal  matter 33.30 

f  Tribasic  phosphate  of  calcium 51 .04 

Carbonate  of  calcium 11.30 

Earthy  salts.  A   Fluoride  of  calcium 2.00 

Phosphate  of  magnesium 1.16 

^  Soda  and  chloride  of  sodium 1 .20 

100.00 

In  childhood  the  bones  are  softer,  more  elastic,  and  less  likely  to  fracture  than 
in  the  adult.  Of  the  earthy  salts  in  bone,  it  is  seen  that  the  phosphate  of  cal- 
cium is  the  most  abundant,  and  it  is  the  most  important.  Hence  it  is  termed 
"bone  earth."  The  phosphate  of  calcium,  combined  with  animal  matter,  pro- 
duces a  hard  compound.  The  enamel  of  the  tooth  consists  chiefly  of  phos- 
phate of  calcium  (88J  per  cent.),  while  the  softer  egg-shell  consists  chiefly  of 
the  carbonate  of  calcium.  The  strength  of  bone  is  remarkable,  being,  according 
to  Holden,  when  compared  with  wood,  nearly  three  times  that  of  the  elm  or  ash, 
and  double  that  of  the  oak.  It  is  elastic  on  account  of  the  animal  matter 
which  it  contains.  If  a  long  bone  be  placed  at  right  angles  upon  a  hard  sub- 
stance, and  the  projecting  end  receive  a  blow  from  a  hammer,  the  latter  will 
rebound.     The  Arab  children  are  said  to  make  bows  of  the  camel's  ribs. 

If  a  longitudinal  section  be  made  through  a  long  bone,  we  observe  a  hard 
or  compact  outer  part,  and  in  the  interior  the  medullary  canal,  containing  mar- 
row. In  birds  of  flight  the  hollow  of  the  bones  contains  air  instead  of  mar- 
row, and  this  air  communicates  with  the  lungs. 


328    AMERICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 

The  hard  or  compact  portion  of  bone,  though  solid  like  a  stone,  consists  of 
layers  in  close  apposition,  so  that  there  is  no  interval  between  them.  On 
approaching  the  joints  the  internal  layers  of  the  compact  structure  separate 
from  each  other,  forming  the  cancellous  tissue,  so  that  the  compact  wall  becomes 
thinner.  If  the  earthy  salts  be  removed  by  an  acid,  the  animal  matter  remain- 
ing is  found  to  consist  of  layers,  Avhich  can  be  separated  from  each  other.  In 
inflammation  the  afflux  of  blood  and  the  exudation  cause  separation  of  the 
layers  and  enlargement  of  the  bone. 

The  cancellous  tissue  occupies  the  interior  of  the  bone,  and  is  most  abun- 
dant in  its  articular  ends.  The  bony  layers  in  the  cancellous  structure  are 
separated  from  each  other,  so  as  to  form  cavities,  which  are  strengthened  by 
cross-plates  like  latticework.  In  the  adult  the  marrow  in  the  interior  of  the 
shafts  of  the  long  bones  is  yellow,  consisting  of  96  per  cent,  of  fat,  but  in  the 
articular  ends  of  the  long  bones,  in  the  ribs,  cranial  bones,  and  short  bones,  the 
marrow  has  a  reddish  tinge,  and  it  consists  of  about  75  per  cent,  of  water  and 
about  25  per  cent,  of  albumin,  Avithout  fat  or  only  a  trace  of  it.  This  kind 
of  marrow  occurs  in  all  the  bones  of  the  foetus  and  the  infant,  and  it  contains 
cells  Avith  many  nuclei,  designated  "myeloid  cells."  Holden  says  that  bones 
are  as  minutely  provided  with  blood-vessels  and  nerves  as  are  the  soft  tissues. 
Near  the  extremities  of  the  long  bones  are  numerous  minute  openings  through 
which  blood  is  conveyed  to  and  from  the  cancellous  tissue.  On  the  shafts  of 
the  long  bones  are  slight  grooves  parallel  with  the  shafts,  at  the  bottom  of 
which  are  minute  holes,  scarcely  visible,  through  which  blood  is  conveyed  to  and 
from  the  compact  tissue.  The  blood  which  supplies  the  osseous  tissue  is  con- 
veyed through  these  holes  by  minute  arteries  from  the  vessels  of  the  periosteum, 
and  is  returned  by  veins  to  the  periosteum.  Near  tbe  middle  of  the  shaft  of  the 
long  bone  is  a  distinct  canal  passing  obliquely  through  the  shaft.  This  canal 
contains  the  nutrient  artery  of  the  medulla,  dividing,  after  entering  the  medul- 
lary cavity,  into  two  branches,  one  passing  upward  and  the  other  downward. 
The  blood-vessels  supplying  the  different  parts  of  the  bone  from  these  various 
sources  intercommunicate.  Other  bones  than  the  long  bones  are  supplied  with 
blood  in  a  similar  manner,  and  the  nutrient  vessels  are  accompanied  by  nerves, 
as  in  other  parts  of  the  system. 

The  microscope  is  required  in  order  to  reveal  the  minute  anatomy  of  bone. 
It  is  found  to  consist  of  canals,  termed  the  Haversian,  and  around  each  canal 
the  bone  is  arranged  in  concentric  layers,  like  the  concentric  rings  of  a  tree. 
Between  the  rings  are  dark  spots,  designated  lacunae,  arranged  concentrically, 
now  known  to  be  minute  reservoirs  containing  blood.  Minute  lines  are  seen 
connecting  the  reservoirs  with  each  other  and  Avith  the  adjacent  Haversian 
canal.  The  lines  are  minute  blood-vessels,  and  through  them  the  blood  is  con- 
veyed to  every  part  of  the  bone.  They  are  designated  canaliculi.  They  con- 
nect externally  Avith  the  vessels  of  the  periosteum,  and  internally  Avith  the 
vessels  of  the  medullary  membrane  or  endosteum.  In  the  interspaces  between 
the  lacunae  and  canaliculi.  in  the  animal  matter,  an  infinite  number  of  osseous 
granules  is  deposited,  consisting  mainly  of  phosphate  and  carbonate  of  lime. 

Alterations  in  tJie  Osseous  System  in  Rachitis. — For  convenience  of  descrip- 
tion the  course  of  rachitis  as  regards  the  osseous  system  is  divided  into 
three  periods :  (1)  That  of  proliferation  and  altered  nutrition  of  cartilage  and 
periosteum ;  (2)  That  of  curvature  and  deformity ;  (3)  That  of  reconstruc- 
tion. 

1.  Anatomical  Characters  in  the  Stage  of  Proliferation  and  Altered 
Nutrition. — The  long  bones  in  normal  groAvth  increase  in  length  by  the 
formation  of  bone  in  the  cartilage  betAveen  the  diaphysis  and  epiphysis,  and 


RACHITIS.  329 

in  thickness  by  the  development  of  bone  from  the  vascular  and  cellular  under- 
surface  of  the  periosteum.  As  regards  the  flat  and  short  bones,  growth  in 
the  thickness  occurs  from  the  periosteum,  and  growth  in  breadth  occurs  from 
the  development  and  ossification  of  the  cartilaginous  borders  and  edges,  which 
correspond  with  the  epiphyseal  cartilage  of  the  long  bones. 

If  we  examine  the  epiphyseal  cartilage  of  a  long  bone  during  normal  ossifi- 
cation, we  observe,  beginning  at  the  distal  end,  a  white  zone,  consisting  of  the 
hyaline  matrix,  in  which  are  the  usual  cartilage-cells.  This  constitutes  most  of 
the  cartilage.  Underneath  this,  and  nearer  the  bone,  is  the  zone  of  prolifer- 
ation, the  cartilage  in  which  is  softer  and  more  yielding  than  that  of  the  distal 
zone,  in  consequence  of  cell-formation  and  absorption  of  the  matrix  to  make 
way  for  cell-groups.  Each  cell  in  the  proliferating  zone  has  divided  into 
two  cells,  and  each  of  these  cells  into  two  other  cells ;  and  the  division  has  been 
repeated,  so  that  eight  cells  instead  of  one  are  observed,  surrounded  by  a  com- 
mon capsule.  The  capsule  becomes  distended  by  the  cell-multiplication  and 
the  swelling  of  each  cell,  the  size  of  which  is  considerably  greater  than  that  of 
the  parent  cell.  Near  the  bone,  along  the  extremity  of  the  diaphysis,  the  cell- 
groups,  enclosed  in  their  capsules,  nearly  touch  each  other,  the  matrix  having 
been  for  the  most  part  absorbed.  The  end  of  the  diaphysis  is  covered  with  a 
layer  of  these  cell-groups  about  to  undergo  ossification,  with  almost  no  inter- 
vening matrix.  The  proliferating  zone  has  very  little  depth.  It  appears  to  the 
naked  eye  as  a  very  thin,  scarcely  perceptible  layer  of  a  reddish-gray  color 
upon  the  end  of  the  shaft.  It  is  so  thin  that  it  but  slightly  increases  the  thick- 
ness of  the  cartilage. 

In  rachitis  the  state  is  different.  The  zone  of  proliferation,  instead  of 
being  confined  to  a  single  or  at  most  double  layer  of  cell-groups,  consists  of 
many  layers,  involving  nearly  the  whole  epiphyseal  cartilage.  The  cells,  still 
enclosed  in  their  capsules,  undergo  a  more  frequent  division  than  in  health,  so 
that,  instead  of  groups  of  eight  cells,  as  in  the  normal  state,  each  group  con- 
sists of  thirty  or  forty  cells  enclosed  in  the  distended  capsule.  Therefore  in 
rachitis  the  proliferating  cartilaginous  zone  is  a  broad  cushion,  very  soft,  of  a 
grayish  translucent  appearance,  causing  the  characteristic  swelling  observed 
around  the  joint.  Over  the  distal  end  of  the  proliferating  cartilage  there  may 
still  be  a  zone,  though  perhaps  of  little  depth,  of  normal  cartilage  like  that  in 
health. 

While  the  changes  described  above  occur  in  the  cartilages,  the  ossifying 
process  is  arrested  or  rendered  abnormal.  We  indeed  perceive  an  effort  in  the 
direction  of  bone-formation.  The  Haversian  canals,  surrounded  by  capillary 
loops,  extend  from  the  bone  into  the  proliferating  zone  of  cartilage.  Their 
extension  is  effected  by  absorption  of  the  matrix  and  appropriation  of  cell- 
groups  which  lie  in  their  way.  The  cells  in  these  groups,  as  they  enter  the 
Haversian  system,  become  much  smaller  by  rapid  segmentation,  forming  medul- 
lary cells.  We  also  find,  as  further  evidence  of  the  attempt  at  bone-formation, 
granules  and  masses  of  lime  scattered  through  the  cartilage,  and  here  and  there 
spiculse  and  nodules  of  true  bone  springing  up  from  the  bony  substance  of  the 
shaft.  Some  of  the  canals  are  prolonged  far  into  the  cartilage — nearly,  indeed, 
to  its  free  surface-^but  most  of  them  terminate  in  its  lowest  portions. 

We  have  stated  that  the  growth  of  bone  in  thickness  occurs  from  the  under 
surface  of  the  periosteum.  In  health  a  soft,  vascular  germinal  tissue  springs 
from  the  periosteal  surface,  rapidly  receives  lime  salts,  and  is  transformed 
into  bone.  This  germinal  tissue,  consisting  largely  of  capillaries  rising  from 
the  fibrous  tissue  of  the  periosteum,  is  a  very  thin  substance,  barely  visible, 
transient,  and  constantly  changing  from  its  conversion  into  bone. 


330    AJIEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

In  rachitis  this  vascular  subperiosteal  tissue,  not  undergoing,  or  undergoing 
slowly  and  imperfectly,  the  osseous  transformation,  and  at  the  same  time  increas- 
ing more  rapidly  than  in  health  under  the  irritating  influence  of  the  rachitic 
disease,  becomes  a  thick  layer.  Its  color  and  appearance  are  like  spleen-pulp, 
so  that  the  older  observers  supposed  that  there  was  hsemorrhagic  extravasation 
between  the  periosteum  and  the  bone.  There  is,  however,  no  extravasation  of 
blood,  unless  it  accidentally  occurs  from  the  numerous  delicate  capillaries. 
The  resemblance  to  extravasated  blood  or  spleen-pulp  is  due  to  the  abundant 
growth  of  large  and  thin-walled  capillaries  from  the  under  surface  of  the  perios- 
teum, as  shown  by  the  microscope.  This  vascular  outgrowth  is,  for  the  most 
part,  quite  uniform  over  the  shafts  of  the  long  bones,  while  upon  the  cranial 
bones  its  thickness  is  much  greater  in  one  locality  than  in  another.  The 
attempt  at  ossification  also  appears  in  this  tissue.  Lime  salts  are  scantily  and 
loosely  deposited  through  it,  forming  osteophytes,  vascular  and  fragile,  rather 
than  true  bone.  The  question  naturally  arises.  How  does  rachitis  affect  bone 
which  is  already  formed  when  the  rachitic  state  begins  ?  Virchow's  answer  is 
the  following:  "Rachitis  has  by  more  accurate  investigation  been  shown  to 
consist,  not  in  a  process  of  softening  in  the  old  bone,  as  it  has  previously  been 
considered  to  be,  but  in  a  non-consolidation  of  the  fresh  layers  as  they  form : 
the  old  layers  being  consumed  by  the  normally  progressive  formation  of  medul- 
lary cavities,  and  the  new  remaining  soft,  the  bone  becomes  brittle." 

"  We  have  seen  that  in  healthy  bone  the  earthy  salts  are  in  excess  of  organic 
matter  nearly  in  the  proportion  of  two  to  one,  but  in  rachitis  the  proportion  is 
reversed,  the  organic  matter  being  much  in  excess.  The  following  table  gives 
analyses  of  rachitic  bones  by  Marchand,  Davy,  Boettger,  and  Friedleben : 

Femur.  Radius.  yertebra. 


Inorganic.  Organic.       Inorganic.       Organic.       Inorganic.       Organic. 

Case  I.    .    .    .    .  20.60  74.40  21.24  78.76  18.68  81.32 

Case  II 37.80  62.20  20.00  80.00  32.29  67.71 

Casein.    .    .    .  20.89  79.11 

Case  IV.    .    .    .  52.85  47.15 

As  might  be  expected,  the  relative  proportion  of  the  inorganic  matter  (the 
earthy  salts)  and  the  organic  matter  varies  greatly  in  different  cases.  In  severe 
rachitis  many  bones  are  affected.  It  is  stated  that  there  is  no  bone  in  the 
entire  skeleton  that  may  not  suffer,  but  in  mild  cases  only  a  few  are  involved, 
at  least  to  such  an  extent  as  to  produce  structural  changes  appreciable  to  touch 
or  sight. 

Rachitic  bone,  when  the  disease  is  still  in  its  active  period,  presents  a  bluish 
or  dusky-red  appearance  from  its  increased  vascularity.  After  a  variable  time 
— weeks  or  months  according  to  the  severity  of  the  disease — deformities  begin 
to  appear. 

2.  Anatomical  Characters  of  the  Stage  of  Deformity. — Characters 
OF  THE  Rachitic  Fcetus. — Spiegelberg's  description  of  the  rachitic  foetus  cor- 
responds for  the  most  part  with  what  I  observed  in  the  one  whose  skeleton 
is  represented  in  a  foregoing  page.  According  to  this  writer,  the  body  and 
limbs  are  plump,  the  latter  short  and  curved,  the  abdomen  large  and  prominent, 
and  the  head  sometimes  hydrocephalic.  The  skin  is  well  developed  and  mov- 
able, the  adipose  tissue  sufficient,  the  liver  large,  the  epiphyses  swollen  and 
soft,  the  short  and  curved  diaphyses  sometimes  broken  ;  the  rotundity  of  the 
thorax  is  preserved,  and  the  sternum  is  not  carried  forward,  since  there  has 
been  no  respiration.  The  ribs  in  softness  and  liability  to  fracture  correspond 
with  the  long  bones  of  the  extremities.     The  sternum,  most  of  all  the  bones, 


PLATE  XI. 


RACHITIS. 


RACHITIS.  331 

shows  the  delay  in  ossification ;  the  clavicle  is  among  those  least  afi"ected.  The 
cranium  may  be  represented  by  a  membranous  bag  with  plaques  of  bone,  or 
the  cranial  bones  may  be  formed  and  in  shape,  but  thickened  and  softened ; 
the  sacral  promontory  is  pressed  forward  and  downward;  the  ilia  flattened 
and  widened ;  the  pubic  arch  increased. 

Characters  of  the  Rachitic  Child. — In  typical  rachitis  the  bone  sel- 
dom retains  its  normal  form  or  shape  :  its  projecting  points  are  rounded,  and 
as  soon  as  it  softens  it  begins  to  yield  to  pressure  exerted  upon  it.  Hence  the 
curvatures  so  common  and  characteristic.  The  portion  of  a  long  bone  which 
is  formed  after  rachitis  commences  contains  so  little  earthy  matter  that  it  bends 
readily  in  its  fresh  state  either  by  muscular  action  or  by  the  weight  of  the 
trunk  "  in  the  manner,"  says  Vogel,  "  of  a  quill  or  willow  stick."  The  interior 
of  the  bone,  which  was  formed  before  rachitis  began,  and  which  contains  nearly 
or  quite  the  normal  proportion  of  lime,  is  likely  to  break  instead  of  bending, 
but,  as  it  is  surrounded  on  all  sides  by  the  soft  tissue,  the  fragments  are  not 
displaced,  and  probably  do  not  crepitate.  So  scanty  is  the  calcareous  deposi- 
tion in  typical  cases  that,  says  Trousseau,  "  the  bones  ....  can  be  cut 
with  a  knife  with  as  much  ease  as  a  carrot  or  other  soft  root,"  and  the  dried 
specimen  weighs  from  one-sixth  to  one-eighth  of  the  weight  of  normal  bone. 
One  writer  states  that  the  dried  rachitic  bone  is  sometimes  so  porous  from  the 
small  amount  of  lime  which  it  contains  that  it  is  possible  to  respire  through  it 
as  through  a  sponge. 

In  ordinary  cases  the  bones  which  exhibit  most  strikingly  the  rachitic 
change,  and  which,  therefore,  should  be  examined  carefully  in  making  the 
diagnosis,  are  the  cranial  bones,  the  ribs,  and  the  radius — the  sternal  ends  of 
the  ribs  and  the  lower  end  of  the  radius.  It  is  seldom  that  these  bones  do  not 
give  evidence  of  the  disease  if  it  be  present,  and  in  greater  degree  than  other 
bones.  They  are  the  first  to  be  affected  to  an  extent  that  is  appreciable  to  the 
observer. 

Changes  in  the  Cranial  Bones. — In  these  bones  interesting  and  important 
alterations  occur.  Their  edges,  which  correspond  with  the  epiphyseal  cartilages 
of  long  bones,  undergo  proliferation,  and  become  thickened  like  the  latter. 
This  thickening  and  the  delayed  union  of  the  sutures  produce  grooves  which 
can  be  traced  by  the  fingers  between  the  bones,  and  which  are  sometimes 
appreciable  to  the  sight.  Rachitis  causes  enlargement  of  the  cranium,  but  the 
enlargement  seems  greater  than  it  really  is,  on  account  of  the  retarded  growth 
of  the  facial  bones.  In  a  discussion  on  rachitis  in  the  London  Pathological 
Society,  reported  in  the  London  Lancet  (1880,  ii,  1017),  it  was  stated  that  in 
seventeen  rachitic  children  with  an  average  age  of  4.72  years,  the  average  cir- 
cumfex'ence  of  the  head  was  21.22  inches,  while  in  the  same  number  who  were 
non-rachitic,  and  whose  average  age  was  6.05  years,  the  average  circumference 
was  19.95  inches.  The  retarded  ossification  is  manifested  not  only  in  the  open 
sutures,  but  also  in  the  large  size  and  patency  of  the  fontanelles,  which  are  not 
closed  until  long  after  the  usual  time.  The  anterior  fontanelle  in  the  healthy 
infant  is  closed  at  about  the  fifteenth  or  sixteenth  month,  but  in  the  rachitic  it 
remains  membranous  a  longer  time :  in  some  cases  it  is  still  membranous  as  late 
as  the  third  or  fourth  year.  Since  examination  of  the  anterior  fontanelle  aids  in 
determining  whether  or  not  rachitis  be  present,  it  should  be  borne  in  mind  that 
in  the  normal  state  this  space  increases  in  size  till  the  seventh  month,  when  it 
is  at  its  maximum,  and  that  after  the  ninth  month  it  becomes  progressively 
smaller.  Ossification  in  severe  rachitis  is  retarded  for  a  longer  period  than  is 
stated  above,  for  Gerhard  relates  a  case  in  which  the  anterior  fontanelle  had  not 
entirely  closed  at  the  ninth  year. 


332    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  shape  of  the  rachitic  head  varies.  In  general,  instead  of  its  normal 
rounded  form  it  approaches  a  square  shape.  Another  type  is  sometimes  observed 
in  which  there  is  no  marked  angularity,  but  in  -which  the  antero-posterior  diam- 
eter is  enlarged.  In  the  square  head  the  forehead  projects,  and  both  the  frontal 
and  parietal  protuberances  are  unusually  prominent.  The  sutures  are  depressed 
to  a  certain  extent,  as  has  already  been  mentioned,  and  the  anterior,  lateral, 
superior,  and  posterior  surfaces  are  more  flattened  than  in  health.  The  undue 
prominence  of  the  frontal  and  parietal  eminences  is  largely  due  to  the  exaggerated 
proliferation  of  the  periosteum  and  to  the  vascularity  and  infiltration  under- 
neath. Enlarged  veins  are  seen  ramifying  in  the  scalp,  which  in  marked  rachi- 
tis supports  a  scanty  growth  of  hair.  The  free  perspiration  from  the  scalp,  and 
in  some  cases  the  activity  of  its  sebaceous  follicles,  will  be  mentioned  elsewhere. 

Craniotahes. — Thinning  of  the  cranial  bones  in  places,  so  that  the  brain 
lacked  proper  protection,  had  long  been  noticed  in  the  examination  of  rachitic 
heads,  but  the  injury  that  resulted  to  the  infant  was  overlooked  until  pointed 
out  by  Elsasser.  Craniotahes  occurs  for  the  most  part  in  infants  under  the  age 
of  one  vear,  and  a  large  proportion  are  under  eight  months.  Its  occurrence  in 
the  foetus,  as  shown  by  a  case  published  in  the  Neiv  York  Obstetrical  Journal 
in  1870,  and  by  Heitzmanns  case,  has  already  been  alluded  to.  The  factors 
in  producing  this  thinning  are  rachitic  softening  of  the  bones  and  pressure  from 
the  brain  within  and  from  the  pillow  without.  Consequently,  the  portions  of 
the  cranium  in  which  the  thinning  is  most  pronounced  are  the  posterior  and 
lateral,  the  occipital  bone  and  the  posterior  half  of  the  parietal.  If  the 
infant  lie  in  its  crib  chiefly  on  one  side,  on  this  side  the  craniotahes  occurs, 
while  those  portions  of  the  cranium  which  are  not  pressed  upon  exhibit  no 
thinning  or  a  less  degree  of  it.  The  soft  spots  in  the  cranium  are  yielding 
when  pressed  upon,  and  in  the  cadaver  they  are  seen  to  be  translucent  when 
the  bone  is  held  to  the  light.  There  are  in  some  instances  simple  depres- 
sions like  erosions  in  the  bone,  a  continuous  but  thin  bony  layer  remain- 
ing. In  other  cases,  such  as  have  been  particularly  examined  and  studied  by 
physicians,  the  bony  absorption  has  been  complete  over  areas  of  greater  or  less 
extent.  On  examining  a  child  for  craniotahes  it  should  be  borne  in  mind  that 
the  margins  of  the  cranial  bones,  even  when  there  is  no  thinning,  but  thicken- 
ing from  the  cartilaginous  proliferation,  are  flexible  in  the  rachitic.  The  pres- 
sure must  be  made  in  a  direction  away  from  the  sutures  to  ascertain  whether 
craniotahes  has  occurred.  The  pressure  should*  at  first  be  made  lightly  and 
cautiously  with  the  fingers,  for  if  there  be  total  absence,  unless  of  very  little 
extent,  deep  and  forcible  pressure  might  injure  the  brain,  since  so  soft  and  del- 
icate an  organ,  covered  only  by  scalp  and  dura  mater,  badly  tolerates  pressure. 
If  the  first  examination  detect  no  soft  place,  the  fingers  may  be  pressed  more 
firmly  against  the  scalp,  when,  if  the  bone  be  much  thinned,  so  that  there  is 
only  a  small  layer  of  lime  salts  underneath,  it  will  be  found  to  yield.  The  sen- 
sation communicated  to  the  fingers  when  there  is  an  open  space  in  the  cranium, 
and  the  dura  mater  and  scalp  are  in  contact,  has  been  likened  to  that  expe- 
rienced when  pressing  upon  a  fully-distended  bladder.  At  a  meeting  of  the 
London  Pathological  Society,  reported  in  the  Lancet  for  November,  1880,  Dr. 
Lees  presented  statistics  to  show  that  craniotahes  is  one  of  the  lesions  of  inher- 
ited syphilis ;  but  whether  it  does  sometimes  result  from  inherited  syphilis  or 
not,  the  evidence  that  there  is  a  cranial  softening  which  is  sti'ictly  rachitic,  and 
which  occurs  in  those  who  have  not  inherited  syphilis,  appears  from  reported 
observations  to  be  conclusive. 

Changes  in  the  Vertebrce,  etc. — The  short  bones  which  participate  in 
the  rachitic  disease  become  softer  and  more  yielding,  and  their  cancelli  are  filled 


RACHITIS. 


333 


with  a  reddish  pulpy  substance.  In  many  rachitic  cases  the  vertebrge  are  but 
sli"-litly  involved,  so  that  no  deformity  of  the  spinal  column  results;  but  occa- 
sionally, when  many  bones  are  affected,  the  vertebrae  and  intervertebral  carti- 


Fig.  2. 


Head  of  a  Rachitic  Child  in  the  New  York  Infant  Asylum.    This  child  also  had  laryngismus  stridulus. 

lages  soften,  and  spinal  curvatures  result.  The  curvatures  are  due  to  the  weight 
of  the  shoulders  and  head  on  the  spinal  column.  They  are,  with  some  devia- 
tions, an  exaggeration  of  those  present  in  the  normal 
state.  Rachitic  curvatures  of  the  spinal  column  are 
therefore  mainly  antero-posterior,  often  with  more  or 
less  lateral  deflection.  When  there  is  much  curvature 
the  vertebrge  become  wedge-shaped,  narrowed  upon  the 
concavity  and  thickened  upon  the  convexity.  The  in- 
tervertebral cartilao;es  are  also  more  or  less  changed 
by  the  pressure,  being  thinned  where  the  vertebrae 
approximate  to  each  other  on  the  concave  aspect  of 
the  curvature,  and  of  normal  thickness  or  thicker 
than  normal  upon  the  convexity.  The  accompany- 
ing wood-cut  exhibits  the  appearance  and  nature  of 
rachitic  spinal  curvature  continuing  into  adult  life. 
Rachitis,  having  occurred  at  the  usual  age,  resulted 
in  the  permanent  deformity  here  illustrated. 

In  extreme  cases,  fortunately  rare,  the  functions 
of  important  organs  may  be  seriously  impaired  by 
the  curvature  and  consequent  compression,  as  they  are 
in  Pott's  disease.  Thus,  according  to  Miller,  the  aorta 
has  been  so  doubled  upon  itself  as  to  materially  dim- 
inish the  flow  of  blood  to  the  lower  extremities,  so  that 
their  nutrition  was  sensibly  impaired.  The  effect  of  so 
great  curvature  upon  the  heart  and  lungs  must  obvi- 
ously be  detrimental.  At  first  the  spinal  curvatures 
disappear  when  the  child  reclines  or  is  lifted  by  the 
axillae  so  as  to  raise  the  head  and  shoulders  from  the  spine ;  but  when  the 
deformity  has  continued  so  long  that  the  vertebrae  and  cartilages  have  become 


Eachitic  Spinal  Curvature  in 
an  Adult  (from  a  specimen 
in  the  Wood  Museum,  Belle- 
vue  Hospital). 


334   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Fig.  4. 


wedge-shaped,  it  remains  for  life  or  can  only  be  rectified  slowly  and  with 
difiiculty  by  mechanical  appliances.  As  seen  in  the  wood-cut,  the  common 
curvature  in  the  dorsal  region  is  backward  (kyphosis),  while  to  compensate 
the  patient  instinctively  carries  the  neck  forward,  with  the  head  thrown  back, 
causing  cervical  lordosis,  a  similar  anterior  curvature  being  common  in  the 
lumbar  region.  Lateral  curvature  (scoliosis)  may  or  may  not  be  present  even 
when  there  is  considerable  antero-posterior  flexure.  Scoliosis. is  sometimes 
produced  by  the  nurse  in  carrying  the  infant  habitually  over  one  arm. 

Changes  in  the  Maxillce. — Fleischmann  has  investigated  the  changes 
which  rachitis  produces  in  the  maxillary  bones.  Stunted  growth  of  the  facial 
bones,  generally,  has  long  been  known,  and  has  been  remarked  upon  by  various 
writers ;  but,  according  to  Fleischmann.  other  interesting  changes  occur  in  the 
jaw-bones  which  affect  the  direction  and  position  of  the  teeth.  According 
to  this  observer,  the  arched  shape  of  the  lower  jaw  becomes  polygonal,  and  the 
direction  of  its  alveoli  also  changes,  so  that  they  incline  inward.  This  devi- 
ation in  the  arch  and  in  the  alveolar  border  of  the  lower  jaw.  which  begins  in 
the  region  of  the  canine  teeth,  necessarily  causes  softening  of  the  jaw.  Com- 
mencing soon  after,  a  change  is  observed  in  the  upper  jaw-bone  from  the  zygo- 
matic arch  forward,  so  as  to  cause  length- 
ening of  this  bone,  changing  the  shape  of 
the  arch  and  the  position  of  the  teeth. 
The  external  incisors,  instead  of  being 
in  front,  have  a  lateral  position,  and 
when  the  jaws  are  closed  the  superior 
incisors  and  molars  overlap  the  corre- 
sponding teeth  of  the  lower  jaw  in  front 
and  upon  the  sides — a  condition  opposite 
to  that  seen  in  the  jaws  of  old  people. 
Fleischmann  attributes  these  changes  in 
the  lower  jaw  to  the  action  of  the  mas- 
seter  and  the  mylo-hyoid  muscles,  and 
perhaps  the  genio-glossus,  and  to  pressure 
of  the  lip,  the  deficiency  of  earthy  salts 
in  the  bone  rendering  it  more  easily 
acted  on  by  the  muscles.  The  change 
in  the  upper  jaw-bone  he  attributes 
largely  to  lateral  pressure  of  the  zygo- 
matic arches. 

Changes  in  the  Ribs. — The  ribs  are 
easily  affected  in  rachitis.  The  swell- 
ing of  their  anterior  ends,  where  they 
unite  with  the  costal  cartilages,  pro- 
ducing the  "rachitic  rosary,"  has  been 
already  alluded  to  as  one  of  the  first 
and  most  conspicuous  signs  of  rachitis.  The  costochondral  articulations  are 
enlarged  in  all  directions,  appearing  as  nodules  under  the  skin.  If  at  an 
autopsy  an  opportunity  of  inspecting  the  pleural  surface  of  the  articulation 
occur,  the  nodular  prominence  is  seen  to  be  even  greater  and  more  distinct 
than  under  the  skin  (Fig.  4). 

The  deformity  of  the  thorax,  consequent  upon  softening  of  the  ribs,  is 
interesting.  Commencing  with  the  spine,  the  ribs  extend  nearly  directly  out- 
ward :  at  the  union  of  the  dorsal  and  lateral  portions  they  make  a  short  curve 
forward  and  then  turn  inward,  also  with  a  short  curve,  toward  the  sternum 


Rachitic  Child  with  characteristic  deformity  of 
head  and  ribs.  (From  a  patient  in  the  New 
York  FoundUng  Hospital). 


RACHITIS. 


335 


(Fig.  5).  This  abrupt  bending  of  the  ribs,  which  in  their  softened  state  has 
been  caused  by  atmospheric  pressure  during  respiration,  produces  a  depress- 
ion in  the  thoracic  wall  at  about  the  point  Avhere  the  ribs  and  their  cartilages 
unite.  A  groove  extends  on  the  antero-lateral  aspect  of  the  thorax  from  the 
second  or  third  rib  dowjiward  and  a  little  outward.  In  some  cases  the  costo- 
chondral  articulations  are  in  the  line  of  greatest  depression  in  the  thoracic 
walls  ;  in  other  cases  they  are  a  little  inside  or  outside  of  the  deepest  part  of 
the  groove.  The  transverse  diameter,  therefore,  of  the  anterior  half  of  the 
thorax  is  less  than  that  in  the  normal  rotund  form  of  health.  This  neces- 
sarily diminishes  the  antero-lateral  expansion  of  the  lungs  in  inspiration  and 
causes  unusual  prominence  of  the  sternum.  Hence  the  expressions  "pigeon- 
breasted,"  "resemblance  to  the  prow  of  a  ship,"  etc.  applied  to  this  deformity. 
The  presence  of  the  heart  renders  the  depression  or  groove  less  on  the  left 
side  between  the  fourth  and  sixth  ribs  than  on  the  opposite  side,  since  this 
organ  affords  partial  support  to  the  chest-wall.  On  the  other  hand,  the  depres- 
sion on  the  right  side  below  the  sixth  or  seventh  rib  is,  on  account  of  the 
support  given  by  the  liver,  less  than  on  the  left  side.  But  on  the  left  side, 
as  well  as  on  the  right,  the  lower  part  of  the  thorax,  that  below  the  eighth 
or  ninth  ribs,  widens,  being  pressed  outward  and  supported  by  the  abdominal 
viscera.  This  gives  rise  to  an  antero-lateral  furrow  or  groove  near  the  base 
of  the  chest,  sometimes  designated  Harrison's  groove. 

The  ribs  with  their  attached  muscles  are  important  agents  in  respiration, 
but  their  soft  and   yielding  nature    in  the   rachitic   retards,   and  to  a  great 

Fig.  o. 


Deformity  of  Chest  in  Racliitis. 


extent  prevents,  the  lateral  expansion  of  the  thorax  which  is  necessary  for 
normal  and  full  inspiration.  The  action  of  the  respiratory  muscles  and  the 
pressure  of  the  air  from  within  descending  along  the  air-passages  is  not  suffi- 


336   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cient  to  fully  overcome  the  external  atmospheric  pressure  in  the  absence  of  the 
proper  resiliency  of  the  ribs.  Consequently  -with  each  inspiration  we  observe 
more  or  less  sinking  of  the  thorax  on  each  side,  just  as  when  a  moderate 
obstruction  to  the  entrance  of  air  exists  in  the  larynx  or  trachea.  As  the 
ribs  become  firmer  from  the  deposit  of  lime  salts,  respiration  is  more  regular 
and  normal. 

Changes  in  Bones  of  Upper  Extremities. — Although  swelling  of  the 
lower  end  of  the  radius  is  one  of  the  earliest  signs  of  rachitis,  the  bones  of 
the  upper  extremities  are  less  frequently  curved  and  distorted  than  those 
of  the  lower  extremities.  The  clavicle  sometimes  softens  and  bends,  pro- 
ducing two  curvatures — one  backward  near  the  scapula,  and  another,  of  larger 
radius,  nearer  the  sternum,  directed  forward  and  a  little  upward.  Careful 
examination  shows,  in  some  rachitic  patients,  thickening  of  the  margins  of  the 
scapulae  like  that  of  the  cranial  bones.  The  humerus  is  occasionally  bent,  and 
usually  at  the  insertion  of  the  deltoid  in  consequence  of  the  powerful  action  of 
this  muscle  in  raising  and  supporting  the  arm.  The  radius  and  ulna  are  bent 
outward  and  twisted.  This  deformity  is  attributed  by  Sir  William  Jenner  to 
the  fact  that  rickety  children  support  themselves  while  in  the  sitting  posture 
upon  the  palms  of  the  hands  pressed  upon  the  floor  or  couch.  Supporting  the 
weight  of  the  body  in  this  manner  not  only,  in  his  opinion,  causes  bending  of 
the  ulna  and  radius,  but  also  aids  in  producing  the  deformities  of  the  humerus 
and  clavicle. 

Changes  in  the  Bones  of  the  Pelvis. — The  deformities  of  the  pelvic  bones 
resulting  from  rachitic  softening  are  very  important  in  the  female  infant, 
since  pelvic  deformities  during  the  procreative  period  are  the  common  cause  of 
tedious  or  instrumental  labor  and  stillbirth.  These  deformities,  which  elon- 
gate some  and  contract  other  axes  of  the  pelvis,  necessarily  occur  when  the 
rachitic  child  is  in  the  erect  position,  since  the  pelvic  bones  support  the  weight 
of  the  trunk,  head,  and  shoulders.  A  common  deformity  produced  in  this 
manner  is  the  carrying  forward  of  the  promontory  of  the  sacrum,  which  sus- 
tains the  weight  of  the  spine.  There  is,  moreover,  twofold  pressure  from  below 
— that  caused  by  the  heads  of  the  thigh-bones  in  standing,  and  that  exercised 
by  the  tuberosities  of  the  ischia  in  sitting.  Both  these  forms  of  pressure  have 
a  tendency  to  narrow  the  outlet  of  the  pelvis.  Hence  the  marriage  of  the 
female  who  has  been  rachitic  in  infancy  may  involve  serious  consequences. 


Fig.  6. 


Fm.  7. 


Fig.  8. 


Rachitic  Deformities  of  the  Pelvis  (from  specimens  in  Wood's-  Museum). 


Many  of  the  tedious  instrumental  labors  in  the  families  of  the  city  poor, 
which  severely  tax  the  patience  and  endurance  of  young  practitioners,  are 
attributable  to  rickets  in  early  life. 


RACHITIS. 


337 


€}iange8  in  the  Bones  of  the  Lower  Extremities. — The  curvature  of 
the  femur  is  usually  forward  or  forward  and  outward.  The  neck  of  the  femur 
sometimes  bends  bj  the  weight  of  the  body  or  by  use  of  the  legs,  so  that  the 


Fig.  9. 


Fig.  10. 


Fig.  11. 


Fig.  12. 


Rachitic  LteiijiLLiiLies  ol  the  Femur  (V<  ood  s  Museum). 

angle  Avhich  it  forms  with  the  shaft  is  changed.  The  accompanying  wood-cuts 
show  the  rachitic  bend  of  this  bone  in  an  adult,  years  after  rachitis  had  ceased 
and  when  the  bone  had  become  consolidated  by  the  new  deposition  of  lime 
salts.     (Figs.  9  and  10.) 

The  curvature  of  the  tibia  and  fibula  varies  in  difi'erent  cases.  In  those 
under  the  age  of  one  year  it  is  likely  to  be  outward,  so  that  the  knees  are  sep- 
arated from  each  other.  In  those  old  enough  to  stand,  the  weight  of  the  body 
usually  determines  a  forward  bending  of  these  bones.  In  one  case  in  my  prac- 
tice an  anterior  curvature,  so  abrupt  that  an  angle  of  about  70°  was  formed, 
existed  about  five  inches  above  each  ankle.  This 
patient,  although  old  enough  to  walk,  almost  con- 
stantly sat  during  the  day  with  the  feet  extended 
beyond  the  sofa,  so  that  the  edge  of  the  latter  corre- 
sponded with  the  abrupt  curvature  or  angle  of  the 
legs.  It  seemed  that  the  weight  of  the  feet,  unsup- 
ported beyond  the  edge  of  the  sofa,  had  caused  these 
curvatures,  especially  as  the  case  was  one  of  very 
marked  rachitic  softening  of  the  difi'erent  bones. 

Still,  tibial  and  fibular  bending  at  this  point  has 
been  noticed  by  difi'erent  observers,  who  have  attri- 
buted it  to  the  weight  of  the  bodv  in  walking.  Vari- 
ous  other  curvatures  besides  those  mentioned  occur  in 
the  bones  of  the  lower  extremities,  the  direction  in 
which  the  limbs  bend  being  determined  by  the  par- 
ticular circumstances  of  the  case.  In  mild  cases  of 
rickets  most  of  the  deformities  described  above  may 
be  lacking,  but  in  typical  cases  certain  of  them  stand 
out  prominently,  so  as  to  be  readily  detected  by  one 
familiar  with  the  disease.  In  all  such  cases  the  nature 
of  the  malady  is  apparent,  for  the  changes  that  occur 
are  not  only  conspicuous,  but  pathognomonic. 

Rachitis  produces  another  important  eff'ect  on  the 
skeleton.  Its  growth  is  stunted,  not  onlv  during  the 
rachitic  period,  but  subsequently,  so  that  those  who 
have  been  rachitic  in  childhood,  unless  very  mildly, 
have  less  than  the  average  stature  in  adult  life.  The 
stunted  growth  is  apparent,  though  ample  allowance 

be  made  for  curvatures.  The  arrest  of  development  is  greater  in  some  bones 
than  in  others.  It  is  greatest  in  the  bones  of  the  face,  pelvis,  and  lower  extre- 
mities.    Stunted  growth  of  the  pelvic    bones  of  the  female  infant,  conjoined 

22 


Rachitic  Deformities  of  the 
Femur,  Tibia,  and  Fibula 
(Wood's  Museum). 


338    A3fERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

with  the  deformities  alluded  to  above,  may  seriously  affect  her  subsequent  life, 
for  the  stunted  development  of  the  pelvic  bones,  like  the  deformities  mentioned 
above,  constitutes  a  valid  reason  for  avoiding  marriage.  As  a  rule,  the  older 
the  child  is  when  rachitis  begins,  the  less  is  the  skeleton  affected  and  the  less, 
consequently,  is  the  deformity. 

Effect  of  Rachitis  on  Dentition. — As  might  be  expected  from  the  nature 
of  rachitis,  dentition  suffers  severely.  The  delay  in  dentition  has  been  con- 
sidered elsewhere  in  this  paper.  Teeth  which  appear  during  the  rachitic 
state  are  frail,  deficient  in  enamel,  and  crumble  readily.  They  decay  and 
break  before  the  usual  time.  If  certain  teeth  have  appeared  before  rachitis 
begins,  several  months  elapse  before  others  cut  the  gum.  It  is  even  said 
that  a  child  who  has  rachitis  sevei-ely  for  a  lengthened  period  may  never  have 
a  tooth,  and  may  remain  toothless  for  life  ;  but  I  have  never  observed  such  a 
case.  Ordinarily,  when  the  rachitic  state  ceases  and  the  health  is  fully  restored 
dentition  goes  on  in  the  normal  way. 

3.  Anatomical  Characters  of  the  Stage  of  Reconstruction. — This 
stasre  will  be  better  understood  if  we  recollect  what  has  occurred  durino-  the 
first  and  second  stages.  The  very  vascular  periosteum  is  drawn  tightly  over 
the  convexities,  the  pressure  upon  which  diminishes  the  hyperaemia  and  the 
amount  of  exudation  underneath.  Over  the  concavities  the  periosteum  is 
loose :  it  is  hypertemic  with  abundant  new  capillaries,  the  interspace  between 
it  and  the  bone  being  filled  with  the  exuded  soft  material  having  a  gelatiniform 
appearance.  The  reparative  process  goes  forward  rapidly,  the  deposition  of 
lime  salts  being  more  abundant  upon  the  concave  surfaces,  where  there  has 
been  free  exudation  with  no  compression  of  the  capillaries,  than  elsewhere. 
The  lime  salts  are  deposited  from  the  blood.  Consequently,  from  the  increased 
capillary  circulation  and  hyper?emic  state  of  the  periosteum  produced  by  rachi- 
tis, the  earthy  material  is  rapidly  deposited  wherever  there  is  an  open  space 
under  the  periosteum  and  where  the  capillaries  are  in  a  state  of  enlargement. 
Hence  the  reconstructed  bone  is  thicker  and  firmer  upon  the  concave  aspect  of 
the  long  bones  than  elsewhere,  and  thinnest  upon  the  convex  aspect,  where  the 
periosteum  is  more  tense  and  its  capillaries  more  or  less  compressed. 

Normal  ossification  does  not  at  first  take  place  during  the  reparative  stage. 
The  deposition  of  the  earthy  salts  is  designated  by  some  writers  as  a  petrifac- 
tion rather  than  a  true  bone-formation.  Trousseau  likens  it  to  the  formation 
of  a  callus  upon  a  fracture.  A  deposition  occurs  of  lime  salts  more  compact 
than  ordinary  bone.  The  term  "eburnation"  has  been  applied  to  this  new 
osseous  formation,  and  I  have  designated  it  osteo-sclerosis.  It  resembles,  as 
regards  its  hardness  and  morphological  appearance,  the  enamel  of  the  tooth 
rather  than  true  bone,  the  Haversian  canals  and  lacunte  being  small  and  im- 
perfectly formed.  Of  course  after  complete  recovery  the  subsequent  formation 
of  bone  is  normal.  Recovery  from  rickets  is  gradual.  Little  by  little  the  car- 
tilaginous and  periosteal  proliferations  cease,  the  hyperjemia  abates,  and  the 
various  parts  of  the  osseous  system  and  the  soft  tissues  resume  their  normal 
function  and  development. 

General  Symptoms  of  Rachitis. — Preceding  and  accompanying  rachitis 
symptoms  may  be  present  Avhich  are  due  to  indigestion  and  intestinal  catarrh, 
such  as  flatulence,  unhealthy  stools,  and  poor  and  capricious  appetite.  When 
rachitis  begins  the  infant  becomes  fretful ;  its  sleep  is  frequently  restless  and  dis- 
turbed, and  it  awakens  often.  It  repels  attempts  to  amuse  it,  and  is  apparently 
annoyed  by  them.  Nurse  and  mother  speak  of  it  as  a  cross  child.  It  perspires 
freely  from  the  head  and  neck  both  Avhen  awake  and  when  asleep,  while  its 
extremities  and  trunk  are  dry.     Its  pillow  is  wet  with  perspiration  during  sleep, 


BACHITIS.  339 

and  sweat-drops  may  be  seen  upon  forehead  and  face.  If  the  surface  be  dry, 
a  little  excitement  or  elevation  of  temperature  causes  perspiration  to  appear. 
The  rachitic  child  does  not  well  tolerate  the  bed-clothes,  and  it  attempts  to 
throw  them  oif  from  its  limbs,  even  in  cool  weather  lying  exposed  and  causing 
considerable  annoyance  to  the  nurse,,  who  strives  to  prevent  its  taking  cold. 
Sometimes  miliaria  due  to  the  moist  state  of  the  skin  appears  upon  the  face 
and  neck.  We  have  elsewhere  stated  that  the  subcutaneous  veins  that  return 
blood  from  the  head  are  large  and  the  jugular  veins  full.  Another  symptom 
is  soon  observed,  to  wit :  tenderness  over  a  considerable  part  of  the  surface, 
perhaps  largely  due  to  the  morbid  state  of  the  periosteum  over  so  many  bones, 
though  it  is  also  experienced  when  pressure  is  made  upon  soft  parts,  as  the 
abdomen.  The  tenderness  is  probably  the  cause  in  part  of  the  fretful  disposi- 
tion. The  little  patient  appears  to  dread  to  be  touched ;  its  flesh  is  sore ;  it 
repels  attempts  to  amuse  it,  and  wishes  to  be  quiet.  Dangling  it  upon  the 
arms,  swinging  it,  or  even  walking  with  it,  which  delights  the  healthy  child 
and  elicits  a  smile  or  notes  of  glee,  only  adds  to  its  discomfort.  It  is  most  at 
ease  when  left  alone  upon  a  soft  cot  or  pillow,  or,  if  it  have  craniotabes,  when 
quietly  held  over  the  shoulder.  Languor,  disinclination  to  use  the  limbs  or  to 
play,  moderate  thirst,  with  other  symptoms  referable  to  the  digestive  apparatus 
which  are  present  in  many  cases,  and  which  have  already  been  described,  are 
soon  followed  by  changes  in  the  skeleton  that  are  perceptible  to  the  sight  and 
on  palpation.  The  pulse  and  temperature  in  a  large  proportion  of  the  ordinary 
chronic  cases  do  not  deviate  from  the  healthy  state,  except  that  in  some  patients 
there  is  a  moderate  rise  in  temperature  and  acceleration  of  the  pulse  in  the  lat- 
ter part  of  the  day,  indicative  of  a  slight  fever. 

A  hruit  de  souffle  of  greater  or  less  intensity,  synchronous  with  the  pulse, 
has  frequently  been  heard  in  rachitic  cases  by  applying  the  ear  over  the  ante- 
rior fontanelle.  Drs.  Whitney  and  Fischer,  New  England  physicians,  first 
called  attention  to  this  murmur,  believing  it  to  be  a  sign  of  chronic  hydrocepha- 
lus. MM.  Rilliet  and  Barthez  heard  it  in  cases  of  rachitis,  and  therefore  con- 
cluded that  the  American  physicians  had  confounded  the  two  diseases.  More 
recent  observations  have  established  the  fact  that  this  bruit  has  little  diagnostic 
significance.  It  is  heard  whenever  there  is  sufiicient  patency  of  the  anterior 
fontanelle  both  in  health  and  disease.  It  is  conducted  from  the  base  of  the 
brain  through  the  brain-substance  to  the  membranous  covering  of  the  fonta- 
nelle.  Dr.  Wirthgen  heard  the  bruit  in  22  of  52  infants,  of  whom  all  except 
4  were  in  good  health.  I  have  auscultated  the  anterior  fontanelle  in  29  infants 
who  were,  with  two  exceptions,  between  the  ages  of  three  and  thirty  months. 
All  were  well  or  affected  merely  with  trivial  ailments  which  did  not  disturb 
the  cerebral  circulation.  In  most  of  them  a  murmur  could  be  distinctly  heard 
synchronous  with  the  respiratory  act,  and  in  15  of  the  29  cases  no  other  sound 
could  be  detected,  while  in  the  remaining  14  a  bruit  could  be  detected  synchro- 
nous with  the  pulse. 

As  might  be  expected,  craniotabes  gives  rise  to  symptoms  quite  distinct 
from  those  of  the  general  rachitic  disease.  It  usually  occurs  during  the  first 
year  of  infancy,  and  most  frequently  prior  to  the  tenth  month.  The  brain  at 
this  age  is  soft  and  yielding,  since  it  contains  a  large  percentage  of  water. 
Unless  handled  with  care  at  an  autopsy,  it  is  readily  lacerated,  and  moderate 
pressure  upon  it  is  seen  to  disturb  and  move  it  a  considerable  distance  from  the 
point  of  contact.  It  will  assist  to  a  proper  understanding  of  the  symptoms 
referable  to  the  cerebro-spinal  system  to  which  the  rachitic  are  liable,  to  recall 
to  mind  the  fact,  well  known  to  surgeons,  that  slight  depression  of  even  a  small 
portion  of  the  skull  is  likely  to  produce  grave  consequences.     It  is  not  surpris- 


340    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ing,  therefore,  that  craniotabes,  when  there  is  a  space  of  considerable  size  in 
the  cranial  arch  destitute  of  bone,  is  attended  by  symptoms  due  to  the  mechan- 
ical eftect  of  external  pressure  whenever  a  substance  less  yielding  than  the 
brain  comes  in  contact  with  the  unprotected  part. 

Every  rachitic  child  is  fretful,  but  one  with  craniotabes  is  especially  so  if  _ 
the  open  spaces,  in  which  the  lime  salts  are  lacking  or  constitute  a  thin  and 
yielding  layer,  are  of  considerable  size.  If  the  child  lie  upon  the  pillow  in  the 
position  that  is  most  natural  for  it,  the  unprotected  portion  of  the  brain  may 
be  so  pressed  upon  by  the  Aveight  of  the  head  that  it  is  uncomfortable  and  rest- 
less. It  does  not  have  quiet  sleep  because  the  cerebral  circulation  and  functions 
are  disturbed  because  of  the  fact  that  the  cranial  arch  no  longer  protects  the 
brain  from  undue  pressure.  Carefully  placed  in  an  apparently  comfortable 
position,  it  awakens  often  and  frets  until  it  is  taken  in  the  nurse's  arms.  Some- 
times it  instinctively  seeks  a  position  on  the  edge  of  the  pillow,  with  its  face 
downward,  and  it  becomes  more  quiet  when  resting  over  the  nurse's  shoulder 
with  no  pressure  or  support  upon  the  cranial  arch. 

But  if  fretfulness,  disturbed  sleep,  and  the  necessity  of  closer  attention  on 
the  part  of  mother  and  nurse  were  the  only  ill  effects  of  craniotabes,  it  would 
possess  much  less  pathological  significance  than  pertains  to  it.  Pressure  upon 
so  delicate  and  important  an  organ  as  the  brain  involves  risks  and  produces 
serious  symptoms  in  proportion  to  its  degree.  Even  a  slight  injury  of  the 
skull  which  causes  depression,  though  it  may  be  of  trifling  amount,  will  cause 
serious  forms  of  nervous  disorder.  Rachitic  craniotabes  sustains  a  causal  rela- 
tion in  not  a  few  instances  to  one  of  the  most  dangerous  of  the  neuroses — to 
■wit,  laryngismus  stridulus,  or  spasm  of  the  glottis.  Pressure  on  the  cardiac 
and  vaso-motor  centres  of  the  medulla  in  the  rachitic  infant,  in  whom  reflex 
excitability  is  exaggerated,  causes  contraction  of  the  muscles  that  close  the 
glottis.  It  is  certain  that  a  large  proportion  of  those  who  suffer  from  laryn- 
gismus stridulus  are  rachitic,  so  that  it  is  more  common  and  severe  where 
rachitis  is  prevalent,  as  in  England,  than  where  it  is  rare,  as  in  the  rural 
districts  of  America.  It  is  not  often  the  cause  of  death  in  America,  and  the 
fatal  cases  that  do  occur  are,  I  think,  nearly  always  in  the  cities,  whereas  in 
parts  of  Europe,  where  rachitis  is  much  more  common  than  with  us,  it  is  said 
to  cause  not  a  few  deaths. 

Certain  infsints  when  in  a  state  of  excitement  have  what  are  termed  "hold- 
ing-breath spells."  The  face  is  flushed  and  breathing  ceases  for  some  seconds, 
after  which  respiration  returns  and  is  normal.  The  attacks  are  unimportant, 
but  they  appear  to  be  the  same  in  nature  with  the  more  severe  and  dangerous 
seizures  of  laryngismus  stridulus.  They  have  no  pathological  significance, 
excepting  that 'they  show  the  same  neuropathic  state  as  that  in  laryngismus, 
and  that  they  may  be  precursors  of  it. 

Laryngismus  stridulus,  or  glottic  spasm,  is  usually  preceded  by  more  or 
less  impairment  of  the  general  health  and  often  by  fretfulness,  which  is  charac- 
teristic of  the  rachitic  state ;  but  the  attack  occurs  suddenly,  without  premonition, 
and  is  of  short  duration.  It  begins  with  an  arrest  of  respiration,  a  true  apnoea, 
as  if  from  paralysis  of  the  respiratory  centre  in  the  medulla  ;  the  lips  may  be 
livid,  a  pallor  spreads  over  the  face;  sometimes  more  or  less  rigidity  of  the 
limbs  occurs,  with  carpo-pedal  contractions.  After  a  few  seconds,  a  quarter 
or  half  minute,  a  long  and  deep  but  difficult  inspiration  through  the  narrow 
chink  of  the  glottis  folloAvs,  accompanied  in  many  patients  by  a  whistling  or 
crowing  sound,  and  the  attack  ends  with  perhaps  a  momentary  appearance  of 
bewilderment  or  dread  on  the  child's  face.  Laryngismus  stridulus,  like  eclamp- 
sia, does  not  have  a  uniform  causation.     In  certain  cases  it  is  a  reflex  phe- 


RACHITIS.  341 

nomenon  due  to  an  irritant  in  some  part  of  the  system,  as  in  the  intestines, 
but  many  observations  establish  the  fact  that  rachitis  is  probably  its  most 
common  cause.  A  large  proportion  of  the  infants  affected  with  it  exhibit 
unmistakable  rachitic  signs  ;  and  it  has  been  held  that  the  exposed  state  of 
the  brain  in  craniotabes  affords  explanation  of  the  symptom.  But  from  obser- 
vations which  I  have  made  and  from  those  of  other  observers,  like  Senator,  it 
is  certain  that  laryngismus  stridulus  is  common  in  the  rachitic  who  do  not  have 
craniotabes,  so  that  there  must  be  a  causal  relation  in  rachitis  to  spasm  of  the 
glottis  independently  of  the  cranial  softening. 

Distinguished  British  observers,  as  Gee  and  Jenner,  have  noticed  the  fact 
that  rachitic  infants  ai'e  especially  liable  to  eclamjjsia.  The  immediate  or 
exciting  cause  seems  to  be  in  many  cases  the  severe  catarrh  of  the  respiratory 
and  digestive  systems  to  which  rachitic  infants  are  especially  liable.  Indiges- 
tion, flatulence,  and  fermentative  diarrhoea,  common  disorders  of  the  rachitic, 
are  perhaps,  in  some  instances,  the  exciting  causes  of  the  eclampsia.  Similar 
remarks  may  be  made  in  reference  to  tetany,  which,  although  it  occurs  in  the 
adult  and  is  comparatively  rare,  appears  to  be  more  frequent  in  rachitic  than 
in  other  children. 

Those  physicians  w^ho  attend  in  institutions  in  which  children  coming  from 
tenement-houses  are  treated  in  a  large  city  like  New  York  have  noticed  the 
fact  that  the  various  tissues  of  the  body,  besides  those  that  are  conspicuously 
affected  in  rachitis,  are  more  liable  to  inflammatory  diseases  than  are  the  same 
tissues  in  those  who  have  sound  constitutions.  The  frequency  of  the  different 
forms  of  dermatitis,  of  nasal,  post-nasal,  faucial,  and  bronchial  catarrhs,  and 
of  gastro-intestinal  maladies,  we  must  attribute  to  the  fact  that  rachitis  dimin- 
ishes the  resisting  poAver  to  noxious  agents  in  the  various  soft  tissues,  and  ren- 
ders them  more  liable  to  disease. 

If  the  deformity  in  the  thoracic  wall — to  wit,  the  lateral  depression  of  the 
ribs  and  anterior  projection  of  the  sternum — be  great,  we  would  naturally 
expect  that  the  two  important  organs  underneath,  the  heart  and  lungs,  would 
receive  some  detriment.  Upon  the  surface  of  the  heart,  at  the  point  where  it 
supports  the  softened  ribs,  a  white  patch  is  often  found,  due  to  thickening  of 
the  pericardium  and  proliferation  of  the  endothelial  cells,  just  as  thickening  of 
the  skin  in  the  palm  of  the  hand  occurs  from  friction  and  pressure  upon  that 
part.  It  is  probable  that  in  ordinary  cases  this  pressure  does  not  seriously 
impair  the  function  of  the  heart,  but  it  may  increase  the  weakness  of  its  move- 
ments in  supervening  asthenic  diseases,  which  may  occur  during  the  rachitic 
period.  The  injury  sustained  by  the  lungs  is  greater  and  more  apparent.  If 
the  lateral  depression  of  the  ribs  be  considerable,  full  inflation  of  the  lungs 
does  not  occur  in  those  parts  where  the  depression  is  greatest.  The  semi- 
collapse  of  certain  lobules  is  likely  to  occur,  and  even  complete  collapse  of  the 
distant  thin  edges  of  the  lungs.  The  stress  of  respiration  falls  unequally  upon 
different  parts  of  the  lung.  The  anterior  portion,  which  ascends  with  the 
sternum  as  that  is  propelled  forward,  is  more  fully  dilated  than  the  lateral  and 
posterior  parts,  and  it  may  in  consequence  become  emphysematous.  If  in  this 
state  of  the  thorax  and  lungs  severe  bronchitis  or  broncho-pneumonia  occurs, 
the  muco-pus,  being  expectorated  with  difficulty,  clogs  the  tubes,  produces 
dyspnoea,  and  imperils  the  safety  of  the  child.  Even  in  comparatively  mild 
forms  of  inflammation  the  result  may  be  unfavorable,  owing  to  the  lack  of  full 
expansion  in  the  lateral  and  depending  portions  of  the  lung — a  condition 
required  to  expel  the  mucus.  Severe  bronchitis  and  broncho-pneumonia  are 
the  causes  of  death  in  not  a  few  cases  of  rickets  attended  by  marked  deformity 
of  the  thorax. 


342    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Rachitic  Paralysis. — In  not  a  few  instances  in  the  course  of  rachitis  the 
use  of  the  limbs  is  greatly  impaired,  so  as  to  resemble  paralysis,  and  be  desig- 
nated by  this  name,  though  the  term  "paralysis"  is  probably  a  misnomer. 
Cases  like  the  following,  related  by  Dr.  H.  AV.  Berg  in  the  New  York  Medical 

Record,  which  closely  resemble  paralysis,  occasionally  occur:  J.  S ,  aged 

two  years  and  eight  months,  was  admitted  into  the  Orthopaedic  Dispensary 
Sept.  23,  1885.  The  parents  stated  that  the  child  had  never  walked  or  stood 
alone.  The  legs  were  wasted,  apparently  from  disease ;  the  patellar  reflex  was 
good;  there  seemed  to  be  some  rigidity  of  the  muscles  about  the  knee;  and 
the  patient  was  admitted  with  the  diagnosis  of  "spastic  paralysis."  A  closer 
examination  disclosed  the  fact  that  the  disease  was  one  of  typical  rachitis,  and 
by  the  use  of  the  proper  diet,  with  iron  and  phosphorus,  the  patient  was  able 
to  walk  in  November,  and  in  a  few  months  was  entirely  cured.  The  British 
Medical  Journal,  Jan.  4,  1890,  contains  the  account  of  a  case  of  rickets  dis- 
cussed by  the  Edinburgh  Medical  Society,  Dec.  4,  1889.  The  patient,  a  boy 
of  three  years,  had  the  Avaddling  gait  and  straddling  pose  of  pseudo-hypertro- 
phic  paralysis.  The  rachitic  nature  of  the  malady  was  made  apparent  by  the 
symptoms  of  the  case  and  its  history.  I  have  recently  in  private  practice 
observed  two  similar  cases  of  pseudo-paralysis  of  the  lower  extremities  from 
the  same  cause. 

Acute  Rickets. — Occasionally  rachitis  occurs  with  the  sudden  develop- 
ment of  severe  symptoms,  so  that  the  term  "acute  "  is  applied  to  it.  Dr.  Fiirst 
relates  such  a  case  in  the  Jahrh.  fiir  Kinderh.,  Band  xviii.  p.  192:  Tlie 
patient,  aged  two  years  and  one  month,  had  been  largely  fed  upon  starchy 
food,  and  at  six  months  had  dyspeptic  symptoms  and  sweating.  Dentition 
began  in  the  thirteenth  month,  and  ability  to  Avalk  several  months  later.  Spas- 
modic croup  and  swelling  of  the  epiphyses  appeared  at  this  time.  At  the 
above-mentioned  age  the  child  suddenly  fell  ill  with  acute  febrile  symptoms. 
It  had  an  open  anterior  fontanelle,  craniotabes,  and  a  rachitic  chest;  upper 
extremities  free  from  pain  and  not  swollen.  The  left  femur  and  both  tibiae 
showed  diffuse  cylindrical  swelling.  The  appearance  and  feel  of  the  limbs 
were  suggestive  of  diffuse  cellular  infiltration  proceeding  from  the  periosteum 
in  an  attack  of  osteo-myelitis.  The  skin  covering  the  limb  was  tightly  drawn 
and  of  a  reddish  hue.  In  a  few  days  the  right  forearm  was  affected,  and  soon 
after  the  right  arm  and  left  forearm,  and  the  parts  first  attacked  began  to 
improve.  In  four  weeks  the  fever  and  pain  had  abated,  but  swelling  of  the 
epiphyses  and  deformities  of  various  bones  continued.  Cases  like  the  above 
establish  the  fact  that  although  rachitis  is  ordinarily  a  chronic  disease,  insidi- 
ous in  its  commencement,  gradual  and  progressive  in  its  development,  occupy- 
ing months,  there  is  an  acute  form  which  is  attended  by  more  marked  febrile 
movement  and  tenderness  than  occurs  in  the  usual  type,  and  in  which  the 
articular  swelling  appears  more  quickly.      (See  p.   350.) 

Treatment. — Hygiene. — We  recall  the  recent  statement  of  Prof.  Henoch 
of  Berlin  that  the  spread  of  rachitis  has  been  enormous  in  the  cities  of  Central 
and  Northern  Europe.  The  poor  of  these  cities,  among  whom  this  disease 
largely  prevails,  are  emigrating  in  large  numbers  to  the  United  States,  but,  as 
I  have  observed  in  the  asylums  and  dispensaries  of  New  York,  the  severest 
forms  of  imported  rachitis  come  from  Southern  Europe  (Italy).  Evidently,  as 
long  as  the  influx  of  this  class  of  foreigners  continues,  and  the  present  insani- 
tary conditions  exist  in  our  cities  causing  rachitis  in  the  native  born,  this 
will  continue  an  important  disease,  impairing  the  health  and  vigor  of  coming 
generations.  It  is  evident  from  the  nature  of  rachitis  that  success  in  prevent- 
ing it  and  in  curing  those  who  unfortunately  exhibit  its  characteristic  signs 


RACHITIS.  343 

requires  beyond  anything  else  the  employment  of  proper  hygienic  measures. 
The  details  of  the  hygienic  requirements  may  seem  prolix  and  tedious,  but  we 
cannot  expect  any  marked  diminution  of  rachitis  until  they  are  better  known 
and  heeded  by  the  masses. 

The  fact  that  inheritance  is  one  of  the  recognized  causes  of  rickets  renders 
it  very  important  that  the  parents  be  in  good  health.  The  mother  especially 
should  avoid  all  agencies  or  influences  which  impair  the  general  health  during 
the  procreative  period.  She  should,  so  far  as  possible,  encourage  good  appetite, 
take  plain,  easily-digested,  and  nutritious  food,  and  lead  a  quiet,  regular  life, 
with  sufiicient  out-door  exercise  to  promote,  so  far  as  practicable,  a  state  of 
perfect  health.  Country  residence,  with  quiet  exercise  in  the  open  air,  a  diet 
consisting  of  fresh  vegetables,  meats,  fresh  and  abundant  milk,  early  retirement 
to  bed  and  sufficient  sleep,  are  much  more  conducive  to  the  health  of  the  mother 
and  her  child  than  are  the  excitement  and  irregularities  of  city  life. 

We  have  seen  that  there  is  sufficient  clinical  and  experimental  evidence  that 
the  common  and  predominating  factor  in  causing  rachitis  is  the  use  of  a  faulty 
diet,  but  general  insanitary  conditions  are  also  potent  agents.  The  foul  air  and 
noxious  effluvia  of  the  crowded  tenement-house,  so  conducive  to  disease  and  fatal 
to  infants  in  New  York,  should,  if  possible,  be  avoided.  Even  if  poverty  compels 
a  residence  in  the  small  and  dark  apartments  of  a  tenement-house,  crowded  by 
families,  many  of  them  entirely  neglectful  of  sanitary  measures,  yet  parents 
solicitous  for  the  welfare  of  their  children  can  do  much  to  diminish  the  insani- 
tary influences  which  surround  them.  Out-door  air  is  everywhere  available,  and 
every  child  after  the  age  of  two  or  three  months,  unless  suffering  from  acute 
disease,  should  in  ordinary  weather  be  in  the  open  air  one  or  more  hours  each 
day,  as  a  means  of  improving  its  digestion  and  of  producing  a  more  vigorous 
state  of  the  system.  Any  mother  or  nurse  capable  of  the  care  of  a  child  should 
be  able  to  employ  such  measures  as  will  prevent  its  taking  cold  while  in  the 
open  air. 

The  room  occupied  by  a  child,  whether  rachitic  or  not,  should  be  at  a  uni- 
form temperature  of  about  70°  to  73°  F.,  and  it  should  receive  the  sunlight 
or  the  full  daylight,  which  is  often  excluded  by  faulty  construction.  The  under- 
garments worn  during  infancy  and  childhood  should  be  of  wool,  thin  and  light 
during  the  summer,  thicker  and  heavier  in  the  winter.  No  intelligent  mother 
need  be  told  of  the  need  of  personal  cleanliness  of  her  child  as  a  means  of 
promoting  its  health  as  well  as  comfort.  This  is  a  hygienic  measure,  and  we 
need  not  repeat  that  the  more  complete  the  sanitary  conditions  the  less  the  lia- 
bility to  contract  rachitis  or  any  disease  dependent  on  cachexia.  Bathing  of 
children  should  always  be  before  the  fire  or  in  a  warm  room.  The  bath  for  an 
infant  under  the  age  of  six  months  should  be  at  about  90°.  As  the  age 
increases  the  temperature  of  the  bath  should  be  gradually  reduced  to  80°  in  the 
second  year,  to  75°  in  the  third  year,  and  to  70°  subsequently.  The  bath 
should  be  short,  only  long  enough  to  ensure  cleanliness.  For  weakly  infants  it 
is  sometimes  best  to  dispense  with  the  general  bath,  and  employ  the  sponge 
instead.  I  see  no  advantage  in  the  use  of  saline  or  medicated  baths.  After 
the  bath  the  extremities  should  be  warm,  and  to  ensure  a  better  peripheral  cir- 
culation friction  of  the  surface  by  warm  flannel  or  otherwise,  or  the  application 
of  warmth  to  the  limbs,  is  often  useful.  The  extremities  of  a  child  should 
always  be  warm,  for  the  normal  warmth  of  the  surface  not  only  promotes  nutri- 
tion of  superficial  parts,  but  it  tends  to  prevent  internal  congestions  and  inflam- 
mations, to  which  the  rachitic  are  especially  liable.  A  child  that  habitually 
has  cool  extremities  cannot  be  at  the  maximum  of  health,  and  this  is  often  the 
state  of  the  poorly-fed  and  poorly-clad  children  of  the  tenement-houses.     The 


344    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

measures  to  promote  their  normal  circulation  and  warmth,  such  as  exercise  as  far 
as  practicable,  artificial  heat,  exclusion  of  cold  by  woollen  garments,  friction  of 
the  limbs,  either  dry  or  by  the  use  of  mildly  stimulating  lotions,  should  be 
employed.  But  while  the  hygienic  measures  which  we  have  detailed  are 
important  as  means  of  invigorating  the  system  and  rendering  it  less  liable  to 
rachitis  as  well  as  other  cachectic  diseases,  we  repeat  that  the  most  common  and 
potent  cause  of  the  malady  which  Ave  are  considering  is  a  faulty  diet,  so  that 
in  the  endeavor  to  prevent  and  to  cure  rachitis  special  attention  must  be  given 
to  the  feeding. 

Clinical  experience  abundantly  demonstrates  the  fact  that  in  order  to  pro- 
mote healthy  nutrition  the  food  of  the  infant  should  be  breast-milk  until  the 
age  of  ten  or  twelve  months;  and  subsequently,  until  childhood  is  well  advanced, 
its  food  should  consist  largely  of  cow's  milk,  properly  preserved  and  prepared. 

We  need  not  state  that  human  milk  varies  in  its  composition  according  to  the 
health,  diet,  mode  of  life,  and  temperament  of  the  individual  who  furnishes  it. 
Many  mothers  possess  the  requisite  moral  traits  to  be  good  wet-nurses,  and  do 
all  in  their  power  for  the  welfare  of  their  infants,  but  have  an  inadequate  lacteal 
secretion.  Many  mothers,  not  only  in  the  tenement-houses,  but  in  the  Avell-to- 
do  class,  are  unable  to  furnish  sufficient  breast-milk,  and  their  infants,  unless 
they  receive  supplementary  food,  suffer  from  malnutrition  and  are  liable  to 
become  rachitic.  I  have  seen  during  the  last  year  infants  wet-nursed  by  their 
mothers,  fretful,  wasted,  and  at  the  verge  of  starvation,  applied  every  half  hour 
to  the  breast  during  the  hours  of  wakefulness.  Mothers,  deprived  of  the 
needed  sleep  and  sacrificing  their  own  health  in  the  constant  endeavor  to  pro- 
vide for  the  wants  of  their  infants,  usually  have  insufficient  milk,  as  in  the  cases 
alluded  to.  Under  such  circumstances  a  medicine  designated  nutrolactis,  which 
consists  largely  of  the  Galega  officinalis,  has  been  employed  in  the  New  York 
Infant  Asylum  with  apparent  benefit  as  a  stimnlator  of  the  lacteal  secretion. 
But  if  suckling  by  the  mother  continue  inadequate  and  her  infant  be  under 
the  age  of  six  months,  a  Avet-nurse  should  be  employed.  If  this  be  impossible, 
supplementary  feeding  Avill  be  needed. 

In  normal  and  sufficient  wet-nursing  the  infant  should  go  to  the  breast  at 
regular  intervals  of  about  two  hours,  but  at  longer  intervals  at  night  (ten  times 
in  tAventy-four  hours).  It  should  obtain  Avhat  nutriment  it  requires  in  ten  or 
fifteen  minutes,  after  Avhich  it  falls  into  a  quiet  sleep.  This  alloAvs  the  mother 
time  and  opportunity  to  rest  and  recuperate  between  the  nursings,  so  that  she 
furnishes  milk  more  abundant  and  of  better  quality  than  Avhen  she  is  Avorried 
and  anxious  and  deprived  of  needed  sleep.  The  subject  is  so  important  that 
we  may  be  alloAved  to  repeat  Avhat  Ave  have  elsewhere  stated :  An  infant  that 
draAvs  the  breast  at  short  intervals  of  two  hours  obtains  not  only  more  milk, 
but  richer  milk,  than  Avhen  the  intervals  are  longer. 

There  is  no  more  important,  and  frequently  no  more  perplexing,  duty  of 
the  physician  than  to  direct  the  alimentation  of  infants.  Many  mothers 
express  the  determination  to  wean  for  trivial  reasons,  and  are  found  to  be  giving 
one  of  the  commercial  foods  without  consulting  the  physician.  On  the  other 
hand,  many  mothers  seriously  declare  that  their  babies  are  ravenous  nursers, 
and  that  their  breasts  furnish  an  abundance  of  milk,  Avhen  only  a  few  thin  drops 
can  be  obtained  by  the  breast-pump,  and  the  appearance  of  the  nurslings 
plainly  indicates  innutrition  and  progressive  emaciation.  In  such  cases  addi- 
tional nutriment  is  of  course  required. 

The  practice,  which  is  too  common,  of  early  weaning  with  insufficient 
reason  and  without  consulting  the  physician,  is  very  mischievous.  Acute  and 
transient  ailments  of  the  mother  may  cause  some  diminution  in  her  milk,  but 


RACHITIS.  345 

usually  her  health  is  not  so  injured  by  a  short  sickness  that  she  is  incapaci- 
tated for  wet-nursing  ;  of  course  the  continued  loss  of  appetite,  with  progressive 
debility  and  anaemia,  may  be  such  that  prompt  weaning  is  imperatively  required. 

If  it  be  impossible  to  wet-nurse  the  infant,  or  if  it  have  reached  the  age  of 
ten  or  twelve  months,  at  which  time  weaning  is  proper,  it  will  be  necessary  to 
determine  what  food  shall  be  given.  In  New  York  City — and  the  same  is  prob- 
ably true  in  other  cities — the  infant  should  not  be  weaned  in  the  hot  months, 
since  the  change  of  diet  from  the  natural  to  the  artificial  at  this  time  is  very 
likely  to  cause  that  fatal  disease,  the  summer  diarrhoea.  The  infant  should  be 
first  removed  to  the  country  before  weaning,  or,  if  removal  be  impossible,  wean- 
ing should  be  postponed  until  after  the  heated  term,  even  if  it  be  at  the  age  of 
fifteen  or  sixteen  months.  But  with  a  large  proportion  of  infants  after  the  age 
of  six  months  the  mother's  milk  is  not  sufficient,  and  it  is  necessary  to  supple- 
ment the  wet-nursing  by  the  use  of  other  foods. 

Notwithstanding  the  many  commercial  foods  designed  for  infant  feeding, 
I  have  every  year  been  more  and  more  convinced  that  cow's  milk,  prop- 
erly prepared,  furnishes  the  best  substitute  for  human  milk,  and  should  be 
used  to  make  up  the  deficiency  when  the  latter  is  insufficient,  and  be  the 
main  food  or  the  basis  of  the  food  employed  after  weaning.  I  have  observed 
the  occurrence  of  rachitis  in  children  Avhose  diet  consisted  chiefly  of  certain 
proprietary  foods  ;  and,  in  looking  over  the  composition  of  these  foods,  one  of 
the  chief  causes  of  this  result  appears  to  be  the  small  amount  of  fat  which  they 
contain.  Thus,  according  to  Prof.  Leeds's  analyses,  Mellin's  Food  contains 
only  0.15  part  in  144.74,  and  Nestld's  Food  only  1.91  parts  in  139.69,  whereas 
human  milk  contains  3.90  per  cent,  of  fat,  and  cow's  milk  3.66  per  cent,  of  fat. 
Especially  in  the  selection  of  food  designed  to  prevent  or  cure  rachitis  our 
choice  should  fall  on  cow's  milk  next  to  human  milk.  But  cow's  milk  contains 
five  times  more  casein  than  human  milk,  and  is  slightly  acid,  whereas  the  latter 
is  always  alkaline.  In  the  country,  cow's  milk  obtained  fresh  and  with  proper 
attention  to  cleanliness  in  its  manipulation  may  not  require  sterilization  by  heat. 
But  that  received  and  used  in  the  city,  exposed  more  or  less  to  an  atmosphere 
containing  numerous  microbes,  it  is  well  to  sterilize  by  steaming  for  a  period 
not  exceeding  twenty-five  minutes.  For  infants  with  feeble  digestion,  who  are 
suffering  from  innutrition,  digestion  of  cow's  milk  can  be  promoted  by  pepton- 
izing by  the  peptogenic  powder  of  Fairchild  in  the  manner  well  known  to  the 
profession.  Inasmuch  as  observations  relating  to  the  causation  of  rachitis, 
which  we  have  quoted  elsewhere,  show  that  deficiency  of  fat  in  the  food  is  a 
common  cause,  I  recommend,  especially  if  any  rachitic  symptoms  appear,  the 
use  of  the  upper  half  or  third  of  the  can  or  bottle  of  milk,  since  this  contains 
a  large  percentage  of  cream. 

A  properly-prepared  farinaceous  substance,  mixed  with  milk,  not  only  has 
nutritive  properties,  but  also,  by  mechanically  separating  the  particles  of  casein, 
tends  to  prevent  the  formation  of  curds  in  the  stomach.  But  as  young  infants 
digest  starch  with  difficulty,  a  flour,  as  barley,  wheat,  or  oatmeal,  in  which  the 
starch  is  to  a  great  extent  converted  into  dextrin,  or,  better,  into  glucose,  may 
be  advantageously  added  to  the  milk,  especially  for  infants  over  the  age  of  six 
months.  The  conversion  of  starch  into  dextrin  may  be  effected  by  a  high  heat, 
and  into  glucose  by  the  action  of  diastase.  If  a  heaped  teaspoonful  of  barley 
flour  be  boiled  in  twenty-five  teaspoonfuis  of  water,  and  when  it  is  lukewarm 
ten  or  fifteen  drops  of  diastase  (Forbes)  be  added  to  it,  the  gruel  in  a  few  min- 
utes becomes  much  thinner  from  the  digestion  of  starch,  and  it  is  a  useful  adju- 
vant to  the  milk  employed  in  the  nursery,  especially  for  infants  over  the  age 
of  six  months. 


346    AMERICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 

But  -while  healthy  development  in  infancy  and  childhood  requires  a  careful 
choice  of  food  suitable  for  the  stage  of  growth  and  development,  the  frequency 
of  the  feeding  and  the  amount  of  food  given  are  also  matters  of  importance. 
There  can  be  no  doubt  that  many  infants  are  under-fed,  some  even  to  starva- 
tion, and  some  infants  are  over-fed.  MM.  Yernois  and  Becquerel,  in  a  careful 
examination  of  89  infants  wet-nursed  by  mothers  apparently  in  good  health, 
ascertained  that  15  were  insufficiently  nourished.  Did  space  permit  I  might 
relate  instances  in  which  infants  were  applied  to  the  breast  even  more  fre- 
quently than  the  prescribed  rules  allow  by  aflfectionate  and  devoted  mothers 
or  by  wet-nurses  supposed  to  have  sufficient  milk,  and  yet  they  continued  to 
lose  flesh  and  strength,  were  almost  constantly  fretful,  and  were  finally  reduced 
to  a  precarious  state  by  insufficient  nutriment.  On  the  other  hand,  overfeeding 
sometimes  occurs  to  the  detriment  of  the  child.  A  half  century  has  elapsed 
since  the  most  distinguished  Xew  England  physician  of  his  day.  Dr.  James 
Jackson,  called  the  attention  of  the  profession  to  the  frequent,  green,  and 
unhealthy  stools,  showing  imperfect  digestion  occurring  in  children  from  over- 
feeding. Among  the  cachexia  developed  from  abnormal  digestion  and  malnu- 
trition we  recognize  rachitis  as  one  of  the  most  frequent. 

A  few  years  ago  Drs.  Chadbourne,  Parker,  and  myself  made  observations 
in  the  Xew  York  Infant  Asylum  and  New  York  Foundling  Asylum  in  order  to 
determine  how  much  food  children  require  at  different  ages.  Those  selected 
for  observation  were  well  nourished,  and  they  were  accurately  weighed  before 
and  after  each  nursing  or  feeding.  Eleven  infants  under  the  age  of  three 
weeks,  who  took  the  breast,  with  three  exceptions,  twelve  times  in  the  twenty- 
four  hours,  were  found  to  take  on  the  average  12.55  ounces  of  the  breast-milk 
in  the  day  and  night.  Therefore,  according  to  these  statistics,  infants  under 
the  age  of  three  weeks,  nourished  at  the  breast  and  suckled  twelve  times  in  the 
twenty-four  hours,  require  only  one  ounce,  or  not  more  than  one  ounce  and  one 
drachm,  at  each  nursing;  and  the  very  small  size  of  the  stomach  at  this  age 
shows  that  it  cannot  receive  much  more  than  this  without  distention.  After 
the  third  week  the  amount  of  food  required  for  healthy  nutrition  gradually 
increases. 

Children,  like  adults,  in  good  health  and  well  nourished,  do  not  all  require 
or  take  the  same  amount  of  food.  Some  need  more  food  than  others,  but  the 
following  table  indicates,  I  think,  nearly  the  quantity  required  during  the  first 
twelve  months  of  infancy,  either  of  breast-milk  or  of  food  prepared  so  as  to 
resemble  as  closely  as  possible  breast-milk  in  consistence  and  nutritive  proper- 
ties. It  will  be  observed  that  this  table  resembles  closely  that  prepared  by 
Prof.  Rotch  of  the  Harvard  Medical  School,  and  published  in  his  instructive 
paper  on  infant  feeding  in  the  Cyclopcedia  of  the  Diseases  of  Children: 

Quantity  of  Food  required  in  the  First  Year  of  Infancy. 

At  each  Feeding.  Number  of  Daily  Feedings.       Total  Daily  Amount. 

During  the  first  week 1  oz.  10  10  oz. 

At  the  third  week IJ  oz.  10  15  oz. 

At  the  sixth     "        2  oz.  8  16  oz. 

At  the  third  month 3  oz.  8  24  oz. 

At  the  fourth    "       4  oz.  7  28  oz. 

At  the  sixth      "       6  oz.  6  36  oz. 

At  the  tenth  to  twelfth  month    .    .    .  8  oz.  5  40  oz. 

The  daily  average  of  food  for  each  child  in  an  aggregate  of  twenty-eight  healthy 
children  between  the  ages  of  two  and  three  years  was  as  follows:  Bread,  7.5  oz. 
avoir. ;  butter,  .98  oz. ;  meat  (beef),  4.6  oz. ;  potatoes,  3.9  oz. ;  milk,  32.6  fl.  oz. 
The  daily  average  for  each  child  in  an  aggregate  of  twelve  children  between  the 


RACHITIS.  347 

ages  of  three  and  six  years  was  as  follows:  Milk,  48.6  fl.  oz. ;  beef,  12.1  oz. 
avoir.;  rice,  13.0  oz. ;  bread,  10.3  oz.;  butter,  1.08  oz.  The  daily  average 
for  each  child  in  an  aggregate  of  twenty-four  children  between  the  ages  of 
four  and  ten  years:  Roast  beef,  12.46  oz.;  bread,  10.23  oz. ;  potatoes,  10.03 
oz. ;  butter,  .99  oz.;  milk,  38.5  fl.  oz. 

The  prevention  and  the  cure  of  rachitis  require  strict  enforcement  of  the 
details  of  hygiene.  Hence  the  above  facts  relating  to  the  mode  of  life  and 
diet  of  children  should  be  observed  in  order  to  prevent  cachexia  and  promote 
a  healthy  growth. 

Medicinal  Treatment. — Medicines  which  aid  the  digestion  and  assimila- 
tion of  properly-selected  foods  are  sometimes  useful.  Irritability  of  the  stomach, 
imperfectly  digested  stools,  flatulence,  colicky  pains,  etc.  indicate  faulty  diges- 
tion, which  may  be  improved  by  pepsin  given  with  each  feeding.  Tonic  reme- 
dies designed  to  improve  the  appetite  and  digestion,  of  a  kind  suitable  for  the 
age  and  condition  of  the  patient,  are  often  useful.  In  anaemia  one  of  the 
readily-assimilated  preparations  of  iron  should  be  given.  The  complications 
which  are  so  common  require  special  management.  The  laryngismus  stridulus, 
eclampsia,  and  tetany  should  be  promptly  treated. 

The  bronchial  catarrh  to  which  rachitic  infants  are  liable  may  be  best 
treated  by  remedies  like  the  following: 

^.  Ammonii  chloridi    .    .    .    .    : 3j. 

Syr.  Tolutan fgij.— M. 

Sig.  Dose  fifteen  drops  every  hour  or  two  hours  for  an  infant  of  six  to  ten 
months. 

!^.  Ammonii  chloridi 

Ferri  et  ammonii  citratis da  3ss. 

Syrupi fgj. 

Aquae f^iij- — M. 

Sig.  Give  one  teaspoonful  every  two  to  four  hours  to  a  child  of  one  year. 

Some  of  the  rachitic  cases  with  protracted  bronchial  catarrh,  especially 
those  which  also  exhibit  scrofulous  symptoms,  may  be  most  relieved  by  the 
syrup  of  the  iodide  of  iron  and  cod-liver  oil  administered  three  times  daily, 
with  the  inhalation  of  moist  air  containing  turpentine  vapor. 

In  the  protracted  intestinal  catarrh  of  rachitic  infants  I  have  observed  the 
best  results,  so  far  as  medicine  is  concerned,  from  the  following  prescription: 

^.  Subnitrate  of  bismuth Sij-iij- 

Essence  of  pepsin  (Fairchild's) f|j. 

Distilled  water f^iij- — M. 

Sig.  Shake  bottle;  give  half  to  one  teaspoonful,  according  to  the  age, 
every  two  hours. 

But  a  remedy  is  needed  which  will  act  promptly  in  the  cure  of  rachitis  so 
as  to  prevent  the  evil  consequences  which  its  continuance  is  sure  to  produce. 
It  is  the  opinion  of  many  of  the  best  clinical  observers  who  have  had  ample 
experience  that  this  has  been  discovered  in  the  daily  use  of  minute  doses  of 
phosphorus. 

Wegner  fed  young  and  growing  animals  (rabbits  and  fowls)  for  months 
with  small,  non-poisonous,  and  easily  assimilated  doses  of  phosphorus,  with 
the  result,  he  believes,  of  expediting  ossification  and  producing  firmer  bone. 


348    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

He  states  that  under  the  influence  of  phosphorus  the  large  marrow  spaces 
diminish,  by  the  formation  of  true  bone,  to  the  size  of  the  Haversian  canals 
in  normal  bone.  According  to  Wegner,  the  administration  of  finely-divided, 
non-poisonous  doses  of  phosphorus  for  a  prolonged  period  to  older  fowls  pro- 
duced to  a  considerable  extent  the  conversion  of  cancellous  into  compact 
bone  of  normal  chemical  composition.  Kassowitz  has  recently  promulgated 
his  vieAvs  at  some  length  on  the  pathology  and  treatment  of  rachitis.  He 
states  that  the  lime  salts  are  not  needed,  since  the  ordinary  food  contains  suf- 
cient  lime ;  nor  should  the  farinaceous  foods  be  restricted.  He  adds  that 
phosphorus  in  small  doses  restricts  the  formation  of  vessels  in  the  growing 
bones  of  small  animals.  Hence  it  is  useful  as  a  means  of  overcoming  the 
hypergemia.  Kassowitz  administers  about  yi-g  of  a  grain  in  a  teaspoonful 
of  cod-liver  oil,  the  dose,  of  course,  varying  according  to  the  age  of  the  infant. 
The  distinguished  podiatrist  of  Vienna,  Dr.  Widerhofer,  says  of  this  remedy 
that  its  employment  "  impresses  him  with  the  belief  that  it  is  not  without  benefit 
in  the  second  year  of  life  and  upward."  He  thinks  that  it  may  be  useful  in 
the  hardening  of  long  bones,  but  he  has  not  been  able  to  obtain  good  results 
in  craniotabes.  Starker  gives  an  analysis  of  23  rachitic  cases  treated  by  Prof. 
Thomas  of  Freiberg  in  his  clinic.     He  used  the  following  formula  : 

^.  Phosphori  ........       1  centigramme  (about  \  grain). 

01.  morrhuge 100  grammes  (about  3  ounces). — M. 

A  coffee-spoonful  was  administered  twice  daily,  but  variations  in  the  dose  accord- 
ing to  the  age  are  not  stated  in  the  report,  the  patients  being  between  the 
ages  of  a  few  months  and  four  years.  Improvement  occurred  in  the  general 
condition  in  18  cases ;  in  the  cranial  development  in  15  cases ;  in  dentition  in 
14  cases  ;  in  the  shapes  of  the  epiphyses  in  21  cases  ;  in  locomotion  in  17 
cases  ;  but  strict  attention  was  bestowed  upon  the  hygiene,  and  especially  upon 
the  diet.  Soltmann  states  that  good  results  occurred  from  the  use  of  phos- 
phorus in  70  cases  which  he  had  under  observation,  and  in  no  instance  were 
unfavorable  results  noticed.  W.  Meyer  obtained  similar  results  in  42  cases. 
He  regards  phosphorus  as  a  specific  for  rachitis.  When  properly  given  it  always, 
says  he,  produces  positive  results.  Petersen  has  treated  200  cases  with  phos- 
phorus, and  regards  it  as  a  specific.  Sigel  concludes,  from  the  observation  of 
40  cases  in  private  practice,  that  constitutional  treatment  is  of  the  greatest 
importance,  but  instead  of  the  administration  of  iron,  lime,  etc.,  phosphorus 
should  be  prescribed.  Unruh  also  made  many  observations  in  the  treatment 
of  rachitic  cases  by  phosphorus  in  the  Dresden  Hospital  in  1885  and  1886,  and 
considers  it  more  efficacious  than  other  remedies. 

Toplitz  of  Breslau  treated  518  cases  with  phosphorus  combined  with  cod- 
liver  oil.  No  ill  effects  were  observed,  and  in  all  the  cases  improvement 
occurred  in  the  general  condition.  Of  208  cases  of  craniotabes,  176  were  cured 
in  eight  weeks.  In  58  cases  of  laryngismus  stridulus  the  attacks  ceased  in 
eight  to  fourteen  days,  after  having  continued  for  months  under  other  forms  of 
treatment.     Dentition  was  also  promoted. 

In  America,  Dr.  A.  Jacobi,  Avho  has  had  a  large  clinical  experience,  also 
highly  recommends  phosphorus  in  the  treatment  of  rachitis.  The  dose  should 
be  small,  even  minute,  not  more  than  2-0-0  *C)  yto  °^  ^  grain,  according  to  the 
age,  three  times  daily. 

As  regards  my  own  observations,  I  am  not  able  to  express  a  positive 
opinion  as  to  the  value  of  the  phosphorus  treatment,  for  reasons  which  I  think 
also  apply  to  many  of  the  cases  embraced  in  the  favorable  statistics  of  the  dis- 


BACHITI8,  349 

tinguished  observers   mentioned  above — to  wit,  the  simultaneous  use  of  cod- 
liver  oil  and  improvement  in  the  diet  and  general  hygiene. 

The  following  prescriptions  may  be  employed — first,  the  oleum  phospho- 
ratum,  made  according  to  the  following  formula  : 

^.  Phosphorus 1  part. 

Ether 9  parts. 

Almond  oil 90     "     — M. 

One  minim  contains  j^  of  a  grain  of  phosphorus. 

Or,  secondly,  the  following,  known  as  Thompson's  mixture : 

I^.  Phosphori gi^-j- 

Alcoholis  (absolut.) TTL  cccl. 

Spts.  month,  piperit KTlx. 

Glycerini fsij. — M. 

Sig.  Six  drops,  increased  to  10,  three  times  daily,  to  a  child  of  two  to  four 
years.  Ten  minims  contain  ^^2"  of  a  grain,  and  thirteen  minims 
contain  yq~q   of  ^  grain. 

Phosphorus  should,  I  think,  be  given  after  the  meals,  in  order  to  prevent 
irritation  of  the  stomach. 

Dr.  H.  H.  Purdy,  physician  to  the  large  class  of  children's  diseases  in  the 
out-door  Department  at  Bellevue,  has  preserved  statistics  of  the  treatment  of 
rachitis  during  the  last  year.  The  cases  which  furnish  the  statistics  numbered 
about  80,  and  he  gives  a  resumd  of  the  results  of  treatment  as  follows  :  "  Some 
were  given  cod-liver  oil  alone,  some,  cod-liver  oil  with  phosphorus,  and  others, 
phosphorus  alone,  and  of  course  all  the  mothers  were  given  instruction  in  feed- 
ing and  hygiene.  Those  infants  that  received  only  phosphorus  were  the  slow- 
est to  improve.  Indeed,  in  several  cases  this  method  of  treatment  was  aban- 
doned because  of  the  absence  of  the  signs  of  improvement.  The  group  treated 
with  cod-liver  oil  did  the  best.  In  fact,  all  of  the  infants  that  could  tolerate 
the  oil  derived  much  benefit  from  it.  The  group  that  were  given  cod-liver  oil 
with  phosphorus  did  very  well,  but  seemingly  no  better  than  those  that  were 
given  only  cod-liver  oil.  The  preparation  that  seems  to  be  the  most  beneficial 
is  one  that  is  used  at  the  Church  Hospital  and  Dispensary.  It  is  an  emulsion 
of  cod-liver  oil  made  with  the  yolk  of  eggs.     The  formula  for  the  emulsion  is : 

I|i.  Yolks  of  ten  eggs. 

Cod-liver  oil Oij. 

Syrup  of  wild  cherry Oj. 

Sherry  wine Oj. — M. 

Sig.  One  or  more  teaspoonfuls  administered  three  or  more  times  daily." 
In  my  opinion  the  treatment  by  phosphorus  is  still  tentative,  notwithstand- 
ing its  recommendation   by  so  many  distinguished  physicians ;    and  the  old 
remedies,  cod-liver  oil  and  iron,  should  not  be  abandoned,  although  trial  may 
be  made  of  phosphorus  at  the  same  time. 

Care  should  be  taken  to  prevent  deformities  while  the  bones  are  soft  and 
yielding.  The  patient  should  not  be  encouraged  to  stand  or  use  the  limbs  until 
they  become  firmer.  He  should  lie  upon  a  soft  and  even  mattress.  Uniform 
support  of  body  and  limbs  is  requisite  in  order  to  prevent  curvature.  In 
craniotabes  the  pillows  should  be  soft,  and  care  should  be  taken  that  the  yield- 


350   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ing  parts  of  the  cranium  be  not  unduly  pressed  upon.  Profuse  perspiration  may 
be  relieved  by  sponging  vrith  vinegar  and  "water.  The  patient  may  be  bathed 
in  "water  a  little  cooler  than  the  body,  and  rock  salt  may  be  added  to  the  bath. 

The  attacks  of  laryngismus  stridulus,  eclampsia,  and  tetany  "which  so  fre- 
quently complicate  rachitis  should  be  promptly  treated  by  the  remedies  Avhich 
are  appropriate  "svhen  they  occur  under  other  circumstances.  Constipation  may 
be  treated  by  enemata  of  glycerin  and  "water  if  not  relieved  by  change  of  diet. 

The  surgical  treatment  of  rachitic  deformities  is  sometimes  important,  but 
Prof.  Ogston  of  the  University  of  Aberdeen  and  other  surgeons  "who  have  given 
special  attention  to  this  subject  state  that  in  young  patients  these  deformities 
frequently  diminish  during  gro"wth,  so  as  to  cause  little  inconvenience  in  adult 
life.  The  measures  employed  by  surgeons  in  order  to  cure  or  minimize  the 
deformities  are  fully  set  forth  in  surgical  treatises. 

[Acute  Rickets. — It  is  now  generally  accepted  by  American  and  English 
observers,  that  the  condition  sometimes  described  as  "  acute  rickets  "is  in 
reality  scorbutic  in  nature.  This  is  certainly  true  of  the  cases  reported  by 
Moller,  Bohn,  Fdrster,  and  Senator.  The  case  of  Flirst.  quoted  by  Dr.  Smith 
on  page  342,  "which  sho"^\ed  diffuse  cylindrical  s"welling  of  both  tibiie  and  of 
the  left  femur,  is  certainly  very  suggestive  of  scorbutus,  despite  the  fact  that 
the  statement  is  distinctly  made,  "  no  scorbutus,  no  stomatitis."  In  this  case 
it  can  only  be  said  that  '•  acute  rachitis  "  is  "not  proven." — Ed.] 


RHEUMATISM. 

By  J.  M.  DaCOSTA,  M.  D.,  LL.D., 

Philadelphia. 


I.  Acute  Rheumatism. 

Acute  eheumatism,  or  rheumatic  fever,  is  a  specific  febrile  malady 
cliai'acterized  by  inflammation  of  fibrous  tissues,  particularly  those  surrounding 
the  joints,  of  Avhich  many  are  apt  to  become  afi'ected  simultaneously  or  in  suc- 
cession. There  is  also  in  rheumatism  a  strong  tendency  for  the  serous  mem- 
branes, especially  those  of  the  heart,  to  become  involved,  and  in  children  we 
frequently  find  these  bearing  the  brunt  of  the  disease  while  the  articular 
afiection  is  very  slight. 

Etiology. — The  cause  of  rheumatism  is  the  accumulation  of  some  poison- 
ous matter  in  the  blood  which  irritates  specially  the  fibrous  and  serous  tissues. 
The  most  commonly  held  opinion  is  that  this  poison  is  lactic  acid,  though  the 
evidence  is  far  from  conclusive.  The  lactic  acid  may  be  the  result  merely  of 
the  morbid  process,  not  the  cause.  Though  sought  for,  specific  micrococci  have 
not  been  demonstrated,  nor  has  the  origin  of  acute  rheumatism  in  disorder  of 
the  nervous  system  been  proved. 

But,  whatever  the  remote  cause,  it  is  certain  that  chilling  of  the  surface  is 
in  the  majority  of  instances  the  immediate  cause  producing  the  attack.  A 
history  of  exposure  to  cold  and  damp  can  be  almost  always  obtained.  In 
instances,  on  the  whole  infrequent,  the  poison  of  scarlet  fever  produces  pain, 
swelling  of  the  joints,  and  even  cardiac  symptoms  indistinguishable  from 
acute  rheumatism. 

The  most  potent  predisposing  cause  of  acute  rheumatism  in  the  young  is 
hereditary  tendency.  Out  of  492  cases  Cheadle  found  a  distinct  history 
of  its  occurrence  in  near  blood  relations  in  173.  The  strong  hereditary  tend- 
ency is  also  illustrated  by  the  experience  of  Steiner  :  of  12  children  of  a 
mother  who  had  suffered  from  acute  rheumatism  and  heart  complication,  11 
had  the  disease  before  they  were  twenty  years  of  age.  Besides  the  complaint 
running  in  rheumatic  families,  I  have  noticed  that  the  children  of  gouty  parents 
develop  rheumatism  in  greater  proportion  than  found  in  those  free  from 
gouty  taint.  With  reference  to  sex,  unlike  what  happens  in  adult  life,  acute 
rheumatism  is  more  common  in  girls  than  in  boys.  It  is  not  often  seen  before 
six  years  of  age.  Yet  August  Seibert  met  with  rheumatism  in  13  children 
under  one  year  of  age,  and  cases  of  its  occurrence  in  very  young  infants  are 
recorded  by  Henoch,  Senator,  and  Koplik.  A  case  of  acute  rheumatism  in  an 
infant  eleven  days  old  is  reported  by  Guthrie,  and  two  remarkable  instances  of 
its  manifesting  itself  soon  after  birth  are  mentioned  by  Jaccoud  :  one  showed 
itself  three  days,  and  another  twelve  hours  after  birth,  the  mothers  at  the  time 
being  ill  with  acute  rheumatism.  I  have  myself  met  with  a  case  of  acute 
rheumatism  under  two  years  of  age.     This  happened  in  a  girl  the  daughter  of  a 

361 


352    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

highly  gouty  father.  She  has  now  grown  to  womanhood,  having  had  three 
severe  attacks  of  rheumatic  fever,  but  without  the  heart  becoming  affected. 

Morbid  Anatomy. — The  joints  show  an  injected  synovial  membrane,  and 
there  is  eflfusion  of  fluid  into  them  and  into  the  surrounding  tissues ;  the  fluid 
contains  blood-cells  and  sometimes  leucocytes.  Minute  haemorrhages  into  the 
membrane  are  not  uncommon  ;  the  cartilages  are  swollen,  but  it  is  very  rare 
for  them  to  suppurate  or  to  ulcerate.  Near  the  aff'ected  joints  and  tendons 
fibrous  nodules  similar  to  those  found  on  the  valves  of  the  heart  are  met  with, 
and  the  parts  around  the  joints,  as  Henoch  has  called  attention  to,  may  be 
infiltrated  with  inflammatory  exudation  that  even  becomes  as  hard  as  bone. 
Nodules  growing  from  the  bone,  a  nodular  periostitis,  have  been  described  by 
Angel  Money.  In  the  heart  inflammatory  lesions  are  usual,  both  in  endocardium 
and  in  pericardium.  The  pericarditis  in  the  acute  rheumatism  of  childhood, 
Cheadle  has  pointed  out,  frequently  extends  to  the  anterior  mediastinum, 
the  connective  tissue  of  which  becomes  extensively  thickened.  The  extent  of 
pericardial  eff'usion  is  not  generally  great,  but  there  is  much  plastic  exudation 
in  the  membrane.  Fibrinous  coagula  are  found  in  the  heart  and  great  vessels. 
Pleurisy  with  or  without  eff'usion  is  often  seen. 

Symptoms. — The  symptoms  of  acute  rheumatism  in  childhood  are  the  same 
as  those  of  adult  life  :  redness  and  swelling  of  the  larger  joints,  pain,  fever,  per- 
spiration, heart  involvement.  But  these  symptoms  do  not  occur  in  the  same 
degree.  The  joint  affection  is  apt  to  be  slight — certainly  the  swelling  and  red- 
ness are — while  stiff"ness  and  tenderness  may  be  marked.  The  joints  become 
successively  involved,  but  in  children  it  is  not  uncommon  to  find  the  rheu- 
matic inflammation  limited  to  a  very  few  joints,  such  as  the  ankles  or  the 
wrists.  Even  there  it  may  be  pain  and  tenderness  rather  than  swelling  that 
arrests  attention.  It  is  on  account  of  the  slight  joint  aff"ection  that  acute  rheu- 
matism in  children  is  often  overlooked,  and  the  pain  and  tenderness  are  attri- 
buted to  a  fall  or  a  sprain  until  the  damaged  heart  tells  the  story. 

The  fever  is  not  high  or  long-continued;  it  is  seldom  above  102°  F.  Of 
those  terrible  cases  with  high  temperature — temperature  reaching  from  107°  to 
110° — of  which  I  have  met  with  many  in  adults,  I  have  never  seen  an  instance 
in  childhood.  Fagge  observed  in  14  cases  of  the  dreaded  complication  not  one 
less  than  eighteen  years  of  age ;  Wilson  Fox,  in  22  cases  none  less  than  seven- 
teen years  ;  Barlow  records  a  fatal  case  in  a  girl  of  thirteen.  Hyperpyrexia  is 
certainly  most  unusual ;  and  so  are  the  cases  with  delirium  and  other  signs 
of  cerebral  disorder,  and  the  cases  with  typhoid  symptoms,  whether  associated 
with  high  temperature  or  not.  "Where  the  febrile  rise  is  high  and  protracted 
there  is  apt  to  be  delirium,  and  the  morbid  signs  generally  depend  upon  a 
heart  aff'ection,  especially  pericarditis.  The  tongue  is  not  so  coated  as  it  is 
in  adults  ;  the  urine  is  high-colored,  dense,  with  an  excess  of  lithates.  From 
among  the  usual  symptoms  of  rheumatic  fever  we  miss  in  children  the  profuse 
acid  sweats.      The  skin  is  moist,  but  not  bathed  in  perspiration. 

The  heart  symptoms  of  the  rheumatic  fever  of  childhood  occur  very  com- 
monly ;  indeed,  in  children  endocarditis  and  pericarditis  are  more  usual 
attendants  on  acute  rheumatism  than  in  adults.  Endocarditis  shows  itself  by 
increased  restlessness,  hurried  breathing,  dry  cough,  uneasiness  or  pain  in  the 
cardiac  region,  a  rise  in  temperature  or  at  least  a  sustained  fever  tempera- 
ture, and  the  development  of  a  murmur,  which  is  generally  at  or  near  the 
apex  and  systolic.  This  mitral  murmur  is  followed  by  an  accentuated  second 
sound,  or  its  reduplication,  at  the  apex  ;  in  rarer  instances  in  place  of  a  mitral 
an  aortic  murmur  is  present ;  in  yet  rarer  instances  there  is  a  diastolic  aortic 
murmur,  or  a  diastolic  or  a  presystolic  mitral  murmur.     The  impulse  is  some- 


RHEUMATISM.  353 

what  increased  in  force,  slightlj  in  extent,  but  the  percussion  dulness,  diffi- 
cult  to  ascertain  in  a  child,  is  not  distinctly  altered.  The  pulse  becomes 
more  tense,  and  its  beats  are  not  equal.  As  the  case  advances,  impaired  pul- 
monary resonance  and  fine  rales  indicative  of  congestion  may  be  noticed,  and 
restlessness  and  anxiety  and  irregularity  of  the  circulation  augment.  Where 
ulcerative  endocarditis  takes  place,  recurring  chills  like  those  of  malarial  fever, 
followed  by  high  temperature  and  profuse  sweats,  are  apt  to  occur.  And 
both  in  this  form  and  in  the  simple  form  of  endocarditis  masses  of  fibrin  may 
be  washed  from  the  vegetations  into  the  vessels  of  the  brain  or  elsewhere, 
and  cerebral  embolism  or  embolic  pneumonia  or  other  kinds  of  embolism  thus 
happen. 

Besides  the  marked  forms  of  endocarditis  we  may  encounter  only  dulness 
of  the  first  sound,  giving  it  a  murmurish  character,  without  decided  general 
symptoms  attending  the  ill-developed  cardiac  changes.  These  are  instances  of 
mere  swelling  and  slight  inflammation,  and  rarely  result  in  persistent  alteration 
of  the  valves,  as  the  cases  with  well-defined  murmur  commonly  do.  Then, 
again,  it  must  be  borne  in  mind  that  there  are  many  cases  in  which  the 
general  symptoms  are  so  slight  that  the  endocarditis  readily  escapes  detection. 
Indeed,  it  is  alone  the  recognition  of  the  changes  in  the  heart-sounds  that 
makes  sure  of  the  presence  of  the  malady. 

Pericarditis,  owing  to  the  greater  difiiculty  of  its  recognition,  is  more  often 
overlooked  than  endocarditis.  This  is  especially  the  case  in  very  young  chil- 
dren, in  whom,  however,  it  is  not  common.  It  may  occur  at  any  stage  of  rheu- 
matism: sometimes  it  precedes  the  joint  aff'ection ;  often  it  pursues  a  sub- 
acute, irregular  course,  subsiding  and  breaking  out  anew  as  fresh  joints 
become  involved.  The  symptoms  are  those  of  endocarditis,  but  there  are 
greater  restlessness  and  distress,  more  marked  signs  of  nervous  disorder,  a 
tendency  to  higher  temperature,  more  cardiac  pain.  The  physical  signs  are 
the  same  as  in  the  adult ;  prominent  among  them  is  the  friction-sound,  fol- 
lowed, when  effusion  takes  place,  by  increased  percussion  dulness,  by  dispro- 
portionate distinctness  of  the  sounds  at  the  base  as  compared  with  those  of  the 
apex,  by  muffled  sounds  at  the  apex,  and  its  upward  displacement.  It  is  much 
more  difficult  in  children  than  in  adults  to  make  out  the  dulness,  or  to  deter- 
mine its  triangular  shape  or  its  existence  in  the  fifth  interspace  to  the  right 
of  the  sternum ;  and  very  often  the  dulness  is  of  irregular  shape,  and  dependent 
upon  thick  layers  of  plastic  pericarditis,  indicating  its  existence  by  coarse 
friction  and  by  the  sounds  of  the  heart  being  much  the  same  at  the  apex  and 
at  the  base.  This  form  of  pericarditis  without  liquid  effusion  is,  indeed,  com- 
mon in  childhood. 

So  is  pleurisy  as  an  attendant  upon  acute  rheumatism  common,  and  not 
only  single  pleurisy,  likely  then  to  be  left-sided,  but  double  pleurisy.  One  of 
the  dangers  of  left-sided  pleurisy  is  that  the  inflammation  is  apt  to  spread  to 
the  pericardium ;  at  all  events,  whether  from  contiguity  or  from  simultaneous 
action  of  the  rheumatic  poison,  pleurisy  and  pericarditis  are  often  combined, 
and  both  may  be  of  the  exudative  plastic  variety  rather  than  attended  with 
effusion.  Still,  effusion  does  happen  in  rheumatic  pleurisy,  and  may  be  of 
slow  absorption  or  become  purulent.  Pneumonia  rarely  complicates  the 
pleurisy ;  when  it  does,  it  may  only  reveal  itself  by  rise  of  temperature,  with- 
out marked  cough  or  expectoration,  and  by  the  physical  signs.  Cheadle 
believes  that  these  are  diff"erent  from  those  of  pneumonia  in  the  absence, 
except  in  the  embolic  form  of  the  malady,  of  fine  crepitation. 

Chorea  bears  a  very  close  relation  to  the  rheumatism  of  childhood.  Rheu- 
matic children  are  very  apt  to  be  irritable,  nervous,  emotional  children,  and 

23 


354    A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

therefore  with  nervous  systems  predisposing  to  chorea.  The  chorea  associated 
with  acute  rheumatism  has,  in  my  experience,  most  generally  shown  itself 
toward  the  end  of  the  attack  and  when  the  acute  symptoms  have  disappeared. 
In  the  majority  of  instances  there  has  been  pericar.ditis  or  endo-pericarditis. 
Sometimes  the  choreic  movements  begin  at  the  height  of  the  malady,  or  the 
chorea  even  precedes  the  joint  affection.  It  must  further,  in  estimating  the 
relation  of  chorea  to  rheumatism,  be  borne  in  mind  that  chorea  does  not  always 
follow  an  acute  attack,  but  may  come  on  in  those  of  rheumatic  taint,  without 
previous  well-defined  rheumatic  manifestations. 

Cutaneous  erujJtions  are  often  seen  in  the  rheumatism  of  childhood.  ^The 
most  common  form  is  erythema,  which  appears  on  the  limbs  and  the  body,  and 
is  of  the  papulated  or  marginated  form,  or  shows  itself  as  urticaria,  less  often 
as  erythema  nodosum ;  in  rare  instances  it  is  purpuric  and  associated  with  sub- 
cutaneous hjBmorrhages.  Barlow  has  pointed  out  that  the  erythematous  rashes 
may  appear  simultaneously  with  pericarditis,  or  precede  this  and  the  articular 
symptoms. 

But  more  important  tlian  these  rashes,  and  much  more  strictly  linked  to 
rheumatism,  are  the  fibrous  nodules.  Of  extreme  rarity  in  adults,  they  are 
not  uncommon  in  children.  They  are  mainly  to  be  found  about  the  joints,  are 
hard  and  painless  or  slighly  tender  on  pressure,  of  size  varying  from  a  pin's 
head  to  a  cherry,  and  are  chiefly  to  be  ascertained  by  the  touch.  They  come 
and  go  in  a  few  weeks,  though  they  may  last  for  months.  It  is  not  unusual 
to  have  them  appearing  in  crops,  and,  though  these  subcutaneous  nodules  may 
project  from  the  surface,  the  skin  over  them  is  not  discolored.  They  are  almost 
constantly  associated  with  endocarditis  or  with  pericarditis,  and  Avhen  abun- 
dant and  frequently  recurring  imply  a  progressive  cardiac  affection. 

Among  disorders  we  frequently  meet  with  in  the  rheumatism  of  child- 
hood is  tonsillitis.  It  is  often  antecedent  to  the  rheumatic  attack  or  occurs  in  its 
course,  and  is  combined  with  decided  rise  of  temperature  and  pain  in  swallow- 
ing.    It  is  not  followed  by  either  ulceration  or  suppuration. 

The  anceniia  that  attends  the  rheumatism  of  childhood  is  very  pronounced, 
and  persists  long  after  tlie  attack.  Where  successive  rheumatic  seizures  occur 
it  becomes  more  and  more  decided,  and  is  often  associated  with  marked  irrita- 
bility of  the  nervous  system  and  emotional  disturbance.  In  its  persistence  it 
may  become  a  factor  in  the  mischief  wrought  by  a  heart  disease  and  in  i\  3 
development  of  dropsv. 

Diagnosis. — The  diagnosis  of  acute  rheumatism  in  a  child  is  more  diflficult 
than  in  an  adult,  because  the  joint  affection  is  often  very  slight,  and  may  be 
nothing  more  than  mere  stiflFening  attended  with  moderate  fever,  or  pain  in 
moving  certain  muscles  and  tendons.  Under  these  circumstances  we  have 
to  lay  great  stress  on  the  family  history,  on  the  character  of  previous  seizures, 
on  the  occurrence  of  attacks  of  tonsillitis.  Signs  of  endocarditis  or  pericar- 
ditis, or  pleurisy,  or  erythematous  rash,  or  nodules,  would  be  conclusive.  In 
some  instances,  too,  epistaxis,  an  occasional  symptom  of  the  rheumatism  of 
childhood,  is  very  significant ;  so  is  chorea.  Endocarditis  or  pericarditis  in 
a  doubtful  case  would  be,  however,  the  most  certain  of  proofs. 

When  the  joint  affection  is  distinct,  scarlatinal  rheumatism  is  the  disease 
most  likely  to  be  confounded  with  ordinary  acute  rheumatism.  As  regards 
the  symptoms  I  know  no  difference  ;  heart  affections  in  scarlatinal  rheumatism 
are  less  common,  but  they  arise.  I  have  sometimes  thought  the  absence  of 
sweating  diagnostic,  but  the  acid  sweats  of  rheumatic  fever  are  also  often 
absent  in  the  rheumatism  of  childhood.  Nothing  but  the  antecedent  his- 
tory makes  the  case  absolutely  certain.     The  severe  pain  and  the  swelling 


BHEUMATI8M.  355 

of  the  joints  sometimes  observed  in  cerebro-spinal  fever  may  cause  this  to 
be  mistaken  for  rheumatism.  But  the  violent  headache,  the  retracted  head, 
the  rosy  or  petechial  eruption,  the  irregular  temperature  and  pulse,  are  very 
different  from  the  combination  of  symptoms  noticed  in  rheumatic  fever.  In  its 
earlier  stages  rickets  may  mislead,  on  account  of  the  swelling  near  the  joints, 
the  pain,  the  sweats,  the  fever.  Yet  the  absence  of  redness  of  the  joints, 
the  size  of  the  epiphyses,  the  undisturbed  heart,  the  cachexia,  the  pale  urine, 
and  the  fact  that  the  wrist-joints  are  apt  to  be  the  ones  first  disturbed,  or  that 
the  swelling  shows  itself  chiefly  on  the  dorsum  of  the  foot  and  on  the  back  of 
the  hand,  are  full  of  significance. 

From  pyaemia,  rare  in  children,  rheumatism  differs  by  the  irregular  fever 
of  the  former,  the  sweats,  the  great  pain  and  swelling  that  are  found  in  only 
one  or  in  a  few  joints,  and  the  course  of  the  disease.  There  is  a  py?emic  arthri- 
tis to  which  infants  are  liable,  that  Townsend  has  well  described,  which  runs 
an  acute  course,  is  mostly  confined  to  the  hip  or  knees,  and  in  which  the  effusion 
speedily  becomes  purulent.  Its  occurrence  in  infants  at  the  breast  or  when 
gonorrhoeal  ophthalmia  or  vaginitis  is  present  also  distinguishes  it. 

Scurvy  may  present  pain  and  swelling  of  the  joints;  the  absence  of  fever 
and  the  condition  of  the  gums  tell  us  that  it  is  not  rheumatism."  In  congenital 
syphilis  the  state  of  the  bones  near  the  joint  may  lead  to  the  thought  of  rheuma- 
tism, but  the  characteristic  eruption,  the  snuffles,  the  emaciation,  the  enlarge- 
ment of  the  spleen,  the  rarity  of  fever,  and  the  fact  that  ths^.  symptoms  arise 
in  early  infancy  are  diagnostic. 

The  diagnosis  of  the  most  dreaded  affection  in  rheumatism,  the  endocar- 
ditis, presents  the  same  points  for  consideration  as  it  does  when  it  is  not  of 
rheumatic  nature,  and  is  discussed  in  another  part  of  the  volume.  I  will  only 
here  mention  how  important  it  is  to  remember  the  anaemic  state  that  rheuma- 
tism develops  in  the  young,  and  not  to  regard  every  murmur  arising  in  its 
course,  and  especially  when  it  has  nearly  run  its  course,  as  organic  and  as 
likely  to  lead  to  permanent  valve-injury.  These  soft,  systolic  blood-murmurs 
are  unconnected  with  change  in  valve  or  in  muscular  texture,  and  gradually 
pass  away. 

Course  and  Duration. — The  course  of  acute  rheumatism  in  childhood 
depends  very  much  upon  the  complications,  especially  upon  the  cardiac  lesions. 
Nor  do  we  find  as  many  frank  cases  running  their  course  in  a  definite  time ; 
the  cases  are  mostly  subacute,  with  subsidences  and  fresh  outbreaks.  On  the 
other  hand,  in  infants  there  are  instances  of  very  rapid  progress.  Jaccoud's 
cases  in  infants  soon  after  birth  terminated,  one  in  eight  days,  the  other  in 
little  more  than  two  weeks.  As  a  general  rule,  the  rheumatic  fever  of  child- 
hood lasts  between  two  and  three  weeks.  Slight  cases,  Steiner  estimates,  get 
well  in  from  ten  to  fourteen  days.  Goodhart's  results  in  ten  cases,  of  which 
he  stated  that  the  longest  duration  was  four  days,  is  not  the  general  experience. 
It  is  difficult  to  be  precise  in  this  matter  of  duration,  since  much  depends  upon 
how  early  the  patient  has  come  under  treatment  and  how  well  he  responds  to 
treatment.  Under  the  salicylates  we  see  the  duration  often  much  abridged,  in 
instances  particularly  of  joint  affection  without  internal  lesions.  Where  the 
heart  is  affected  the  case  frequently  runs  on  for  five  or  six  weeks.  Frank 
relapses  are  not  common.  But  a  succession  of  subacute  attacks  in  rapid  suc- 
cession, affecting  the  joints  but  slightly  while  adding  to  the  mischief  in  the 
heart,  is  not  uncommon. 

Prognosis. — This  is  favorable ;  few  die  in  the  disease.  Certainly  this  is 
true  of  the  first  attack;  if  the  attacks  be  repeated,  there  is  much  more  danger 
during  the  acute  seizure.     And  the  danger,  again,  depends  rather  upon  the 


356    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

condition  of  the  heart  than  upon  the  mere  recurrence  of  the  rheumatic  fever. 
The  liability  to  cardiac  disease  increases  with  the  number  of  attacks.  Yet 
this  does  not  always  happen.  I  have  mentioned  a  case  in  Avhich  three  severe 
attacks  happened  without  heart  implication  ;  and  A.  Clark  tells  of  one  in  a  boy 
of  twelve  in  which  eight  attacks  occurred,  the  heart  remaining  sound.  Such 
instances  are,  however,  very  exceptional.  Age  has  something  to  do  with  the 
prognosis.  Of  cases  between  one  and  ten  years  of  age,  83  per  cent.,  McPhe- 
dran  calculates,  have  heart  lesions ;  between  ten  and  twenty,  69  per  cent. 
In  54  fatal  cases  of  rheumatic  heart  disease  Sturges  encountered  none  under 
two  years  of  age ;  42  out  of  the  54  happened  between  six  and  twelve  years. 
Embolism  and  thrombosis  are  rare,  but  very  grave. 

The  chief  concern  where  cardiac  affections  exist  is  as  regards  the  amount  of 
mischief  that  will  remain  after  the  acute  symptoms  have  subsided.  A  murmur 
indicative  of  mere  roughening  of  the  valve  may  in  the  course  of  a  few  months 
disappear.  But  very  often  it  persists,  and  gradually,  if  the  lesion  have  been  more 
than  mere  roughening  of  the  valve,  the  signs  of  hypertrophy  with  dilatation 
become  manifest.  This  may  not  happen  from  the  first  attack  ;  but  during 
slight  recurring  rheumatic  sei?ures — slight  at  least  so  far  as  the  joints  are  con- 
cerned— the  heart  affection  is  little  by  little  added  to  ;  or  this  is  aggravated  by 
a  more  severe  attack,  in  which  a  fresh  extensive  endocarditis  occurs.  From 
pericarditis  we  may  have  the  same  consequences  as  in  adults — adherent  peri- 
cardium with  hypertrophy  or  dilatation ;  considerable  effusions  are  very  rare. 
Rheumatic  pericarditis  by  itself  has  a  better  prognosis,  both  at  the  time  and  in 
its  ultimate  consequences,  than  endocarditis.  But  Avith  reference  to  the  latter 
it  must  be  borne  in  mind  that  it  is  mostly  associated  with  some  pericarditis, 
really  an  endo-pericarditis ;  for  few  are  the  cases  where  endocarditis  of  rheu- 
matic origin  alone  exists.  Persistent  angemia  after  rheumatic  endocarditis  or 
pericarditis  is  always  a  bad  sign.  The  hypertrophy  or  dilatation,  which  under 
any  circumstances  happens  more  rapidly  in  children  than  in  adults,  gains  at 
increased  rate.  The  frequent  occurrence  of  fibrous  nodules  is  a  sign  of 
danger,  as  fresh  mischief  is  apt  at  the  same  time  to  be  wrought  in  the  heart. 
It  is  then  here,  as  it  is  throughout  in  acute  rheumatism,  the  heart,  after  all,  that 
chiefly  determines  the  prognosis.  Chorea  is  rarely  a  serious  complication.  The 
joint  affection  mostly  passes  off  completely;  rheumatic  thickening  and  anky- 
losis are  very  seldom  seen  in  childhood. 

Treatment. — The  treatment  of  acute  rheumatism  in  a  child  is  the  same  as 
in  the  adult.  The  greatest  care  must  be  taken  to  keep  the  patient  at  rest  and 
from  being  chilled,  and  with  this  view  the  child  should  be  kept  in  bed  in  a 
flannel  night-dress  or  between  blankets.  The  diet  should  be  at  first  chiefly 
farinaceous,  with  bread  and  moderate  amounts  of  milk  ;  later  in  the  disease 
broths  and  fish  may  be  allowed.  Of  medical  remedies,  the  most  prominent  is 
salicylic  acid  or  its  compounds ;  among  these,  salicylate  of  sodium  or  of 
ammonium  is  well  adapted.  The  dose  to  a  child  five  years  of  age  is  thirty  to 
forty  grains  in  divided  doses  in  twenty-four  hours ;  to  a  child  of  ten,  sixty  to 
eighty  grains.  It  may  be  given  in  syrup  of  orange,  or  in  simple  syrup  with 
spirits  of  lavender.  The  salicylates  relieve  the  joint  affection  and  the  pain, 
and  their  action  is  rapid ;  after  the  third  or  fourth  day  the  dose  may  be  dimin- 
ished one-half  or  more.  If  no  result  be  seen  from  them  in  three  or  four  days, 
they  are  not  likely  to  produce  any,  and  some  other  remedy  had  better  be 
administered.  Nor  ought  they  to  be  trusted  to  where  heart  complications  exist. 
Further  experience,  indeed,  both  in  children  and  in  adults  has  only  added  to 
my  conviction,  expressed  some  years  since,  that  the  salicylates  neither  prevent 
pericarditis  or  endocarditis,  nor  benefit  its  course  after  it  has  set  in.     Their 


RHEUMATISM.  '      357 

chief  use  is  where  there  is  much  pain  and  the  joint  aifection  decided;  and  it 
is  always  well  in  any  case  to  give  also  alkalies  from  the  start.  When  the 
circulation  becomes  depressed,  or  buzzing  in  the  ears  or  giddiness  occurs,  the 
salicylates  should  be  at  once  discontinued.  Salicin  is  by  some  recommended  as 
less  objectionable,  in  doses  of  from  five  to  eight  grains  every  third  or  fourth 
hour  to  a  child  of  five,  after  the  salicylates  have  been  administered  for  a  day 
or  two,  or  even  from  the  beginning. 

Under  any  circumstances,  in  instances  of  heart  complication  or  where  a 
heart  lesion  has  existed  from  a  previous  attack,  the  alkalies  are  vastly  prefer- 
able remedies.  It  is,  indeed,  to  decided  doses  of  the  alkalies  that  we  must  trust. 
Fifteen  to  twenty  grains  of  bicarbonate  of  sodium  in  simple  syrup  and  mint- 
water  every  third  or  fourth  hour  to  a  child  eight  or  ten  years  of  age,  or  two 
drachms  of  the  acetate  of  potassium  in  divided  doses  in  the  twenty-four  hours, 
form  the  proper  average  dose.  These  alkalies  should  be  administered  until  the 
urine  becomes  alkaline  or  neutral,  and  then  enough  be  ordered  to  keep  it 
neutral. 

Quinine  is  very  valuable.  It  may  be  given  in  decided  doses  when  the  tem- 
perature tends  to  run  high,  as,  however,  it  is  not  apt  to  do  in  children  unless 
there  be  endocarditis  or  pericarditis.  In  doses  of  about  six  grains  daily  to  a 
child  five  years  of  age  it  is  an  excellent  remedy  when  the  more  acute  symptoms 
have  subsided,  whether  the  alkaline  or  the  salicylate  treatment  be  the  one 
pursued. 

Opium  is  another  remedy  of  great  value.  It  allays  restlessness  and  pain 
and  procures  sleep.  In  coexisting  endocarditis  or  pericarditis  it  may  be  directed 
in  small,  continuous  doses,  and  is  indispensable.  The  bromides  relieve  rest- 
lessness and  excitability,  and  are  not  without  influence  on  the  course  of  the 
disease.  Conjoined  to  chloral,  they  give  rest  at  night;  and  Goodhart  lauds  the 
combination  of  five  grains  of  the  bromide  of  potassium  and  one  or  two  of 
chloral  as  almost  a  specific  for  the  nightmare  of  rheumatism  in  young  children. 

The  treatment  of  the  main  internal  lesions,  the  endocarditis  and  the  peri- 
carditis, is  discussed  in  another  part  of  this  volume.  I  will  only  here  speak 
of  my  favorable  experience  in  pericarditis  with  brandy  or  whiskey  in  decided 
quantities,  and  with  opium.  The  pleurisy  is  treated  as  all  pleurisies  are ;  the 
iodides  are  especially  applicable  to  the  plastic  form.  The  salicylate  of  sodium 
has  been  recently  highly  spoken  of  in  this  kind  of  pleurisy ;  I  have  had  no 
experience  with  its  use.  In  the  tonsillitis  of  rheumatism  the  salicylates  give 
quick  results. 

The  local  treatment  of  rheumatism  consists  in  wrapping  the  affected  joints 
in  cotton  wool,  or,  where  they  are  very  painful,  in  a  flannel  bandage  saturated 
with  a  solution  of  nitrate  of  potassium,  one  to  two  drachms  to  the  ounce,  to 
which  laudanum,  twenty  drops  to  the  ounce,  has  been  added.  For  lingering 
swelling  of  the  joints  the  rubbing  in  of  iodine,  ten  to  twenty  grains  to  half  an 
ounce  of  lanolin  and  half  an  ounce  of  belladonna  ointment,  is  well  adapted. 
During  convalescence  iron  is  strongly  indicated ;  and  there  should  be  then,  as 
always  in  rheumatic  children,  the  greatest  care  exerted  with  reference  to  warm 
clothing,  to  the  food  being  of  easily  digestible  kind,  and  to  the  avoidance  of 
exposure  to  cold  and  damp  as  well  as  to  fatigue  and  over-exertion. 

n.  Muscular  Rheumatism. 

This  is  met  with  in  children,  as  it  is  in  adults,  mostly  following  cold  and 
exposure,  especially  exposure  to  draughts,  or  fatigue.  The  disorder  is  generally 
subacute,  and  attended  with  but  little  constitutional  disturbance.     The  prom- 


358    A3£EBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

inent  symptom  is  pain  in  moving  the  parts  involved.  It  is  very  rarely  a  general 
disorder,  but  is  limited  to  particular  groups  of  muscles.  We  find  it  in  the  del- 
toid ;  or  in  the  muscles  of  the  loins,  as  lumbago  ;  or  giving  rise  to  stiff  neck, 
as  torticollis  ;  or  involving  the  intercostal  muscles  and  restricting  the  acts  of 
breathing,  as  pleurodynia ;  or  in  the  muscles  of  the  head,  as  cephalodynia. 
Wherever  it  is,  it  has  the  same  characteristics — pain  on  motion,  slight  tender- 
ness, little  if  any  fever.  Not  unfrequently  the  urine  is  high-colored  and  full 
of  urates. 

Diagnosis. — In  the  diagnosis  of  the  affection  we  have  to  distinguish  it  from 
neuralgia.  The  stricter  limitation  of  the  pain  of  neuralgia  to  particular  spots, 
and  its  passing  along  special  lines  of  nerve-distribution,  the  far  less  influence 
motion  has  on  it,  form,  broadly  speaking,  the  traits  of  distinction.  We  must 
also  not  be  misled  in  considering  as  muscular  rheumatism  "growing  pains,"  or 
the  pains  of  aching  muscles  after  unusual  exercise. 

Prognosis. — The  prognosis  is  always  favorable.  The  main  object,  when 
the  immediate  attack  has  been  remedied,  is  to  prevent  recurrences. 

Treatment. — Rest  of  the  affected  muscles,  the  application  of  warmth  by 
hot  fomentations  or  the  hot-water  bag,  the  use  of  liniments  containing  chloral, 
chloroform,  or  opium,  are  all  beneficial.  Atropine  and  morphine  hypoder- 
matically,  so  valuable  in  adults,  cannot  be  so  generally  employed  in  children. 
Diaphoretics  are  always  serviceable  ;  a  combination  of  nitrate  of  potassium  and 
Dover's  powder  is  eminently  so ;  and  in  lingering  cases  the  bromide  of  ammo- 
nium or  the  iodide  of  potassium  or  of  ammonium  is  of  distinct  benefit.  So  is 
the  continuous  current.  Jacobi  considers  that  the  best  preventive  is  the  habit- 
ual use  of  cold  water. 

m.  Chronic  Rheumatism. 

Chronic  rheumatism,  as  we  see  it  in  adults,  is  rare  in  children  ;  certainly 
long-continued  stiffness  of  muscles  and  chronic  enlargement  of  joints  are  rare. 
As  already  pointed  out,  recurrence  of  short  attacks  with  stiffness  and  pain  is 
the  form  in  which  the  persistency  of  rheumatism  in  childhood  much  more 
generally  shows  itself. 

The  few  cases  that  present  the  same  appearances  noticed  in  the  chronic 
rheumatism  of  adults  may  be  mistaken  for  rheumatoid  arthritis — a  disease 
which  is  not  unknown  in  childhood,  though  it  is  rarely  spoken  of.  The 
previous  history  of  the  case,  the  occurrence  of  rheumatoid  arthritis  in  those  of 
feeble  health,  the  wasting  of  the  muscles,  the  enlarged,  crepitating,  or  fixed 
joints  with  the  gradually  developing  characteristic  distortion  of  the  fingers  and 
toes,  and  the  absence  of  all  tendency  to  cardiac  affection,  are  significant  in  the 
distinction. 

In  the  treatment  of  chronic  rheumatism  the  chief  remedies  are  the 
iodides,  the  muriate  of  ammonium,  and  arsenic,  with  great  attention  to  general 
health  and  thorough  protection  by  dressing  warmly.  Using  iodine  to  the 
affected  joints  or  rubbing  them  with  ammoniated  liniments,  or,  if  there  be 
effusion  or  bony  thickenings,  small  blisters  applied  from  time  to  time,  will  give 
the  best  results.  Good  is  also  done  by  massage,  and  by  warm  baths  with  carbo- 
nate of  sodium  dissolved  in  them,  or  by  a  recourse  to  the  sulphuretted  and 
alkaline  mineral-water  springs  that  have  been  found  to  be  of  real  service  in  the 
chronic  rheumatism  of  adults. 


PART  Y. 

DISEASES  OF  THE  BLOOD. 


ANEMIA,  SPLENIC  ANJEMIA,  LYMPHATIC 
ANEMIA,  AND  LEUKAEMIA. 

BY  FREDERICK  A.  PACKARD,  M.  D., 

Philadelphia. 


While  in  most  respects  the  blood  of  infants  and  children  resembles  that 
of  adults,  there  are  in  the  blood  of  the  new-born  a  few  variations  from  the 
adult  standard  which  require  mention. 

During  the  first  twelve  days  of  life  the  blood  has  a  somewhat  venous 
appearance  when  seen  in  bulk. 

In  the  new-born  child  the  red  blood-corpuscles  are  of  much  more  unequal 
size  than  they  are  in  older  children  and  in  adults,  the  largest  of  them  being 
larger,  and  the  smallest,  smaller.  During  the  first  four  days  of  life  there  are 
to  be  found  a  varying  number  of  nucleated  red  cells.  These  soon  disappear, 
although  some  observers  claim  that  they  are  to  be  found  up  to  the  second  or 
third  year. 

Owing,  presumably,  to  the  ready  solubility  of  the  haemoglobin  in  young 
infants,  numerous  "shadows,"  or  red  blood-cells  that  have  lost  their  haemo- 
globin, are  present.  The  red  cells  are  more  easily  affected  by  reagents  than 
is  the  case  in  adults,  moisture  in  particular  causing  them  to  very  readily 
assume  the  spherical  form.  The  number  of  red  cells  is  proportionally  larger 
in  the  newly-born,  the  count  varying,  according  to  different  observers,  from 
4,300,000  (Bouchut,  Dubrisay)  up  to  7,500,000  (Gundobin)  per  cubic  milli- 
metre.    The  daily  variations  in  their  number  are  very  marked. 

There  is  marked  increase  in  the  number  of  colorless  blood-cells  in  young 
infants  as  compared  to  adults.  The  subject  of  the  relative  number  of  the  dif- 
ferent forms  has  been  most  carefully  studied  by  Gundobin  {Jahrh.  f.  Kinder- 
TieilTc.  u.  phys.  Erziehung^  Bd.  xxxv.  Hffc.  1  and  2,  Jan.,  1893).  According  to 
this  author,  the  relative  percentage  of  lymphocytes  in  sucklings  is  three  times 
as  great  as  in  adults,  while  the  neutrophiles  are  relatively  twice  as  small  in 
number.  From  the  seventh  to  the  tenth  day  is  the  period  at  which  the  rela- 
tive and  absolute  numbers  attain  the  proportions  maintained  in  later  life. 

The  amount  of  haemoglobin  is  greater  in  young  infants  than  in  adults. 
This  relative  increase  is  maintained  for  some  weeks,  at  the  end  of  which  time 
it  begins  to  diminish,  until  at  about  the  middle  of  the  first  year  it  has  reached 
its  lowest  point,  thereafter  slowly  increasing  to  the  normal  of  adult  life. 

The  specific  gravity  is  said  to  be  high  immediately  after  birth  (1.066),  but 
it  soon  sinks  to  a  little  below  that  of  adult  blood. 

Plethora. — It  is  now  granted  that,  while  this  term  may  be  used  as  a  con- 
venient means  of  describing  certain  conditions,  it  is  not  accurate,  in  so  far  as 

359 


360    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

it  implies  an  actual  increase  of  the  total  mass  of  blood  or  of  its  corpuscular 
flements.  The  term  was  employed  to  indicate  a  condition  formerly  supposed 
to  be  due  to  "  full-bloodedness,"  but  now  known  to  be  a  condition  wherein  the 
appearance  of  vascular  turgescence  is  due  not  to  any  over-richness  in  blood, 
but  to  local  changes  in  the  superficial  vessels.  That  a  relative  increase  above 
the  normal  of  the  number  of  red  blood-corpuscles  can  exist  is  true  only  in 
conditions  where  the  watery  constituents  are  decreased,  as  in  cholera.  To 
this  condition  the  term  "plethora  "  is  manifestly  inapplicable,  the  loss  of  fluid 
merely  increasing  the  number  of  corpuscles  in  the  drop. 


ANEMIA. 

Anemia  is  a  condition  of  the  blood  due  to  a  decrease  in  its  richness  in 
either  corpuscular  elements  or  haemoglobin,  either  from  primary  disease  in  the 
blood-making  or  blood-destroying  organs,  or,  secondarily,  from  general  or  local 
disease  that  interferes  with  normal  absorption,  metabolism,  and  assimilation,  or 
is  productive  of  abnormal  loss  of  nutritive  material  from  the  body. 

In  the  above  definition  anaemia  is  spoken  of  as  a  condition  instead  of  as  a 
disease,  since  in  the  vast  majority  of  instances  it  is  merely  a  symptom  of  some 
well-recognized  tiisease  of  the  whole  body  or  of  individual  organs.  The  anae- 
mias produced  by  morbid  processes  that  are  recognizable  as  distinct  diseases 
are  spoken  of  as  secondary,  whereas  those  occurring  without  apparent  cause 
save  disease  of  the  blood-making  or  blood-destroying  organs  are  spoken  of  as 
primary.  In  the  latter  class  we  must  still  place  chlorosis,  progressive  per- 
nicious anaemia,  splenic  anaemia,  lymphatic  anaemia  (Hodgkin's  disease),  and 
leukaemia. 

SECONDARY    ANEMIA. 

Etiology. — Our  knowledge  of  the  process  of  blood-formation  and  blood- 
destruction  is  not  sufficiently  advanced  to  explain  the  production  of  anaemia 
in  all  cases  in  which  it  occurs.  Where  actual  escape  of  blood  from  the  blood- 
vessels takes  place,  the  explanation  is,  of  course,  manifest ;  but  it  is  far  from  evi- 
dent in  exactly  what  manner  prolonged  high  temperature,  loss  of  albumin  from 
continued  suppuration  or  Bright's  disease,  the  rheumatic  poison,  and  certain 
toxic  influences  produce  decrease  in  the  richness  of  the  blood  in  corpuscles  or 
haemoglobin.  In  childhood  the  chief  causes  of  secondary  anaemia,  aside  from 
those  operative  equally  in  adult  life,  are  due  to  improper  hygiene  as  to  diet, 
exercise,  and  ventilation.  A  frequent  cause  is  mucous  disease,  which  seems  to 
act  by  preventing  the  proper  digestion,  absorption,  and  assimilation  of  nutri- 
tive material.  Improper  articles  of  diet  and  improperly  prepared  food  may  act 
in  practically  the  same  way ;  that  is,  by  a  failure  to  supply  nutritive  material 
proper  to  the  needs  of  the  body.  Too  rapid  growth  is  capable  of  causing  anae- 
mia, the  frame  seeming  to  outgrow  the  quantity  of  blood  manufactured,  just  as 
it  is  apt  to  become  too  large  for  the  functional  capacity  of  certain  organs.  In 
addition,  we  must  recognize  the  fact  that  in  some  individuals  a  condition  of 
anaemia  seems  to  be  a  constitutional  characteristic,  and  to  be  not  incompatible 
with  a  fair  degree  of  health.  Malaria,  as  a  cause  of  anaemia,  seems  to  act 
with  even  greater  intensity  in  children  than  is  the  case  in  adults,  while  the 
anaemia  of  acute  rheumatism  at  times  reaches  an  extreme  grade.  Further 
than  in  these  respects  the  secondary  anaemia  of  childhood  differs  in  no  way  etio- 
logically  from  that  in  adult  life. 


ANEMIA,  361 

Symptoms. — The  general  appearance  of  a  child  with  simple  anaemia  is 
too  well  known  to  require  description.  The  white  skin,  pallid  mucous  mem- 
branes, waxy  appearance  of  the  nails,  and  blueness  of  the  white  of  the  eye 
are  seen  in  children  as  plainly  as  in  adults,  if  not  more  so.  The  subjective 
symptoms  of  anaemia  do  not  attain  much  prominence  in  childhood,  as  not  only 
is  the  child  less  well  able  to  express  its  sensations  than  is  the  adult,  but  also 
because  it  simply  ceases  to  play  around  or  to  exert  itself  when  it  feels  the  sub- 
jective sensations  produced  by  anaemia,  instead  of  being  compelled,  as  is  the 
adult,  to  struggle  against  discomfort  in  the  endeavor  to  continue  the  duties 
of  life. 

One  of  the  most  frequent  symptoms  observed  in  children  is  the  tendency 
to  syncopal  attacks.  These  may  occur  apparently  causelessly,  or  may  be 
readily  induced  by  violent  emotion,  slight  pain,  or  confinement  in  a  poorly 
ventilated  apartment.  Shortness  of  breath  upon  exertion  is  also  frequently 
present,  although  in  children  too  young  to  feel  the  stimulus  of  competition  this 
may  be  shown  merely  by  an  indisposition  to  exertion.  Rarely,  except  in  cases 
of  extreme  degree,  is  any  oedema  discoverable. 

The  hgemic  murmur  at  the  apex  or  base  does  not  seem  to  be  produced  in 
children  so  readily  as  is  the  case  with  adults. 

The  examination  of  the  blood  shows  a  reduction  in  the  red  blood-cor- 
puscles, with  a  corresponding  diminution  of  haemoglobin ;  that  is  to  say,  the 
valeur  glohulaire  does  not  differ  from  the  normal.  In  extreme  cases  poikilocy- 
tosis  may  be,  observed.  A  relative  increase  of  white  blood-cells  as  compared  to 
the  red  may  be  present,  owing  to  the  reduction  in  number  of  the  latter. 

Diagnosis. — There  is,  as  a  rule,  no  difficulty  in  determining  the  existence 
of  simple  anaemia,  but  the  diagnosis  cannot  be  considered  as  complete  until 
the  cause  of  the  poverty  of  the  blood  has  been  detected.  The  question 
of  the  causative  factor  in  simple  anaemia  of  the  young  requires  not  only  a 
careful  examination  of  the  child  itself,  but  a  minute  scrutiny  of  all  of  the 
hygienic  surroundings. 

The  differential  diagnosis  between  simple,  secondary  anaemia  and  that  of 
chlorosis  and  of  pernicious  anaemia  is  readily  made  by  an  examination  of  the 
blood.  In  simple,  secondary  anaemia  blood-corpuscles  and  haemoglobin  are 
reduced  together,  and  to  an  almost  equal  extent,  whereas  in  chlorosis  the 
haemoglobin  reduction  far  exceeds  that  of  the  corpuscles,  and  in  progressive 
pernicious  anaemia  the  corpuscular  poverty  exceeds  that  of  haemoglobin.  From 
splenic  anaemia  the  diagnosis  must  be  made  by  the  detection  of  a  cause  other 
than  the  enlarged  spleen. 

Prognosis. — This  depends  entirely  upon  the  cause.  The  anaemia  itself 
rarely  reaches  a  de^ee  sufficient  to  cause  anxiety. 

Treatment. — While  removal  of  the  cause,  when  possible,  is  the  prime 
object  of  treatment,  we  may  frequently  combine  our  symptomatic  treatment 
of  the  anaemia  with  the  hygienic  and  medicinal  treatment  of  the  previous 
affection.  Good,  nourishing  food  in  quantity  and  quality  to  suit  the  age  of  the 
patient  and  the  condition  of  the  digestive  organs,  abundance  of  fresh  air,  and 
an  amount  of  exercise  adapted  to  the  primary  disease  and  to  the  strength  of 
the  patient  are  all-important  aids  in  treatment. 

For  the  purpose  of  increasing  the  richness  of  the  blood  in  corpuscles  and 
coloring  matter  we  have  two  drugs  upon  which  reliance  can  be  placed,  iron  and 
arsenic.  In  employing  iron  it  is  important  to  remember  its  marked  tendency 
to  interfere  with  digestion,  and  in  cases  dependent  upon  gastro-intestinal  dis- 
turbances we  can  frequently  increase  the  lacking  blood-elements  more  rapidly 
by  first  correcting  the  digestive  troubles,  when,  indeed,  the  iron  may  not  be 


362    A3IERICAN  TEXT-BOOK   OF  DISEASES  OF  CHILDREN. 

required  at  all.  The  best  forms  for  its  administration  to  children  are  the  syrup 
of  the  iodide  of  iron,  reduced  iron,  or  one  of  the  vegetable  salts  of  iron.  The 
dose  of  whatever  preparation  may  be  selected  should  be  carefully  regulated  to 
the  age  of  the  patient,  and  the  drug  should  be  discontinued  or  its  amount 
lessened  when  it  produces  constipation  or  when  the  stools  are  distinctly  dark- 
ened. In  this  form  of  annemia  it  is  unwise  to  give  more  iron  than  can  be 
absorbed  and  utilized,  whereas  in  chlorosis  even  the  iron  that  is  voided  with 
the  fseces  seems  to  have  been  of  some  utility. 

Arsenic  is  of  great  value  as  a  restorer  of  the  red  corpuscles,  probably  by  its 
action  upon  the  blood-making  organs.  It  is  pre-eminently  useful  in  the 
anaemia  of  chronic  malarial  poisoning,  and  is  of  marked  value  in  the  latei- 
treatment  of  mucous  disease  with  anaemia.  It  is  often  well  to  combine  iron  and 
arsenic,  as  they  seem  to  virtually  assist  each  other  in  many  cases ;  some  such 
form  as  the  following  may  be  employed : 

IB^.  Liquor,  potassii  arsenitis f^j. 

Syrup,  ferri  iodidi fgix. — M. 

Sig.  Ten  drops  thrice  daily. 


THE   PRIMARY   ANAEMIAS. 
Chlorosis. 

While  essentially  a  disease  of  youth  as  opposed  to  childhood  and  infancy, 
this  disease  is  occasionally  met  with  before  the  former  period  of  life  is  reached. 
It  is  therefore  proper  that  it  should  find  a  place  in  a  work  upon  pediatrics. 

Etiology. — While  much  has  been  written  upon  the  essential  cause  of  this 
condition,  it  cannot  as  yet  be  said  that  the  etiology  is  by  any  means  definitely 
settled.  The  theories  regarding  it  are  too  numerous  to  be  even  enumerated. 
The  most  satisfactory  explanation  is  that  the  excessive  destruction  or  imperfect 
formation  of  haemoglobin  is  due  to  either  the  defective  absorption  and  assimila- 
tion of  iron  from  the  intestinal  tract  or  to  the  absorption  from  the  bowel  of 
poisonous  principles  with  hasmolytic  properties.  The  view  advocated  by  Vir- 
chow  that  it  is  caused  by  congenital  hypoplasia  of  the  vascular  system,  and  the 
view  that  it  depends  upon  developmental  imperfection  of  the  genital  apparatus, 
cannot  be  considered  as  tenable  considering  the  rapid  and  complete  cure  fol- 
lowing the  employment  of  proper  hygienic  and  medicinal  treatment. 

Age  is  an  etiological  factor  of  great  importance,  most  of  the  cases  occurring 
between  the  thirteenth  and  twentieth  years  of  life.  Instances  have  been 
observed,  however,  in  individuals  even  below  the  former  age. 

Sex  has  a  strong  determining  influence,  the  vast  majority  of  cases  occur- 
ring in  females,  and  but  light  grades  of  the  affection  being  seen  in  boys.  Hered- 
ity cannot  be  said  to  have  any  but  a  predisposing  influence,  and  even  that  is 
doubtful,  although  Trousseau  and  others  claim  that  the  disease  is  very  frequent 
in  tuberculous  families. 

Habits  of  life  play  an  important  part  in  its  production,  the  overworked 
with  but  little  opportunity  for  the  enjoyment  of  fresh  air,  exercise,  and  mental 
relaxation  being  those  most  frequently  aifected.  Depressing  emotions,  sexual 
abuse,  and  fright  seem  to  act  as  causes,  either  directly  or  remotely.  The 
menstrual  disturbance  so  frequently  seen  in  connection  with  this  particular 
alteration  in  the  composition  of  the  blood  must  be  looked  upon  as  a  result 
rather  than  as  a  cause. 

Symptoms. — The  complaint  that  induces  a  patient  with  chlorosis  to  seek 


ANEMIA.  363 

medical  advice  is  variable.  Sometimes  it  is  the  shortBess  of  breath  upon 
exertion,  at  times  the  interruption  of  the  menstrual  periods,  and  at  times  the 
cephalalgia.  The  usual  history  given  is  that  the  patient  has  suffered  from 
vertical  headache  for  a  variable  time,  with  shortness  of  breath  upon  exertion, 
palpitation,  marked  lassitude,  and  frequent  fainting-spells.  The  date  of  appear- 
ance of  the  several  subjective  sensations  is  as  variable  as  is  their  relative 
intensity.  The  symptoms  above  enumerated  are  those  most  constantly  present. 
Constipation  is  usually  marked,  and  a  desire  for  unnatural  articles  of  diet  is 
at  times  a  prominent  feature.     Gastralgic  attacks  are  frequently  present. 

The  appearance  of  the  patient  is  extremely  characteristic.  The  skin  has  a 
peculiar  olive  tint,  which,  taken  in  connection  with  the  pale  lips,  is  imitated  by 
no  racial  peculiarities  of  coloring.  There  is  apt  to  be  a  certain  ashy  appear- 
ance about  the  angles  of  the  mouth.  The  expression  is  usually  languid  with 
an  appearance  of  sadness,  while  the  features  frequently  show  some  heaviness 
of  outline.  There  is  a  variety  of  chlorosis,  first  described  by  Wendt,  wherein 
the  cheeks  retain  an  abnormally  red  color — chlorosis  florida  seu  rubra.  Occa- 
sionally a  deposit  of  pigment  in  the  neighborhood  of  joints  is  observed.  The 
mucous  membranes  are  pallid  to  a  varying  degree  according  to  the  extent  of 
the  anaemia.  There  may  be  slight  puffiness  beneath  the  eyes,  and  the  feet  or 
ankles  may  show  slight  oedema  with  but  little  pitting  upon  pressure.  Marked 
oedema  is,  however,  rare.  There  may  be  visible  pulsation  of  the  vessels  of  the 
neck.  The  subcutaneous  fat  is  seldom  decreased  ;  in  fact,  the  condition  of 
embonpoint  is  that  most  frequently  seen.  The  pulse  is  usually  rapid  and 
compressible.  The  apex-beat  of  the  heart  is  usually  plainly  visible,  and  more 
diffuse  than  in  health.  Auscultation  reveals,  in  all  marked  cases,  a  soft 
blowing  murmur  at  either  the  apex  or  base,  or  both,  with  sharply-defined  and 
somewhat  valvular  first  sound.  Over  the  veins  of  the  neck  there  is  almost 
always  to  be  heard  a  loud  venous  hum.  Thrombosis  is  apparently  rather 
favored  by  the  condition  of  the  blood. 

The  examination  of  the  blood  is  of  itself  sufficient  for  a  diagnosis.  The 
characteristic  change  is  a  marked  decrease  of  the  percentage  of  haemoglobin. 
With  a  corpuscle  count  of  4,500,000,  or  even  over  5,000,000,  per  cubic  mil- 
limetre the  haemoglobin  may  be  decreased  to  50  or  40  per  cent,  of  the  normal. 
Less  characteristic  appearances  are  the  pallor  of  the  drop  as  it  flows  from  the 
finger  and  the  variety  in  the  size  and  shape  of  the  red  blood-cells  when  seen 
through  the  microscope. 

The  genital  apparatus  is  usually  said  to  be  undeveloped.  I  have,  however, 
seen  within  the  past  year  a  chlorotic,  aged  fifteen  years,  with  mammae,  areolae, 
and  nipples  of  the  size  and  appearance  of  those  seen  in  adult  life.  The  urine 
presents  no  changes  of  note  save  in  that  it  is  of  low  specific  gravity  and  pale 
in  color,  contrasting  strongly  with  the  low  specific  gravity  and  dark  color  of 
the  urine  in  cases  of  pernicious  anaemia.  Albumin  in  small  quantities  is  occa- 
sionally found. 

Morbid  Anatomy. — There  have  been  no  distinctive  lesions  found  in  the 
few  fatal  cases  that  have  come  to  autopsy.  The  narrowness  of  the  arteries 
with  the  small  size  of  the  heart  noted  by  Virchow,  and  the  presence  in  some 
cases  of  a  poorly-developed  uterus  and  its  appendages,  are  all  that  have  been 
noted  aside  from  the  apparent  bloodlessness  of  the  organs  and  the  retention  of 
a  fair  amount  of  adipose  tissue.  In  some  cases  the  left  ventricle  has  been 
dilated.     Xo  alterations  in  the  blood-forming  organs  have  been  reported. 

Diagnosis. — As  has  been  said,  the  appearance  is  characteristic.  The  tint 
of  the  skin  is  quite  different  from  the  yellowish-brown  stain  of  jaundice  and 
from  the  lemon-yellow  tint  of  pernicious   anaemia  and   the   cachexise.     The 


364    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

sclerotics  are  of  a  clear  blue  color,  in  contradistinction  to  the  yellowish  colora- 
tion of  icterus. 

From  these  as  well  as  other  diseases  the  blood-examination  will  separate 
this  affection  at  once.  From  pernicious  anaemia  and  Bright's  disease  the 
absence  of  retinal  disturbances  would  readily  distinguish  it ;  while  in  the  for- 
mer the  examination  of  the  blood  is  as  characteristic  as  it  is  in  chlorosis,  and 
in  the  latter  the  presence  of  tube-casts  and  absence  of  oligochromaemia  are 
points  of  plain  significance. 

Prognosis. — The  outlook  is  extremely  favorable,  providing  only  that 
patients  can  be  persuaded  to  continue  treatment  until  absolute  cure  is  estab- 
lished. The  tendency  to  relapse  is  very  marked,  and  patients  frequently  cease 
their  visits  when  their  most  marked  symptoms  have  been  relieved,  only  to 
return  in  their  former  condition  after  the  lapse  of  a  few  weeks.  The  disease 
is  but  very  rarely  fatal,  and  the  unfavorable  result  is  due  to  the  onset  of  some 
incidental  affection.  The  only  complication  of  note  is  gastric  ulcer,  and  this 
is  seen  but  rarely.  Permanent  disease  of  the  heart  may  result  in  protracted 
cases. 

Treatment. — This  is  most  satisfactory  if  the  patient  persist  in  treatment 
until  cure  is  complete. 

Hygiene  plays  an  extremely  important  part.  Plenty  of  fresh  air,  with 
moderate  exercise  and  a  plain  but  nourishing  diet,  will  do  much  to  hasten  the 
cure.  In  some  cases  absolute  rest  in  bed  with  milk  diet  seems  to  act  well,  par- 
ticularly in  the  more  severe  and  obstinate  cases. 

The  daily  use  of  the  flesh-brush  upon  rising  in  the  morning  is  of  value,  not 
only  in  relieving  the  coldness  of  the  extremities  that  is  often  present,  but  in 
improving  the  general  nutrition.  In  vigorous  subjects  cold  sponging  before 
breakfast  will  help  to  increase  the  general  tone  of  the  system.  The  bowels 
must  receive  careful  attention.  Daily  evacuations  should  be  procured  by  regu- 
lation of  the  diet,  the  use  of  "cannon-ball"  massage  to  the  abdomen,  and,  if 
necessary,  by  the  use  of  tonic  laxatives.  Of  the  latter,  the  best  by  far  is  aloes 
or  aloin.  The  latter  may  be  made  up  into  a  pill  with  extract  of  nux  vomica 
and  extract  of  belladonna,  and  should  be  taken  at  bed-time.  The  pill  of  aloes 
and  myrrh  of  the  United  States  Pharmacopoeia  is  an  excellent  combination 
for  older  subjects. 

The  specific  remedy  for  the  disease  is  iron.  The  simpler  the  form  in  which 
it  is  given,  the  better.  The  most  satisfactory  is  in  the  combination  known  as 
Blaud's  pill  (I^.  Ferri  sulphat.  exsiccat.,  Potas.  carb.  (pur.),  ad  gr.  iij). 
This  may  be  given  after  meals,  increasing  from  one  to  three  times  a  day,  to 
two  pills  three  times  daily  in  the  first  ten  days,  and  maintaining  or  even 
increasing  this  number  until  the  haemoglobin  has  reached  the  normal  amount. 
Where  objection  is  made  to  taking  pills,  as  is  frequently  the  case  among  the 
class  in  which  this  disease  is  most  prevalent,  powdered  iron  may  be  readily 
given.  The  great  point  is  to  give  the  drug  steadily  and  unremittingly  until 
the    oligochromsemia  has  been  absent  for  one  or  two  weeks  or  even  longer. 

Progressive  Pernicious  Anemia. 

This  is  an  intense,  generally  progressive,  alteration  of  the  blood  arising 
spontaneously,  characterized  clinically  by  the  symptoms  and  signs  of  marked 
anaemia,  by  diminution  of  the  number  of  the  red  blood-corpuscles  without  cor- 
responding decrease  in  the  amount  of  haemoglobin,  and  by  an  almost  invariably 
fatal  result. 

The  name  of  this  condition  must  be  looked  upon  as  being  provisional.      It 


ANEMIA.  365 

is  probable  that  in  the  future  some  more  definite  knowledge  may  be  obtained 
that  will  enable  us  to  separate  the  cases  now  grouped  together  under  the  above 
title  into  separate  classes  depending  upon  etiological  factors  that  are  at  present 
unknown.  Formerly  cases  Avere  grouped  under  this  title  that  are  now  known 
to  be  separate  pathological  processes,  of  which  the  anaemia  was  merely  a 
symptom,  notably  those  of  atrophy  of  the  gastric  mucosa  and  those  due  to 
intestinal  parasites.  At  present,  however,  we  must  include  under  one  name  a 
class  of  cases  that  have  no  apparent  causation  in  organs  other  than  those 
immediately  concerned  in  blood-formation,  and  which  still  present  a  uniform 
grouping  of  symptoms. 

Etiology. — The  actual  cause  of  this  disease  is  as  yet  unknown.  The 
researches  of  Quincke  and  Peters  upon  the  excess  of  iron  found  in  the  liver 
of  patients  dying  of  it,  and  the  observations  of  Hunter  upon  the  dark  color 
of  the  urine  from  the  presence  of  pathological  urobilin,  would  point  to  the 
existence  of  some  cause  for  an  increase  of  hsemolysis.  Whether  this  be  a 
poison  created  within  the  body  has  not  as  yet  been  proven,  but  from  the 
remarkable  resemblance  between  this  and  the  anaemia  from  atrophy  of  the 
stomach  it  is  at  least  possible  to  suppose  that  the  hemolysis  may  be  produced 
by  the  absorption  of  some  toxic  principle  from  some  portion  of  the  alimentary 
tract. 

Age  is  a  marked  etiological  factor,  inasmuch  as  the  large  majority  of 
cases  occur  during  middle  life.  That  it  does  occur  in  young  persons  with 
moderate  frequency  is  shown  by  the  fact  that  cases  have  been  collected  by 
Griffith,^  wherein  the  disease  has  occurred  at  the  ages  of  sixteen  months,  three, 
five,  seven,  eight,  ten  (2  cases),  eleven  (2  cases),  twelve,  fifteen,  and  eighteen 
years,  and  in  one  other  boy  in  which  the  age  was  not  given ;  while  I  have 
found  additional  cases  reported  as  pernicious  anaemia,  without  an  exhaustive 
search  of  the  literature,  at  ages  of  eleven  months.^  one  year  and  four  months,^ 
two,*  four,^  eleven  (2  cases),^  thirteen,'^  fifteen,^  sixteen,^  seventeen,^"  and  twenty^^ 
years. 

The  female  is  rather  more  prone  to  the  disease  than  is  the  male  sex. 

In  one  of  Escherich's  cases  the  appearance  of  the  disease  followed  close  upon 
vaccination  with  animal  lymph,  but  whether  there  was  any  relation  between  the 
two  events  it  is  impossible  to  say. 

Symptoms, — The  most  striking  subjective  symptom  is  extreme  and  pro- 
gressive weakness.  Shortness  of  breath  and  vertigo  soon  become  prominent 
symptoms.  While  feeling  extremely  ill,  the  patient  retains  a  fair  amount  of 
fat,  and  save  for  extreme  pallor  has  the  appearance  of  a  well-nourished  indi- 
vidual. 

The  weakness  and  pallor  increase  gradually  with,  at  times,  temporary  short 
intervals  of  apparent  improvement.  Dyspnoea  increases,  the  extremities 
become  oedematous,  and  the  patient  is  at  length  compelled  to  remain  in  bed, 

^  Keating's  Cydopcedia  of  Diseases  of  Children.  1890,  vol.  iii.  p.  809. 

^  D'Espine  and  Picot  (Pievue  de  Med.,  1890,  p.  859) :  blood-count  not  given,  doubtful. 

^  Ibid. :  blood-count  not  given,  probablv  a  true  case. 

^  Escherich  ( Wiener  klin.  Wochenschr.,  1892,  Xo.  13,  p.  193). 

=  Mott,  Practitioner,  Aug.,  1890. 

^  Ashbj  and  Wright  {Diseases  of  Children,  1892,  p.  337)  :  no  bkx)d-count,  urine  of  low  spec. 
grav.,  and  pale,  therefore  doubtful. 

'  D"E?pine  and  Picot  [loc.  cit.)  :  no  blood-count  given. 

^  Taylor  {Guy's  Hosp.  Hep.,  1878) :  doubtful,  no  blood-count. 

^  Wilks  {Guy's  Hosp.  Rep.,  1857,  p.  203):  probably  a  case  of  pernicious  anaemia,  though 
described  as  a  case  of  "  idiopathic  fattv  degeneration." 

10  Handford  i  Br.  Med.  Jour.,  1891,  p.  445  1. 

11  Eoosevelt  {N.  T.  Med.  Record,  1888,  p.  407). 


366    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  whole  body  being  sometimes  water-logged  with  anasarca.  Occasionally 
irregular  elevations  of  temperature  arise  without  apparent  cause.  Gastro- 
intestinal disturbance  may  be  present,  but  in  cases  unassociated  with  gastric 
and  intestinal  atrophy  they  sink  into  insignificance  in  comparison  with 
the  intense  languor  and  shortness  of  breath.  Haemorrhages  from  the  mucous 
membranes  and  beneath  the  skin  are  sometimes  present  and  may  be  profuse. 

As  a  result  of  treatment  or  without  apparent  cause,  the  condition  may  for 
a  time  improve,  but  the  course  is  usually  progressively  downward  until  death 
occurs  from  simple  asthenia,  possibly  hastened  by  an  attack  of  intestinal  dis- 
turbance or  by  the  onset  of  some  acute  inflammatory  trouble. 

The  appearance  of  the  patient  is  almost  pathognomonic.  The  skin  is  of  a 
peculiar  pale-lemon  tint,  the  lips  almost  white,  the  conjunctivae  of  a  pearly 
whiteness.  Areas  of  pigmentation  may  be  present  on  various  parts  of  the 
body.  The  retention  of  a  fair  degree  of  embonpoint  with  the  extreme  pallor 
at  once  suggests  this  disease  to  one  who  has  seen  a  case  thereof. 

Upon  physical  examination  nothing  abnormal  may  be  found  save  soft 
hgemic  murmurs  at  the  apex  or  pulmonary  cartilage  and  venous  murmurs  in 
the  neck.  The  pulse  is  soft,  readily  compressible,  and  gives  an  impression  to 
the  finger  similar  to  that  of  aortic  regurgitation,  which  disease  this  also  some- 
what resembles  in  the  occasional  presence  of  a  capillary  pulse.  The  urine  is 
peculiar  in  that  with  low  specific  gravity  the  color  is  quite  decided — due, 
according  to  Hunter,  to  the  presence  of  pathological  urobilin.  Upon  ophthal- 
moscopic examination  streaks  of  hgemorrhagic  extravasation  are  frequently  to 
be  seen. 

The  examination  of  the  blood  is  of  itself  sufficient  to  determine  the  dia- 
gnosis. The  blood  as  it  exudes  from  the  finger  is  usually  of  a  paler  color  than 
normal,  and  may  be  obtained  only  with  great  difficulty.  Upon  examining  a 
fresh  specimen  there  is  found  to  be  extreme  irregularity  in  the  size  and  form  of 
the  red  cells.  There  are  seen  in  the  same  field  numerous  red  cells  smaller 
than  the  normal,  side  by  side  with  others  of  double  the  size  of  the  latter. 
Nucleated  red  cells  of  large  size  are  also  seen.  There  is  little  tendency  to 
the  formation  of  rouleaux.  The  red  blood-cells  are  far  below  the  normal 
average  per  cubic  millimetre.  Their  number  varies  much  with  the  duration 
and  severity  of  the  individual  case :  it  may  sink  to  below  500,000  per  cubic 
millimetre.  The  estimation  of  haemoglobin  shows  that  this  is  in  excess  of  the 
amount  corresponding  to  the  cellular  reduction.  This  disproportion  of  the 
number  of  red  cells  and  the  amount  of  haemoglobin  is  characteristic  of  the 
disease — the  valeur  glohulaire  is  exceedingly  higli. 

Morbid  Anatomy. — The  skin  is  generally  of  a  markedly  yellowish-white 
color.  The  subcutaneous  fat  is  usually  remarkably  well  preserved  and  is  of  a 
light-yellow  color.  The  muscles  are  peculiarly  red,  in  marked  contrast  with 
the  pallor  of  other  tissues  and  of  the  muscular  tissue  in  other  forms  of  anaemia. 
All  of  the  internal  organs  look  blanched,  but  upon  the  various  serous  mem- 
branes ecchymotic  areas  are  frequently  seen.  Punctiform  haemorrhages  may 
also  be  present  in  the  skin,  mucous  membranes,  connective  tissue,  muscles, 
heart-wall,  bone-marrow,  lymph-glands,  spleen,  liver,  pancreas,  lungs,  and 
dura  mater.  They  are  due,  according  to  Berraer,  to  fatty  degeneration  of  the 
capillaries,  although  other  observers  have  failed  to  find  the  change  described. 
In  the  serous  cavities  a  varying  amount  of  clear  serum  is  present.  The  heart 
is  usually  large  and  soft,  its  walls  flabby,  its  chambers  almost  empty  of  blood. 
"Tabby-cat  mottling"  of  fatty  degeneration  is  frequently  present,  or  the 
whole  tissue  may  be  pale  and  fatty-degenerated.  The  spleen  shows  no  constant 
changes.     The  gastric  mucosa  may  be  found  atrophied  in  some  cases  of  appa- 


ANEMIA.  367 

rently  true  idiopathic  pernicious  ansemia ;  but  these  cases  should  not  be  classed 
under  the  name  of  the  disease  under  consideration  unless  the  view  that  atrophy 
of  the  gastric  and  intestinal  glands  is  one  of  the  results  thereof.  The  liver 
is  fatty,  and  shows  the  only  really  characteristic  change  of  any  of  the  organs. 
Upon  microscopic  examination  there  is  found  an  excess  of  free  iron  in  the 
cells  of  the  outer  and  middle  zones  when  the  sections  are  treated  with  proper 
reagents.  The  kidneys  may  be  the  seat  of  marked  fatty  degeneration,  and 
iron  has  been  occasionally  detected  in  the  renal  cells.  The  marrow  of  the 
shaft  of  the  long  bones  is  of  a  deep  brick -red  color,  resembling  the  foetal  con- 
dition, but  the  appearance  is  not  characteristic,  as  it  has  also  been  found 
in  other  forms  of  anaemia.  In  the  posterior  columns  of  the  spinal  cord  there 
has  been  found  a  process  resembling  in  every  respect  that  seen  in  locomotor 
ataxia. 

Diagnosis. — The  chief  difficulty  in  diagnosis  lies  in  the  exclusion  of  a 
primary  cause  for  the  anaemia.  The  appearance  of  the  patient,  the  subjective 
symptoms,  and  the  progressive  course  will  usually  lead  to  a  correct  diagnosis. 
An  examination  of  the  blood  definitely  decides  the  question.  The  diseases 
which  most  resemble  pernicious  anaemia  are  atrophy  of  the  gastric  tubules  and 
malignant  disease  of  the  internal  organs,  particularly  those  of  the  digestive 
tract.  Careful  examination  will  usually  exclude  the  latter  even  without  an  exam- 
ination of  the  blood.  Certain  cases  of  atrophy  of  the  gastric  tubules  have  so 
resembled  pernicious  anaemia  as  to  render  a  distinction  between  them  an  impos- 
sibility. Unfortunately,  in  these  cases  the  chemical  examination  of  the  gastric 
contents  is  of  but  little  aid,  as  Ewald  has  found  that  hydrochloric  acid  is  absent 
from  the  gastric  juice  in  pernicious  anaemia  asmell  as  in  gastric  atrophy,  and 
the  peptonizing  power  is  diminished  in  both  conditions. 

Prognosis. — The  outlook  is  extremely  grave.  As  a  rule,  death  comes  in 
spite  of  all  our  efforts.  A  fatal  result  occurred  one  month  after  the  first 
appearance  of  pallor  in  the  two-year-old  child  reported  by  D'Espine  and 
Picot,  and  in  Kjellberg's  case  of  a  boy  aged  five  years  death  occurred  six 
weeks  after  development  of  symptoms.  Recovery  may  be  considered  impos- 
sible if  the  red  cells  number  500,000  per  cubic  millimetre  or  less.  Since  the 
discovery  of  the  value  of  arsenic  in  this  disease  the  prognosis  is  somewhat  less 
hopeless  than  formerly.  By  its  use  apparently  hopeless  cases  may  be  at  least 
temporarily  relieved.  Too  often,  however,  the  improvement  is  but  temporary, 
and  relapse  soon  takes  place.  Death  comes  from  exhaustion  or  from  the  onset 
of  some  intercurrent  disease.  A  sharp  attack  of  diarrhoea  or  an  inflammatory 
disease  of  the  respiratory  tract  is  frequently  the  immediate  cause  of  death. 
Haemorrhage  is  rarely  of  sufficient  amount  to  cause  death.  Litten  reports  a 
case  that  apparently  passed  into  leukaemia. 

Treatment. — Absolute  rest  with  freedom  from  worry  and  excitement  is  of 
prime  importance.  A  diet  selected  with  care  and  adapted  to  the  needs  and 
capacity  of  the  individual  is  to  be  directed. 

Among  drugs  none  can  equal  arsenic  in  value.  By  its  means  the  number 
of  red  blood-cells  may  be  increased  to  within  a  fair  degree  of  normal,  and  with 
corresponding  amelioration  of  symptoms.  It  should  be  given  freely  up  to  the 
point  of  tolerance.  It  is  better  to  begin  with  small  doses  well  diluted,  and  to 
increase  as  rapidly  as  is  consistent  with  the  avoidance  of  toxic  symptoms  :  upon 
the  appearance  of  gastro-intestinal  disturbance  or  of  oedema  either  the  use  of 
the  drug  should  be  entirely  discontinued  for  a  time  or  the  dose  should  be  much 
reduced.  The  pigmentation  occasionally  seen  in  the  course  of  the  disease  should 
not  cause  needless  fear  of  arsenical  pigmentation.  Iron  is  but  seldom  of  value. 
It  may,  however,  be  used  in  cases  showing  an  intolerance  to  arsenic.     Rectal 


368    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

injections  of  blood  prepared  in  various  ways  are  no  longer  considered  worthy 
of  the  hope  that  was  at  one  time  placed  in  them. 

The  inhalation  of  oxygen  may  relieve  the  dyspnoea  that  is  at  times  severe, 
but  nothing  more  than  palliation  can  be  expected  to  result  from  its  use. 

If  the  theory  of  intestinal  absorption  of  ptomaines  in  the  causation  of  this 
disease  be  correct — and  there  seem  many  reasons  for  believing  it  to  be  so — 
rendering  aseptic  the  intestinal  canal  would  be  a  rational  means  of  cure.  It 
is  Avell,  therefore,  to  keep  the  bowels  opened  regularly,  and  to  administer  in 
appropriate  quantities  salol,  thymol,  or  ^-naphthol  in  order  to  accomplish  what 
we  can  in  this  direction. 

Splenic  Anemia. 

In  a  considerable  number  of  children  there  is  found  a  marked  degree  of 
aneemia  associated  with  no  appreciable  lesion  save  enlargement  of  the  spleen. 
Rendu  has  reported  a  case  wherein,  after  the  lapse  of  two  years,  an  increase 
in  the  number  of  white  blood-corpuscles  occurred,  and  Gilbert  saw  a  case  that 
later  was  transformed  into  lymphatic  leuktemia. 

Etiology. — Much  discussion  has  been  indulged  in  as  to  the  cause  of  this 
form  of  anaemia  in  childhood,  and  even  now  it  cannot  be  said  that  any  uni- 
formity of  opinion  has  been  obtained.  Malaria  is  certainly  capable,  when  long 
operative,  of  producing  both  amemia  and  chronic  splenic  enlargement  in  chil- 
dren, just  as  in  the  case  of  adults.  The  cases  presenting  a  malarial  history 
comprise,  however,  but  a  very  small  minority  of  the  cases  in  which  this  affection 
has  been  observed. 

The  two  diseases  that  appear  to  have  most  claims  as  etiological  factors  are 
rickets  and  inherited  syphilis.  Out  of  30  cases,  Carr  found  27  with  other 
distinctly  rachitic  lesions  ;  in  14  cases  syphilis  played  at  least  a  prominent  part. 
In  60  rachitic  children  Kuttner  found  a  palpable  spleen  in  44,  in  33  of  which 
the  organ  was  markedly  enlarged.  In  only  2  of  the  60  cases  Avas  there  a  clear 
history  of  syphilis,  but  in  13  thei'e  was  a  history  that  the  mother  had  had  mis- 
carriages or  stillbirths.  In  63  cases  examined  by  them,  Fox  and  Ball  found 
that  rachitic  symptoms  were  present  in  almost  all ;  and  in  one  series  of 
105  consecutive  cases  of  rickets  the  spleen  was  enlarged  in  14  per  cent.  ;  in 
another  series  of  84  cases  of  very  marked  rickets,  enlargement  was  present  in 
40  per  cent.  That  inherited  s^^philis  may  be  more  than  a  predisposing  foctor 
is  rendered  highly  probable  from  further  statistics  furnished  by  the  last-named 
authors.  In  63  cases  of  enlargement  of  the  spleen  with  ansemia  they  found 
inherited  syphilis  in  41  per  cent.  ;  while  in  155  cases  of  inherited  syphilis  the 
spleen  was  enlarged  in  48.4  per  cent.  The  influence  of  hereditary  syphilis  in 
causing  rickets  should  not  be  overlooked,  and  it  seems  more  than  likely  that 
the  most  potent  factor  is  rickets.  It  is  interesting  in  this  connection  to  learn 
that  Sutton  (according  to  Fox  and  Ball)  has  found  both  liver  and  spleen  con- 
stantly enlarged  in  monkeys,  where  rickets  is  produced  by  causes  other  than 
syphilitic  taint. 

The  disease  would  appear  to  be  frequently  found  in  members  of  the  same 
family,  partly  due,  no  doubt,  to  the  fact  that  the  individuals  were  all  subject 
to  the  same  conditions  of  life. 

Boys  are  more  often  affected  than  girls,  Kuttner  having  found  it  in  37  boys 
out  of  60  cases.  The  disease  has  been  seen  at  the  age  of  two  months  (Cavr) 
and  in  adult  life,  so  that  no  definite  statement  can  be  made  as  to  age  as  a 
predisposing  factor. 

Pathological  Anatomy. — The  only  characteristic  lesions  found  relate 
to  the  spleen.     The  organ  is  enlarged,  the  capsule  thickened  and  adherent,  the 


ANjEMIA.  369 

parenchyma  firm,  with  marked  increase  of  fibrous  tissue.  The  microscopic 
examination  shows  increase  of  fibrous  tissue,  with  atrophy  of  Malpighian  bodies 
and  disappearance  of  adenoid  tissue  (Peter).  The  marrow  of  the  long  bones 
may  have  become  lymphoid  in  character.  In  the  other  organs  various  changes 
are  to  be  found  as  coincidental  affections.  These  are  practically  the  lesions 
discovered  after  death  in  children  with  rickets  or  inherited  syphilis.  The  most 
frequent  abnormal  conditions  found  relate  to  the  respiratory  organs.  There 
may  be  bronchitis,  atelectasis,  pneumonic  consolidation,  or  the  deposition  of 
tubercles.  The  gastro-intestinal  tract  may  show  the  lesions  of  a  chronic  catar- 
rhal inflammation. 

Symptoms. — Lassitude  and  general  weakness  on  the  part  of  the  child 
may  be  the  causes  of  medical  treatment  being  sought.  In  other  cases  the 
peculiar  pallor  may  have  called  the  attention  of  the  parents  to  the  child's 
condition.  The  enlarged  spleen  may  have  caused  anxiety,  or  the  child  may 
have  been  brought  for  treatment  on  account  of  the  catarrh  of  the  respiratory 
or  digestive  tract  that  is  a  frequent  accompaniment  of  the  condition.  The 
existence  of  the  disease  may  be  discovered  accidentally  in  examining  a  child 
presenting  other  manifestations  of  rickets.  The  complexion  is  of  a  peculiar 
waxy,  pallid  hue,  with  rather  a  muddy  tint.  The  mucous  membranes  are 
blanched,  the  tongue  pale  and  flabby. 

Upon  examination  of  the  trunk  there  are  found  in  rachitic  children  not 
only  the  prominent  abdomen  that  is  usually  seen  in  children  of  this  class,  but 
there  may  be  visible  tumor  in  the  hypochondriac  and  lumbar  regions  of  the 
left  side.  Frequently  the  enlargement  of  the  spleen  may  not  be  discovered 
until  palpation  reveals  a  resisting  mass.  In  marked  cases  the  spleen  can  be 
readily  felt  as  a  sharply-defined  solid  tumor,  with  its  anterior  edge  notched  in 
one  or  two  places.  The  organ  can  be  made  more  prominent  by  pressure  with 
the  free  hand  upon  the  left  hypochondriac  and  lumbar  regions.  In  less  well- 
marked  cases  careful  palpation,  with  firm  pressure  upon  the  left  flank,  may 
be  required  in  order  to  bring  the  anterior  edge  forward  sufficiently  to  be  felt 
through  the  abdominal  wall.  Testi  heard  a  vascular  murmur  over  the  enlarged 
spleen. 

Examination  of  the  blood  reveals  a  reduction  in  the  number  of  red  corpuscles. 
Kuttner  found  the  number  in  10  cases  to  vary  from  1,020,000  to  4,080,000, 
with  a  haemoglobin  value  of  35  per  cent,  in  the  former  instance  and  73  per 
cent,  in  the  latter.  There  is  no  absolute  increase  in  the  number  of  white  blood- 
corpuscles,  although  in  fatal  cases  there  may  be  at  times  an  increase  in  these 
elements  toward  the  close  of  life. 

Irregular  fever  is  frequently  present,  possibly  owing  to  the  frequent  catar- 
rhal complications.  In  some  cases  epistaxis  may  be  present,  in  some  sub- 
cutaneous hgemorrhages.  Albuminuria  seems  to  be  rare,  although  Carr  found 
it  present  in  two  of  his  cases.  The  liver  is  frequently  enlarged,  and  there  may 
be  some  enlargement  of  the  deeper  sets  of  lymphatic  glands.  Catarrhal  inflam- 
mation of  the  bronchial  mucous  membrane  and  in  the  gastro-intestinal  tract  is 
frequent,  but  it  is  impossible  to  attribute  it  to  the  condition  of  splenic  anaemia, 
owing  to  the  frequent  coexistence  of  the  rachitic  condition. 

Diagnosis. — When  the  spleen  is  much  enlarged  the  history  of  the  case  and 
the  examination  of  the  blood  render  the  diagnosis  a  matter  of  ease.  The 
absence  of  increase  of  white  blood-cells  would  diff'erentiate  the  disease  from 
splenic  leukaemia,  and  an  examination  of  the  blood  for  the  plasmodium  malaria 
would  cast  out  malarial  enlargement.  From  enlargement  of  the  spleen  from 
amyloid  infiltration  the  absence  of  a  history  of  the  influences  causative  of  that 
affection,  and  the  failure  of  evidence  of  a  similar  infiltration  of  the  liver  and 

24 


370   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

kidneys,  would  differentiate  this  disease.  From  an  enlarged  left  kidney  the 
diagnosis  is  to  be  made  by  the  presence  of  notches  in  the  anterior  border,  by 
the  direction  of  enlargement,  by  the  greater  motility  of  the  tumor  upon  biman- 
ual examination,  and  by  the  absence  of  urinary  changes.  The  acute  enlarge- 
ments from  typhoid  fever,  embolic  abscess,  and  acute  malarial  poisoning  are 
readily  excluded  by  the  history  of  the  case.  Enlargement  from  cirrhosis  of  the 
liver  would  be  but  little  apt  to  cause  embarrassment  in  arriving  at  a  diagnosis. 

Prognosis. — While  fatal  cases  are  not  rare,  the  prognosis  is  not,  as  a  rule, 
bad  if  proper  hygienic  conditions  can  be  enforced.  Of  Carr's  30  cases,  10 
died,  6  disappeared  from  sight,  13  recovered,  and  1  remained  stationary.  The 
chief  cause  of  death  is  the  occurrence  of  acute  respiratory  or  digestive  inflam- 
matory complications. 

Treatment. — Of  prime  importance  is  the  securing  of  proper  hygienic  sur- 
roundings. Plenty  of  fresh  air,  well-ventilated  sleeping  apartments,  and  a 
proper  amount  of  outdoor  exercise  are  essential.  The  diet  must  receive  care- 
ful attention.  The  food  should  be  plain  and  nourishing,  with  absence  of  excess 
of  fjirinaceous  articles.     The  clothing  also  should  be  regulated. 

Of  drugs,  cod-liver  oil,  arsenic,  and  iron  are  the  most  useful.  Phosphorus 
may  be  used  in  those  markedly  rachitic.  In  cases  that  have  a  distinct  history 
of  inherited  syphilis  mercury  may  be  given,  but  even  in  the  manifestly  syph- 
ilitic the  splenic  enlargement  is  apt  to  undergo  no  diminution  from  its  use. 
The  judicious  administration  of  cod-liver  oil  by  either  internal  means  or  by 
inunction,  or  by  both  methods  combined,  with  the  use  of  a  combination  of 
iron  and  arsenic,  such  as  was  mentioned  in  the  section  upon  Secondary 
Anajmia,  will  be  found  to  be  the  best  line  of  treatment  in  connection  with 
careful  correction  of  insanitary  conditions. 

The  application  of  electricity  over  the  spleen  may  produce  lessening  in  the 
size  of  the  organ. 

Lymphatic  Anjemia. 

This  affection  is  a  more  or  less  generalized  condition  of  the  lymphoid 
tissue  of  the  body,  characterized  by  enlargement  of  groups  of  glands  or 
increase  in  the  normal  lymphoid  structures  of  a  part,  accompanied  by  oligo- 
cythaemia  and  a  varying  amount  of  enlargement  of  the  spleen. 

The  disease  bears  in  many  respects  a  close  resemblance  to  the  lymphatic 
form  of  leukaemia,  and,  in  fact,  the  leucocytosis  that  frequently  is  present  to  a 
marked  extent  has  been  seen  to  pass  into  a  condition  of  true  leukaemia.  The 
whole  subject  of  the  relation  between  these  two  diseases  of  the  lymphoid  tissues 
of  the  body,  and  also  between  them  and  diffuse  sarcomatous  disease  of  the 
lymphatic  glands,  still  needs  further  study,  in  spite  of  the  work  that  has 
already  been  done  in  attempting  to  assign  them  to  their  proper  position. 

Etiology. — This  is  still  far  from  decided.  Inherited  syphilis  has  been 
supposed  to  play  a  certain  role,  but  it  is  doubtful  whether  the  association  has 
been  more  than  a  coincidence.  Age  certainly  exerts  some  influence,  as  the 
disease  is  very  common  in  the  young.  Males  are  more  frequently  attacked 
than  females.  Heredity  has  not  been  shown  to  exert  any  influence.  The 
action  of  continued  local  irritation  or  inflammation  would  seem  to  be  a  strong 
etiological  factor,  and  it  may  be  owing  to  the  frequency  of  long-standing 
lesions  of  the  skin,  of  the  face  and  head,  of  the  jaws  and  ears,  that  the 
cervical  chains  so  frequently  are  the  earliest  and  most  markedly  involved 
groups. 

Symptoms. — The  disease  begins  insidiously  with  enlargement  of  some 
group  of  lymphatic  glands,  with   increasing  anaemia  with  its  accompanying 


ANJEMIA.  371 

subjective  symptoms,  and  with  progressive  vreakness.  The  glands  most  fre- 
quently attacked  are  those  in  the  posterior  cervical  triangle,  but  the  axillary 
or  inguinal  glands  may  be  first  involved.  Deeper  sets  of  glands,  as  those 
in  the  thoracic  or  abdominal  cavities,  may  be  involved  before  the  exter- 
nal tumors  appear,  or  even  without  involvement  of  the  superficial  groups. 
The  external  glands  may  form  large  masses,  producing  much  disfigurement. 
The  cervical  glands  may  obliterate  the  outlines  of  the  neck  or  may  encircle  the 
front  portion  of  the  neck  like  a  collar,  and  produce  marked  dyspnoea.  The 
axillarj^  group  may  be  enlarged  sufficiently  to  prevent  the  apposition  of  the 
arm  to  the  side,  while  the  inguinal  glands  may  enlarge  sufiiciently  to  embarrass 
locomotion.  Pressure  of  these  masses  may  produce  various  secondary  results, 
such  as  pain  radiating  down  the  trunks  of  the  nerves  running  near  to  the  tumors, 
and  oedema  from  pressure  upon  the  venous  trunks.  When  the  visceral  sets 
of  glands  are  involved,  there  may  be  no  outward  signs  of  their  presence, 
although  the  retroperitoneal  and  mesenteric  groups  may  be  enlarged  so  much  as 
to  be  both  seen  and  felt.  By  pressure  upon  various  organs,  blood-vessels,  or 
ducts  they  may  produce  eifects  varying  with  the  part  involved.  Dyspnoea  may 
be  produced  from  pressure  upon  the  bronchi ;  cyanosis  or  oedema  of  the  face 
from  pressure  upon  the  superior  vena  cava.  Dyspeptic  symptoms,  constipa- 
tion, anuria,  ascites,  and  oedema  of  the  lower  extremities  may  be  caused  by 
enlargement  of  the  groups  within  the  abdominal  cavity.  Secondary  involve- 
ment of  the  spinal  cord  may  produce  paraplegia  from  pressure. 

The  lymphoid  tissue  in  the  tonsils,  tongue,  pharynx,  skin,  and  intestinal 
wall  is  occasionally  the  seat  of  the  same  outgrowth,  producing  symptoms  vary- 
ing with  the  situation  involved. 

Either  continued  mild  pyrexia,  alternating  periods  of  pyrexia  and  apyrexia, 
or  distinctly  intermittent  fever  is  usually  present  during  some  period  of  the  course. 

The  general  symptoms  are  those  due  to  the  angemia.  Vertigo,  headache, 
lassitude,  and  dyspnoea  may  be  obtrusive  symptoms.  The  patient  is  usually 
very  pale,  and  the  white  skin  with  thickened  neck  forms  a  picture  that  could 
with  difiiculty  fail  to  suggest  the  presence  of  this  disease. 

The  examination  of  the  blood  shows  a  decrease  of  the  number  of  red 
blood-cells  to  a  varying  degree.  Poikilocytes  are  common,  and  nucleated  red 
blood-corpuscles  are  occasionally  seen.  There  is  leucocytosis,  which  in  some 
cases  attains  to  such  a  degree  that  the  case  must  be  classed  as  a  lymphatic 
leukaemia. 

The  patient  usually  succumbs  after  a  period  varying  from  less  than  a  year 
to  five  years  (Gowers)  from  asthenia.  Obstinate  diarrhoea  may  occur  at  any 
time,  even  without  involvement  of  the  intestinal  canal.  Death  may  occur 
from  pressure  upon  the  air-passages  before  the  general  condition  of  the  patient 
would  excite  alarm. 

Morbid  Anatomy. — The  skin  is  pale,  the  subcutaneous  layer  of  adipose 
tissue  more  or  less  decreased.  The  post-mortem  findings  vary  much  in  dif- 
ferent cases  in  accordance  with  the  glands  involved.  Usually  there  are  masses 
of  enlarged  superficial  glands  in  the  neck,  axillas,  or  groins.  These  are  found 
to  be  composed  either  of  isolated,  enlarged  nodules  varying  from  the  size  of  a 
pigeon's  egg  to  that  of  a  hen's  egg,  or  of  masses  of  lymphatic  glands  welded 
together  or  even  infiltratino;  neicchborinfj  structures,  from  which  thev  mav  be 
separated  either  with  difficulty  or  not  at  all.  Upon  section  the  individual 
glands  present  various  appearances  even  in  the  same  case.  They  may  be  soft 
and  of  a  color  not  diifering  much  from  the  normal,  and  may  yield  an  abundant 
milky  juice,  or  they  may  be  hard  and  firm,  showing  a  clear  white  color  of  the 
cut  surface  without  any  j  nice. 


372    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Any  of  the  lymphatic  glands  in  various  parts  of  the  body  may  be  involved 
in  the  same  way.  The  groups  of  glands  in  the  mediastina,  the  bronchial 
glands,  the  retroperitoneal,  or  the  mesenteric,  may  each  or  all  of  them  be 
enlarged  and  more  or  less  matted  together.  The  thymus  gland  has  been  found 
either  uniformly  enlarged  or  the  seat  of  lymphoid  tumors. 

The  spleen  is  enlarged  in  the  great  majority  of  cases,  either  from  simple 
hypertrophy  or  from  the  presence  of  tumors  of  lymphoid  tissue.  The  liver  and 
kidneys  may  show  nodules  of  lymphoid  tissue.  The  lungs  are  sometimes 
affected  from  encroachment  of  growths  from  the  bronchial  group  of  glands  or 
by  the  growth  of  independent  foci  of  lymphoid  tumors.  The  heart  rarely 
shows  similar  growths  in  its  substance. 

Various  secondary  morbid  changes  are  produced  by  the  pressure  of  the 
masses  of  glands  upon  neighboring  structures. 

The  marrow  of  the  long  bones  may  have  a  puriform  appearance  or  may  be 
of  an  intense  red  color. 

Histologically,  the  lymphoid  tissue  of  the  enlarged  glands  and  of  the  isolated 
tumors  is  found  to  be  composed  of  a  delicate  reticulum  enclosing  round  cells. 
In  some  glands  there  is  also  an  increase  of  fibrous  tissue. 

Diagnosis. — In  many  cases  it  is  impossible  to  state  whether  the  case  in 
hand  should  be  classed  as  one  of  pseudo-leukaemia  or  as  a  true  lymphatic 
leukaemia.  In  the  latter  disease  the  spleen  more  frequently  attains  a  con- 
siderable size  than  in  the  cases  now  classified  as  pseudo-leukaemia.  As  this 
disease  may  pass  into  a  true  leukaemia,  in  so  far  as  the  blood-estimation  forms  a 
criterion,  and  as  the  treatment  is  practically  the  same  for  the  two  affections, 
the  differential  diagnosis  makes  but  little  practical  difference.  The  name 
"  pseudo-leukaemia  "  should,  however,  be  applied  only  to  those  cases  wherein 
the  proportion  of  white  tQ  red  cells  does  not  exceed  one  to  thirty. 

From  tubercular  adenitis,  the  so-called  scrofulous  enlargement  of  the  glands, 
the  differential  diagnosis  must  be  based  partly  upon  the  family  and  past  per- 
sonal history,  partly  from  the  appearance  of  the  patient,  but  chiefly  from  the 
more  localized  character  of  the  glandular  swelling  and  the  tendency  to  casea- 
tion and  suppuration  in  the  tubercular  disease. 

Secondary  involvement  of  the  lymphatic  glands  by  cancer  will  not  enter 
into  consideration  in  those  below  adult  life. 

Prognosis. — The  outlook  is  extremely  unfavorable.  The  progressive 
tendency  of  the  disease  may  sometimes  be  combated  by  treatment,  but  cure 
can  be  expected  but  rarely.  In  the  early  stages,  where  the  involved  glands 
are  accessible  to  the  surgeon,  the  disease  may  be  cured  by  operative  treatment. 
The  degree  of  asthenia  and  the  extent  of  the  anaemia  offer  some  means  of 
forming  a  prognosis  as  to  duration. 

Treatment. — In  early  cases,  where  superficial  glands  are  alone  attacked, 
the  chance  of  cure  by  surgical  means  should  not  be  neglected.  In  cases  of 
doubtful  nature,  where  the  diagnosis  between  this  affection  and  an  essentially  local 
disease  of  the  affected  glands  is  difficult,  the  safest  course  is  to  avail  ourselves 
of  surgical  means  of  cure.  Of  drugs,  arsenic  is  the  only  one  upon  which 
dependence  can  be  placed.  It  should  be  administered  in  ascending  doses  until 
the  point  of  tolerance  is  reached.  Iron  is  of  secondary  value  as  a  haematonic, 
but  may  be  combined  with  arsenic,  preferably  in  the  form  of  the  officinal  syrup 
of  the  iodide  of  iron.  External  applications  to  the  affected  glands  can  only  be 
of  value  where  the  integrity  of  the  skin  is  in  danger. 

Tracheotomy  may  be  necessitated  by  pressure  upon  the  trachea  or  if  the 
enlarged  glands  interfere  with  the  nerve-supply  of  the  vocal  cords. 


LEUKEMIA.  373 

LEUKEMIA. 

Leukemia  is  a  disease  of  the  blood-making  organs,  characterized,  clin- 
ically, by  the  symptoms  of  anaemia,  excessive  increase  in  the  number  of  white 
blood-cells,  and  a  tendency  to  hsemorrhagic  extravasation ;  pathologically,  by 
enlargement  of  the  spleen  and  lymphatic  glands  and  by  changes  in  the  bone- 
marrow,  either  separately  or  in  combination. 

The  condition  of  the  blood  in  this  disease  is  mimicked  in  health  after  eat- 
ing (physiological  leucocytosis)  and  in  various  organic  diseases  wherein  there 
is  an  intense  local  lesion  (pathological  leucocytosis),  as  in  pneumonia,  empyema, 
etc.  The  term  "leukaemia,"  however,  must  be  limited  to  cases  wherein  leuco- 
cytosis is  more  or  less  constant,  is  of  marked  degree,  and  is  associated  with 
the  characteristic  lesions  of  spleen,  lymph-glands,  or  bone-marrow. 

As  to  the  nature  of  the  disease  there  is  much  diversity  of  opinion.  The 
term  "leukaemia"  is  at  present  the  most  applicable,  because  non-committal, 
name  that  we  can  apply  to  it. 

Various  divisions  have  been  made  in  respect  to  the  part  chiefly  or  solely 
involved  in  the  disease — splenic,  lymphatic,  or  medullary  (myelogenous). 
Rarely  is  any  one  form  present  alone,  but  the  cases  usually  fall  into  the  classes 
lieno-medullary  or  lieno-lymphatic.  Cutaneous,  intestinal,  and  tonsillar  forms 
are  curiosities. 

The  disease  bears,  in  many  respects,  a  close  resemblance  to  sarcomatosis. 

Etiology. — The  precise  etiology  of  the  disease  has  not  yet  been  decided. 
It  is  preceded  by  malaria  and  syphilis  in  a  number  of  cases  sufficient  to  render 
it  possible  that  these  diseases  have  at  least  a  predisposing  influence.  Trauma 
in  the  splenic  region  has  been  followed  by  its  appearance.  Some  of  the  more 
acute  cases  pursue  a  course  that  is  strongly  suggestive  of  an  infectious  origin. 
Fermi,  Powlowski,  Bonardi,  Kelsch  and  Vaillard,  Klebs,  Roux,  and  others 
have  reported  the  finding  of  various  micro-organisms  in  the  blood  or  tissues  of 
cases  of  the  disease.  Negative  results  were  reached  in  Westphal's  case  in  an 
attempt  to  obtain  cultures  from  the  spleen  during  life  and  from  the  blood  and 
bone-marrow  after  death.  Gilbert  unsuccessfully  attempted  to  inoculate 
healthy  dogs  with  lymphatic  glands  from  a  dog  aff"ected  with  the  disease. 
Hosier  failed  to  produce  the  disease  by  the  injection  of  leuksemic  blood  into 
dogs  and  rabbits.  Bollinger  met  with  a  similar  result  in  attempting  to  pro- 
duce the  disease  in  healthy  animals  by  the  injection  of  blood  from  leukaemic 
animals  of  the  same  species.  Apparent  infection  occurred  in  Obrastzow's 
experience,  where  an  attendant  upon  a  case  died  after  fourteen  days'  illness 
with  purpura,  haemorrhages,  fever,  albuminuria,  and  a  proportion,  in  the  blood, 
of  one  white  to  nine  red  blood-cells. 

The  disease  is  seen  at  all  ages  from  birth  up  to  the  seventy-fifth  year.  It  is 
most  frequent  between  the  ages  of  thirty  and  fifty  years.  It  is  not  rare  in 
childhood,  many  cases  having  been  reported  in  infants  less  than  two  years  of 
age,  while  Sanger  has  reported  its  existence  in  a  stillborn  child.  It  is  more 
common  in  males  than  in  females.  Heredity  has  not  been  proven  to  be  an 
etiological  factor.  Horses,  oxen,  dogs,  pigs,  cats,  and  mice  sufier  from  a  sim- 
ilar affection. 

Symptoms. — The  usual  symptoms  that  impel  the  patient  to  seek  advice 
are  the  general  weakness,  the  pallor,  the  shortness  of  breath,  haemorrhages 
from  the  mucous  membranes,  the  enlargement  of  the  abdomen,  or  the  super- 
ficial lymphatic  tumors.  The  disease  usually  arises  gradually,  so  that,  as  a 
rule,  marked  changes  in  the  organs  and  blood  have  occurred  before  the  patient 
is  brought  for  treatment. 


374    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  symptoms  produced  by  the  abnormal  condition  of  the  blood  are  similar 
in  the  different  forms  of  the  disease,  but  the  examination  of  the  patient  yields 
results  varying  with  the  type.  Bi'eathlessness  upon  exertion  is  usually  a  very 
marked  feature.  It  may  be  accompanied  by  marked  vertigo  upon  change  of 
posture.  The  bodily  strength  is  impaired  to  a  great  degree,  but  in  some  cases 
it  is  remarkably  well  preserved  in  view  of  the  serious  changes  in  the  composi- 
tion of  the  blood.  Haemorrhages  may  have  occurred  from  the  nose,  throat, 
stomach,  or  intestines,  or  there  may  be  hsemorrhagic  extravasations  beneath 
the  skin.  Haemorrhages  in  the  fundus  oculi  may  produce  sufficient  interfer- 
ence with  vision  to  attract  the  attention  of  the  patient.  Edes  has  recorded  a 
case  wherein  priapism  was  the  first  symptom.  During  the  course  of  the 
disease  occasional  rises  of  temperature  may   be  noted. 

Upon  examination  there  is  found  more  or  less  pallor  of  skin  and  mucous 
membranes.  The  pulse  is  soft  and  compressible,  with  increased  rate.  If  the 
anaemia  be  marked,  there  may  be  heard  a  hsemic  murmur  over  the  position 
of  the  apex-beat  or  in  the  second  left  intercostal  space.  The  lungs  usually 
present  no  morbid  signs  save  toward  the  close  of  fatal  cases,  when  oedema, 
congestion,  or  a  fluid  accumulation  in  the  pleural  cavity  may  be  found.  In 
some  cases  there  is  found  in  the  lung  what  clinically  resembles  lobar  pneu- 
monia, but  histologically  is  found  to  present  features  differing  from  the 
ordinary  form. 

Diarrhoea  may  be  persistent,  and  in  some  cases  a  species  of  dysentery  is 
present.  Vomiting  is  not  a  frequent  symptom.  The  occasional  occurrence  of 
hsematemesis  has  been  mentioned  above. 

The  urine  is  usually  unaltered  save  for  an  increase  in  the  amount  of  uric 
acid  excreted. 

On  the  part  of  the  nervous  system  we  may  have  no  symptoms.  Vertigo 
and  cephalalgia  are  at  times  marked.  Death  may  occur  from  intracranial 
haemorrhage.  Vision  may  be  much  impaired,  due  to  the  presence,  as  revealed 
by  the  ophthalmoscope,  of  retinal  haemorrhages  or  of  leuksemic  deposits. 
Hearing  may  be  impaired.  Suchamick  has  noted  a  peculiar  brownish  discolora- 
tion of  the  nasal  mucous  membrane  in  one  case. 

The  usual  course  of  the  disease  is  slowly  progressive,  covering  a  period  of 
months  or  years.  There  have  been  reported  some  cases  running  an  extremely 
rapid  course,  as  in  that  of  Guttmann,  where  a  fatal  termination  occurred  after 
an  illness  of  four  and  a  half  days. 

The  examination  of  the  blood  is  all-important  in  determining  the  nature  of 
the  disease.  The  constant  feature  is  an  increase,  both  relative  and  absolute, 
of  the  white  corpuscles.  This  may  attain  to  an  extreme  degree,  the  relative 
number  of  white  to  red  cells  having  even  been  as  two  to  one  in  a  case  reported 
by  Robin.  The  average  ratio  of  white  to  red  cells  is  as  one  to  fifty  or 
twenty,  in  cases  without  great  reduction  in  the  latter  elements,  as  opposed  to 
one  to  500  or  700,  the  average  ratio  of  health.  The  various  forms  of  white 
blood-cells  are  present  in  different  proportions  in  the  lieno-medullary  and  in 
the  lymphatic  varieties.  In  the  former  the  eosinophilous  cells  of  Ehrlich  are 
the  predominant  form,  whereas  in  the  acute  lymphatic  variety  the  lymphocytes 
form  the  main  proportion  of  the  colorless  elements.  Where  the  lymphatic, 
splenic,  and  medullary  varieties  exist  together  in  the  same  patient,  the  propor- 
tion of  the  forms  of  leucocytes  will  produce  variations  from  the  two  types 
mentioned.  Myelocytes  may  be  present  in  large  numbers.  Charcot's  crystals 
are  said  to  form  after  the  blood  has  remained  upon  the  slide  for  a  short  time. 

In  the  splenic  form  a  prominent  feature  is  the  gradual  enlargement  of  the 
spleen.     This  occurs  to  a  varying  degree,  the  organ  in  extreme  cases  even 


LEUKAEMIA.  375 

reaching  to  or  beyond  the  median  line  of  the  abdomen.  The  splenic  enlarge- 
ment takes  place  chiefly  in  a  diagonal  direction,  downward  and  toward  the 
right.  When  the  hand  is  placed  over  the  mass,  a  rub  may  be  felt  and  tender- 
ness be  elicited  by  pressure.  Spontaneous  pain  or  sense  of  pressure  may 
be  an  annoying  symptom,  while  the  weight  of  the  organ  may  produce  dis- 
order of  digestion  or  marked  constipation. 

When  the  marrow  of  the  bones  is  affected,  there  may  be  tendei'ness  over 
the  affected  parts,  with  localized  swellings  on  the  shafts  of  the  long  bones  or 
the  ribs  or  sternum. 

The  lymphatic  glands  are  less  frequently  involved  than  is  the  spleen. 
The  superficial  glands  show  enlargement  and  can  be  readily  felt,  or  even 
seen  as  isolated  groups  or  chains.  The  deep  glands  of  the  abdominal  cavity 
may  be  affected. 

Morbid  Anatomy. — The  skin  is  pale,  the  subcutaneous  fat  usually  much 
diminished.  The  blood  has  a  chocolate  color,  or  may  even  almost  resemble 
sanious  pus.  When  clotted  it  has  a  greenish-yellow  color.  On  the  serous 
membranes  there  may  be  areas  of  hiemorrhagic  extravasation.  In  the  serous 
cavities  there  is  usually  an  excess  of  fluid. 

The  heart  is  frequently  found  distended  with  clotted  blood.  The  lungs  present 
no  constant  changes,  although  posterior  congestion  is  often  seen.  Rarely  are 
there  any  changes  in  the  thymus  gland. 

The  spleen  is  almost  invariably  enlarged  to  a  greater  or  less  degree. 
Adhesion  to  neighboring  organs  is  common,  explaining  the  sharp  attacks  of 
pain  sometimes  experienced  in  the  left  hypochondriac  region.  The  organ  is 
usually  symmetrically  enlarged,  is  of  increased  density,  and  on  section  may 
show  either  a  brownish  color  throughout  the  surface,  or  there  may  be  scattered 
areas  of  a  white  color  due  to  localized  infiltration  with  lymphoid  cells,  either  in 
the  Malpighian  follicles  or  in  the  pulp.  Hemorrhagic  areas  may  be  present. 
The  spleen  may  enlarge  so  rapidly  as  to  cause  a  rupture  of  its  capsule. 

The  intestines  show  at  times  evidences  of  lymphoid  infiltration,  either  in 
the  glands  of  Peyer  or  in  other  parts,  by  thickening  without  ulceration.  The 
tonsils,  pharynx,  and  stomach  have  been  found  to  show  signs  of  the  over- 
growth of  lymphoid  tissue. 

Lymphoid  tumors  have  been  found  in  the  liver  in  sufficient  number  to 
notably  increase  the  size  of  the  organ,  while  the  kidneys  also  may  present 
whitish  areas  of  lymphoid  infiltration,  as  in  the  case  reported  by  Frankel. 
The  lymphatic  glands  of  the  superficial  sets  or  of  deeper  parts,  as  near  the 
root  of  the  mesentery,  are  in  some  cases  much  enlarged,  although  rarely  to  so 
great  an  extent  as  in  pseudo-leukaemia. 

The  marrow  of  the  bones  is  affected  in  a  considerable  number  of  cases, 
chiefly  in  conjunction  with  splenic  involvement.  In  these  cases  it  is  found 
to  be  of  a  puriform  appearance  or  to  be  of  a  dark-red  color.  Hemorrhagic 
areas  may  be  present.  The  shaft  may  be  found  expanded  and  the  wall  thinned. 
Microscopically,  the  marrow  shows  large  numbers  of  nucleated  red  blood-cells, 
eosinophiles,  and  myelocytes. 

Diagnosis. — The  only  diseases  with  which  leukaemia  is  apt  to  be  con- 
founded are  pseudo-leukemia,  splenic  anemia,  and  scrofulosis.  From  these 
the  diagnosis  may  readily  be  made  by  an  examination  of  the  blood.  The 
numerical  increase  of  the  white  blood-cells  is  alone  sufficient  to  make  the  dia- 
gnosis, save  in  cases  of  non-leukemic  leucocytosis.  From  this  the  diagnosis 
cannot  be  made  with  certainty  by  the  hemocytometer  alone,  as  in  leucocytosis 
the  relative  increase  of  white  cells  may  be  greater  than  in  some  cases  of 
leukemia.     For  the  differentiation  of  these  two  conditions  we  may  employ  the 


376    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

method  of  differential  staining  according  to  Ehrlicli's  procedure.  While  some 
question  has  been  raised  as  to  the  value  of  the  eosinophile  cells  as  diagnostic 
criteria,  this  objection  cannot  now  be  said  to  be  of  weight  save  in  the  lym- 
phatic variety,  where  the  cells  having  eosinophile  granules  are  not  present  in 
large  number. 

Prognosis. — The  prognosis  as  to  recovery  is  grave,  although  cases  have 
been  known  to  recover.  The  disease  is  usually  fatal  within  a  few  years.  In 
some  cases  of  acute  lymphatic  leukaemia,  as  in  the  case  reported  by  Guttmann, 
death  may  occur  within  a  few  weeks  or  days. 

Treatment. — Rest  is  of  prime  importance.  The  dietary  should  be  selected 
with  care,  and  should  be  suited  to  the  digestive  power  of  the  individual. 

Arsenic  is  almost  the  only  drug  that  can  be  said  to  be  of  any  real  value. 
It  should  be  pushed  up  to  the  verge  of  tolerance,  and  its  use  should  be  per- 
sisted in  until  either  it  is  evident  that  no  result  is  being  obtained  or  until  the 
patient  is,  mayhap,  relieved  of  the  disease. 

Quinine  should  be  tried  in  cases  giving  a  malarial  history,  but  it  will  rarely 
be  productive  of  much  benefit. 

Injections  of  arsenic  into  the  spleen  are  not  likely  to  materially  benefit  the 
patient,  and  are  not  without  risk.  "Westphars  case  died  after  a  puncture  of  the 
spleen  for  diagnostic  purposes,  the  organ  being  surrounded  by  a  large  blood- 
clot  at  the  autopsy.  Splenectomy  cannot  be  considered  justifiable,  in  spite 
of  Franzolini's  successful  case,  in  view  of  the  large  mortality  attending  the 
operation. 


HAEMOPHILIA. 

By  WILLIAM  PERRY  NORTHRUP,  M.  D., 

New  York. 


HAEMOPHILIA  is  a  tendency  to  obstinate  bleeding ;  inherited ;  often  asso- 
ciated with  swelling  of  the  joints. 

Etiology. — The  haemorrhages  may  be  traumatic  or  spontaneous  in  origin. 
Certain  families  are  known  as  "  bleeders,"  the  hgemorrhagic  diathesis  manifest- 
ing itself  at  any  time  from  early  infancy  to  the  end  of  life.  Hereditary  trans- 
mission takes  place  mostly  through  the  mother  and  to  her  male  offspring.  If  a 
woman  descended  from  bleeders  marry  a  healthy  man,  the  sons  will  inherit  the 
haemorrhagic  diathesis,  the  daughters  escaping.  In  the  succeeding  generations 
the  sons  in  whom  haemophilia  is  manifest  will  not  transmit  the  diathesis, 
whereas  the  daughters,  who  show  in  themselves  no  signs  of  it,  will  transmit  the 
diathesis  again  to  their  sons.  The  maternal  transmission  so  continues  to  many 
generations,  the  hgemorrhagic  condition  appearing  in  the  males,  the  females 
escaping,  but  transmitting  the  diathesis  to  their  sons.  Bleeders  usually  have 
large  families,  some  of  whom  may  escape  the  disease.  They  are  to  be  found 
in  all  localities,  in  all  conditions  of  life ;  are  healthy  in  appearance,  commonly 
having  fine,  soft  skins.     The  Hebrew  race  is  said  to  be  particularly  liable  to  it. 

The  real  cause  of  haemophilia  is  unknown.  It  is  believed  that  the  condi- 
tion has  in  some  individual  instances  been  acquired. 

Pathological  Anatomy. — The  post-mortem  findings  do  not  explain  the 
nature  of  the  afi"ection.  An  unusual  thinness  of  the  walls  of  the  vessels  has 
been  observed,  though  the  microscope  fails  to  reveal  any  essential  and  constant 
alterations.  The  tissues  are  blanched  from  loss  of  blood.  Petechise  and 
bruised  patches  are  frequently  observed  upon  the  surface  of  the  body.  The 
swelling  of  the  joints  is  due  to  haemorrhages  into  the  articulations  and  the 
surrounding  tissues.  Occasionally  there  is  evidence  of  joint  inflammation. 
At  present  it  has  not  been  determined  whether  the  hemorrhage  is  due  to  some 
fault  in  the  walls  of  the  vessels,  or  whether  there  is  some  peculiarity  in  the 
character  of  the  blood  on  account  of  which  thrombi  are  not  formed. 

Symptoms, — At  birth  there  is  nothing  in  the  appearance  of  the  child  to 
indicate  the  peculiarity  of  his  inheritance.  He  is  usually  healthy  and  bright, 
and  may  in  the  first  year  develop  no  signs  of  haemophilia.  The  severing  of 
the  umbilical  cord  does  not  usually  give  occasion  for  obstinate  bleeding,  and 
not  until  his  growth  and  strength  lead  him  into  accidents,  such  as  bruises,  cuts, 
scratches,  and  punctures,  does  the  haemorrhagic  tendency  become  apparent. 
Epistaxis  is  the  most  common  experience  which  calls  attention  to  the  diathesis. 
This  may  be  acute,  obstinate,  and  alarming.  Besides,  there  may  be  petechias, 
ecchymoses,  haematomata,  interstitial  and  external  bleeding,  traumatic  or  spon- 
taneous. 

A  common  symptom  is  swelling  of  the  joints  closely  resembling  rheumatism. 
It  is  not  uncommon  to  find  haemorrhage  of  the  gums  at  the  eruption  of  the 
second  crop  of  teeth.     Slight  cuts  give  rise  to  troublesome  haemorrhage,  slight 

377 


378    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

blows  to  marked  ecchymoses,  and  a  blister  may  contain  blood  instead  of  serum. 
Prolonged  and  dangerous  bleedings  may  follow  tbe  extraction  of  a  tootb  in 
spite  of  the  application  of  the  strongest  styptics. 

The  bleeding  is  from  the  capillaries,  most  often  an  oozing,  which  may  con- 
tinue from  hours  to  weeks.  The  subjects  of  hemophilia  are  very  sensitive  to 
cold,  and  suffer  from  joint-pains  apart  from  those  dependent  upon  haemorrhage. 
Such  patients  pass  through  the  exanthemata  and  other  diseases  of  childhood 
without  special  dangers,  and  have  no  marked  proneness  to  phthisis.  Sloughing 
and  gangrene  are  not  uncommon  accidents  of  this  condition. 

Prognosis. — From  the  nature  of  the  disease  it  must  be  considered  a  con- 
stant menace  to  life.  However  mild  the  tendency  in  the  infiint.  the  prognosis 
should  be  considered  very  serious.  Of  152  cases  of  hjemophilia  traced  by 
Grandidier,  more  than  half  died  before  completing  the  seventh  year,  and  only 
19  attained  majority.  The  exhaustion  of  repeated  haemorrhages,  or,  more 
commonly,  the  di-aming  away  of  blood  by  continued  oozing,  may  destroy  life. 
The  most  difficult  of  control  and  the  most  frequently  fatal  are  the  hjemorrhages 
following  extraction  of  teeth  or  from  epistaxis. 

There  are  examples  of  bleeders  who  have  attained  a  good  age  and  led  busy 
lives.  To  this  class  belongs  a  very  busy  practitioner  of  the  writer's  acquaint- 
ance, who  is  never  without  fresh  petechise  of  the  face,  and  constantly  carries  a 
large  red  handkerchief  for  accidental  epistaxis. 

In  females  the  prognosis  is  good,  neither  menstruation  nor  childbearing 
being  complicated  by  this  capricious  example  of  atavism. 

Treatment. — Prophylaxis  avails  somewhat  to  diminish  the  accidents  of 
hgemorrhage.  The  system  may  be  fortified  by  abundant  fresh  air  and  tonics, 
by  judicious  exercise  and  general  hygiene.  The  child  should  be  guarded,  so 
far  as  possible,  from  bruises,  cuts,  and  punctures.  Vaccination,  though  not 
historically  accounted  a  dangerous  procedure  in  bleeders,  should  be  accom- 
plished rather  by  scarification  than  by  incision.  Slight  operations  should  be 
seriously  considered  before  they  are  undertaken,  and  every  needed  means 
of  haemostasis  should  be  at  hand.  The  extraction  of  teeth  should  be  avoided. 
Nearly  every  practitioner  has  had  at  least  one  trying  experience  with  obstinate 
haemorrhage  from  such  cause  in  a  person  not  hemophilic,  and  can  Avell  under- 
stand the  importance  of  this  advice. 

It  is  well  to  have  the  diet  properly  regulated  for  haemophilics,  giving  vege- 
tables and  generally  wholesome  mixed  meals,  without  excess  of  meat.  The 
boAvels  should  be  regulated  so  as  to  correct  any  tendency  to  a  '•  full-blooded  " 
condition.  Where  premonitory  symptoms  indicate  an  impending  haemorrhage, 
it  is  well  to  relieve  the  bowels  by  a  mercurial  purge,  followed  by  a  saline. 

In  case  of  haemorrhage  treatment  will  necessarily  be  modified  by  the  region 
in  which  it  takes  place.  Cuts  and  bruises  should  be  cleansed  and  bound  up, 
with  ice,  perchloride  of  ii'on,  or  nitrate  of  silver  applied  to  the  point  of  bleed- 
ing. In  epistaxis  the  nasal  cavities  may  be  treated  by  irrigating  the  parts  with 
cold  water  or  by  an  absorbent-cotton  plug  saturated  with  peroxide  of  hydrogen ; 
if  need  be,  the  cavities  may  be  tightly  plugged  with  cotton  soaked  in  an  iron 
solution.  If  the  haemorrhage  arise  from  the  socket  of  an  extracted  tooth, 
apply  crystals  of  subsulphate  of  iron  or  a  cotton  pledget  soaked  in  Monsel's 
solution,  or  apply  caustics.  Haemorrhages  from  the  bowel  should  be  treated 
with  opium  to  secure  quiet  and  rest,  and  by  cold-water  injections. 

Haemophilics  should  be  dressed  warmly,  should  avoid  cold,  damp  climates, 
and  all  so-called  rheumatic  surroundings.  The  joint  afi"ectious  may  be  treated 
much  like  similar  conditions  in  chronic  rheumatism,  perfect  rest  and  soothing 
applications  being  primarily  indicated. 


PURPURA  HJEMORRHAGICA, 

By  GEORGE  ROE  LOCKWOOD,  M.  D., 

New  York. 


Under  the  term  "  Purpura  Hgemorrhagica  "  we  include  a  clinical  group  of 
cases  characterized  by  the  association  of  purpura  with  haemorrhages  from  any 
of  the  mucous  membranes,  less  frequently  into  serous  membranes  and  joints  or 
into  the  substance  of  the  viscera.  First  described  by  Werlhof  in  1775,  it  is 
often  known  as  " Werlhof 's  disease."  It  is  also  known  as  "morbus  macu- 
losus." 

A  careful  study,  however,  of  the  cases  embraced  by  this  definition  shows 
such  a  variety  in  their  clinical  course  and  in  their  etiological  factors  that  ic 
seems  impossible  to  regard  them  even  as  different  types  of  the  same  disease. 
Their  symptoms,  in  a  general  way,  may  be  alike,  but  in  some  cases  they  appear 
suddenly  and  peracutely  without  assignable  cause,  associated  with  symptoms  of 
acute  sepsis,  often  causing  death  within  a  few  hours  or  days.  In  other  cases 
without  known  cause  the  symptoms  appear  subacutely,  and  are  less  marked, 
the  constitutional  symptoms  being  mildly  septic  in  character.  In  still  others 
the  symptoms  occur  either  as  a  complication  of  some  coexisting  disease  or  as 
the  result  of  a  well-known  cause.  It  seems  better,  therefore,  to  regard  the  term 
purpura  haemorrhagica  as  one  purely  clinical  in  its  scope,  including  a  number 
of  cases  distinct  in  their  clinical  course,  pathology,  and  etiology,  but  which 
present,  in  common,  symptoms  of  sufficient  similarity  to  be  included  under  one 
general  name. 

The  study,  then,  of  purpura  heemorrhagica  is  rendered  more  clear  by  dividing 
the  cases  of  this  disease  into  two  groups :  I.  essential,  and  II.  symptomatic  pur- 
pura licemorrhagica ;  the  essential  group  including  those  cases  in  which  the 
disease  begins  without  known  cause,  the  haemorrhages  and  purpura  being  asso- 
ciated with  more  or  less  marked  septic  symptoms,  and  running  a  course 
resembling  that  of  an  infectious  disease  ;  the  symptomatic  group  including 
those  cases  in  which  the  symptoms  arise  from  a  well-known  cause  (as  poisoning 
from  over-use  of  potassium  iodide),  or  as  a  complication  of  a  severe  blood  or 
infectious  disease  (as  in  profound  anaemia  or  in  the  exanthemata). 

The  essential  cases  seem  to  the  author  to  constitute  the  only  true  group  to 
which  the  term  purpura  haemorrhagica  should  be  rightly  applied,  and  these  will 
therefore  be  described  more  fully  than  the  symptomatic  cases,  which  should 
more  properly  be  classed  among  the  symptoms  of  the  diseases  which  they 
complicate. 

I.  Essential  Purpura  Hemorrhagica, 

This  form  occurs  both  subacutely  and  acutely,  the  former  being  far  the  more 
common,  and  about  which  we  know  most. 

379 


380    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Subacute  Purpuka  Hemorrhagica. 

This  variety  of  the  disease  is  seen  more  frequently  in  females  than  in 
males.  While  no  age  is  exempt,  it  usually  attacks  children  and  young  adults. 
Food  deficient  in  quantity  and  quality,  poor  hygiene,  and  a  weak,  sickly 
constitution  predispose  to  the  disease,  but  not  as  markedly  so  as  in  scurvy. 
Often  it  attacks  those  who  are  healthy,  well  fed,  and  well  housed.  There  is 
rarely  a  family  history  of  any  hismorrhagic  disease,  although  in  two  cases  in 
young  girls  under  the  author's  observation  the  father  of  each  had  been  subject 
to  severe  attacks  of  epistaxis  in  early  life.  The  subacute  cases  occur  in  two 
clinical  forms :  (1)  ordinary  cases,  and  (2)  cases  of  Henoch's  disease. 

Ordinary  Subacute  Cases. — This  form  usually  begins  with  prodromal 
symptoms,  anorexia,  malaise,  chilly  feeling,  and  irregular  rise  in  temperature, 
especially  at  night.  These  may  precede  the  onset  by  several  days  or  even 
weeks.  In  other  cases  there  is  no  prodromal  period.  When  the  disease  is 
fairly  developed  we  have  both  haemorrhagic  and  constitutional  symptoms. 

Symptoms.  —  Ha^morrhagic  Syrti'ptoms.  —  There  appear  purpuric  spots, 
usually  first  noticed  on  the  extremities,  though  they  may  be  generally  dis- 
tributed. Their  size  varies  from  that  of  a  pinhead  to  that  of  the  palm  of  the 
hand.  In  severe  cases  we  may  have  large  areas  of  ecchymoses,  which  may  be 
extensive  enough  to  cause  gangrene  of  the  skin.  Successive  crops  of  purpura 
appear  during  the  disease,  and  they  may  be  often  produced  by  rubbing  or 
scratching  the  skin.  Rarely  we  have  associated  with  the  purpura  and  ecchy- 
moses hsemorrhagic  vesicles  and  bullae. 

There  are  free  haemorrhages  from  any  of  the  mucous  membranes — nose, 
mouth,  gums,  bronchi,  stomach,  intestines,  and  pelvis  of  the  kidney.  There 
may  be  also  metrorrhagia.  The  most  frequent  sources  of  haemorrhage  are  from 
the  nose,  pelvis  of  the  kidney,  intestines,  and  uterus  respectively. 

These  haemorrhages  occur  spontaneously,  and  not  from  traumatism  alone, 
as  is  the  case  in  haemophilia.  They  may  be  moderate  in  their  severity  or 
profuse  enough  to  cause  the  death  of  the  patient. 

Pain  and  swelling  of  the  joints,  especially  those  of  the  hands,  feet  and 
knees,  are  frequently  noticed.  The  symptoms  are  identical  with  those  of  pur- 
pura rheumatica.  There  may  be  swelling  of  the  fibro-serous  tissues  about  the 
joint,  or  the  joint-cavity  may  be  filled  by  an  effusion  either  serous  or  fibrino- 
serous.  In  severe  cases  the  joint  may  become  ankylosed  or  an  arthritis  may  be 
caused.  The  primary  symptoms  are  due  to  haemorrhages  either  into  or  around 
the  joints. 

Internal  haemorrhage  may  occur  at  any  time  and  into  the  substance  of  any 
of  the  viscera,  especially  the  brain  and  its  membranes,  the  suprarenal  capsules, 
or  the  lung.  These  internal  haemorrhages,  however,  are  rare  in  the  subacute 
form,  though  more  common  in  acute  cases. 

The  gums  may  be  normal  or  swollen,  although  this  is  denied  by  many 
writers.  They  may  be  covered  by  blackish  scabs,  and  may  bleed  even  when 
they  are  not  swollen.     The  teeth,  however,  are  not  loosened  as  in  scurvy. 

In  no  case  are  ulcers  of  the  intestine,  due  to  submucous  haemorrhages,  ever 
seen.  Free  haemorrhage  from  the  skin  does  not  occur.  Although  the  kidneys 
are  frequently  the  source  of  haemorrhage,  nephritis  has  not  been  observed. 

Constitutional  Symptoms. — These  appear  in  varying  intensity,  and  are  due 
both  to  the  anaemia  from  the  haemorrhage  and  also  to  moderate  sepsis.  A  dis- 
tinct chill  at  the  onset  is  rare,  but  chilly  feelings  are  common  and  may  continue 
through  the  attack.  The  temperature  varies  from  100°  to  103°,  or  even  104°, 
b<ing  higher  in  severe  cases  and  in  children.    It  is  higher  at  night.    After  the 


PURPURA    HEMORRHAGICA.  381 

severity  of  the  attack  is  over  the  temperature  gradually  returns  to  normal :  a 
sudden  fall  in  temperature,  with  a  subsequent  rapid  rise,  is  noted  in  cases  of 
sudden  severe  haemorrhage,  especially  if  such  occur  into  the  viscera. 

The  pulse  is  of  low  tension  and.  somewhat  rapid.  It  may  become  rapid, 
small,  and  weak.     Attacks  of  syncope  are  common. 

General  anaemic  symptoms  are  always  present,  even  in  cases  in  which  the 
haemorrhages  are  slight,  but  they  are  more  severe  when  the  haemorrhages  are 
profuse.  They  appear  early  in  the  attack  and  continue  throughout  its  dura- 
tion ;  after  the  attack  subsides  the  recovery  is  long  and  tedious,  and  often  it 
takes  weeks  or  months  before  the  blood  returns  to  its  normal  condition. 

Examination  of  the  blood  during  the  attack  shows  rapid  diminution  of  the 
number  of  red  blood-corpuscles,  and  a  corresponding  diminution  in  the  amount 
of  haemoglobin.  The  white  cells  are  at  first  increased  in  number,  as  is  the 
case  after  acute  haemorrhage,  but  later  their  number  steadily  diminishes,  even 
during  early  convalescence,  while  the  number  of  red  corpuscles  and  the  amount 
of  haemoglobin  are  steadily  increasing. 

These  points  are  well  shown  by  the  records  of  blood-examinations  made  in 
a  case  reported  by  Osier : 


Number  of  red  cells. 

Number  of  white  cells. 

Per  cent,  of 
hEemoglobin. 

1st  day, 

5,350,000  (107%) 

8,000 

95 

2d  day, 

3,000,000(60%) 

12,500 

50 

8th  day, 

2,500,000  (50%) 

12,500 

37 

14th  day, 

3,000,000(60%) 

7,000 

47 

50th  day, 

4,000,000  (80%) 

2,500 

62 

70th  day, 

4,250,000  (82^%) 

72 

Prostration  is  a  prominent  symptom,  and  is  always  more  marked  than  can 
be  accounted  for  by  the  haemorrhage  and  constitutional  symptoms.  It  remains 
usually  for  some  weeks  after  all  other  symptoms  have  disappeared.  In  severe 
or  long-continued  cases  it  may  be  so  profound  that  the  patient  passes  into  the 
"  typhoidal  condition,"  with  rapid  and  feeble  pulse,  dry  brown  tongue,  stupor 
alternating  with  mild  delirium,  or  even  coma  and  death. 

The  spleen  and  liver  are  usually  enlarged  during  the  attack.  The  enlarge- 
ment of  the  liver  in  some  cases  is  well  marked,  and  may  be  distinctly  appre- 
ciable for  weeks  or  months  after  the  subsidence  of  the  disease.  The  conges- 
tion and  enlargement  of  the  liver  often  cause  a  mild  catarrhal  jaundice,  which, 
added  to  the  anaemic  appearance  of  the  patient,  gives  a  bright  fawn-yellow 
color  to  the  skin. 

The  duration  of  the  attack  varies  from  a  few  days  to  several  weeks,  but  the 
disease  may  be  protracted  for  weeks,  months,  or  years  by  the  appearance  of 
similar  attacks  (or  "relapses"  of  some  authors).  These  attacks  may  recur  at 
regular  or  irregular  intervals,  their  usual  number  being  four  or  five.  In  one 
unique  case  under  the  author's  observation  the  attacks  have  persisted  for  fifteen 
years,  the  patient  showing  no  signs  of  improvement  at  the  end  of  this  time. 
The  next  case  of  longest  duration  is  one  reported  by  Hryntschak,  in  which  the 
attacks  lasted  for  seven  years. 

Nature  and  Pathology. — For  the  blood  to  escape  from  its  vessels  and 
cause  haemorrhage  we  must  naturally  conclude  that  the  vessel-wall  must  first 
rupture.  As  this  does  not  normally  occur,  except  from  traumatism,  we  must 
also  conclude  that  its  wall  is  weakened  either  from  inflammation  or  from 
degeneration  due  to  disease,  to  poor  blood-supply,  to  toxic  blood,  or  to 
thrombi. 

Much  light  has  been  thrown  on  this  subject  by  Silberman,  who  gave  fifteen 


382     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

dogs  small  steady  doses  of  pyrogallic  acid  until  there  appeared  areas  of  stasis  in 
the  small  arteries,  capillaries,  and  veins.  After  pressing  out  the  stasis-blood 
he  injected  fibrin  ferment  into  the  arteries.  The  dogs  had  abdominal  tender- 
ness, purpura,  bloody  vomiting,  and  bloody  stools.  Autopsy  showed  in  the 
hsemorrhagic  areas  thrombi  in  the  small  arteries  and  veins,  whose  Avails  had 
undergone  hyaline  degeneration  Avith  areas  of  necrosis,  thus  alloAving  the  free 
escape  of  blood. 

Many  attempts  have  been  made  to  discover  a  specific  bacterium,  but  before 
the  time  of  Letzerich  the  examinations  were  so  incomplete  as  to  be  entirely 
Avithout  value.  Letzerich,  hoAvever,  in  1889  made  scientific  bacterial  exam- 
inations, and  discovered  a  bacillus  Avhich  he  believes  to  be  the  specific  germ 
of  the  disease.  x\lthough  his  experiments  have  not  been  corroborated  by  others, 
their  success  still  remains  of  the  greatest  value.  His  patient  Avas  a  girl  suflfer- 
ing  from  the  subacute  form.  Bacterial  examinations,  scientifically  performed 
in  every  detail,  showed  in  the  purpuric  spots  the  presence  of  long  bacilli 
capable  of  groAvth  in  gelatin,  the  pure  cultures  of  which,  injected  into  the 
abdomen  of  rabbits,  reproduced  the  original  clinical  symptoms  in  all  of  the 
tAvelve  cases,  and  in  these  a  bacillus  Avas  found  identical  with  that  in  the  pure 
culture  injected.  An  examination  of  the  purpuric  spots  in  the  rabbits  shoAved 
dilatation  of  the  capillaries,  emigration  of  Avhite  cells,  and  rupture  of  the  capil- 
lary Avail,  permitting  tlie  escape  of  red  cells.  The  capillaries  Avere  filled  Avith 
the  bacilli  with  abundant  spore-groAvth.  (The  bacilli  and  spores  had  been 
previously  described  by  Petrone,  in  his  examinations  of  a  case  of  Werlhof 's 
disease,  but  he  considered  the  disease  to  be  due  to  a  mixed  infection.) 

Upon  squeezing  the  section  Letzerich  found  that  little  plugs  resembling 
hyaline  casts  containing  bacilli  emerged  from  the  capillaries,  and  these  he  con- 
sidered the  result  of  the  action  of  the  bacillus  in  its  products  upon  the  fibrino- 
plastic  elements  of  the  blood.  The  liver  in  the  rabbits  was  regularly  enlarged, 
and  the  portal  capillaries  were  almost  occluded  by  an  extraordinary  growth  of 
the  bacilli.  Letzerich  considers  the  liver  to  be  the  breeding-place  of  the 
bacilli,  the  liver  being  to  this  disease  what  the  spleen  is  to  malarial  fever.  If 
he  be  correct  in  his  conclusions,  it  explains  both  the  scattering  of  the  lesions — 
a  bacterial  embolism  of  the  capillaries  causing  hyaline  thrombi  within  them 
with  rupture  of  the  capillary  wall — and  also  the  tendency  of  the  disease  to 
relapse.  While  conducting  his  experiments  Letzerich  Avas  himself  seriously 
attacked  by  this  disease,  attributing  his  infection  to  handling  his  cigar  Avhile 
at  work.  This  case  of  infection  seems  to  prove  the  advisability  of  disinfection 
after  an  attack. 

Prognosis. — This  is  generally  good,  almost  all  patients  recovering  from 
the  primary  and  secondary  attacks.  Recovery,  hoAvever,  is  sIoav,  the  ansEmia 
and  prostration  often  lasting  for  months  after  the  disappearance  of  other  symp- 
toms. The  occurrence  of  the  secondary  attacks  cannot  be  foretold.  In  rarer 
cases  the  disease  terminates  fatally,  the  cause  of  death  being  either  profound 
anaemia,  fatty  degeneration  of  the  heart,  Avith  or  Avithout  dilatation,  from  long- 
continued  antemia,  visceral  hfeniorrhages,  or  exhaustion. 

Treatment. —  This  is  unsatisfactory,  both  in  shortening  and  mitigating  the 
attack  and  in  the  prevention  of  subsequent  relapses,  as  there  is  no  specific 
known  that  acts  in  this  disease  as  quinine  does  in  malarial  fever.  Our  treat- 
ment, then,  must  be  entirely  symptomatic,  and  consists  in  treatment  during  the 
attack  and  prophylactic  treatment  destined  to  prevent  future  attacks. 

The  treatment  during  the  attack  consists  in  efforts  to  check  the  haemor- 
rhage and  in  the  relief  of  constitutional  symptoms.  To  check  the  htiemor- 
rhages  no  one  drug  is  certain.     We  employ,  in  turn,  a  number,  until  we  find 


PUBPUBA    H^MOBBHAOICA.  383 

one  that  is  efficacious,  but  we  may  run  through  the  entire  list  of  hsemosta- 
tics  without  result.  The  drugs  which  are  most  frequently  used  are  aromatic 
sulphuric  acid,  ergot,  turpentine,  digitalis,  quinine,  and  gallic  acid.  During 
a  haemorrhage  the  patient  must  be  kept  absolutely  quiet,  even  if  morphine  be 
required  for  this  purpose.  In  all  cases  and  at  all  times  care  should  be  taken 
to  guard  against  traumatism,  over-exertion,  and  excitement.  Alcohol  and 
highly-seasoned  food  may  also  give  rise  to  a  hgemorrhage.  Epistaxis  may  be 
checked  by  astringent  sprays  or  by  plugging  the  nares.  Uterine  hsemorrhage 
should  be  treated  by  firm  tamponage. 

If  the  joints  be  affected,  salicylic  acid  is  often  of  service.  The  pain  may 
be  relieved  by  anodyne  applications,  as  lead-and-opium  wash,  ichthyol  or  iodine 
ointment,  or  by  the  application  of  heat  and  cold.  Firm  compression  is  often 
grateful. 

Constitutional  symptoms  are  treated  on  general  principles.  The  patient 
must  be  put  to  bed  and  on  a  low  diet  during  the  attack.  La.ter  he  may  be 
about  the  room,  and  a  more  generous  diet  mav  be  allowed,  vegetables  and  vege- 
table  acids  and  fruit  being  especially  indicated.  In  all  cases  the  patient  should 
be  kept  quiet  and  free  from  excitement  or  exertion.  The  bowels  must  be  kept 
open,  and  any  digestive  errors  corrected.  Should  the  pulse  become  rapid  and 
feeble,  cardiac  stimulants  are  indicated,  especially  digitalis  and  strychnine. 
Alcohol  in  large  doses  should  not  be  used. 

During  the  close  of  the  attack  tonics  are  to  be  given,  quinine,  strychnine, 
and  arsenic  being  the  best  combination.  Iron  is  contraindicated,  as,  by  experi- 
ence, we  know  that  its  early  administration  may  bring  on  a  fresh  attack. 

If  the  ansemia  be  marked  during  the  attack,  arsenic  is  the  drug  most 
efficient.  It  is  to  be  given  in  increasing  doses  to  the  point  of  tolerance,  then 
stopping  its  use  for  a  day  or  so,  and  then  increasing  its  dose  as  before. 

If  symptoms  of  sudden  profound  anaemia  occur,  we  apply  warmth  to  the 
body,  hot  applications  over  the  heart,  and  give  cardiac  tonics,  especially  opium 
in  small,  repeated  doses.  Inhalation  of  pure  oxygen  gas  is  of  the  greatest 
service.  In  severe  cases  we  employ,  in  addition,  rectal  or  hypodermatic  injec- 
tions of  a  warm  sterilized  saline  solution.  Several  pints  can  be  given  in  this 
way  with  great  improvement  of  the  symptoms,  although  this  may  be  but  tem- 
porary. Arterial  transfusion  is  not  to  be  used,  because  of  the  danger  of  trau- 
matic haemorrhage.  Elevation  of  the  foot  of  the  bed  and  ligatures  applied  to 
the  extremities  are  often  followed  by  good  results. 

The  prophylactic  treatment  employed  during  and  after  convalescence  is 
intended  to  lessen  the  chances  of  subsequent  attacks. 

The  patient  must  live  and  work  in  airy,  sunny  rooms  and  take  graded 
exercise  in  the  open  air,  for  fresh  air  and  moderate  exercise  are  of  the  first 
importance.  The  plumbing  must  be  in  perfect  sanitary  condition.  The  diet 
should  be  wholesome  and  varied,  and  every  digestive  error  corrected. 

For  the  an?emia,  arsenic  in  small  continued  doses  is  by  far  the  best  treat- 
ment. It  should  be  continued  until  the  blood  becomes  normal.  It  may  be 
combined  with  quinine  and  strychnine.  Iron  is  not  to  be  used  at  first,  but 
several  weeks  after  the  primary  attack  has  subsided  it  should  be  given  in  small 
doses  at  first,  then  slowly  increasing.  Should  a  relapse  threaten,  the  iron  must 
at  once  be  stopped. 

Prostration  is  to  be  treated  on  general  principles  by  rest,  fresh  air,  graded 
exercise,  and  change  of  climate.  The  climate  most  suitable  is  one  in  which 
the  air  is  light,  dry,  and  bracing  ;  and  the  location  must  be  inland,  as  we  find 
that  the  disease  more  extensively  prevails  on  the  sea-coast. 

As  the  disease  is  probably  due  to  an  infectious  specific  germ,  and  as  the  sub- 


384  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

sequent  attacks  are  also  probably  due  to  reinfection,  it  seems  certainly  better 
to  disinfect  the  room  and  the  clothes  of  the  patient  after  the  illness.  The  more 
we  study  this  disease,  the  more  we  incline  toward  such  disinfection. 

Henoch's  Disease.  —  The  severe  form  of  the  subacute  cases  was  first 
described  by  Henoch,  and  is  known  as  "Henoch's  disease"  or  "Henoch's 
purpura  hsemorrhagica."  This  form  occurs  with  greater  frequency  in  children, 
especially  between  the  ninth  and  twelfth  years.  It  has  been  observed,  however, 
between  the  third  and  forty-sixth  years.  It  occurs  five  times  more  frequently 
in  males  than  in  females.     It  is  a  rather  rare  form. 

Symptoms. — There  is  usually  a  short  prodromal  period  with  malaise,  slight 
fever,  and  sometimes  with  pains  in  the  joints. 

The  onset  is  manifested  by  the  appearance  of  purpura,  in  severe  cases 
accompanied  by  ecchymoses,  these  differing  in  no  way  from  those  described 
under  the  first  form.  Immediately  after  the  purpura,  appear  the  severe  abdomi- 
nal symptoms  which  characterize  the  disease.  There  is  marked  pain  and  ten- 
derness over  the  abdomen,  the  pain  being  of  a  colicky  character,  with  exacer- 
bations of  great  intensity.  The  abdomen  is  rigid  and  retracted.  There  is 
severe  rectal  tenesmus  with  bloody  stools  and  severe  vomiting,  the  vomited 
matter  being  either  like  that  of  acute  gastritis  or  containing  blood.  These  abdom- 
inal symptoms  seem  to  be  due  to  submucous  haemorrhages  or  to  hsemorrhagic 
infarctions  caused  by  thrombi  in  the  small  blood-vessels  of  the  gastro-intestinal 
wall,  which  become  degenerated  and  rupture,  allowing  free  hgemorrhage. 
Patches  of  intestinal  ulceration  result  in  rare  cases,  and  rupture  into  the  peri- 
toneal cavity  with  fatal  peritonitis  may  occur  even  after  apparent  recovery. 

These  symptoms  continue  with  great  intensity  for  one  or  two  days,  and 
then  gradually  subside.  They  may  continue  longer,  but  in  such  cases  there  are 
periods  of  temporary  improvement.  Joint  symptoms  may  appear  as  in  the 
first  form.  H?ematuria  is  seen  in  one-fifth  of  the  cases.  The  spleen  is  usually 
enlarged,  and  there  is  a  slight  rise  of  temperature  during  the  attack. 

After  such  an  attack  the  patient  is  liable  to  have  a  series  of  similar  ones, 
usually  at  short  intervals.  There  are  generally  four  or  five  such,  but  their 
number  has  been  recorded  as  high  as  twenty. 

The  nature  of  the  disease  is  unknown.  No  specific  micro-organism  has 
as  yet  been  found,  but  as  the  reported  cases  are  few,  it  is  possible  that  in  time 
one  will  be  discovered,  either  Letzerich's  bacillus  or  some  other  bacterium  pro- 
ducing the  same  results. 

The  duration  varies  according  to  the  length  of  the  attacks,  their  number, 
and  the  intervals  between  them.  It  is  usually  six  to  twelve  weeks,  but  may  be 
limited  to  a  week  or  be  extended  to  nine  months. 

Prognosis. — This  is  fairly  good,  being  better  in  children  (mortality,  5  per 
cent.)  than  in  adults  (mortality,  25  per  cent.).  The  possibility  of  intestinal 
rupture  and  peritonitis,  though  rare,  must  be  taken  into  account. 

Treatment  during  an  attack  is  purely  symptomatic.  Between  the  attacks 
we  improve  the  general  condition  in  every  way. 

Acute  Purpura  Hemorrhagica 

is  far  more  rare  than  the  subacute  form.  The  same  symptoms  are  present, 
but  run  an  acute  and  more  severe  course,  overwhelming  the  patient  by  their 
violence  and  the  rapidity  of  their  onset.  The  acute  form  differs,  moreover, 
from  the  subacute  in  the  severity  of  septic  symptoms,  in  the  frequency  of 
visceral  hsemorrhages,  and  its  disposition  to  attack  pregnant  women.     We  can 


PURPURA    HEMORRHAGICA.  385 

broadly  subdivide  the  acute  cases  into  three  groups :  (1)  cases  with  marked 
sepsis;  (2)  cases  with  visceral  hsemorrhages ;  (3)  cases  complicating  preg- 
nancy. 

1.  Cases  with  marked  Sepsis, — These  present  both  severe  hsemorrhagic 
and  septic  symptoms,  but  the  latter  are  so  predominant  that  the  course  of  the 
disease  is  essentially  that  of  acute  septicsemia. 

The  attack  usually  begins  by  a  chill  or  chilly  feelings,  with  a  rise  in  tem- 
perature to  103°  or  104°  F.  Hsemorrhagic  symptoms  soon  develop,  purpura 
and  haemorrhages  from  any  of  the  mucous  membranes.  These  are  severe,  and 
are  not  readily  controlled  by  treatment.  Septic  symptoms  are  marked  from 
the  onset — severe  prostration,  mental  apathy,  stupor,  or  semi-coma,  alternating 
with  periods  of  restlessness,  anxiety,  and  mild  delirium,  and  finally,  in  fatal 
cases,  complete  coma.  The  temperature  remains  high,  103°  to  104°,  but  in 
severe  cases  it  may  rise  to  105°  or  106°.  The  pulse  becomes  rapid,  feeble, 
and  irregular ;  and  the  patient  usually  dies  early  in  the  disease,  either  from 
sepsis  or  from  acute  anaemia. 

The  following  case,  personally  observed,  illustrates  most  typically  the  clin- 
ical course  of  this  form  : 

L.  M ,  female,  nineteen  years,  had  always  lived  in  most  affluent  circumstances ; 

had  never  been  sick  except  from  slight  anaemia  for  the  past  two  years.  Father  when  a 
boy  would  bleed  severely  from  slight  causes.     No  further  haemophilic  history. 

March  7th,  1  A.  M.,  slight  chill  without  rise  in  temperature.  Very  nervous  and 
anxious.  12.45  P.  M.,  marked  chill,  fever  rising  to  103.5°,  and  epistaxis  becoming  more 
and  more  profuse  in  spite  of  every  effort  to  check  it. 

March  8th,  1  p.  M.,  first  seen  by  author.  T.  98.4°;  P.  130,  irregular  and  weak; 
marked  pallor  of  skin ;  prostration  profound ;  complete  mental  apathy,  though  her  mind 
was  clear  when  she  was  aroused.  New  purpuric  spots  appearing.  Gums  normal.  No 
evidence  of  endocarditis  nor  of  any  other  appreciable  disease.  Spleen  enlarged  ;  epis- 
taxis still  continuing,  the  blood  being  dark  and  not  coagulating.  Profuse  uterine  haemor- 
rhage. Haemorrhages  were  checked  by  plugging  posterior  and  anterior  nares  with  cotton 
dipped  in  collodion  and  by  firm  tamponing.  8  P.  M.,  T.  102.8°  ;  P.  130-180,  weak  and 
irregular ;  semi-coma,  alternating  with  periods  of  restlessness  and  mild  delirium.  Still 
slight  hsemorrhagec  from  nose  and  uterus  in  spite  of  former  treatment.  10  P.  M.,  about 
a  pint  of  warm  sterilized  saline  solution  was  given  by  rectum  and  by  hypodermatic 
injections,  with  slight  but  temporary  improvement.  Cardiac  tonics,  whiskey,  and  digit- 
alis were  freely  administered. 

March  9th,  9  A.  M.,  T.  104.8°;  P.  148 ;  R.  32.  Large  offensive  tarry  stool  of  altered 
blood.  Injection  of  saline  solution  continued.  6  P.  M.,  complete  coma.  T.  106.2° ; 
pulse  weaker  and  flickering. 

March  10th,  2  a.  m.,  she  died,  two  and  a  half  days  after  the  onset  of  the  disease.  No 
autopsy  was  permitted,  and  bacterial  examinations  could  not  then  be  made. 

Etiology. — There  is  no  known  cause  for  this  disease.  It  occurs  more  fre- 
quently in  men  than  in  women.  The  average  age  of  the  males  aifected  is 
twenty-eight  years ;  of  the  females,  twelve  years.  It  has  been  observed,  how- 
ever, between  one  and  seventy  years  of  age. 

The  average  duration  of  the  attack  is  about  one  week,  although  it  may  last 
from  one  to  twenty  days. 

Prognosis. — The  prognosis  is  bad,  75  per  cent,  of  the  cases  terminating 
fatally. 

Treatment  consists  in — (1)  checking  the  haemorrhages  by  plugging  the 
nares,  by  firm  tamponage,  or  by  the  use  of  haemostatics,  as  described  in  the  sub- 
acute form.  (2)  In  controlling  the  sepsis.  This  is  often  more  than  we  can  do, 
although  in  some  cases  alcohol  in  large  doses  seems  to  do  good.  (3)  In  the 
treatment  of  dangerous  symptoms.  Heart-failure  is  to  be  treated  by  hot  appli- 
cations over  the  precordium  and  by  cardiac  stimulants.  The  restlessness  and 
anxiety  are  best  controlled  by  opium  given  in  small  doses.     Profound  anaemia 

25 


386    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

is  to  be  treated  by  external  warmth,  rectal  and  hypodermatic  injections  of  a 
warm  sterilized  saline  solution,  elevation  of  foot  of  the  bed,  and  ligatures 
applied  to  the  extremities.     Arterial  transfusion  is  contraindicated. 

2.  Cases  with  Visceral  Haemorrhage. — In  these  cases  the  brain  and 
the  suprarenal  capsules  are  the  organs  most  frequently  involved. 

In  the  brain  cases  the  disease  begins  with  the  ordinary  symptoms  of  acute 
purpura  haemorrhagica.  After  several  days  these  are  followed  by  those  of 
meningeal  or  cerebral  haemorrhage,  usually  multiple,  and  without  any  especial 
seat  of  selection.     It  is  seen  far  more  frequently  in  males  than  in  females. 

Illustrative  Cases: 

1.  Girl,  aged  two  years.  For  two  days  diarrhoea  and  vomiting  :  then 
purpura,  fever,  and  collapse.  Death  in  a  few  hours  from  multiple  haemorrhages 
into  the  medulla.      (Zlielchauer,  Berl.  klin.  Wochensch.,  1869,  No.  17.) 

2.  Young  man.  General  acute  symptoms.  Death  on  fourth  day  from 
haemorrhages  into  left  Sylvian  fossa,  pons,  and  ventricles.  (Kurkowski,  V. 
unci  H.  Jahresbericlit,  1885,  ii.  p.  493.) 

In  cases  of  haemorrhage  into  the  adrenals  the  course  of  the  disease  is  exceed- 
ino-lv  acute,  and  death  results  in  a  few  hours  after  the  onset. 
Illustrative  Cases  : 

1.  Soldier,  aged  twenty-two.  Purpura ;  haemorrhage  from  mouth,  lungs, 
and  kidneys.     Death  in  seven  hours  from  adrenal  haemorrhage.     (Bourrieff, 

V.  unci  H.  Jahresher.,  1878,  ii.  p.  275.) 

2.  Male,  aged  two  years  and  nine  months.  Purpura,  fever,  and  collapse. 
Death  in  fifteen  hours  from  adrenal  hemorrhage.  (Wolff.  Berl.  klin.  Wochensch., 
1879,  No.  18.) 

3.  Cases  Complicating  Pregnancy. — In  the  cases  in  which  the  disease 
attacks  pregnant  women  we  have  the  ordinary  acute  symptoms  at  first,  fol- 
lowed by  miscarriage  and  post-partum  haemorrhage.  It  may  also  follow  labor 
at  term.     The  disease  runs  a  rapid  course,  and  recovery  is  rare. 

Illustrative  Cases  : 

1.  Female,  aged  twenty-one,  six  months  pregnant.  Purpura  four  days ; 
then  rapid  onset  of  increasing  purpura,  with  haemorrhages  from  nose,  gums, 
kidneys,  and  stomach.  Miscarriage  sixth  day,  with  post-partum  haemorrhage. 
Death  on  eighth  day,  four  days  after  the  acute  onset.  (Puech,  Annales  de 
Gynecologies  xvi.,  1887,  p.  273.) 

2.  Female,  aged  thirty.  Five  previous  normal  labors.  Seven  months  preg- 
nant. Purpura,  with  miscarriage  in  a  few  hours  with  post-partum  haemorrhage. 
Death  on  second  day.     (Phillips,  Brit.  Med.  Journal,  Nov.  13,  1886.) 

3.  Female,  aged  thirtj'-two.  Seven  previous  normal  labors.  Seven  months 
pregnant.  Purpura,  haemorrhages  from  nose  and  mouth.  Miscarriage  on 
third  day,  with  placental  hemorrhage.  Recovery  in  two  weeks.  (Phillips, 
loc.  cit.) 

When  we  study  these  acute  cases  together,  we  are  struck  with  their  similar- 
itv  to  the  class  of  acute  infectious  diseases.  The  absence  of  assignable  cause,  the 
rapidity  of  the  onset,  the  multiplicity  and  scattering  of  the  lesions,  the  enlarge- 
ment of  the  liver  and  spleen,  and  the  constitutional  symptoms  out  of  propor- 
tion to  the  lesions,  seem  to  prove  by  analogy  the  assertion  that  we  are  dealing 
with  an  acute  infection,  the  nature  of  Avhich  is  at  present  unknown.  Compar- 
ing these  cases,  however,  with  those  of  the  subacute  form,  the  identical  symp- 
toms are  found  in  each,  and  it  seems  most  probable  that  in  both  foims  we  are 
dealing  with  the  same  disease  in  all  essential  features,  differing  only  in  the 
intensity  and  rapidity  of  the  infection.  As  the  infection  in  the  subacute  cases 
seems  to  be  due  to  the  presence  of  Letzerich's  bacillus,  it  is  more  than  possible 


PURPURA  ' HJEMOBRHAGICA.  387 

that  the  acute  cases  may  be  due  to  a  more  intense  infection  by  the  same  germ. 
Much  attention  has  been  called  to  the  relationship  of  essential  purpura  hsemor- 
rhagica  to  two  diseases  of  the  hsemorrhagic  group — purpura  simplex  and  pur- 
pura rheumatica. 

Purpura  simplex  is  due  to  a  variety  of  causes.  In  some  cases  the  cause 
is  apparent,  as  in  severe  anaemia,  debility,  after  certain  drugs,  or  occurring  in 
infectious  diseases.  In  other  cases  no  cause  can  be  found  and  the  nature  of 
the  disease  is  obscure.  In  either  we  may  have  mild  or  severe  constitutional 
symptoms. 

In  purpura  rheumatica  we  have  not  only  simple  purpura,  but  also  pain  and 
swelling  of  the  joints.  Formerly  it  was  regarded  as  a  separate  disease  from 
purpura  simplex,  but  of  late  efforts  have  been  made  to  associate  them,  purpura 
rheumatica  being  considered  either  as  a  purpura  occurring  in  rheumatic  sub- 
jects, thus  accounting  for  the  joint  symptoms,  or  as  a  severe  purpura  simplex, 
in  which  haemorrhages  occur  in  and  around  the  joints.  The  author  regards 
the  latter  supposition  as  the  more  correct,  as  in  all  hsemorrhagic  diseases,  pur- 
pura hsemorrhagica,  as  well  as  scurvy,  multiple  sarcoma,  etc.,  the  joints  may 
be  affected,  together  with  the  appearance  of  purpuric  spots.  If  this  view  be 
correct,  why  regard  them  as  separate  diseases?  Is  it  not  justifiable  to  consider 
purpura  rheumatica  as  an  intenser  form  of  purpura  simplex  with  haemorrhagic 
joint  lesions? 

If  purpura  hgemorrhagica  be  due  to  an  infection,  may  not  the  cases  of  pur- 
pura simplex  occurring  without  known  cause,  and  cases  of  purpura  rheumatica 
not  associated  with  rheumatism,  be  considered  as  lighter  forms  of  the  same  infec- 
tion, especially  as  in  some  cases  of  subacute  purpura  hgemorrhagica,  purpura  or 
purpura  with  joint  symptoms  may  be  the  most  marked  features,  the  free 
haemorrhages  being  of  very  slight  importance,  often  not  appearing  for  several 
days  after  the  other  symptoms?  Even  in  the  acute  form  is  this  seen,  as  the 
case  of  Puech's,  cited  on  the  preceding  page,  illustrates,  the  purpura  alone 
existing  four  days  before  the  onset  of  acute  symptoms. 

In  support  of  this  theory  may  be  cited  cases  of  secondary  purpura  hgemor- 
rhagica, such  as  those  occurring  after  the  administration  of  certain  drugs,  in 
which  small  doses  in  some  patients  produce  merely  purpura,  while  large  doses 
cause,  in  addition,  free  haemorrhages  and  marked  constitutional  symptoms. 
The  only  difference  seems  to  be  that  in  one  case  we  are  dealing  with  a  cause 
unknown,  though  probably  bacterial,  while  in  the  other  the  cause  is  known, 
and  by  its  intensity  we  have  all  grades,  from  simple  purpura  to  purpura  hgemor- 
rhagica, even  of  an  acute  type. 

n.  Secondary  Purpura  Hemorrhagica. 

Under  this  class  we  include  those  cases  of  purpura  and  free  hgemorrhages 
which  complicate  some  existing  disease  or  to  which  a  definite  cause  can  be 
assigned.  In  nearly  all  of  these  cases  we  may  have  either  a  simple  purpura  or 
purpura  hgemorrhagica  with  constitutional  symptoms  of  a  mild  or  severe  charac- 
ter, in  some  even  running  a  fatal  course.  Only  a  brief  mention  can  be  made 
of  these  cases. 

(1)  Cases  due  to  the  Administration  of  Certain  Drugs,  potassium  iodide, 
chloral,  quinine,  and  salicylic  acid  being  the  ordinary  drugs  causing  such  a 
result.  There  is  a  great  difference  in  their  action  in  different  patients,  some 
developing  no  symptoms,  others  a  simple  purpura,  while  in  still  others  we  have 
a  striking  exhibition  of  spreading  purpura,  free  and  internal  haemorrhages,  with 
coma,  collapse,  and  even   death.     These  various  types  can  proceed  from   the 


388    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

same  cause  acting  more  intensely  upon  some  patients  than  upon  others,  either 
from  a  maximum  of  cause  on  the  one  hand  or  the  minimum  of  personal  resist- 
ance on  the  other. 

(2)  Cases  which  Accompany  or  closely  Folhnv  Severe  Infectious  Diseases, 
such  as  acute  atrophy  of  the  liver,  snake-bites,  typhoid  fever,  pneumonia,  and  the 
exanthemata  ("black  measles,"  etc.).  In  these  cases  "we  have  various  grades, 
from  simple  purpura  up  to  acute  purpura  hsemorrhagica.  Many  authors  attrib- 
ute such  a  complication  to  an  added  infection  of  essential  purpura  hemor- 
rhagica complicating  tlie  primary  disease.  Henoch,  for  example,  reports  a 
case  of  a  child  with  lobar  pneumonia  in  whom  a  supposed  infection  of  pur- 
pura hgemorrhagica  occurred  two  days  after  crisis,  causing  death  from  collapse 
in  twenty-four  hours.  If  a  drug  like  potassium  iodide  will  so  disorganize  the 
blood  or  render  pervious  the  blood-vessels,  why  may  not  the  poison  of  an 
infectious  disease  produce  the  same  result  without  supposing  an  added  infection 
of  a  new  disease  ?  It  is  no  argument  against  this  view  that  purpura  hsemor- 
rhagica  may  appear  after  the  crisis,  because  we  know  that  a  temperature 
crisis  does  not  mark  the  end  of  the  disease,  but  only,  as  Fraenkel  has  recently 
demonstrated  in  pneumonia,  the  end  of  the  fever-producing  quality  of  the 
infecting  germ. 

(3)  Cases  of  Severe  Jaundice  may  be  accompanied  by  purpura  and  haemor- 
rhages. These  seem  to  be  due  to  the  disorganization  of  the  blood  from  the 
cholaemia. 

(4)  Cases  of  Profound  Ancemia,  Leukcemia,  or  Pseudo-leukcemia,  and  of 
Exhausted  and  Cachectic  Conditions. — In  these  we  may  have  simple  purpura, 
purpura  hsemorrhagica,  or  continued  haemorrhage  after  operations  or  injuries. 
"We  do  not  know  whether  to  attribute  these  haemorrhages  to  blood-changes  or 
to  changes  in  the  wall  of  the  small  arteries. 

(5)  Cases  of  Kew-born  Infayits  with  Congenital  Syphilitic  Changes  in  the 
Arterial  Walls,  producing  purpura,  bloody  sweating,  and  free  haemorrhages, 
especially  from  the  umbilicus. 

(6)  Cases  of  New-born  Infants  tvithout  Syphilitic  Parentage. — This  form, 
according  to  Partridge,  occurs  in  about  1  per  cent,  of  cases,  with  a  mortality 
of  60  to  75  per  cent.  He  attributes  its  causes  to  the  change  of  functional 
activities  and  to  the  altered  circulation,  allowing  a  brief  interruption  of  the 
nutrition  of  the  vessel-walls  sufficient  for  the  transudation  of  their  contents. 

(7)  Cases  complicating  3Ialignant  Endocarditis,  the  purpura  and  haemor- 
rhages being  probably  due  to  embolism  of  the  capillaries  by  vegetation-frag- 
ments, and  their  subsequent  degeneration  and  rupture. 

(8)  Cases  of  Multiple  Sarcomata,  with  Purpura,  with  free  haemorrhages, 
purpura,  rheumatic  pains,  and  fever.  It  is  hard  to  say  whether  these  result 
from  malignant  cachexia,  with  blood-changes,  or  from  emboli  of  sarcomatous 
fragments  lodging  in  the  small  blood-vessels,  causing  their  degeneration  and 
rupture. 

(9)  Cases  occurring  after  Fright,  Deep  Emotion,  Hysteria,  and  Hypnotism. 
In  these  cases  the  haemorrhages  seem  to  be  due  to  vaso-motor  relaxation  or  to 
enfeeblement  of  the  arterial  walls  sufficient  to  allow  of  the  escape  of  their  con- 
tents.    This  latter  explanation  is  warmly  endorsed  by  AVeir  Mitchell. 


SCORBUTUS. 


By  WM.  perry  NORTHRUP,  M.  D.  and  DAVID  BOVAIRD,  M.  D., 

New  York. 


Infantile  scurvy  is  a  constitutional  disease  produced  by  improper 
feeding,  characterized  by  swelling,  disability,  excessive  tenderness  and  pain 
on  motion  in  the  lower  extremities,  and  spongy  gums :  it  is  further  charac- 
terized by  rapid  recovery  under  corrected  regimen. 

The  first  case  of  infantile  scurvy  was  reported  by  Jalland,  and  the  report 
summarized  in  Virchow's  JaJireshericlit  for  1873,  but  England  has  been  the 
source  of  most  of  the  reported  cases  and  most  of  the  literature  of  scurvy  in 
children.  To  W.  B,  Cheadle  and  Thomas  Barlow  of  Great  Ormond  Street 
Hospital  is  due  the  credit  of  "  having  first  shown  on  clinical  grounds  the 
true  affinities  of  this  form  of  infantile  cachexia  ''  (Cheadle),  and  of  demon- 
strating the  anatomical  nature  of  the  disease  from  post-mortem  examinations 
(Barlow).  Prior  to  the  work  of  these  observers  infantile  scurvy  had  been 
regularly  regarded  as  acute  rickets  or  gone  astray  as  purpura  hsemorrhagica. 

The  first  case  of  infantile  scurvy  in  the  United  States  was  met  with  upon 
the  autopsy  table  of  the  New  York  Foundling  Hospital.  A  second  was  soon 
afterward  recognized  in  consultation,  treated,  and  recovered.  At  the  time  of 
the  publication  of  the  first  edition  of  this  work  11  cases  were  on  record,  and 
were  made  the  basis  of  the  first  article  on  infantile  scurvy  in  an  American  text- 
book. In  1894,  36  cases  were  collected  and  reported  by  Crandall  and  North- 
rup.  Since  that  time  cases  have  been  reported  from  all  parts  of  the  country. 
One  observer  alone  (Rotch  of  Boston)  has  seen  60  or  70  cases.  The  subject 
of  infantile  scurvy  can,  therefore,  rightly  cl^im  the  attention  of  the  general 
practitioner. 

Etiology. — The  cause  of  scurvy  in  children  is  persistent  feeding  with 
improper  foods.  Examining  the  dietaries  of  scorbutic  children,  we  find 
enumerated  almost  everything  that  could  possibly  be  employed  as  food  for  a 
child — all  manner  of  proprietary  foods,  condensed  milk,  porridge,  oatmeal- 
and  barley-water,  various  mixtures  of  cow's  milk  and  cream.  They  agree 
only  in  one  respect :  they  all  lack  or  have  been  deprived  of  the  quality  which 
we  designate  as  fresh  or  "live." 

When  milk  or  cream  has  been  given  it  has  regularly  been  deprived  of 
this  quality  by  sterilization.  For  some  time  there  has  been  active  debate 
whether  prolonged  sterilization  of  the  food  could  of  itself  cause  scurvy.  The 
writer  has  recently  seen  2  cases  of  typical  scurvy  developed  in  children  fed 
upon  perfectly  proper  milk  mixtures  which  had  been  sterilized  by  prolonged 
boiling.  Both  recovered  promptly  on  the  same  food  when  the  over-steriliza- 
tion was  stopped ;  moreover,  one  of  them  has  now  gone  for  several  months 
upon  the  same  food  unsterilized,  without  any  return  of  the  symptoms.  Like 
experience  has  been  recorded  by  Starr  and  Holt. 

Scurvy  among  nursing  infants  is  very  rare.     In  the  first  case  met  with 

389 


390     AMERICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 

in  this  country  the  child  had  been  nursed  by  a  woman  who  suckled  her  own 
child  as  well.  The  latter  thrived;  the  foster-child  developed  scurvy.  There 
is  little  doubt  in  such  a  case  that  the  child  was  starved  into  scurvy. 

Southgate  has  also  recorded  a  case  of  scurvy  in  a  nursling.  Moreover, 
the  analysis  of  the  milk  made  in  this  case  shows  it  to  have  been  rich  in 
quality.  In  the  light  of  all  other  observations  we  can  only  say  that  this 
case  stands  uni(jue  and  unexplainable. 

The  patent  baby-foods  are,  by  all  means,  the  most  fre(|uent  offenders  in 
the  production  of  scurvy.  The  measure  of  the  responsibility  of  any  partic- 
ular one  seems  to  rest  only  on  the  extent  of  its  popularity.  Those  most 
widely  used  are  most  often  met  Avith  in  the  scurvy  records. 

As  the  number  of  reported  cases  increases  the  stronger  becomes  the 
indictment  against  the  patent  foods.  There  seems  no  greater  surviving  fal- 
lacy in  medical  practice  than  the  routine  feeding  of  infants  with  patent  prod- 
ucts of  commercial  firms.  Condensed  milk  deserves  to  rank  with  the  other 
proprietary  foods. 

Surroundings  seem  to  have  little  influence  upon  the  production  of  this 
cachexia.  Most  of  the  reported  cases  have  been  observed  in  private  practice. 
In  the  great  majority  the  surroundings  have  been  good,  in  many  luxurious. 
The  affection  has  been  met  with  in  all  parts  of  the  land,  both  in  cities  and  in 
the  country,  along  the  seaboard  and  on  the  mountains  of  Montana.  Per- 
sistent feeding  with  improper  food  can  produce  scurvy  anywhere.  The  dis- 
ease is  usually  met  with  after  the  sixth  month  and  under  two  years,  but 
these  limits  cannot  be  regarded  as  absolute.  It  takes  time  to  develop  scurvy, 
no  matter  how  bad  the  diet,  and  after  the  second  year  the  diet  usually 
becomes  so  general  that  all  danger  is  removed. 

We  are  still  unable  to  reach  the  ultimate  cause  of  scurvy.  It  seems  un- 
questionably to  be  deprivation,  but  of  what  has  not  yet  been  determined. 
All  that  we  can  say  is  that  the  missing  elements  are  found  in  fresh  milk  and 
fresh  fruit-juice. 

Pathology. — The  lesions  of  infantile  scurvy  are  well  set  forth  in  North- 
rup's  report  of  the  autopsy  on  his  first  case.  The  child  was  emaciated, 
its  eyelids  swollen  and  ecchymotic.  The  gums  were  prominent,  spongy, 
dark,  covered  with  dried  blood,  the  lips  blood-stained.  The  pale,  thin  face, 
with  two  black  eyes,  gave  a  most  striking  appearance  to  the  dead  baby. 
The  main  interest  lies  in  the  condition  of  the  legs.  Left  thigh  symmetrically 
enlarged,  larger  than  the  right,  although  both  were  obviously  above  normal 
in  size.  Left  femur  was  normal  at  its  upper  extremity,  epiphysis,  and  end 
of  shaft.  The  lower  half  was  invested  by  a  black,  grumous,  subperiosteal 
layer  of  blood  two  or  three  millimetres  thick.  The  lower  epiphysis  Avas 
detached  ;  the  lower  end  of  the  shaft  macerated,  eroded,  and  soft,  lying  loose 
in  the  black,  disintegrating  blood-clot.  The  femur  of  the  right  leg  Avas  sur- 
rounded for  its  loAver  tAvo-thirds  by  a  thinner,  black,  subperiosteal  blood- 
layer.  The  loAver  epiphysis  Avas  not  detached,  though  both  it  and  the  shaft 
Avere  congested.  No  hemorrhage  into  joints.  The  right  and  left  tibiae  Avere 
surrounded  by  a  thin,  dark,  hemorrhagic  layer  beneath  the  periosteum,  and 
the  proximal  portions  of  both  were  congested.  The  fibule  and  bones  of  the 
upper  extremity  Avere  normal.  Microscopical  examination  of  the  bone  dis- 
closed no  syphilitic  or  rachitic  changes,  and  no  inflammatory  changes  in 
bone  or  periosteum.  The  softened,  macerated  bone  gave  no  evidence  of 
suppuration,  but  there  was  moderate  congestion  of  the  felloAv-femur  and 
upper  extremities  of  the  tibiae.  A  small  amount  of  blood,  dark  and  dis- 
integrated, was  found  in  the  intestines ;  no  lesion  discovered.     The  accom- 


SCORBUTUS. 


391 


Fig.  1. 


panying  illustration  (Fig.  1)  was  drawn  from  a  specimen  which  consists  of 
a  lateral  half  of  the  side  less  aifected. 

To  this  we  need  only  add  that  subperiosteal  haemorrhages  may  occur 
upon  any  of  the  bones — those  of  the  upper  extremity,  of  the  cranium,  of 
the  thorax.  There  may  also  be  haemorrhages 
from  various  mucous  membranes — the  nose,  the 
stomach,  bladder,  etc. 

Symptoms. — The  characteristic  symptoms 
of  infantile  scurvy  are  the  swollen,  spongy, 
purple,  and  easily  bleeding  gums,  and  extreme 
pain  on  motion,  tenderness,  swelling,  and  dis- 
ability in  one  or  both  lower  extremities.  Ex- 
amination of  the  affected  extremities  reveals  a 
fusiform  or  cylindrical  swelling  about  the  long 
bones.  The  affection  is  usually  most  marked 
about  the  femur,  but  the  bones  of  the  leg  or 
ankle  may  be  involved.  The  affection  is  usually 
bilateral,  but  not  symmetrical,  one  extremity 
presenting  more  marked  changes  than  the  other. 
In  a  few  cases  the  upper  extremities  have  been 
involved,  but  these  cases  are  rare,  and  in  almost 
all  thus  far  reported  there  was  an  antecedent 
affection  of  the  legs.  The  joints  themselves  are 
not  involved  in  the  process.  The  affected  limbs 
are  usually  held  in  a  semi-flexed  position  (Fig. 
2),  and  no  attempt  is  made  to  use  them,  so  that 
the  disease  is  often  mistaken  for  a  paralysis. 
This  disability  is  spoken  of  as  pseudo-paralysis. 
"Rheumatism  of  the  legs"  is  another  favorite 
diagnosis  for  this  scorbutic  affection  of  the  ex- 
tremities, but,  as  already  noted,  the  joints 
themselves  are  not  involved  in  infantile  scurvy. 
The  pathological  lesions  alread}^  described  ren- 
der these  symptoms  readily  explicable. 

In  addition  to  the  characteristic  symptoms, 
subcutaneous  ecchymoses  or  haemorrhages  are 
of  frequent  occurrence.  They  may  be  seen 
upon  any  part  of  the  body,  but  are  especially 
characteristic  about  the  orbit,  giving  the  little 
patient  a  typical  "  black  eye." 

Haemorrhages  may  also  occur  from  mucous 
membranes  other  than  the  gums,  so  that  there 
may  be  bleeding  from  the  nose,  stomach,  intestine,  or  bladder ;  but  such 
haemorrhages  are  seen  only  in  the  severer  types  of  the  cachexia. 

For  weeks  before  the  development  of  the  evidences  of  scurvy  the  child 
may  suffer  from  gastric  or  intestinal  disturbances,  with  vomiting,  colic,  diar- 
rhoea, or  constipation.  In  the  severer  cases  a  sallow,  muddy  complexion, 
due  to  severe  anaemia,  is  often  met  with.  The  examination  of  the  blood 
shows  the  changes  of  simple  anaemia.  Many  of  the  cases  are  marantic,  but 
scurvy  may  also  be  seen  in  children  who  have  suffered  from  no  gastric  or 
intestinal  disorder  and  are  well  nourished  and  ruddy. 

The  affection  of  the  gums  is  seen  only  about  the  teeth.  If  the  child  has 
no  teeth,   the  gums  will  appear  normal.     In  the  report  of   Crandall  and 


Specimen  from  a  case  of  Infantile 
Scurvy,  showing  subperiosteal 
hsemorrhage  about  femur  and  tibia 
of  the  side  less  affected.  (Drawn 
from  the  specimen  preserved  in 
the  Museum  of  the  College  of  Phy- 
sicians and  Surgeons,  N.  Y.) 


392     AMERICA JV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Nortbrup  the  condition  of  the  gums  was  noted  in  32  cases.  Of  these,  2 
had  no  teeth ;  the  gums  were  normal.  Of  the  remaining  30,  24  had  what 
was  termed  "•spongy  "  gums,  3  had  ulcerated  gums,  in  3  they  were  described 
as  "bleeding."  In  34  other  cases  of  which  the  records  are  available,  31  had 
spongy  gums ;  in  3  the  gums  were  normal.  Of  the  latter,  2  had  no  teeth. 
One,  although  it  had  two  teeth  and  presented  a  typical  scorbutic  affection 
of  the  extremities  and  subcutaneous  ecchymoses,  had  no  mouth-symptoms 
whatever.  The  affection  of  the  gums,  although  regularly  present,  cannot, 
therefore,  be  considered  essential  to  the  diagnosis. 

The  constitutional  disturbance  of  scurvy  may  be  of  any  degree  of  severity, 
depending  upon  the  gravity  of  the  affection  and  the  time  of  observation.  In 
the  mildest  cases  the  baby  may  appear  perfectly  well,  except  for  the  pain  on 
motion  of  the  extremities.  In  the  severer  types  there  are  marked  anoemia, 
emaciation,  fever,   and  prostration,  which  may  result  in  death.     Fever,  if 

Fig.  2. 


Infautile  Scurvy  :  characteristic  attitude  of  the  legs. 

present,  is  usually  slight,  but  may  reach  102°  or  103°  F.  It  is  apparently 
dependent  upon  accompanying  disturbances,  and  not  upon  the  scurvy  itself. 
Relation  to  Rickets. — The  relation  of  scurvy  to  rickets  has  long  been 
the  subject  of  debate.  Previous  to  the  work  of  Barlow  and  Cheadle  infantile 
scurvy  was  regularly  described  as  "acute  rickets,"  and  in  the  early  days  of 
observation  rickets  Avas  supposed  to  constantly  precede  or  accompany  the 
appearance  of  scurvy.  In  the  report  previously  quoted  rickets  was  referred 
to  nineteen  times.  Five  cases  showed  marked  rickets,  6  slight ;  in  8  it  was 
definitely  not  present.  In  34  other  cases,  of  which  the  records  are  available, 
rachitis  was  noted  as  present  only  in  5,  and  in  most  of  these  the  only  evidence 
of  rachitis  was  "beaded"  ribs.  Rickets  and  scurvy  are  both  developed  dur- 
ing infancy.  Improper  diet  is  a  causative  factor  in  both,  but  either  may  be 
developed  without  the  other.  The  lesions  of  rickets  are  found  in  the  bones ; 
those  of  scurvy  are  evidently  in  the  blood-vessels.  The  subperiosteal  or 
subcutaneous  haemorrhages  of  scurvy  may  be  promptly  absorbed  and  the  child 
left  perfectly  well.  The  changes  of  rickets  are  more  or  less  permanent.  The 
correction  of  diet  suflScient  to  cure  scurvy  in  a  few  days  makes  no  impression 


SCORBUTUS.  393 

upon  rickets.  The  two  affections  may  be  comrades  ;  they  are  not  generically 
related. 

Illustrative  Cases. — Three  cases  representing  the  several  types  of  infan- 
tile scurvy  will  be  presented  : 

Case  I. — A  mild  case.  A  boy,  aged  twelve  months ;  only  child,  birth 
normal.  Parents  both  very  well  and  surroundings  good.  Child  artificially 
fed  from  birth.  For  first  two  months  he  was  given  diluted  condensed  milk. 
Thereafter  the  food  consisted  of  a  mixture  of  cow's  milk  regularly  boiled  for 
fifty  minutes.  Upon  this  the  child  throve,  became  fat,  rosy,  and  vigorous. 
He  had  no  gastric  or  intestinal  disturbance.  The  bowels  moved  twice  a  day ; 
the  passages  were  quite  normal.  In  short,  he  had  been  considered  a  remark- 
ably healthy  and  vigorous  baby  until  he  was  ten  months  old.  His  mother 
then  noticed  that  he  would  no  longer  attempt  to  stand  or  use  his  legs  in  any 
way.  At  the  same  time  he  began  to  cry  whenever  moved  or  touched,  and 
sweated  a  great  deal.  He  became  more  and  more  fretful,  and  cried  a  great 
deal,  especially  at  night.  These  symptoms  persisted  and  became  worse  up 
to  the  time  he  was  brought  to  the  clinic  of  the  New  York  Orthopedic  Dis- 
pensary. 

Examination. — A  large,  well-nourished  baby,  of  good  color,  and  with  no 
evidence  of  rachitis.  Lying  perfectly  quiet  in  his  mother's  lap,  he  would 
smile  and  play  as  though  perfectly  well,  but  the  first  suggestion  of  a  touch 
or  any  motion  called  forth  piteous  wails.  The  four  incisors  were  present. 
About  the  upper  pair  the  gums  were  purple,  the  mouth  otherwise  normal. 
Both  lower  extremities  were  swollen  from  the  ankle  to  the  knee.  Although 
the  least  attempt  at  examination  made  him  scream  with  pain,  he  made  no 
effort  to  withdraw  the  legs  or  move  them  in  any  way.  To  touch  there  was  a 
sensation  of  deep  thickening  about  the  long  bones  of  the  legs.  In  every 
other  way  the  child  was  perfectly  normal. 

For  treatment  the  mother  was  directed  to  give  him  the  same  mixture  of 
milk  unboiled,  with  two  or  three  teaspoonfuls  of  fresh  orange-juice  daily. 
Two  days  after  beginning  this  treatment  the  baby  slept  all  night  for  the  first 
time  in  two  months.  In  five  days  he  ceased  to  cry  and  the  legs  could  be 
moved  without  pain.  In  two  weeks  he  was  able  to  stand,  and  since  that  time 
has  been  the  "picture  of  health." 

Case  II. — A  typical  case.  A  girl  sixteen  months  old,  a  second  child. 
At  the  time  of  the  consultation  the  father  and  mother  of  the  little  patient 
were  present ;  both  were  within  the  thirties,  healthy  and  vigorous,  the  father 
looking  like  a  hardy  yachtsman.  The  family  history  on  both  sides  was  good. 
The  home  was  located  in  the  most  hygienic  surroundings  of  up-town  New 
York.  When  the  child  was  in  its  fourth  month  the  mother's  milk  failed 
to  be  of  sufficient  quantity,  and  soon  thereafter  ceased  altogether.  One  of 
the  proprietary  foods  was  then  given.  By  some  misunderstanding  this  food 
was  diluted  with  water  and  milk,  the  proportion  of  the  latter  being  too  small. 
For  a  time  the  child  apparently  thrived  very  well,  although  it  was  rather  back- 
ward. Its  digestion  was  good,  its  bowels  were  reasonably  satisfactory,  and  it 
seemed  satisfied  with  its  food.  It  never  gave  any  evidence  of  rickets ;  teeth 
in  normal  number  made  their  appearance  at  the  usual  time. 

Three  weeks  before  the  visit  spoken  of  (this  fact  was  subsequently  elicited 
after  close  questioning)  the  nurse  had  noticed  some  change  in  the  child's  gums. 
The  change  was  not  marked. 

One  week  later  the  patient  developed  trouble  in  the  right  loiver  limb,  evi- 
denced by  worrying,  sensitiveness  on  handling,  and  a  tendency  to  keep  the  limb 
nearly  straight.     There  seemed  no  reason  why  the  case  should  not  speedily 


394     A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

come  out  of  its  condition  of  slight  depression,  as  the  food  was  improved  and 
antirheumatic  treatment  instituted. 

During  the  succeeding  week  very  little  is  known  concerning  the  child ; 
the  parents  were  absent  from  home ;  the  family  physician  was  not  called ; 
the  nurse  drew  no  conclusions  from  the  now  rapidly  changing  gums,  and  as  to 
the  ''rheumatism  "  the  progress  was  slow. 

The  child  cried  on  seeing  a  strange  face,  becoming  alarmed  also  for  the 
safety  of  its  lame  leg.  In  the  wry  face  of  crying  the  little  patient  fairly 
unbuttoned  from  between  its  lips  two  rows  of  irregularly  nodulated,  purplish 
gums,  from  the  summits  of  which  the  points  of  its  teeth  barely  protruded. 
In  the  upiJer  ^i^ongy  row  was  a  depression  with  ulcerated  walls  and  sloughing 
shreds.  The  gums  ivere  dark,  and  hied  freely  in  the  act  of  crying  from  com- 
pression of  the  lips  alone.  There  was  nothing  further  abnormal  about  the 
face  beyond  a  worried  expression  ;  no  ecchymoses,  no  petechia  ;  conjunctivae 
were  normal ;  no  evidence  of  unhealthy  condition  of  the  mucous  membrane 
of  the  nose.  There  was  no  history  of  nose-bleeding,  no  hematuria,  no  h^em- 
orrhao-es  from  the  bowels.  The  child  was  now  stripped  of  all  clothing  and 
laid  upon  its  back  on  the  bed.  It  continued  to  Avhimper,  throw  its  arms  about 
freely,  draw  up  its  left  leg;  as  for  its  right,  it  could  move  it  slowly,  but  only 
a  little,  and  could  not  be  induced  to  flex  it.  The  right  thigh  was  distinctly 
larger  than  the  left  to  observation  ;  by  measurement  it  showed  a  diff"erence 
of  about  two  and  a  half  inches,  which,  considering  the  thin  thighs  of  the  small 
patient,  augured  a  marked  diff"erence.  The  enlargement  was  fusiform,  great- 
est just  above  the  knee.  Apart  from  the  spongy  gums  and  swollen  thigh 
there  were  no  external  manifestations. 

This  case  promptly  recovered  on  corrected  regimen. 

Case  III. — Fatal  scurvy ;  child  of  eighteen  months ;  autopsy.  This 
child  was  an  inmate  of  the  Ncav  York  Foundling  Hospital,  and  was  what  is 
called  a  "  nurse-baby;"  that  is,  she  was  nursed  by  a  mother,  who,  in  addition 
to  her  own  baby,  nursed  a  second  of  about  equal  age.  Her  own  child  thrived ; 
the  second  furnished  the  example  of  malnutrition  and  the  pathological  speci- 
men already  referred  to.  Since  we  are  considering  a  case  of  scurvy  develop- 
ing in  a  breast-fed  {sic)  child,  it  is  well  to  bear  in  mind  the  above  facts,  and 
the  added  fact  that  nearly  all  babies  nursing  two  at  one  woman  require  more 
or  less  artificial  food.  AVe  are  justified  in  forming  our  own  conclusions  as  to 
which  was  nursed  more  and  which  less ;  we  know  which  baby  was  hers  and 
which  was  not.  which  thrived  and  which  developed  fatal  scurvy. 

Briefly,  the  history  of  the  illness  was  as  follows :  The  foster  child  when 
sixteen  months  old  was  observed  to  be  failing,  and,  as  the  history  reads,  "  on 
account  of  impaired  nutrition  was  taken  from  the  breast  and  was  given  vege- 
table acids."  In  the  seventeenth  month  of  life,  which  was  one  month  before 
death,  the  right  leg  and  knee  became  swollen  and  tender.  Temperature  was 
101°  F.  After  two  days  the  symptoms  seemed  temporarily  to  disappear. 
Two  weeks  before  death',  and  sixNveeks  after  the  weaning,  the  child  appeared 
to  be  very  sick ;  her  gums  Avere  swollen,  smoky-black,  and  bled  freely  :  two 
days  later  her  left  eyelid  became  swollen,  black,  having  the  appearance  of 
the  classical  "black  eye."  Temperature  thus  far  continued  about  101°  F. 
One  week  later  there  developed  the  physical  and  rational  signs  of  pneumonia. 
At  this  time  her  other  eyelid  became  ecchymotic  and  the  other  thigh  markedly 
swollen. 

During  the  remaining  days  of  life  the  little  patient  became  excessively 
anaemic,  having  a  metallic  pallor,  which  gave  a  particularly  wretched  appear- 
ance Avith  the  contrasting  ecchymoses  about  the  eyes.     Her  passages  Avere 


SCORBUTUS.  395 

black  and  pasty ;  no  petechise ;  the  child  failed  rapidly  and  died  with  pro- 
nounced symptoms  of  pneumonia.    (For  autopsy  see  "Pathological  Anatomy.") 

Prognosis. — When  recognized  and  properly  treated  scurvy  disappears 
with  almost  magical  rapidity.  Unrecognized  and  improperly  treated,  it  may 
readily  prove  fatal.  The  outcome  depends  upon  the  diagnosis.  Under 
proper  treatment  complete  recovery  ought  to  be  obtained  in  three  weeks. 

Diagnosis. — Scurvy  in  infants  is  most  frequently  mistaken  for  "rheuma- 
tism of  the  legs,"  infantile  paralysis,  acute  rickets,  or  an  osteomyelitis.  Sar- 
coma of  the  femur  and  simple  stomatitis  have  also  been  recorded  in  the 
category  of  erroneous  diagnoses,  and  the  limbs  have  been  laid  open  for  pus 
only  to  find  pure  blood. 

Four  points  suffice  for  an  absolute  diagnosis : 

1.  The  age  of  the  child — over  six  months,  under  two  years. 

2.  The  history  of  improper  feeding,  especially  proprietary  foods,  con- 
densed milk,  or  milk  mixtures  sterilized  by  prolonged  boiling. 

3.  The  painful,  sAvollen  extremities,  without  local  heat  or  redness,  and 
Avithout  involvement  of  the  joints. 

4.  The  spongy,  purple,  easily-bleeding  gums. 

A  thorough  examination  should  establish  the  diagnosis  in  any  case.  If 
doubt  remains,  a  few  days'  treatment  will  settle  the  question.  On  an  anti- 
scorbutic diet  improvement  should  be  prompt. 

Treatment. — Briefly,  correct  the  diet.  Put  the  child  upon  a  proper 
mixture  of  cow's,  milk,  raw  or  pasteurized ;  when  possible,  give  milk  warm 
from  the  cow.  Administer  orange-juice  freely,  a  teaspoonful  every  tAvo  or 
four  hours.  Improvement  Avill  be  almost  immediate,  and  complete  recovery 
not  long  delayed. 

Stimulants  will  be  required  only  in  cases  of  extreme  exhaustion.  If  the 
anaemia  is  severe,  iron  is  indicated.  It  is  best  giA^en  in  the  form  of  the 
powder  (Quevenne's  iron),  gr.  j  to  ij,  t.  i.  d. 

As  a  rule,  the  dietetic  treatment  is  all  that  is  required. 


PART  VI. 

DISEASES  OF  THE  DIGESTIVE   ORGANS 


DISEASES  OF  THE  MOUTH    AND  DENTITIOK 


By  F.  FORCHHEIMER,  M.  D., 

Cincinnati. 


I.  DISEASES  OF  THE  MOUTH. 

The  mouth  of  an  infant  differs  in  many  respects  from  that  of  an  adult  or 
even  a  child :  up  to  the  third  or  fourth  month  of  life  it  is  to  be  looked  upon 
merely  as  a  passage-way  for  food.  Then  comes  the  first  outpouring  of  saliva, 
and  with  it  the  functions  of  the  mouth  are  increased  by  that  of  incipient 
digestion,  which  reaches  its  full  development  after  a  period  that  varies  in  indi- 
vidual cases.  The  lack  of  saliva  produces  more  or  less  dryness  of  the  infant's 
mouth,  a  coating  of  the  tongue  due  to  epithelial  cells,  detritus,  and  food,  and  a 
peculiar  glistening  appearance  by  reflected  light.  After  saliva  is  formed  the 
child  does  not,  at  first,  know  what  to  do  with  it,  so  that,  even  when  normal 
in  quantity,  the  greater  part  of  it   is  not  swallowed. 

For  most  of  the  inflammations  of  the  mouth  the  etiology  is  still  a  matter 
of  surmise.  While  there  can  be  no  doubt  that  lower  forms  of  life  must  play 
a  very  important  role  in  their  production,  yet  as  a  matter  of  fact  but  few 
forms  of  stomatitis  can  be  definitely  ascribed  to  this  cause.  The  mouth  is  a 
veritable  culture-tube  for  microbes  and  lower  forms  of  life,  but,  as  a  rule, 
they  do  not  produce  disease.  General  conditions  of  the  patient  must  seriously 
be  taken  into  consideration  (syphilis,  rickets,  scurvy) ;  possibly  these  may 
produce  a  soil  favorable  to  low  conditions  of  life,  resulting  in  the  production 
of  troubles  in  the  mouth.  Local  conditions  within  the  mouth  must  always  be 
sought  in  examining  a  case — lack  of  cleanliness,  rough  attempts  at  cleansing, 
sharp  or  diseased  teeth,  the  introduction  of  irritants  or  poisons ;  while,  on  the 
other  hand,  causes  may  be  found  only  in  diseased  conditions  of  remote  organs. 
One  important  fact  must  always  be  taken  into  consideration,  that  the  glands  of 
the  mouth  are  not  only  secretory,  but  also  excretory,  so  that  substances  taken 
into  the  circulation,  as  well  as  others  formed  within  che  body,  may  leave  the 
body  by  means  of  these  glands  and  produce  local  lesions. 

In  the  matter  of  treatment  care  must  always  be  exercised  in  removing  the 
cause  of  the  disease ;  where  this  is  impossible,  purely  symptomatic  treatment 
is  called  for,  and  this,  in  the  main,  is  antiseptic  in  nature.  The  most  potent 
mouth-antiseptics  are  potassium  chlorate,  potassium  permanganate,  silver  nitrate, 

396 


DISEASES   OF   THE  MOUTH.  397 

and  sodium  salicylate.  Each  one  has  its  own  indications,  but  the  first  and 
second  are  almost  universally  serviceable.  Potassium  chlorate,  especially, 
when  used  internally,  requires  cautious  administration  on  account  of  its  effects 
upon  the  blood  and  the  kidneys.  It  is  safe  to  say,  however,  that  the 
danger  has  been  largely  over-estimated  by  some,  and  in  comparison  with  the 
frequency  with  which  the  drug  is  used  the  number  of  cases  of  poisoning  is 
exceedingly  small. 

The  examination  of  the  mouth  should  be  thoroughly  conducted,  without 
force,  but  in  such  a  way  that  all  parts  can  be  seen  to  advantage.  It  is 
necessary  to  insist  upon  this  part  of  clinical  examination,  since,  simple  though 
it  be,  it  is  frequently  neglected,  so  that  very  valuable  aids  to  diagnosis  in  many 
diseases  are  overlooked. 

The  classification  which  follows  is  one  which  is  principally  based  upon  clin- 
ical data ;  it  is  completely  satisfactory  as  a  working  formula  up  to  the  present, 
but  will  undoubtedly  require  revision  in  the  future.  The  term  "  stomatitis  " 
is  retained  for  many  reasons,  not  the  least  important  being  that  it  has  been  used 
quite  universally.  The  following  are  the  forms  of  stomatitis:  I.  Stomatitis 
catarrhalis ;  II.  Stomatitis  aphthosa ;  III.  Stomatitis  mycosa ;  IV.  Stoma- 
titis ulcerosa;  V.  Stomatitis  gangrenosa;  VI.  Stomatitis  crouposa ;  Stoma- 
titis diphtheritica ;  VII.  Stomatitis  syphilitica. 

I.  Stomatitis  Catarrhalis. 

Also  called  simple  stomatitis,  of  which  there  are  two  kinds — ^local  and 
general. 

Etiolog-y.  — Two  things  must  be  taken  into  consideration — an  irritant  and 
the  mucous  membrane.  In  healthy  children  the  mucous  membrane  resists  to  a 
greater  extent  than  in  children  sick  with  any  disease  whatsoever.  The  most 
favorable  conditions  for  the  production  of  stomatitis  catarrhalis  are  to  be  found 
in  children  with  acute  febrile  disease  and  in  bottle-fed  babies.  The  irritants 
are  either  mechanical,  thermal,  chemical,  or  to  be  traced  to  some  lower  form 
of  life  acting  mechanically  or  chemically.  In  healthy  children  teething  does 
not  produce  stomatitis,  and  it  is  denied  by  many  that  this  process  is  even  a 
predisposing  cause.  Lack  of  cleanliness,  over-cleanliness,  and  food  introduced 
at  too  high  a  temperature  are  common  causes  for  this  trouble.  Many  of  the 
acute  infectious  diseases  produce  stomatitis  catarrhalis,  which  then  precedes  the 
appearance  of  the  characteristic  lesions  within  the  mouth.  Nearly  all  other 
forms  of  stomatitis  are  preceded  by  this  form — most  especially  is  this  the  case 
with  stomatitis  mycosa ;  and  all  other  forms  are  associated  with  more  or  less 
catarrhal  inflammation.  In  all  probability,  substances  excreted  by  the  glands 
of  the  mouth,  as  the  result  of  faulty  digestive  processes  in  the  intestines  or  of 
incomplete  elimination,  will  be  found  to  be  of  vast  importance  in  the  etiology. 
This  will  be  the  most  rational  way  of  explaining  the  frequent  concurrent 
appearance  of  diseased  processes  within  the  mouth  and  the  intestinal  tract. 
For  the  localized  form,  it  is  a  local  irritation — a  sharp  tooth,  a  discharging 
abscess,   or  the  rubbing  of  the  gums  to  facilitate  teething. 

Symptoms. — We  may  recognize  two  varieties,  the  erythematous  and  the 
true  catarrhal.  In  the  erythematous  form  the  whole  mucous  membrane  of 
the  mouth  is  of  a  deep-red  color,  produced  by  hypergemia.  The  blood-vessels 
are  sometimes  subjected  to  such  great  pressure  that  rhexis  occurs,  or  red  cor- 
puscles may  be  forced  into  the  submucous  tissues,  and  the  hsemoglobin  may 
there  be  changed  to  hsematoidin,  with  a  resulting  distinct  yellow  discoloration. 
This  condition  is  frequently  found  in  the  mouth  of  the  new-born ;  erythema 


398  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  the  mouth  may  be  looked  upon  as  normal  during  this  period  of  life,  requir- 
inor  no  treatment  except  gentleness,  and  is  of  no  special  importance. 

In  pertussis  and  the  acute  exanthemata  there  is  produced  a  peculiar  form 
of  erythematous  change.  In  pertussis  and  measles  it  consists  of  a  blue  tint 
given  to  the  tongue  and  the  buccal  cavity ;  in  scarlatina  the  whole  mouth  is 
more  or  less  reddened,  and  in  all  the  acute  exanthemata  the  eruption  appears  in 
well-defined  places  in  the  characteristic  form  seen  upon  the  skin. 

In  general  stomatitis  catarrhalis  we  have  all  the  symptoms  of  an  inflam- 
mation— swelling,  pain,  heat,  redness.  The  whole  lining  of  the  mouth  is 
hyperi^mic  ;  there  is  more  or  less  pufl5ness,  especially  where  there  is  pressure, 
and  here  the  mucous  membrane  is  somewhat  paler.  The  lips  frequently 
become  more  tense,  and  the  mucous  membrane  is  covered  with  small,  round 
prominences  due  to  swelling  of  the  muciparous  follicles.  When  the  ducts  of 
the  latter  become  tightly  closed  the  glands  dilate,  and  there  are  produced 
cysts,  the  contents  of  which  are  clear,  viscid  mucus.  We  also  find  slight 
epithelial  abrasions,  sometimes  leading  to  the  production  of  a  deeper  process — 
at  all  events,  important  in  that  they  may  become  the  seat  of  infection. 

The  tongue  is  coated,  at  first  dry  and  white,  then  yellowish  or  grayish,  and, 
as  secretion  increases,  whole  flakes  of  this  coating  are  washed  off",  leaving  red 
spaces  partially  uncovered.  The  tongue  never  looks  like  the  scarlet-fever 
tongue,  since  the  catarrhal  process  seems  to  aff"ect  only  the  superficial  layer 
of  epithelium,  sparing  the  fungiform  and  even  the  bases  of  the  filiform  papillae. 
When  this  process  in  the  mouth  is  the  result  of  long-continued  fevers,  the 
appearance  changes;  nutrition  to  all  epidermal  structures  being  less  active,  the 
tongue  and  the  mouth  suff'er  comparatively  more  than  when  the  process  is 
purely  catarrhal. 

In  nearly  all  the  inflammations  of  the  mouth  the  lymphatics  become  in- 
volved, and  the  intensity  of  the  stomatitis  can  be  measured,  as  a  rule,  by  the 
degree  of  involvement  of  the  glands.  Increased  temperature  is  observed  (in 
rare  instances  as  high  as  104°  F.  in  the  rectum),  the  prominent  symptoms, 
however,  being  local.  Of  these  the  most  important  is  pain,  producing  restless- 
ness, fretfulness,  and  more  or  less  difiiculty  in  nursing.  With  this,  when  the 
child  is  old  enough,  there  is  increased  flow  of  saliva,  producing,  sometimes, 
irritation  of  the  skin  upon  the  lower  lip  or  eczema  of  the  face. 

Prognosis. — As  this  is  usually  an  acute  process  of  moderate  intensity,  the 
prognosis  is  good.  Indirectly,  there  may  be  produced  loss  in  weight,  dyspepsia, 
catarrhal  conditions  of  the  intestine,  continued  enlargement  of  the  ghinds, 
possibly  tuberculosis,  and,  therefore,  a  vulnerability  of  the  mucous  mem- 
brane, so  that  the  smallest  local  irritant  will  be  followed  by  a  return  of  the 
stomatitis. 

Treatment. — In  the  majority  of  instances  the  disease  runs  its  course 
without  any  special  treatment.  The  cause  must  be  removed  when  possible. 
Next,  relief  must  be  given  to  symptoms ;  cold  water,  applied  by  means  of 
cotton,  either  wrapped  around  a  stick  or  the  finger  of  the  nurse,  or  small 
pieces  of  ice  wrapped  in  a  handkerchief.  All  food  must  be  given  cold  i  usually 
this  causes  least  pain  ;  sometimes  the  opposite  will  be  found  necessary.  Much 
comfort  will  be  given  by  frequent  and  gentle  washing  of  the  mouth  with  ice- 
cold  sterilized  water,  to  which  there  has  been  added  boric  acid  (1-3  per  cent.), 
sodium  biborate  (2-3  per  cent.),  zinc  sulphate  (i-1  percent.),  sodium  salicylate 
(1  per  cent.),  etc.  The  addition  of  any  of  these  is  not  imperative;  chlorate 
of  potassium  is  unnecessary  and  without  value  in  this  form  of  stomatitis. 
Silver  nitrate  (J-1  per  cent.)  is  the  most  reliable  of  all  remedies  ;  if  the 
stomatitis  does  not  disappear  in  four  or  five   days,  the  mouth  must  first  be 


DISEASES   OF   THE  MOUTH.  399 

thoroughly  cleaned,  and  then  pencilled  with  this  weak  solution  once  a  day. 
Where  there  is  loss  of  epithelium  the  spot  should  be  touched  with  the  mitigated 
stick,  which  can  be  accurately  applied  by  first  melting  and  then  dipping  a 
silver  probe  into  it.  Cysts  should  be  duly  opened,  and  their  walls  should  be 
cauterized  when  necessary. 

n.  Stomatitis  Aphthosa. 

Aphtha  (from  a(pda,  an  eruption  or  ulceration)  is  a  subepithelial  vesicle 
of  different  color  from  the  mucous  membrane  upon  which  it  occurs,  and  is 
surrounded  by  an  areola  which  changes  in  a  peculiar  way  during  its  existence. 
It  has  nothing  to  do  with  the  muciparous  follicles,  appearing  in  places  where 
there  are  none;   it  is  therefore  not  follicular. 

Etiology. — No  uniform  local  cause  has  ever  been  found.  Micro-organisms, 
usually  pus-producers,  have  been  observed,  but  no  connection  could  be  discov- 
ered between  them  and  the  disease.  Aphthse  have  been  produced  artificially 
(caustics,  the  end  of  a  burning  match),  but  no  one  has  ever  succeeded  in  pro- 
ducing the  whole  series  of  symptoms  associated  with  this  form  of  stomatitis. 
It  is  said  that  the  disease  is  most  common  between  the  tenth  and  thirteenth 
months  of  life  (Bohn),  and  therefore  teething  has  something  to  do  with  the 
eruption.  However  this  may  be,  we  find  stomatitis  aphthosa  associated  with  a 
great  number  of  diseases — pneumonia,  ague,  gastro-intestinal  catarrhs,  the 
acute  exanthemata,  etc.  We  must  therefore  look  for  the  cause  in  a  general, 
not  a  local,  disturbance,  and  as  the  disturbance  is  the  same  as  herpes,  the 
same  etiology  will  be  found  to  hold  good  for  aphthee  as  for  herpes.  The  dis- 
ease is  not  contagious,  but  the  same  cause  may  not  infrequently  produce  it  in 
several  members  of  the  same  family,  and  usually  those  are  selected  whose  diges- 
tive tracts  are  either  temporarily  or  permanently  weak. 

The  foot-and-mouth  disease  in  cattle  can  be  definitely  accepted  as  causative, 
but  as  this  disease  is  very  rare  in  this  country,  it  can  be  almost  absolutely 
excluded  as  an  etiological  factor.  In  a  recent  epidemic  near  Berlin  studied  by 
Siegel,  an  ovoid  bacillus  0.5^  long  was  found  in  all  cases ;  only  those  con- 
nected with  the  animals  had  local  lesions,  but  were  protected  in  a  measure, 
infection  taking  place  from  man  to  man. 

The  conclusions  arrived  at  by  the  author  in  regard  to  the  etiology  of  this 
disease  are  as  follows :  It  is  a  disease  produced  by  some  form  of  deleterious 
material  in  the  circulation,  which  may  have  its  origin  in  various  processes,  bac- 
terial or  otherwise.  It  may,  therefore,  be  of  various  kinds.  This  material  acts 
upon  a  nerve  or  nerves,  or  upon  a  nerve  centre  or  nerve-centres,  and  produces 
an  herpetic  eruption  which  is  the  aphthous  process. 

Symptoms. — On  the  part  of  the  general  system  there  is  a  great  diversity, 
depending  largely  upon  the  patient  affected.  We  may  have,  for  two  or  three 
days  preceding  the  eruption,  manifestations  pointing  to  the  inception  of  almost 
any  disease  common  to  children — vomiting,  constipation,  high  fever,  pain  in 
the  throat  or  mouth,  enlargement  of  lymphatics,  a  slight  cough,  depending 
upon  the  localization  of  the  disease,  and  even  nervous  symptoms,  so  that  it 
will  be  almost  impossible  to  foretell  what  is  coming.  On  the  other  hand,  some 
patients  are  very  little  affected  beyond  a  slight  rise  of  temperature,  fretfulness, 
and  loss  of  appetite.  An  examination  of  the  mouth  made  at  this  period  usually 
reveals  stomatitis  catarrhalis,  sometimes  a  whitish  spot  upon  the  tonsil.  Then, 
possibly  the  next  day,  the  characteristic  eruption  appears  with  lightning  rapidity. 
This  consists  of  white  or  yellowish-white  subepithelial  spots,  single  or  in  groups, 
surrounded  by  an  areola,  and  developing  anywhere  within  the  mouth,  not  uni- 


400  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

lateral,  and  sometimes  extending  into  the  pharynx,  and  possibly  also  into  the 
larynx.  After  from  twelve  to  thirty-six  hours  the  epithelial  coating  is  soaked 
oif,  and  there  is  left  the  so-called  aphthous  ulcer.  After  a  few  days  more  the 
floor  of  the  ulcer  is  clean  or  the  exudate  is  lifted  up  between  regenerating 
epithelial  cells  ;  it  is  lifted  beyond  the  level  of  the  mucous  membrane,  and 
finally  disappears.  Some  aphthge  are  absorbed  without  going  through  this 
normal  course.  They  appear  in  successive  crops,  and  it  is  not  unusual  to  have 
the  course  of  the  disease  extend  to  from  ten  to  fourteen  days.  The  exudate  is 
made  up  of  fibres,  indifferent  cells,  and  various  lower  forms  of  life.  No  cic- 
atrix is  left  where  these  spots  have  been,  showing  that  the  submucous  tissue 
has  not  been  affected. 

The  local  symptoms  are  those  of  stomatitis  catarrhalis ;  where  denudation 
takes  place  there  is  more  pain.  The  most  common  complication  which  occurs 
is  stomatitis  ulcerosa,  and  unless  this  is  present  the  saliva  in  stomatitis  aphthosa 
is  never  fetid — a  matter  of  great  diagnostic  importance.  In  some  instances 
the  aphthae  are  so  numerous  that  the  mouth  looks  as  if  it  were  covered  by  a 
diphtheritic  membrane.  A  day  of  waiting  will  clear  away  any  doubts  on  the 
subject,  as  by  this  time  the  characteristic  denudation  will  have  appeared. 

Prognosis. — The  prognosis  is  absolutely  good.  The  disease  is  self-limited, 
doing  no  harm  except  to  interrupt  the  general  thriving  of  the  child.  Infection 
with  other  poisons  has  been  known  to  take  place,  but  this,  fortunately,  is  very 
rare.  Relapses  are  very  rare,  and  the  small  ulcers,  as  a  rule,  heal  without 
difficulty. 

Treatment. — This  is  the  same  as  that  used  for  catarrhal  ulcers — viz.  the 
nitrate  of  silver.  Permanganate  of  potassium  may  be  used  locally  to  great  advan- 
tage (gr.  iij  to  f  Ij),  but  must  not  be  looked  upon  as  a  specific.  General  treat- 
ment, as  a  rule,  is  not  required,  and  Avhen  it  is  necessary  it  is  purely  sympto- 
matic. Laxatives,  usually  given  early,  seem  to  have  no  influence  upon  the 
process ;  calomel  does  not  abort  it,  and  must  be  used  according  to  the  indica- 
tions which  govern  its  administration  in  other  conditions.  The  poison  has 
done  its  work  before  we  are  able  to  attempt  to  counteract  its  bad  effects ;  it  is 
probably  eliminated  by  the  time  we  see  the  patient,  and  therefore  all  causal 
thei'apy  is  futile. 

Bednars  Aphtlice  are  found  only  in  the  new-born.  They  are  shallow 
ulcers  covered  by  a  gray  or  yellowish  coating,  and  found  upon  the  soft  palate, 
the  posterior  part  of  the  hard  palate,  the  palatine  suture,  always  near  the  velum 
palati.  They  may  be  mistaken  for  the  ulcers  produced  by  the  breaking  down 
of  milia  or  retention-cysts,  or  for  that  condition  described  by  E.pstein  in  Avhich 
there  are  congenital  defects  in  the  mucous  membrane  filled  up  with  epithelial 
detritus. 

These  aphth?e  are  always  produced  by  violence  in  cleansing  the  mouth ; 
this  explains  their  position  and  their  course.  They  are  rarely  found  in  private 
practice  except  where  the  midwife  still  holds  absolute  sway.  Their  course  is 
benign,  they  require  no  treatment,  and  are  only  dangerous  when  they  become 
infected.  With  the  modern  rubber  nipples,  when  badly  shaped,  they  some- 
times develop  far  forward  upon  the  hard  palate  ;  changing  the  shape  of  the 
nipple  always  results  in  their  cure. 

m.  Stomatitis  Mycosa. 

This  condition,  commonly  termed  Thrush,  is  a  disease  produced  by  a  pecu- 
liar fungus,  first  discovered  by  Berg  of  Stockholm,  and  called  oidium  albicans 
by  Robin.     Rees  and  Grawitz  were  the  first  to  show  that  the  fungus  is  not  an 


DISEASES    OF   THE  MOUTH.  401 

oidium,  but  a  saccharomyces.  All  later  investigations  agree  in  showing  that  it 
is  not  oidium,  but  all  do  not  agree  that  it  is  saccharomyces  albicans.  For  the 
present,  however,  until  the  exact  position  of  the  fungus  is  determined,  it  seems 
wise  to  adhere  to  the  last  name,  saccharomyces  albicans. 

Etiology. — The  fungus  is  the  only  cause,  but  it  must  be  deposited  upon 
favorable  soil  to  produce  the  disease.  The  saccharomyces  albicans  may  be 
found  upon  every  mucous  membrane  in  the  body,  the  alimentary,  the  respi- 
ratory, and  genito-urinary :  it  has  been  found  in  the  parenchyma  of  organs,  as 
the  brain  and  lungs,  and  in  blood-vessels.  It  is  usually  carried  to  children  by 
the  nipple  or  by  the  nursing-bottle.  The  fact  that  weak  and  unhealthy  chil- 
dren are  most  predisposed  to  thrush  has  been  emphasized  entirely  too  much  : 
perfectly  healthy  children  have  thrush.  It  has  also  been  stated  that  flat  epi- 
thelium is  necessary  for  the  development  of  thrush  ;  this,  however,  can  no 
longer  be  maintained,  as  we  see  the  fungus  on  a  great  many  surfaces  lined  by 
cylindrical  epithelium.  It  is  admitted  on  all  hands,  however,  that  catarrhal 
stomatitis  exists  either  before  or  with  the  appearance  of  thrush.  It  is  more 
than  probable  that  this  is  the  predisposing  cause,  and  that  it  works  mechani- 
cally— viz.  by  a  dislocation  of  the  swollen  cells,  preventing  perfect  protection 
to  the  mucous  membrane,  and  allowing  the  spores  of  the  fungus  to  find  a  place 
for  development.  Anything  producing  this  mechanical  injury  to  the  mem- 
brane of  the  mouth,  such  as  badly-formed  or  hard  nipples,  will  act  in  the  same 
way.  The  younger  the  child  or  the  weaker,  the  more  successful  will  be  the 
implantation  of  the  saccharomyces,  because  the  function  of  motion  of  the 
tongue  and  jaw  will  be  least  developed.  The  disease  is  therefore  found 
especially  in  infants  reduced  by  illness,  and  in  older  children  in  connection 
with  diseases  that  are  followed  by  great  loss  of  strength,  such  as  long-continued 
fevers,  wasting  diseases,  or  those  in  which  motion  is  very  much  impaired. 

The  fungus  is  found  in  two  forms,  depending  largely  upon  the  culture- 
material — the  yeast  form  and  the  globulo-filamentous  form  (frequently  called 
mycelium).  There  is  no  ascospore ;  therefore,  according  to  Roux  and  Linois- 
sier,  the  fungus  is  not  a  saccharomyces.  The  chlamydospore  has,  however, 
not  been  satisfactorily  worked  out.  Propagation  goes  on  in  three  ways — by 
filaments  produced  from  conidia,  by  isolated  conidia,  and  by  spores. 

Pathology. — The  first  lodgement  comes  between  the  epithelial  cells  of  the 
mouth,  and  from  this  the  growth  works  its  way  toward  the  free  surface  and 
toward  the  mucous  membrane  proper.  In  the  direction  of  the  free  surface  the 
growth  is  not  so  luxuriant,  but  in  both  directions  it  is  principally  in  the  myce- 
lium form.  In  mucous  membranes  lined  by  flat  or  squamous  epithelium  the 
growth  of  the  saccharomyces  is  facilitated  by  the  relation  of  the  cells  to  each 
other ;  in  membranes  lined  by  cylindrical  epithelium  growth  takes  place,  but 
not  so  readily,  because  there  is  but  one  layer  of  cells.  After  the  first  develop- 
ment growth  goes  on  very  rapidly :  after  having  found  a  nidus,  the  cells  are 
pushed  aside,  surrounded  by  mycelium,  the  whole  forming  the  characteristic 
thrush-spot.  Pus  is  rarely  produced ;  when  this  does  occur  the  affection  is  of 
a  complex  nature.  The  growth  begins  in  small  spots,  sometimes  one,  some- 
times more  ;  from  these  infection  spreads,  and  at  times  the  whole  mucous  mem- 
brane is  covered  with  a  rich  growth  of  the  saccharomyces. 

Symptoms. — Preceded  or  accompanied  by  stomatitis  catarrhalis,  the  local 
symptoms  vary  with  the  intensity  of  this  process.  Frequently  no  symptoms 
are  present,  and  the  existence  of  the  small  spots  is  the  first  indication  of  the 
presence  of  thrush.  These  vary  in  size,  seem  a  part  of  the  mucous  mem- 
brane, are  usually  of  a  grayish-white,  creamy  color,  and  may  or  may  not  be 
elevated  above  the  surface  of  the  mucous  membrane.     They  appear  first  W>n 


402  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  tongue  and  cheeks,  then  frequently  upon  the  lips  and  soft  palate,  and  may 
be  found  upon  the  tonsils,  the  pharynx,  or  the  oesophagus.  With  only  mode- 
rate care  of  the  mouth  they  seem  to  last  indefinitely  ;  without  care  they  spread 
rapidly,  and  instead  of  the  spots  we  may  see  membranes,  in  the  case  of  the 
oesophagus  whole  casts  being  formed,  which  fill  its  lumen  and  often  prevent 
swallowing.  In  hospital  practice  thrush  has  proved  a  formidable  disease ;  in 
private  practice  it  amounts  to  nothing  more  than  a  local  disturbance,  unless 
neglected.  In  the  latter  class  of  patients  there  is  always  associated  some 
gastro-intestinal  disturbance,  which  may  prove  serious  if  not  fatal.  In  debili- 
tated subjects — and  thrush,  from  the  mechanical  reasons  pointed  out  before,  is 
more  common  in  such — these  gastro-intestinal  troubles  may  be  the  affection 
which  terminates  the  child's  life.  When  the  membrane  drops  off  there  is  left  a 
slight  abrasion  which  may  become  the  focus  of  infection  by  any  other  morbific 
agent. 

But  it  must  not  be  inferred  that  thrush  occurs  only  in  debilitated  or  sick 
children.  It  may  occur  in  children  that  seem  perfectly  healthy,  although  care- 
ful investigation  Avill  always  reveal  some  lesion  in  the  mouth  which  has  pre- 
ceded the  thrush.  Again,  not  every  child  with  stomatitis  mycosa  has  gastro- 
intestinal symptoms  :  the  food  carrying  saccharomyces  frequently  carries  other 
lower  forms  of  life  capable  of  producing  diarrhoea,  but  in  properly-treated 
cases  these  symptoms  are  wanting,  and  when  taken  early  enough  thrush  is 
local,   and  local  only. 

The  thrush-spots  develop  within  the  epithelium,  and  examination  by 
reflected  light  will  show  this ;  the  spot  is  often  surrounded  by  a  narrow  ring 
of  injected  blood-vessels.  Removal  from  the  mucous  membrane  requires 
considerable  violence.  The  next  step  in  development  is  a  pushing  up  beyond 
the  level  of  the  mucous  membrane,  and  after  this  more  extensive  infection  of 
the  mouth  may  be  expected  unless  counteracted  by  treatment.  At  times  the 
whole  mass  may  drop  off  and  leave  an  ulcer,  sometimes  very  intractable,  or 
the  many  spots  may  coalesce  to  form  a  membrane.  The  diflFerential  diagnosis 
is  not  difficult  if  all  the  above  be  taken  into  consideration,  and  a  positive 
diagnosis  can  be  made  under  all  circumstances  with  the  microscope. 

Treatment. — Prophylaxis  is  very  important.  In  young  children  all 
abrasions  and  all  slight  forms  of  stomatitis  ought  to  be  looked  after.  Every- 
thing coming  in  contact  with  the  mouth  of  the  infant  should  be  kept  aseptic — 
the  nipples,  the  feeding-bottle,  the  food. 

The  treatment  is  simple  enough  if  properly  carried  out.  A  solution  of 
sodium  bicarbonate  (1  drachm  to  a  tumbler  of  water)  is  to  be  applied  with  a 
brush  between  the  times  of  nursing  or  feeding  and  immediately  after  feeding  or 
nursing.  Ulcers  should  be  treated  as  has  been  described  under  Stomatitis 
Catarrhalis.  (Esophageal  thrush,  when  the  diagnosis  is  possible,  should  be 
treated  by  the  introduction  of  a  soft-rubber  tube  (catheter)  into  the  stomach. 
The  intestinal  troubles  are  best  treated  by  small  doses  of  calomel  or  corrosive 
sublimate,  combined  with  careful  diet. 

IV.  Stomatitis  Ulcerosa. 

This  is  a  peculiar  process,  characterized  by  destruction  of  tissue,  beginning 
on  the  gums  around  the  teeth,  never  extending  beyond  the  mouth,  infecting 
healthy  parts  of  the  mouth,  and  never  occurring  where  there  are  no  teeth. 

Etiology. — A  clinical  picture  resembling  the  disease  is  produced  by  the 
internal  administration  of  certain  remedies — mercury,  copper,  and  iodine. 
Mercurial  stomatitis  is  almost  identical  with  stomatitis  ulcerosa,  and  in  these 


DISEASES    OF   THE   MOUTH.  403 

cases  we  find  that  a  local  irritation  caused  by  bad  teeth  or  uncleanliness  of  the 
mouth  is  a  decided  factor  in  the  production  of  this  affection.  But,  in  addition, 
the  remedies  are  excreted  by  the  mouth,  and  in  this  fact  there  is  to  be  found  a 
possible  clue  as  to  the  etiology  of  stomatitis  ulcerosa.  Whether,  in  addition, 
there  are  lower  forms  of  life  or  chemical  substances,  or  both,  which  cause  this 
peculiar  form  of  inflammation,  it  is  for  the  present  impossible  to  decide. 

The  disease  usually  develops  in  connection  with  bad  hygienic  surroundings, 
or  following  certain  diseases,  especially  measles  and  scarlatina,  and  frequently 
malaria,  pertussis,  typhoid  fever,  or  pneumonia.  It  is  said  to  be  endemic  in  the 
wards  of  certain  hospitals  or  in  certain  barracks ;  and  damp,  poorly-ventilated 
houses,  with  or  without  insufficient  nourishment,  certainly  favor  its  develop- 
ment. The  disease  is  usually  held  to  be  non-contagious,  but  experiments 
with  inoculation  have  proven  to  me  that,  Avith  proper  precautions,  the  disease 
can  be  propagated.  It  is  not  infrequent  with  soldiers,  especially  when  confined 
in  bai-racks,  and  the  likelihood  of  a  scorbutic  affection  being  the  predisposing 
factor  cannot  be  disposed  of  at  present.  It  is  rarely  observed  before  the  age 
of  five  years,  most  frequently  between  the  ages  of  five  and  ten,  but  it  does 
occur  at  any  time  of  life,  provided  teeth  be  present. 

Pathology. — The  process  is  one  of  necrobiosis.  There  is  cellular  death, 
but  at  the  same  time  there  results  softening  of  the  tissues,  and  not  death 
en  masse.  The  peculiarity  of  this  form  of  necrosis  is  that  it  does  not  respect 
any  form  of  tissue,  but  may  extend  to  the  periosteum,  finally  producing 
necrosis  of  bone.  It  is  not  unusual  to  find  sequestra  of  large  size  ready  to 
be  removed.  The  process  may,  at  the  same  time,  produce  caries  of  the  bone, 
although  this  is  certainly  exceptional.  The  disease  always  begins  at  the  free 
border  of  the  gums,  from  which  it  extends  in  all  directions,  frequently 
infecting  healthy  mucous  membrane,  but  never  extending  beyond  that  of  the 
mouth. 

Symptoms. — We  first  find  swelling  of  the  mucous  membrane  only  at 
the  lower  part  of  each  tooth  (most  commonly  the  lower  incisors),  and  this 
gradually  increases  until  the  curved  outline  of  the  gum  is  converted  into  a 
more  or  less  straight  line.  This  swelling  may  become  so  great  as  to  produce 
eversion  of  the  part  affected ;  at  the  same  time  there  is  great  injection,  almost 
lividity,  accompanied  by  more  or  less  bleeding  upon  the  slightest  provocation. 
The  anterior  aspect  of  the  gum  is  first  affected,  but  in  severe  cases  the  posterior 
portion  also  takes  part  in  the  process.  Soon  the  gums  can  be  detached  from 
the  teeth,  and  there  is  exposed  a  cavity  or  sac  filled  with  a  muco-purulent 
secretion.  These  characteristic  local  symptoms  are  further  distinguished  by 
the  appearance  upon  the  swollen  gum  of  a  yellowish  seam,  which  may  become 
a  broad  band.  This  represents  the  ulceration,  and  is  due  to  cellular  necrosis. 
With  this  there  is  a  constant  flow  of  fetid  saliva  from  the  mouth,  but  the 
odor  comes  from  the  diseased  gums,  except  in  very  bad  cases,  when  it  may 
in  part  occur  from  diseased  bone.  In  older  children  subjective  symptoms 
are  slight ;  in  younger  ones  the  principal  evidence  is  pain,  fretfulness,  change 
in  disposition,  crying,  and  wakefulness. 

The  outpouring  of  large  quantities  of  saliva  commonly  produces  eczema  of 
the  lips,  which  may  persist  long  after  the  cause  has  been  removed.  The  lym- 
phatic glands  are  always  involved ;  they  are  soft,  and  remain  enlarged  fre- 
quently for  a  long  time ;  as  a  rule,  they  do  not  suppurate,  although  this  may 
occur  some  time  after  the  disease  in  the  mouth  has  run  its  course. 

At  this  stage  the  disease  is  very  amenable  to  treatment ;  if  left  to  itself,  it 
goes  on  indefinitely  and  develops.  The  yellowish  seam  increases,  and  when 
removed  there  is  exposed  an  ulcerated  surface.     There  is  greater  formation  of 


404  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

pus;  the  gums  become  more  detached  from  the  teeth,  which  are  loosened. 
Ulcers  may  now  form  upon  other  parts  of  the  mouth,  the  lips,  the  cheeks,  the 
tongue.  In  very  bad  cases  the  whole  of  the  mucous  membrane  covering  the 
body  of  the  lower  gum  has  ulcerated  away,  and  we  look  in  upon  a  cavity  filled 
with  offensive  pus,  bleeding,  and  possibly  showing  a  piece  of  denuded  bone  at 
the  bottom.  In  these  cases  salivation  has  reached  its  maximum  development, 
and  the  whole  room  may  become  tainted  with  a  peculiar  foul  odor.  Sometimes 
ulcers  form  upon  the  mucous  membrane  joining  the  lower  lip  to  the  gum; 
wherever  they  may  be,  however,  it  is  always  the  characteristic  sequence :  first, 
necrobiosis,  the  seam  surrounded  by  injected  tissue,  then  ulceration  below. 

Nature  rarely  cures  these  cases  without  assistance :  when  cure  takes  place 
the  symptoms  disappear  slowly,  but  in  every  case  the  disappearance  of  the 
fetid  saliva  is  the  first  symptom  of  improvement.  Sometimes  the  disease 
becomes  chronic ;  it  then  runs  an  exceedingly  mild  course  when  deep  tissues 
are  not  involved.  It  always  takes  some  time  for  this  to  take  place,  so  that  if 
a  patient  has  had  stomatitis  ulcerosa  for  several  months  without  involvement 
of  deep  structures,  it  is  more  than  probable  that  we  are  dealing  with  the 
chronic  form.  This  is  characterized  by  its  resistance  to  ordinary  methods  of 
treatment  and  by  the  frequency  of  relapses. 

Prognosis  depends  upon  three  factors :  the  disease  upon  which  stomatitis 
ulcerosa  is  engrafted,  the  stage  of  the  disease,  and  the  treatment.     The  worst 

IT 

form  is  found  in  scorbutus.  Where  bone-changes  are  present  the  disease 
assumes  the  aspect  of  a  disease  of  bone,  but  the  prognosis  is  not  bad  when  the 
condition  is  recognized.  The  important  fact  that  stomatitis  gangrenosa  some- 
times develops  must  never  be  forgotten  :  every  case  of  stomatitis  ulcerosa, 
therefore,  requires  most  careful  watching. 

Treatment  is  prophylactic  and  curative.  Improve  the  hygienic  condi- 
tions of  the  patient  and  prevent  extension  of  the  disease  to  others.  Chlorate 
of  potassium  can  be  looked  upon  as  almost  a  specific  in  this  affection.  It  is  to 
be  administered,  with  all  precautions,  in  a  3  per  cent,  solution,  of  which  ^  to  1 
teaspoonful  is  given  every  two  hours.  At  first  its  administration  is  accom- 
panied by  pain,  sometimes  very  intense,  but  this  no  longer  occurs  in  from 
thirty-six  to  forty-eight  hours  after  treatment  has  begun.  It  takes  about 
twenty-four  hours  for  the  remedy  to  produce  any  appreciable  effect,  and  this  is 
evidenced  by  a  diminution  of  salivation.  Soon  this  hypersecretion  disappears 
entirely,  and  with  it  the  fetid  odor  from  the  mouth  ;  in  the  course  of  a  week, 
usually,  all  symptoms  will  have  disappeared.  If  ulceration  has  not  disappeared 
at  this  time,  careful  search  must  be  made  for  the  cause.  Carious  teeth  must 
either  be  removed,  filled,  or  otherwise  treated  by  antiseptics ;  if  this  does  not 
remove  the  ulceration,  recourse  must  be  had  to  cauterization,  either  by  nitrate 
of  silver  or  the  galvano-cautery.  Dead  bone  must  always  be  removed.  Where 
the  cause  of  a  continuance  of  the  process  cannot  be  found,  frequent  applica- 
tions of  permanganate  of  potassium  yield  good  results.  As  a  last  resort,  the 
teeth  around  which  the  ulcerative  process  is  best  developed  must  be  extracted 
and  the  cavity  frequently  washed,  when  the  process  will  soon  be  found  to  come 
to  an  end.  As  potassium  chlorate  is  a  remedy  almost  specific  in  its  properties, 
any  other  medicaments  will  hardly  ever  become  necessary. 

In  chronic  cases  potassium  chlorate  does  not  act  so  universally ;  here,  how- 
ever, its  use  is  also  indicated,  combined  with  local  treatment  in  the  form  of 
applications  of  silver  nitrate  three  times  a  week. 


DISEASES    OF   THE  MOUTH.  405 


V.  Stomatitis  Gangrenosa. 


This  disease,  termed  also  cancrum  oris,  gangrene  of  the  mouth,  or  noma, 
is  comparatively  rare,  most  common  in  hospital  practice,  and  in  private  prac- 
tice depends  for  its  frequency  principally  upon  the  surroundings.  It  is  a 
gangrenous  process,  beginning  upon  the  gums  or  inner  surface  of  the  cheek, 
spreading  with  great  rapidity,  and  destroying  every  kind  of  tissue  upon  which 
it  develops. 

Etiology. — There  can  be  no  doubt  that  the  disease  may  become  infectious 
in  its  nature ;  several  cases  occurring  in  the  same  family  or  a  number  breaking 
out  in  one  ward  of  a  hospital  can  be  offered  in  evidence.  On  the  other  hand, 
a  great  many  cases  are  observed  in  which  it  seems  to  be  impossible  to  take  into 
consideration  anything  like  contagiousness ;  a  case  occurring  in  a  patient  miles 
out  in  the  country  where  no  other  case  of  noma  has  ever  been  observed  in 
that  neighborhood. 

Noma  occurs  only  in  children  sick  with  other  diseases,  never  in  healthy 
children.  Furthermore,  it  follows  in  the  wake  of  such  diseases  as  produce 
great  debility  and  least  cellular  resistance.  The  diseases  most  commonly 
followed  by  noma  are — the  acute  exanthemata  (especially  measles  and  typhus), 
whooping-cough,  syphilis,  scorbutus,  chronic  intestinal  catarrhs,  and  malaria. 
The  excessive  use  of  mercurials  has  been  frequently  considered  the  cause  'of 
this  disease ;  no  doubt  such  consequences  have  followed  the  heroic  doses  of 
former  days,  but  are  certainly  exceptional  now.  Stomatitis  ulcerosa  is  fre- 
quently a  forerunner  of  noma,  being  the  result  of  identical  predisposing 
causes,  but  in  all  probability  the  resemblance  of  the  two  processes  ceases 
there. 

A  great  many  lower  forms  of  life  have  been  found,  but  the  testimony  as  to 
their  causative  relation  is,  as  yet,  inconclusive.  Short  rods,  as  in  pulmonary 
gangrene,  and  streptococci  (Cornil  and  Babes),  streptococci  resembling  those 
found  by  Koch  in  progressive  tissue-necrosis  of  white  mice  (Ranke),  and  bacilli 
in  thread-like  growth  (Lingard),  have  been  looked  upon  as  the  immediate  cause  ; 
but  the  predisposing  cause,  after  all,  is  the  most  important,  and  the  probability 
is  that  sooner  or  later  any  number  of  diflFerent  kinds  of  organisms,  both  patho- 
genic and  otherwise,  are  developed  in  every  case  of  noma. 

Patholog-y. — We  find  all  the  evidences  of  a  phlegmonous  gangrene.  Sur- 
rounding destroyed  tissue  there  is  an  infiltrated  zone.  The  latter  is  a  true 
necrobiotic  process,  all  evidences  of  cellular  tissue  being  destroyed,  only  a 
homogeneous  substance  in  which  are  found  micrococci  being  left.  Around 
this  is  found  increased  connective  tissue,  the  connective-tissue  corpuscles  in 
active  cell-division,  while  the  blood-vessels  are  closed  by  thrombi  and  lower 
forms  of  life.  Outside  of  this  we  find  healthy  tissue.  In  every  case  of  noma 
these  four  zones  can  be  distinguished. 

Symptoms. — The  first  and  most  characteristic  symptom  noticed  is  the  odor 
of  gangrene.  Upon  examination  an  ulcer  will  be  found  upon  the  gums  or  the 
inner  surface  of  the  cheek  ;  this  spreads  very  rapidly.  Very  soon  the  whole 
cheek  begins  to  swell ;  it  becomes  oedematous,  the  skin  is  waxy,  and  within 
twenty-four  hours  the  whole  side  of  the  face  may  become  involved.  Some- 
times the  swelling  is  painful,  but  frequently  children  will  not  complain  of  any 
local  symptoms.  The  ulcer  in  the  mouth  has  now  become  deeper,  and  is  evi- 
dently eating  its  way  through  the  cheek,  producing  symptoms  almost  pathog- 
nomonic as  it  comes  nearer  the  skin.  The  latter  becomes  discolored,  red, 
blue,  purple,  black.  Sometimes  a  bulla  filled  with  ichorous  fluid  is  formed 
upon  the  cheek  ;  then  the  epithelial  covering  breaks  down,  and  with  it  the  gan- 


406  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

grenous  pi'ocess  goes  on  from  without  inward.     Where  no  bulla  is  formed  the 
gangrene  goes  on  from  the  mucous  membrane  to  the  skin.     Perforation  of  the 

Fio,  1. 


^      £k3a0^^''                                           ^^^^^^^^^^1 

^^HK^r   4  M^y('^                               ^^^^^1 

Iwf^F     ^*ip;-    f^^^H 

^^Bfi        ^F^^ijfa^^^H 

^^^^^             '''*^^Tt'         'i^^^^^l 

f^ 

<^->^^--f--H 

Cancrum  oris  in  a  child  five  years  old. 

cheek  takes  place  under  all  circumstances  and  in  a  very  short  time — from  twenty- 
four  hours  to  three  or  four  days.  As  a  rule,  the  process  continues,  involving  the 
whole  of  the  cheek,  the  neck,  the  eyelids,  destroying  the  eye,  but  rarely  becoming 
bilateral.  The  bones  are  denuded,  the  teeth  become  loose,  the  tongue,  hard  and 
soft  palate,  even  the  tonsils,  may  become  infected,  and  there  is  left,  a  discolored, 
fetid,  soft  mass.  The  whole  terminates  in  producing  probably  the  most  repul- 
sive appearance  the  physician  has  opportunity  to  see.  The  odor  is  frightful, 
filling  the  whole  house;  the  flow  of  saliva  is  very  much  increased,  and  death 
usually  results  from  the  depressed  general  condition.  Spontaneous  recovery  is 
rare  :  a  line  of  demarcation  then  forms  around  the  gangrenous  spot,  the  surface 
is  covered  by  granulations,  and  finally  cicatrization  follows,  leaving  most 
horrible  scars.  Relapses  sometimes  occur,  but  they  are  rare.  The  whole  du- 
ration of  the  disease  is  from  one  to  three  weeks,  sometimes  longer,  depending 
upon  the  vitality  of  the  patient.  The  general  symptoms  are  usually  those  of 
the  disease  upon  which  noma  is  engrafted.  Sometimes  children  with  noma  are 
found  playing  in  bed,  picking  out  loose  teeth,  and  apparently  little  concerned 
about  the  intense  fatal  process  going  on  upon  their  cheek.  This  is,  however, 
not  the  rule,  and  Avhen  it  does  occur  it  is  followed  in  a  short  time  by  general 
symptoms  showing  the  severity  of  the  local  process.  The  temperature  is  some- 
times very  high,  becoming  hectic  in  type,  but  not  infrequently  it  becomes  sub- 
normal before  death.  The  pulse  is  small,  easily  compressed,  weak,  and  rapid. 
The  appetite  is  diminished,  and  diarrhoea  is  the  rule,  most  intractable  in  its 
nature  and  probably  due  to  infection  from  the  process  in  the  mouth.  Catar- 
rhal pneumonia,  due  to  inhalation  of  septic  naaterial,  is  common,  and  diphtheria 


DISEASES    OF   THE  MOUTH.  407 

has  been  observed  in  several  cases.  Exhaustion  comes  on,  and  then  the  child 
becomes  apathetic,  refuses  food,  and  dies  in  collapse.  Hsemorrhages  are  rare, 
because  the  blood-vessels  ai'e  filled  with  thrombi. 

Prog-nosis. — This  is  very  bad,  the  mortality  ranging  from  70  to  90  per  cent, 
of  all  cases  affected.     Complications  make  the  prognosis  absolutely  fatal. 

Treatment. — Of  the  general  treatment,  ahvays  of  great  importance,  little 
new  can  be  said,  as  the  physician  has  already  done  all  in  his  power  to  avert  a 
gangrenous  process  by  keeping  up  the  strength  of  the  patient.  "When  noma 
sets  in  stimulants  should  be  used  methodically  and  systematically  ;  food  should 
be  given  in  as  condensed  a  form  as  possible.  If  feasible,  rectal  alimentation 
may  be  tried,  but  this,  as  a  rule,  is  not  very  satisfactory  for  children. 

The  local  treatment  is  of  prime  importance,  and,  as  the  mortality  is  so  great, 
even  the  most  heroic  treatment  can  be  adopted  with  complacency.  The  prin- 
ciple of  local  treatment  is  to  destroy  the  infiltrated  zone  and  the  healthy  tissue 
surrounding  it  for  some  distance,  so  as  to  make  an  artificial  line  of  demarca- 
tion. Kitrate  of  silver  in  stick,  dilute  muriatic  or  other  acids,  chloride  of  zinc, 
and  many  other  remedies  have  been  recommended  for  this  purpose.  To  the 
author  it  seems  that  the  best  and  most  active  method  of  destroying  this  tissue 
is  to  be  found  in  the  use  of  the  thermo-cautery  of  Paquelin  or  the  galvano- 
cautery  ;  and  lately  several  cases  have  been  reported  in  which  success  has 
followed  these  applications,  although  it  is  far  too  early  to  draw  positive  con- 
clusions. As  soon  as  the  gangrenous  nature  of  the  disease  has  been  established 
the  operation  must  be  performed.  A  loss  of  time,  even  of  hours,  means  con- 
siderable loss  of  tissue.  Again,  delay  may  make  the  operation  one  of  great 
magnitude,  in  that  blood-vessels  may  have  to  be  tied  which  before  the  exten- 
sion of  the  process  could  be  safely  cut  with  the  galvano-caustic  knife.  Under 
anesthesia,  when  possible,  necrotic  tissue  should  be  removed,  and  then  every- 
thing that  seems  gangrenous  should  be  destroyed.  After  this  a  certain  amount 
of  healthy  tissue  should  be  cauterized.  If  gangrenous  spots  appear  the  next 
day,  the  operation  should  be  repeated,  and  so  on ;  applications  can  be  made 
daily.  The  wound  is  to  be  treated  according  to  surgical  rules,  and  plastic 
operations  should  be  put  off  as  long  as  possible,  because,  in  the  first  place, 
they  do  not  offer  much  chance  of  success  when  done  early,  and,  in  the  second 
place,  noma  sometimes  recurs  as  the  result  of  these  operations. 

In  conclusion,  it  must  be  stated  that,  whatever  has  been  done  and  will  be 
done,  the  results  must  be  bad,  because  the  process  is  one  developed  in  a 
patient  very  much  reduced,  in  whom  the  least  complication  is  likely  to  prove 
fatal. 

VI.  Stomatitis  Orouposa  ;   Stomatitis  Diphtheritica. 

Croupous  stomatitis  may  be  produced  by  a  variety  of  causes,  both  chemical 
and  bacterial.  Primary  croupous  stomatitis  is  certainly  a  very  rare  affection, 
although  it  may  occur.  As  a  rule,  the  croupous  membrane  develops  contem- 
poraneously with  a  membrane  upon  the  tonsils.  In  very  severe  cases  the 
membrane  has  been  found  upon  the  cheeks,  the  tongue,  and  even  upon  the  lips. 
The  lymphatic  glands  are  not  much  involved,  and  as  the  mouth-process  \a 
commonly  only  part  of  another  of  more  importance,  little  more  will  be  said 
in  this  connection.  The  important  thing  to  establish  is  the  absence  of  the 
Loeffler-Klebs  bacillus  ;  this  will  make  the  diagnosis  absolute.  At  the  present 
time  the  whole  subject  is  being  investigated,  but  enough  has  already  been 
done  to  show  that  all  false  membranes  are  not  diphtheritic. 

Diphtheritic  stomatitis  does  occur  as  a  primary  affection,  although  it  is 


408  A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

not  very  common.  When  primary  in  the  mouth,  the  membrane  usually 
develops  upon  the  lips,  and  may  extend  thence  to  any  part  of  the  mouth.  As 
a  rule,  the  tonsil  is  the  primary  seat,  and  thence  the  membrane  spreads  to 
the  soft  palate,  the  tongue,  the  cheeks,  the  lips,  and  the  gums.  There  is  but 
one  positive  method  of  making  the  diagnosis  of  diphtheria,  and  that  is  by 
proving  the  presence  of  the  Loeffler-Klebs  bacillus  by  cultures,  and  then 
making  inoculative  experiments  upon  lower  animals.  In  primary  diphtheritic 
stomatitis  this  would  become  imperative ;  in  the  secondary  form  there  are, 
fortunately,  still  left  for  the  clinician  combinations  of  certain  symptoms  that 
make  it  possible  to  diagnosticate  the  disease  without  consulting  the  bacteri- 
ologist. 

Salivation  usually  occurs,  and  the  odor  from  the  mouth  is  fetid.  Some- 
times diphtheria  of  the  mouth,  when  primary,  runs  it  course  most  insidiously, 
and  is  overlooked  or  not  recognized  until  further  complications  develop.  The 
membrane  lasts  from  three  to  six  days,  sometimes  longer,  and  then  either  drops 
oif  or  ulcerates  away  ;  in  either  instance  there  is  left  a  denuded  place.  Hgemor- 
rhages  are  common,  either  slight  or  otherwise ;  Avhen  not  due  to  mechanical 
irritation  they  are  matters  of  anxiety.  In  some  instances  hgemorrhage  has 
been  so  great  as  to  cause  death ;  in  others  only  a  slight  loss  of  blood  seems 
sufficient  to  produce  a  fatal  termination.  The  prognosis  depends  largely  upon 
the  form,  whether  primary  or  secondary ;  it  is  very  much  worse  in  the  latter 
than  in  the  former,  but  even  in  the  primary  form  may  become  very  grave 
by  extension.  The  author  has  seen  two  cases  in  which  a  primary  diphtheritic 
stomatitis  has  become  a  laryngeal  one. 

Treatment  is  that  of  diphtheria.  When  possible,  the  membrane  must 
be  removed  if  this  proceeding  be  not  accompanied  by  violence,  so  that  infec- 
tion of  healthy  membrane  be  produced.  Constitutional  treatment  is  of  the 
utmost  importance,  in  order  to  counteract  the  tox-albumins  produced  by  the 
bacillus.  For  this  purpose  corrosive  sublimate,  administered  internally  in  full 
doses  frequently  repeated,  seems  to  be  the  favorite.  In  the  septic  cases  much 
good  can  be  done  by  frequent  local  applications  without  violence. 

Vn.  Stomatitis  Syphilitica. 

Syphilis  produces  stomatitis  only  in  an  indirect  manner,  either  by  causing  a 
specific  deposit,  Avhich,  in  its  turn,  produces  the  disease,  or  by  rendering  the 
mouth  in  such  patients  more  sensitive  to  agents  which  produce  stomatitis. 

The  three  stages  of  syphilis  are  developed  in  the  mouth.  Primary  lesions 
are  very  rai-e,  but  infection  does  take  place  from  syphilitic  wet-nurses,  and 
when  this  occurs  the  lesion  in  the  mouth  of  the  child  does  not  diifer  from  the 
same  lesion  in  the  adult.  The  secondary  manifestations  are  most  common,  and 
any  part  of  the  mucous  membrane  may  be  their  seat.  Upon  the  lips  we  find 
the  following  forms :  syphilitic  fissures,  papules,  plaques,  and  erosions.  The 
fissures  (rhagades)  are  most  common,  and  are  generally  found  at  the  corners  of 
the  mouth  or  upon  the  upper  and  lower  lips.  They  are  syphilitic  infiltrations 
which  have  been  split  near  their  middle,  so  that  at  the  corner  of  the  mouth  one 
part  of  the  infiltration  lies  nearer  the  upper  lip,  the  other  nearer  the  lower,  and 
the  split  seems  a  continuation  of  the  commissure.  Upon  the  lip  rhagades 
usually  end  in  the  mucous  membrane.  Sometimes  these  fissures  are  present 
in  such  great  nuinbers  that  they  disfigure  the  mouth,  and  by  tlie  pain  which 
they  produce  cause  great  annoyance  to  the  patient.  When  they  heal  they  leave 
cicatrices  which,  in  their  turn,  may  permanently  disfigure  the  mouth.  The 
characteristics  of  these  fissures   are  the  infiltration,  the    split,  and  the  lack 


DENTITION.  409 

of  tendency  to  spontaneous  healing.  Papules  are  most  common  at  the 
commissure  and  the  free  border  of  the  lips ;  they  may  also  be  split,  and  then 
resemble  the  former  variety.  As  a  rule  they  look  like  condylomata  lata  in 
similar  positions ;  they  are  elevated,  their  surface  is  moist,  the  centre  has  a 
tendency  to  break  down,  and  unless  they  involve  the  mucous  membrane  they 
do  not  cause  pain.  The  remaining  forms  may  be  found  upon  any  part  of  the 
mucous  membrane  ;  they  cover  more  space,  are  not  characterized  by  the  same 
amount  of  infiltration,  but  usually  produce  more  pain  and  more  salivation. 

Upon  the  tongue  we  most  commonly  find  plaques  muqueuses  and  syphilitic 
ulcers.  Their  localization  depends  largely  upon  irritation,  either  from  a  sharp 
tooth  or  other  cause.  The  healed  ulcers  leave  cicatrices,  but  the  characteristic 
appearance  of  the  tongue,  as  it  is  found  in  the  adult  after  syphilis  has  run  its 
course,  is  exceedingly  rare  in  children.  In  the  early  stages  of  syphilis  we  find 
a  decided  enlargement  of  the  circumvallate  papillae,  and  a  loss  of  the  filiform 
papillae,  so  that  the  tongue  looks  "shaven."  The  so-called  geographical 
tongue  (wandering  rash,  ringworm,  lichenoid  condition)  has  nothing  in  com- 
mon with  syphilis  and  bears  no  relation  to  it. 

Treatment. — As  in  all  forms  of  syphilis,  so  with  stomatitis  syphilitica — gen- 
eral treatment  is  of  most  importance.  When  deformity  or  danger  to  life  is  threat- 
ened, that  method  must  be  used  which  produces  the  quickest  effects.  The  manifes- 
tations in  the  mouth,  as  a  rule,  yield  rapidly  to  constitutional  treatment,  but 
local  prophylaxis  and  treatment  must  not  be  lost  sight  of,  as  being  accessory 
and  highly  important.  Cleanliness  is  absolutely  necessary  to  prevent  saliva- 
tion as  well  as  to  aid  in  recovery.  All  sources  of  irritation  must  be  removed 
and  the  teeth  must  be  kept  in  good  condition.  Frequent  applications  of  silver 
nitrate  are  best  for  ulcers,  erosions,  or  losses  of  substance.  Corrosive  sublimate 
is  preferable  when  there  is  considerable  infiltration,  either  in  weak  solution  as 
a  mouth-wash,  or  in  stronger  solution  applied  with  a  brush,  in  which  case  it  is 
apt  to  produce  pain.  The  weak  solutions  should  be  applied  two  to  four  times 
daily  ;  the  strong  ones  (as  high  as  12  per  cent.)  are  caustic  and  should  be  used 
with  great  caution.  When  children  are  old  enough  an  application  of  emplas- 
trum  hydrargyri  with  lanolin  (1  part  of  lanolin  to  2  parts  of  the  emplastrum) 
upon  chamois  gives  better  results  than  either  of  the  former  remedies  in  rhagades 
at  the  corners  of  the  mouth.  In  cases  of  stomatitis  mercurialis,  potassium 
chlorate  or  any  remedy  containing  tannic  acid,  such  as  tannin  itself  or  tincture 
of  rhatany  or  catechu,  is  very  serviceable. 


n.  DENTITION. 


Nearly  all  diseases  of  childhood  have  been  ascribed  to  teething  ;  even  at 
the  present  time  authors  will  be  found  who  do  not  hesitate  to  work  out  the 
most  improbable  relations  of  teething  to  disease.  But,  be  this  as  it  may,  there 
is  no  one  who  does  not  admit  that  some  children  may  have  teeth  without  any 
great  amount  of  disturbance,  or,  indeed,  that  teething  may  go  on  without  pro- 
ducing any  symptoms  at  all.  This  latter  form  of  teething  would  be  called 
normal ;  the  abnormal  form  has  been  called  dentitio  difficilis.  It  is  proper  to 
state  that  medical  authorities  are  much  divided  as  to  the  importance  of  teeth- 
ing as  an  etiological  factor  of  disease,  and  that  they  can  be  divided  into  three 
classes  :  those  claiming  that  almost  any  disease  can  be  produced  by  teething, 


410  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

those  claiming  that  no  disease  is  produced  by  teething,  and,  lastly,  those  who 
state  that  some  few  diseases  may  follow  the  eruption  of  teeth.  The  first  class 
states  that  normal  teething  occurs  in  only  20  per  cent,  of  all  children. 
Although  teething  in  healthy  and  teething  in  unhealthy  children  is  a  better 
division  from  a  clinical  standpoint,  Ave  will,  for  the  present,  follow  the  division 
as  given  above. 

The  greater  part  of  teething  is  accomplished  before  the  child  is  born.  At 
about  the  seventh  week  of  foetal  life  the  epithelium  within  the  mouth  is  thick- 
ened, forms  a  ridge,  and  at  the  same  time  dips  into  the  embryonic  tissue  about 
to  form  the  jaw.  This  epithelial  process  is  called  the  enamel-germ  ;  it  grows 
so  as  to  surround  a  flask-shaped  cavity,  which  it  lines  ;  partitions  develop  into 
this,  forming  ten  cavities  for  each  jaw.  A  papilla  is  now  developed,  which, 
pushing  up  toward  the  embryonic  tooth,  forms  a  complete  mould  for  the  enamel- 
germ  to  rest  upon,  and  this  is  called  the  dentine-germ.  We  now  have  the 
beginnings  of  the  ten  temporary  teeth  in  the  form  of  the  partitions,  the  enamel- 
and  dentine-germ,  and  the  papillae.  The  connective  tissue  around  these  primi- 
tive teeth  has  at  the  same  time  been  forming  into  the  dental  sac,  an  investing 
membrane  for  each  tooth.  In  the  partitions,  as  well  as  in  the  rest  of  the  jaw, 
bony  tissue  is  being  formed;  the  teeth  become  farther  separated  from  each 
other,  and  by  this  deposit  of  bone  the  alveolus  is  formed,  lined  by  the  dental 
sac  coherent  with  the  gum  along  the  border  of  the  jaw.  This  process  of  devel- 
opment has  taken  the  whole  period  of  foetal  life,  so  that  the  child  comes  into 
the  world  with  all  its  temporary  teeth  fully  formed  within  the  jaw.  The  per- 
manent teeth  are  formed,  in  so  far  that  the  enamel-germ  is  developed  from  the 
enamel-germ  of  the  temporary  tooth  as  a  small .  sac,  from  which  subsequently 
the  development  goes  on,  as  already  described  for  the  temporary  teeth.  The 
topographical  relations  of  the  teeth  at  birth  are  as  follows :  above,  the  tooth-sac, 
the  submucous  connective  tissue,  and  the  mucous  membrane  itself;  on  either 
side,  the  tooth-sac  and  bony  tissue.  There  is  no  bony  tissue  to  impede  the 
tooth  on  its  way  to  the  oral  cavity  ;  all  that  it  needs  to  overcome  is  the  sub- 
mucous coat,  the  mucous  membrane,  and  the  dental  sac,  which  is  very  thin. 
Not  enough  stress  can  be  laid  upon  the  fact  that  the  opening  of  the  alveolus  is 
wider  than  necessary  to  allow  the  tooth  to  pass  through. 

Calcification  of  the  fangs  begins,  and  as  the  tooth  becomes  elongated  by 
means  of  this,  it  is  slowly  forced  in  the  direction  of  least  resistance,  the  mouth. 
Pressure  is  directed  toward  the  mouth  ;  the  papilla  cannot  be  pressed  upon, 
for  the  simple  reason  that  where,  during  growth,  blood-vessels  come  in  contact 
with  bony  substances,  absorption  of  the  latter  is  produced,  the  blood-vessels 
not  being  affected.  It  is  possible  that,  as  Kassowitz  has  pointed  out,  the 
growth  of  the  blood-vessels  causes  the  alveolus  to  be  moved  constantly,  and 
that  this  growth  acts  as  another  cause  for  the  coming  through  of  the  teeth. 
Calcification  of  the  fangs  usually  begins  in  the  lower  incisor  teeth  at  birth, 
beginning  in  those  teeth  first  which  are  first  to  make  their  appearance  in  the 
mouth. 

The  order  of  teething  can  be  described  as  occurring  in  three  ways.  Unfor- 
tunately, there  is  as  yet  no  unanimity  among  authors  as  to  the  most  common 
method.  The  first  is  the  appearance  of  the  teeth  in  pairs,  principally  in  rela- 
tion to  the  incisors.  The  second  is  the  appearance  of  the  first  two  incisors, 
then  all  the  other  incisors,  and  then  the  molars.  The  third,  which  we  believe 
to  be  the  most  common  order,  is  the  appearance  of  the  first  two  lower  incisors, 
then  the  four  upper  incisors,  then  the  first  molars,  and  with  them  the  remain- 
ing two  lower  incisors,  as  follows : 


DENTITION.  411 

I.  Two  lower  central  incisors 5-7  months. 

II.  Four  upper  incisors 8-10       " 

III.  Four  first  molars  and  two  lower  lateral  incisors    .  12-14       " 

IV.  Four  canines 18-20       " 

V.  Four  second  molars 28-34       " 

It  will  be  borne  in  mind  that  this  table  represents  average  times,  and  that 
the  time  for  eruption  depends  upon  a  great  many  difi"erent  causes.  The  nation- 
ality, heredity,  climate,  and  general  development  of  the  child  may  either 
retard  or  accelerate  the  appearance  of  teeth.  Certain  diseases,  especially 
rickets,  have  a  well-marked  retarding  influence,  but  because  a  child  is  late  in 
teething  it  must  by  no  means  be  taken  as  positive  evidence  that  he  has  rickets. 

The  time  of  eruption  depends,  first,  upon  the  distance  the  tooth  has  to 
travel  from  the  dental  sac  to  the  mouth ;  secondly,  the  amount  of  calcification 
in  the  fangs  ;  and,  lastly,  the  condition  of  the  rudimentary  organs.  Increased 
calcareous  deposit  would  compensate  for  length  of  distance,  and  possibly  for 
deficiencies  in  the  rudimentary  organs ;  but  frequently  no  compensation  can 
take  place,  and  the  teeth  are  left  permanently  deformed  as  well  as  late  in 
appearing. 

Premature  teeth  may  occur  from  several  causes :  some  change  in  the 
embryonic  structure  may  result  in  the  production  of  teeth  without  fangs,  which 
are  attached  only  by  mucous  membrane ;  or  the  deposit  of  calcareous  material 
may  be  too  early  or  too  great;  or,  finally,  more  than  twenty  primitive  teeth 
may  have  been  formed,  one  or  more  of  which  project  into  the  cavity  of  the 
mouth.  Premature  ossification  of  the  bones  of  the  skull  is  said  to  be  accom- 
panied by  premature  teeth,  and  in  this  case  Jacobi  claims  that  the  upper 
incisors  then  appear  first.  The  latter  view,  however,  still  requires  verification. 
Premature  teeth  must  not  be  interfered  with  unless  there  is  a  special  indication 
for  their  removal,  because  it  may  be  possible  that  no  second  tooth  shall  appear 
until  the  permanent  one  comes  through  ;  and,  furthermore,  their  removal  is 
not  unattended  by  danger  (haemorrhage).  The  most  urgent  indication  for 
removal  is  to  be  found  in  their  being  in  the  way  of  nursing ;  they  may 
produce  fissure  of  the  nipples  or  may  make  nursing  so  painful  to  the  mother 
that  serious  consequences  follow. 

The  teeth  are  retarded  by  the  constitutional  diseases,  rickets  and  syphilis — 
these  forms  of  general  disturbance  of  nutrition  resulting  in  cachexia  and  in 
long-continued  fevers  or  chronic  diarrhoea.  Acute  febrile  disturbances,  such 
as  the  exanthemata,  may  not  have  any  effect  upon  the  temporary  teeth,  and 
yet  show  distinct  tracings  upon  the  permanent  teeth  ;  or  the  group  coming 
through  at  the  time  of  fever  may  not  be  delayed  at  all,  and  yet  the  next 
one  will  be  delayed  some  time. 

A  food-supply  defective  in  calcareous  material  has  been  frequently  accused 
of  delaying  teething.  This  is,  theoretically,  correct ;  but,  as  a  matter  of  fact, 
when  the  salt  material  of  the  food  is  diminished  to  such  an  extent  as  not  to  be 
able  to  supply  the  small  amount  demanded  for  teething,  life  can  no  longer  be 
sustained  by  such  food.  Our  own  experience  has  been  that  none  of  the 
proximate  principles  of  which  teeth  are -composed,  when  administered  inter- 
nally, have  any  effect  upon  the  appearance  of  the  teeth.  There  is  but  one 
remedy  which  seems  to  hasten  teething,  and  that  one  affects  rachitic  children 
principally,  though  not  exclusively ;  we  refer  to  the  internal  administration  of 
phosphorus. 

The  permanent  teeth  appear  in  about  the  following  order  and  times : 


412  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDBE2^. 

First  Molars.  Incisors.  Bicu.^pids.  Canines.  Second  Molars.  Tkird  Molars. 

6  vears.  7-8  years.        9-10  years.      12-14  years.         12-15  years.  17-25  years. 

In  regard  to  the  symptoms  produced  by  teething,  it  can  be  definitely  stated 
that  in  a  healthy  child  teething  goes  on  without  producing  symptoms  of  any 
sort.  In  children  reduced  by  malnutrition,  affected  by  hereditary  syphilis  or 
rickets,  and  in  those  extremely  nervous  either  as  a  result  of  hereditary  or  other 
causes,  there  are  symptoms  which  can  be  divided  into  two  groups :  first,  local ; 
secondly,  remote.  The  local  symptoms  are  pain,  heat,  irritation,  not  infre- 
quently stomatitis  catarrhalis.  All  these  may  occur  in  healthy  children,  but 
are  manifestly  of  little  importance,  as  they  produce  little  if  any  general 
reaction,  and  are  certainly  very  rare.  At  times  children  may  become  a  little 
fretful  or  cross,  and  in  the  evening  have  a  slight  rise  of  temperature.  As  a 
rule,  however,  the  teeth  which  have  long  been  expected  by  the  anxious 
watchers  make  their  appearance  without  premonitory  signs,  so  that  the  wise 
physician  will  hesitate  before  he  prophesies  when  a  tooth  is  to  appear. 
Salivation  cannot  be  looked  upon  as  a  symptom  of  teething,  as  it  usually 
occurs  from  two  to  three  months  before  the  first  incisors  appear,  and  is 
phy.siological.  The  salivation  occurring  during  teething  is  due  to  stomatitis. 
The  pain  can  only  be  very  slight,  and  can  be  judged  by  analogy  with  that 
produced  during  the  appearance  of  the  second  teeth.  In  an  unhealthy  or 
over-sensitive  child  this,  however,  may  be  sufficient  to  produce  restlessness  or 
peevishness.  That  the  pain  cannot  be  very  great  must  be  accepted  also  from 
anatomical  facts :  the  nerve-filaments  covering  the  tooth  have  either  been 
absorbed  or  rendered  insensitive  by  continuous  pressure  upon  them.  The 
papilla  cannot  be  taken  into  consideration  at  all,  as  it  has  been  shown  that 
the   teeth  could  not  in   any  way  press  upon  it. 

The  symptoms  in  remote  parts  have  to  be  analyzed  carefully,  and  much 
cool  judgment  may  be  required  to  find  their  cause.  ^The  tendency  at  the  pres- 
ent time  is  to  accept  fewer  and  fewer  symptoms  as  due  to  teething ;  but  for 
convenience  we  have  grouped  them  under  the  following  headings :  symptoms 
on  the  part  of  the  nervous  system,  the  digestive  apparatus,  the  skin,  the  respi- 
ratory apparatus,  the  genito-urinary  system,  and  the  organs  of  special  sense. 

The  principal  symptom  on  the  part  of  the  nervous  system,  still  adhered  to 
by  many,  is  convulsions.  It  is  claimed  that  they  are*  of  a  reflex  kind,  the 
tooth  being  the  irritant  producing  an  abnormal  afferent  impulse  to  the  medulla. 
Theoretically,  this  can  be  taken  into  consideration,  but  in  practice  convulsions 
are  not  produced  by  teething,  least  of  all  as  the  result  of  a  reflex  mechanism. 
Tonic  contractions  of  muscles  of  a  local  nature  may  easily  be  produced  by  an 
increased  afferent  impulse,  but  the  most  painful  lesions  involving  the  fifth  pa^r  of 
nerves  in  the  reflex  arc  are  not  followed  by  generalized  muscular  contractions. 
In  the  alimentary  canal  we  find  the  bowels  participating  in  the  general  hvper- 
sensibility  of  the  child.  There  is  no  evidence  to  show  that  bowel  lesions  are 
produced  by  teething,  either  as  the  result  of  swallowing  an  imaginary  excess 
of  saliva  or  otherwise.  The  most  pernicious  doctrine  that  exists  is  the  one 
that  intestinal  disease  is  due  to  teeth.  An  over-fed  or  badly-fed  child — and  at 
the  time  of  the  eruption  of  the  canines  it  is  mo.st  liable  to  be  both — if  suffer- 
ing, generally  has  an  irritable  intestine:  and  very  likely  substances  which 
should  not  enter  the  circulation  may  pass  into  it  from  the  intestine,  aiid  the 
result  will  be  stools  changed  as  to  quantity  and  quality.  This,  in  the  lat- 
ter instance,  is  a  curative  act,  and  disappears  as  soon  as  the  diet  is  corrected. 
There  is  nothing  characteristic  about  this  form  of  diarrhoea;  it  rarely  becomes 
pathological,  and  may  be  helped  along  by  the  administration  of  a"  laxative. 
Any   diarrhoea,    however,    occurring   at   any  time   during   infancy  should   be 


DENTITION.  413 

■watched,  whether  the  child  is  supposed  to  be  teething  or  not,  and,  the  cause 
being  removed,  the  bowels  should  be  "checked."  It  is  important  to  disre- 
gard teething  entirely  in  long-continued  diarrhoea,  and  to  look  to  the  food  or 
other  known  agencies  for  the  cause. 

On  the  part  of  other  organs  the  symptoms  which  occur  must  be  looked 
upon  as  concomitant  with  teething  and  not  caused  by  it. 

Some  have  claimed  that  teething  does  not,  fer  se,  make  children  sick,  but 
that  it  predisposes  them  to  illness.  Predisposition  to  disease  undoubtedly  exists, 
both  temporary  and  permanent,  but  it  is  a  difficult  thing  to  establish,  and,  from 
what  we  know  at  present,  such  a  theory  must  be  denied  absolutely  as  far  as 
teething  is  concerned. 

There  is  no  treatment  for  teething,  as  it  requires  none.  The  healthy  child 
has  no  symptoms  to  manifest  any  diseased  condition,  because  there  is  no  dis- 
ease. The  unimportant  symptoms  that  may  occur  are  to  be  treated  purely 
symptomatically.  The  restlessness,  where  necessary,  will  be  relieved  by  bro- 
mides. The  various  forms  of  stomatitis  are  to  be  treated  by  the  appropriate 
remedies  referred  to  in  another  place.  Bowel  troubles  require  rigid  diet,  always 
a  proper  precautionary  measure  in  all  forms  of  intestinal  disturbances.  Beyond 
this  nothing  is  required. 

Gum-lancing  or  gum-scarifying  is  looked  upon  by  many  as  the  specific 
method  of  treatment  for  teething  ailments.  The  indication  for  the  operation 
is  to  relieve  pressure.  The  tooth  has  been  supposed  to  press  in  any  or  all 
directions,  and  by  means  of  this  pressure  to  produce  the  baneful  results  referred 
to.  Some  authors  claim  that  the  pressure  is  exerted  upon  the  mucous  mem- 
brane ;  others,  upon  the  dental  sac ;  others,  upon  the  alveolus ;  and  finally 
others,  upon  the  "sensitive"  papilla.  Accordingly,  each  one  has  a  peculiar 
method  to  recommend  for  the  operation.  From  a  practical  standpoint  any  of 
these  methods  can  do  good  in  only  one  of  two  ways — either  as  a  method  of  blood- 
letting or  as  a  suggestive  remedy;  but  either  indication  can  be  met  by  simpler 
means.  From  a  theoretical  standpoint  everything  is  against  any  such  method 
of  operation.  It  has  already  been  shown  that  the  papilla  cannot  be  pressed 
upon,  and  that  the  opposite  condition  exists :  the  papilla  is  forcing  the  tooth. 
All  this  in  the  growing  tooth  is  done  so  gradually,  however,  that  very  little 
pressure  is  exerted  in  any  direction.  The  mucous  membrane  cannot  be  accused 
of  suflFering,  for,  as  we  have  seen,  movement  of  the  teeth  toward  the  oral 
cavity  practically  begins  at  birth.  Given  any  mucous  membrane  which  has 
been  pressed  upon  by  a  rigid  substance  for  from  five  to  seven  months,  and 
atrophy  will  undoubtedly  follow — atrophy  of  the  membrane  and  all  its  com- 
ponent parts,  including  the  nerves.  For  the  same  reason  pressure  upon 
the  dental  sac  would  be  impossible.  Pressure  upon  the  bony  walls  is  out  of 
the  question,  because  there  is  ample  room  in  all  directions  for  the  tooth,  the 
opening  of  the  alveolus  being  especially  large,  so  that  the  crown  of  the  tooth 
can  pass  without   difficulty. 

It  cannot  be  denied  that  indiscriminate  gum-lancing  does  harm.  Haemor- 
rhage is  its  greatest  danger :  we  have  collected  twelve  fatal  cases,  and  it  is  not 
overstating  the  matter  when  we  say  that  many  more  have  occurred  that  have 
not  been  recorded.  Behrend,  Churchill,  Barthez  and  Rilliet,  and  Finlayson 
refer  to  the  danger  to  children  arising  from  ansemia  as  a  result  of  this 
operation — a  danger  that  cannot  be  expressed  statistically.  Under  normal 
circumstances  the  pushing  through  of  a  tooth  does  not  leave  a  wound  of  any 
sort :  there  are  no  lymphatics,  no  blood-vessels  opened,  these  having  been 
closed  by  the  process  referred  to  before.  Every  time  a  gum  is  lanced  an  open 
wound  is  produced — fortunately,  one  which,  under  ordinary  circumstances,  heals 


414   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

quite  rapidly.     But  with  the  mouth   as  a  playground  for  many  pathogenic 
microbes  the  danger  of  infection  must  not  be  under-estimated. 

In  conclusion,  I  wish  to  emphasize  the  following  points  :  I.  Gum-lancing  is 
useless,  «,  as  far  as  giving  relief  to  symptoms ;  b,  as  far  as  facilitating  or  hasten- 
ing teething.  II.  It  is  useful  only  as  bloodletting  or  as  a  suggestion,  and  ought 
not  to  be  used  as  such.  III.  It  is  harmful,  a,  in  producing  local  trouble ;  b,  in 
producing  great  disturbance  on  account  of  haemorrhage ;  c,  in  having  estab- 
lished a  method  which  is  too  general  for  specific  good  and  too  specific  for  uni- 
versal use.  IV.  It  is  to  be  used  only  as  a  surgical  procedure  to  give  relief  foi 
surgical  accidents.^ 

^  The  author  certainly  presents  in  a  very  forcible  manner  one  side  of  the  disputed  question 
of  the  advisability  of  gum-lancing.  That  too  many  aberrations  from  health  are  laid  to  the 
score  of  teething,"and  that  lancing  is  often  performed  heedlessly,  unnecessarily,  and  even  inju- 
riously, cannot  be  questioned,  yet  there  are  many  well-informed  physicians  and  clinicians  who 
use  the  lance  in  appropriate  cases,  because  experience — the  crucial  test — has  demonstrated  its 
utility.     In  this  class  the  Editor  must  be  included. — L.  S. 


DISEASES  OF  THE  PHARYNX  AND 
NASOPHARYNX. 

By  W.  E.  CASSELBERRY,  M.  D., 

Chicago. 


I.  Acute  Pharyngitis  and  Naso-pharyngitis. 

The  posterior  wall,  the  vault,  and  the  lateral  angles  of  the  pharynx,  the 
pillars  of  the  fauces,  the  velum  palati,  and  the  tonsils  may  be,  each  alone  or  all 
together,  the  seat  of  an  acute  inflammation  of  the  mucous  membrane,  which  for 
convenience  is  commonly  designated  simply  as  "pharyngitis." 

Predominant  inflammatory  diseases  of  the  tonsils,  however,  are  considered 
apart  under  appropriate  titles,  although  tonsillitis  of  a  superficial  type  is  often  a 
detail  only  of  diffuse  simple  pharyngitis,  and  may  then  be  included  in  the 
latter  term.  The  forms  of  symptomatic  pharyngitis  which  are  incidental  to  the 
exanthemata  are  excluded  from  consideration  at  this  point. 

Etiology. — The  predisposing  conditions  are  chronic  hypertrophy  of  the 
faucial  and  naso-pharyngeal  tonsils,  acute  or  chronic  rhinitis,  previously  exist- 
ing chronic  pharyngitis,  and  digestive  disturbance.  Climatic  inequalities,  with 
exposure  to  chilling  influences,  furnish  adequate  exciting  causes. 

Pathology  and  Symptoms. — Hypersemia  may  be  so  pronounced  and  so 
diffuse  as  to  lend  a  bright  reddish  hue  to  the  entire  oro-pharynx,  or,  on  the 
other  hand,  only  limited  spots  of  congestion  may  be  noticeable.  Often  the 
pillars  of  the  fauces  alone  are  implicated. 

The  posterior  surface  of  the  velum  palati  is  a  frequent  point  of  attack,  and, 
indeed,  the  disease  not  infrequently  embraces  the  rest  of  the  naso-pharynx, 
and  occasions  an  amount  of  pain  and  discomfort  located  high  up  which  is  far 
in  excess  of  that  which  can  be  explained  by  inspection  of  the  fauces  only. 
More  explicitly  speaking,  naso-pharyngitis  may  be  conjoined  with  pharyngitis. 

After  the  first  twenty-four  hours  thickening  and  relaxation  of  the  mucosa, 
with  swelling  and  oedema,  especially  of  the  velum  and  uvula,  is  associated  with 
the  hypersemia,  and  the  disease  culminates  at  times  in  chronic  relaxation  of  the 
velum  and  elongation  of  the  uvula.  The  secretion  is  at  first  diminished,  the 
patient  complaining  of  "  dryness,"  but  later  there  is  an  excess  of  viscid 
mucus. 

In  childhood  the  acute  folliculous  variety  of  pharyngitis  is  very  common ; 
that  is,  the  isolated  muco-lymphoid  glands  which  are  scattered  over  the  pos- 
terior wall  of  the  pharynx  are  especially  the  centres  of  inflammatory  action. 

The  patient  complains  of  a  constant  sense  of  discomfort,  which  necessitates 
frequent  acts  of  deglutition,  which  are  positively  painful,  although  actual 
swallowing  of  food  is  rarely  painful  except  in  severe  forms  of  the  disease. 
There  is  but  little  systemic  derangement  in  uncomplicated  cases. 

Diagnosis. — Critical  inspection  of  the  pharynx  by  means  of  a  good  light, 
preferably  light  reflected  from  a  concave  mirror,  will  establish  the  diagnosis  by 

415 


416    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

correspondence  with  the  signs  above  described.  In  the  first  twenty-four  hours 
it  may  be  difficult  to  distinguish  simple  pharyngitis  from  the  symptomatic 
pharyngitis  of  scarlatina,  the  preliminary  pharyngitis  of  diphtheria,  the  first 
stage  of  acute  infectious  phlegmon  of  the  pharynx,  and  pharyngeal  erysipelas. 
The  presence  of  high  temperature,  perhaps  following  a  distinct  chill  and  accom- 
panied by  pronounced  systemic  derangement,  should  cause  one  to  anticipate 
future  developments. 

Prognosis. — Recovery  is  hastened  by  treatment,  but  in  uncomplicated 
cases  it  would  naturally  ensue  within  ten  days.  It  is  supposed  that  simple 
pharyngitis  may  predispose  a  child  to  infection  by  the  bacillus  diphtherige  and 
other  pathogenic  micro-organisms. 

Treatment. — In  mild  cases  a  simple  gargle  of  potassium  chlorate,  ten  grains 
to  the  ounce,  every  two  hours,  is  sufficient.  This  may  be  made  more  effective 
when  greater  astringency  is  desired  by  the  addition  of  tannic  acid  two  grains 
to  the  ounce.     A  variety  of  other  astringents  are  also  available. 

In  severer  cases,  especially  those  which  are  conjoined  with  naso-pharyn- 
gitis  and  rhinitis,  it  is  important  first  to  cleanse  the  entire  area  by  spraying  or 
gargling  with  an  antiseptic  alkaline  solution  : 

I^.   Sodii  boratis 

Sodii  bicarbonatis aa  gr.  xx. 

01.  eucalypti 1Ttj. 

Thymol g^'-  j- 

Menthol      gr.  ss. 

01.  gaultheriae 111  j. 

Glycerini f5ss. 

Alcoholis fsj. 

Aquae q.  s.  ad  f^j. — M. 

Sig.  Dilute,  adding  one  or  two  fluidrachms  to  one  fluidounce  of  water, 
for  use  as  a  spray  or  gargle. 

Young  children  cannot  gargle,  and  are  often  terrified  by  spraying,  in  which 
case  one  may  project,  through  each  nostril  into  the  throat,  a  half-drachm  of 
this  diluted  mixture  by  means  of  an  ordinary  glass  medicine-dropper.  After 
thus  cleansing  the  parts  the  same  astringent  gargle  may  be  used ;  or  with  larger 
children  and  in  the  hands  of  the  physician,  an  astringent  spray,  preferably  of 
the  sulphate  of  iron  and  ammonium,  three  to  five  grains  to  the  ounce,  may  be 
applied  to  the  pharynx,  and,  if  need  be,  by  an  upward  spray-tip  to  the  naso- 
pharynx. The  astringents  should  never  be  projected  through  the  nose.  In 
painful  cases  much  comfort  and  some  benefit  follow  spraying  by  a  1  per  cent, 
solution  of  cocaine  hydrochlorate,  and  with  especially  irritable  throats  its  pre- 
liminary use  will  permit  subsequent  topical  applications  to  be  made  with  greater 
ease. 

When  necessary,  minute  quantities  of  cocaine  may  be  used  in  the  form  of 
a  lozenge,  as  in  the  following  formula,  recommended  by  Bosworth : 

!^4.   Cocainse  muriatis      gi"*  v. 

Ext.  kramerige g^-ij- 

Sodii  bicarbonatis gr.  xv. 

Ext.  glycyrrhizfB Siiss. — M. 

Ft.  massa  in  trochisci  No.  xxx  div. 

In  office  practice  as  a  final  spray,  or  for  self-medication,  even  alone  or 


DISEASES  OF  THE  PHABYNX  AND  NASO-PHABYNX.     417 


following  an  astringent  gargle,  we  find  the  following  emollient  very  soothing 
to  highly  inflamed  mucous  surfaces : 


^.  01.  pini  Canadensis 
01.  eucalypti  . 
01.  gaultherige 
Thymol  .  .  . 
Menthol  .  .  , 
"  Yaselin  oil  "  , 
Sicr.  Use  with  a  double-bulb  atomizer, 


.  .  .  m  V. 

•  .  m  ij. 

.  •  ■  m  ij. 

.    .    .  gr.  ss. 

.    .    .  gr.j. 

q.  s.  ad  fgj. — M. 


Fig.  1. 


A  laxative  is  usually  indicated,  even  though  the  bowels  may  be  stated  to 
be  regular.  Apart  from  this,  little  constitutional  treatment  is  required,  other 
than  may  seem  appropriate  for  any  associated  conditions. 

n.  Simple  Chronic  Phauyngitis;  Elongation  of  the  Uvula. 

Simple  chronic  pharyngitis  occurs  but  rarely  in  childhood,  and  is  then 
dependent  upon  diseases  of  the  nose,  tonsils,  or  digestive  organs,  and  the  most 
rational  line  of  treatment,  and  the  only  one  likely  to  result  successfully,  is  that 
indicated  by  the  primary  affection.  The  same  is  true  in  part  of  elongation  of 
the  uvula,  but  only  in  part,  since  radical  treatment  directed  to  this  organ  will 
occasionally  be  required. 

Relaxation  of  the  velum  palati  and  paresis  of  its  muscles  are  usually  asso- 
ciated with  lengthening  of  the  uvula,  and  the  disability  is  due  to  chronic  or 
recurrent  acute  inflammation  of  the  nose,  naso-pharynx,  or  pharynx.  Frequent 
necessity  to  dislodge  mucus  by  "hawking"  is  somewhat  instrumental  in  its 
production. 

Symptoms. — The  chief  symptom  is  a  harassing  cough,  which  is  found 
especially  annoying  on  retiring  and  rising  and  at  times  of  acute  inflammation 
of  the  throat.  It  often  causes  the  child  to  be 
treated  indefinitely  for  bronchitis  or  other  in- 
visible disorders,  when  a  critical  inspection  of 
the  pharynx  in  a  state  of  quietude  would  dis- 
close the  palate  lying  on  the  base  of  the  tongue. 
Extreme  elongation  has  even  served  to  excite 
attacks  of  laryngismus  stridulus.  Rarely  the 
uvula  is  bifid,  a  congenital  defect  which  pre- 
disposes it  to  elongation. 

Treatment. — Concerning  the  treatment, 
palliation  may  be  secured,  even  cure  in  recent 
cases,  by  an  astringent  sprav  or  grarcrle.  More 
often  this  will  fail  to  produce  wholly  satisfac- 
tory results,  and  then  attention  must  be  given 
to  whatever  abnormality  underlies  the  elonga- 
tion of  the  uvula:  if  the  tonsils  be  hypertro- 
phied,  they  should  be  abscised;  if  there  be 
naso-pharyngeal  adenoid  hypertrophy,  it  should 
be  removed,  etc.  If  the  difiiculty  then  con- 
tinue, one  should  not  hesitate  to  abscise  the 
surplus  portion  of  the  uvula,  leaving  it  of  nor- 
mal length.      It  is  most  quickly  done  by  a 

uvulatome  fashioned  on  the  principle  of  a  tonsillotome,  but  can  readily  be 
accomplished  by  forceps  and  scissors.     (Fig-  !•) 

27 


Abscission  of  the  Uvula. 


418    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

m.  Chronic  Folliculous  Pharyngitis. 

Although,  as  previously  stated,  simple  chronic  pharyngitis  occurs  but  rarely 
in  childhood,  chronic  folliculous  pharyngitis  is  not  uncommon.  It  is  character- 
ized by  enlargement  of  the  isolated  muco-lymphoid  follicles  which  are  scattered 
o-ver  the  posterior  wall  of  the  pharynx  and  arranged  in  a  chain  in  each  lateral 
angle  of  the  throat  behind  the  posterior  pillar.  These  are  single  follicles  of 
the  same  histological  structure  as  the  tonsils,  which  are  compound  glands.  It 
is  natural,  therefore,  that  they  should  become  hypertrophied  in  response  to  the 
same  underlying  dyscrasia — lymphatism — which  predisposes  patients  to  hyper- 
trophy of  the  tonsils  and  of  the  naso-pharyngeal  adenoid  tissue.  Indeed,  in 
children  the  disease  is  usually  conjoined  with  the  latter  pathological  states. 
Symptoms  are  manifest  only  in  pronounced  cases,  and  then,  usually,  at  times  of 
an  acute  exacerbation.  A  constant  tendency  to  "hawk,"  a  sense  of  discomfort, 
and,  in  rare  instances,  a  sense  of  a  foreign  body  in  the  throat,  are  the  most 
important.  On  inspection  one  observes  small  round  eminences  dotted  irreg- 
ularly over  the  posterior  wall  of  the  pharynx,  and  ridges  of  reddish  hue  in  the 
lateral  angles.  The  latter  aspect  of  the  disease,  when  especially  marked,  has 
been  designated,  in  recent  works,  pharyngitis  lateralis. 

Treatment. — The  enlarged  follicles  should  be  destroyed  by  touching  each 
one  with  the  galvano-cautery  point-electrode.  Three  or  four  may  be  cauter- 
ized at  each  sitting,  and  several  sittings  will  be  required.  The  result  is  very 
satisfactory.  When  tonsillar  and  naso-pharyngeal  adenoid  hypertrophy  is  also 
present,  this  condition  should  first  be  removed,  in  which  case  further  treatment 
often  becomes  unnecessary. 

rV.  Acute  Folliculous  Tonsillitis. 

The  infectious  nature  of  most  cases  of  folliculous  tonsillitis  is  now  defin- 
itely established ;  yet  other  cases  are,  seemingly,  of  simple  catarrhal  origin, 
devoid  of  pathogenic  germ  infection  ;  it  is  therefore  evident  that  one  can 
distinguish,  and  should  describe,  at  least  two  forms  of  this  disease  :  infectious 
pseudo-membranous  tonsillitis  and  simple  folliculous  tonsillitis. 

Infectious  Pseudo-membranous  Tonsillitis 

is  also  termed  "croupous  tonsillitis,"  "tonsillitis  lacunaris,"  "diphtheritic  sore 
throat,"  and  "pseudo-diphtheria,"  although  the  latter  term  has  been  indis- 
criminately applied  also  to  scarlatinous  diphtheria  and  to  all  forms  of  mem- 
branous pharyngitis  not  caused  by  the  Klebs-Loeffler  bacillus. 

Etiology. — The  infectious  nature  of  certain  forms  of  acute  folliculous  ton- 
sillitis has  long  been  suspected,  yet  the  fact  has  not  been  generally  credited, 
for  the  reason  that  Avhen  the  clinical  evidence  of  infectiousness  was  conclusively 
present  the  disease  Avould  be  attributed  to  diphtheritic  origin  or  the  subject 
be  dismissed  as  a  mere  coincidence.  We  now  know  that  the  true  bacillus 
diphthcrke  is  not  present  in  this  disease,  but  that  the  form  described  under 
the  name  of  infectious  pseudo-membranous  tonsillitis,  or  croupous  tonsillitis, 
is  caused  by  local  infection  by  any  one  of  several  species  of  pathogenic  micro- 
organisms ;  e.  g.  streptococcus  erysipelatosus,  streptococcus  pyogenes,  staphy- 
lococcus pyogenes  aureus,  staphylococcus  albus,  etc. 

Symptoms. — Infectious  pseudo-membranous  tonsillitis  is  characterized  by 
deep  congestion,  but  often  only  by  moderate  swelling  of  the  tonsils  and  by  a 
punctated  exudate  of  pseudo-membrane,  the  spots  of  which  are  in  size  from 
2  to  4  mm.  in  diameter,  and  are  attached  around  the  follicular  openings,  pre- 


DISEASES  OF  THE  PHARYNX  AND  NASO-PHARYNX.     419 

senting  the  appearance  as  if  the  crypts  were  also  lined  by  the  same  material ; 
unlike  the  cheesy  pellet,  the  exudate  in  its  typical  form  is  thin,  translucent,  and 
intimately  connected  with  the  underlying  mucosa.  Two  or  more  puncta  may 
join  at  their  borders  and  form  larger  spots,  but  after  cleansing  away  all  muco- 
purulent matter  this  punctated  conformation  of  even  the  larger  areas  may  be 
readily  discovered  (Fig.  2).  In  addition  to  the  tonsils,  any  or  all  of  the  muco- 
lymphoid  glands  in  the  pharynx  may  be  likewise  affected,  especially  the  chain 
of  glands  located  just  behind  the  tonsil  and  separated  from  it  by  the  posterior 
pillar;  but  the  pseudo-membranous  exudate  is  limited  absolutely  to  the  glandular 
structures  of  the  pharynx,  although  careful  cleansing  and  critical  inspection  will 
be  required  to  demonstrate  this  fact. 

The  attack  is  ushered  in  by  chilly  sensations,  perhaps  preceded,  for  a  day 
or  so,  by  malaise,  and  followed  by  a  temperature  of  102°  to  105°  F.,  with  con- 
sequent febrile  symptoms.    After  one 

to   three   days  the  temperature  falls  Fig.  2. 

materially  ;  the  pain,  which  has  been  -    -         ^"^--^ 

quite  severe,   gradually  ameliorates,  ^ 

and  within   one  week   convalescence  ^     _  ^^* 

is  established.  The  cervical  lymph- 
atic glands  are  often  secondarily  in- 
fected, as  evidenced  by  swelling  and  j  '  -_  ^ 
tenderness,  which  last  for  two  or 
three  weeks.  Suppurative  cervical 
adenitis  and  cellulitis  may  follow  in 
rare  instances.  Transient  albumin- 
uria is  an  occasional  complication. 

Diagnosis. — The  opinion  of  bac-  "  "rr_^; Zf5sZS--^^^^''=^~"-^"^~^  ■" 

teriologistS  that  in  these  affections  Acute  infectious  Pseudo-membranous  Tonsillitis 
flinlitbpvia  pnn  nnW  bp  pvplnrlpf]  r\(\'^\  (follicular).     The  two  whitish  points  on  the  pos- 

Uipntneria  can  Oniy  oe  exciuuea  posi-         terior  wall  represent  exudate  formed  on  isolated 

tively  by  the  absence  of  the  Klebs-       muco-iymphoid  fouicies. 
Loeffler  bacillus,  as  determined  micro- 
scopically, is  doubtless  correct  as  applied  to  rare  border-line  cases ;  but  com- 
monly a  differential  diagnosis  can'also  be  made  with  greater  promptness  and  with 
reasonable  certainty  from  the  macroscopic  signs  and  clinical  symptoms. 

True  diphtheritic  exudation  may  commence  at  the  orifices  of  the  crypts  of 
the  tonsil,  but  does  not  long  remain  limited  to  the  tonsils  and  muco-lymphoid 
glands  of  the  pharynx,  as  does  the  exudate  of  tonsillitis.  The  diphtheritic 
membranes  will  extend  within  twenty-four  hours  to  the  pillars,  velum,  or 
pharyngeal  wall.  The  exudate  of  tonsillitis  is  thin,  and  not  materially  raised 
above  the  surface;  it  is  white,  translucent,  and  presents  a  living,  clean  aspect 
devoid  of  necrotic  change;  while  the  exudate  of  diphtheria  is  thickish  or  pro- 
truding from  the  surface,  opaque,  and  dirty-yellow  or  rapidly  becoming  so — 
appearances  indicative  of  necrotic  change. 

The  exudate  of  tonsillitis  is  punctated,  the  spots  corresponding  to  the 
follicular  openings,  and,  while  two  or  more  puncta  may  join  at  their  borders 
and  form  larger  areas,  after  careful  cleansing,  critical  inspection,  under  thorough 
illumination,  will  disclose  this  punctated  conformation,  which  distinctly  differs 
from  the  diffuse  plaque  of  diphtheria,  even  when,  for  the  time  being,  the  diph- 
theritic exudate  occupies  the  tonsil  alone. 

Simple  Folliculous  Tonsillitis. 
With  the  simple  form  there  may  or  may  not  have  been  previous  chronic 


420    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

hypertrophy  or  inflammation  :  it  is  conditioned,  if  not  caused,  by  "  taking 
cold,"  i.  e.  by  refrigeration  of  some  part  of  the  body  surface,  which  determines 
vascular  engorgement  of  the  tonsils,  exactly  as  in  another  individual  it  may 
occasion  vascular  engorgement  of  the  nasal  turbinated  bodies.  The  tonsil 
swells,  the  follicular  openings  are  obliterated  and  the  pent-up  secretion  acts  as 
a  further  irritant ;  it  becomes  inspissated  and  mixed  with  epithelial  debris ;  it 
is  soon  forced  out  to  the  surface  of  the  gland  in  the  form  of  "  cheesy  "  pellets, 
which  are  altogether  different  from  a  pseudo-membrane,  and  which  protrude 
from  the  narrowed  follicular  openings.  Finally,  when  the  tonsils  are  free  of 
this  accumulated  debris,  or  at  times  earlier  if  the  globules  are  forcibly  dis- 
lodged and  removed,  the  tonsillitis  rapidly  subsides.  It  is  not  usually  pre- 
ceded by  a  distinct  chill,  and  not  accompanied  by  much  fever  or  systemic 
depression.  It  is  without  evidence  of  primary  parasitic  infection  as  a  cause, 
and  therefore  not  contagious ;  it  is  capable,  however,  of  being  transposed  into  a 
conglomerate  variety  of  tonsillitis  by  secondary  infection  with  pathogenic 
micro-organisms,  thus  becomino-  contagious. 

In  fact,  between  these  tw^o  types  of  tonsillitis  are  observed  numerous  cases 
of  mixed  variety  which  present  all  degrees  of  approximation  to  one  or  the 
other  type. 

General  Treatment. — The  rheumatic  diathesis  is  frequently  associated 
directly  or  indirectly  with  tonsillitis,  in  Avhich  case  salicylate  of  sodium  or 
salol  should  be  administered  internally.  Otherwise,  the  tincture  of  the  chloride 
of  iron,  1  part  to  10  parts  of  glycerin,  may  be  administered  every  hour  with- 
out further  dilution  in  the  dose  proportionate  to  the  age  of  the  child,  both  for 
its  local  eff'ect,  as  it  is  diffused  over  the  fauces  in  swallowing,  and  for  its  sys- 
temic influence. 

For  the  high  febrile  action  of  the  first  day  or  two  we  have  been  accustomed 
to  give  minute  doses  of  tincture  of  aconite,  conjoined  with  potassium  bromide, 
disguised  in  solution  by  a  few  minims  of  spirit  of  peppermint,  and  to  which 
may  be  added  very  small  quantities  of  morphine  if  it  is  needed  to  control  pain. 

Of  late  years,  antipyrine  or  phenacetin  has  been  often  substituted  advan- 
tageously for  the  aconite  and  bromide  mixture.  A  saline  laxative  is  nearly 
always  needed. 

Local  sprays  by  a  hand-atomizer  are  of  the  greatest  benefit  when  the  child 
is  old  enough  to  tolerate  them.  An  alkaline  and  antiseptic  lotion  (See  Acute 
Pharyngitis)  is  to  be  preferred.  This  should  be  sprayed  every  three  hours 
through  the  mouth,  and  also  through  the  nose,  into  the  naso-pharynx,  thus 
cleansing  that  cavity,  as  well  as  the  fauces,  of  the  viscid  muco-purulent  matter 
which  accumulates  and  conduces  to  much  discomfort. 

Hydrogen  peroxide,  diluted  to  the  point  of  freedom  from  production  of 
smarting  sensation,  is  also  an  excellent  local  spray,  especially  if  used  alter- 
nately with  the  one  above  mentioned ;  and  either  or  both  of  these  may  be  used 
following  a  preliminary  spray  of  1  per  cent,  solution  of  cocaine  hydrochlorate, 
Avhich  serves  to  control  pain  and  super-irritability  of  the  fauces. 

Generally  speaking,  it  is  best  to  avoid  the  use  of  cotton  swabs  and  brushes. 
Gargles  may  be  substituted  for  sprays  when  necessary,  or  made  to  supplement 
spraying,  and  for  use  as  a  gargle  the  formula  for  spray  above  referred  to  should 
be  diluted  doubly  as  much  as  for  use  in  a  spray. 

With  very  young  children  the  naso-pharynx  and  fauces  can  be  readily 
cleansed  by  the  same  solution  freely  diluted,  warmed,  and  injected  gently  in 
small  quantities  by  a  small  syringe  or  an  ordinary  medicine-dropper  through 
the  nares. 


DI8EA8E8  OF  THE  PHARYNX  AND  NASO-PHARYNX.     421 

V.  Peritonsillar  Abscess,  or  Suppurative  Tonsillitis. 

This  condition  is  also  termed  acute  parenchymatous  tonsillitis,  phlegmonous 
tonsillitis,  quinsy,  etc.,  but  of  these  terms  the  best  is  peritonsillar  abscess, 
because  it  is  descriptive,  since  the  suppuration  does  not  occur  in  the  tonsil 
itself,  but  in  the  cellular  tissue  around  it  or  above,  behind,  in  front,  or  to  the 
outer  side  of  the  gland.  The  disease  is  comparatively  rare  in  early  childhood, 
but  about  3  per  cent,  of  all  cases  occur  under  ten  years,  and  about  6  per  cent, 
under  fifteen  years,  of  age. 

Etiolog-y. — The  direct  cause  of  suppuration  here,  as  elsewhere,  is  infection 
by  specific  pathogenic  micro-organisms  from  some  source,  either  from  within  or 
without  the  body. 

The  predisposing  causes  are  exposure,  the  rheumatic  diathesis,  chronic  ton- 
sillitis, and  acute  folliculous  tonsillitis. 

Symptoms. — A  chill  or  chilly  sensation  is  followed  by  a  temperature  of 
102°  to  105°  F.,  and  consequent  febrile  symptoms.  About  the  same  time  a 
sense  of  soreness  and  fulness  is  perceived  in  one  side  of  the  throat,  followed  by 
lancinating  pains  which  dart  through  to  the  ear,  and,  later,  by  a  deep-seated 
throbbing  pain  as  suppuration  ensues.  On  inspection  the  swelling  is  seen  to 
extend  to  the  median  line  of  the  throat,  and  even  far  beyond,  in  severe  cases 
projecting  upward  into  the  naso-pharynx  and  downward  along  the  side  of  the 
pharynx,  sometimes  leaving  only  the  smallest  chink  available  for  respiration 
and  deglutition.  The  latter  function  is  painful,  and  the  diet  must  be  confined 
to  liquids,  for  the  reason,  also,  that  the  lower  jaw  is  "set"  so  that  the  mouth 
can  be  opened  only  about  half  an  inch. 

Viscid  mucus  accumulates  in  the  partially  occluded  pharynx  and  in  the  naso- 
pharynx, causing  suffocative  attacks  and  necessitating  painful  efforts  to  clear 
the  throat.  Indeed,  for  a  night  or  two  the  patient  cannot  assume  a  recumbent 
position  or  sleep  uninterruptedly,  as  voluntary  efforts  are  required  to  maintain 
patency  of  the  throat.  The  uvula  becomes  oedematous,  and  the  opposite  tonsil 
is  usually  somewhat  swollen,  often  suppurating  later,  although  simultaneous 
suppuration  of  the  two  sides  is  rare. 

Diagnosis. — During  the  first  twenty-four  hours  the  disease  cannot  be  dis- 
tinguished with  certainty  from  folliculous  tonsillitis,  which,  indeed,  often  pre- 
cedes the  peritonsillar  abscess.  Later,  the  diagnosis  is  established  by  the 
characteristic  distortion  of  the  throat,  as  represented  in  Fig.  3,  in  which  it 
is  seen  that  the  tonsil  itself  is  not  the  chief  seat  of  swelling,  but  that  this 
gland  is  projected  inward  by  tumefaction  in  the  cellular  tissue  of  the  velum 
palati. 

Prognosis. — This  is  favorable,  except  in  cases  of  rare  complications,  such 
as  oedema  of  the  larynx,  extensive  burrowing  of  pus,  or  haemorrhage. 

Treatment. — During  the  first  twenty-four  or  thirty-six  hours  an  effort 
should  be  made  to  abort  the  disease,  and  to  this  end  the  internal  and  local 
medicinal  treatment  is  much  the  same  as  that  described  for  folliculous  tonsil- 
litis— a  saline  laxative,  the  immediate  administration  of  salicylate  of  sodium  in 
full  doses  because  of  the  common  dependence  of  the  disease  on  the  uric-acid 
diathesis,  and  tincture  of  aconite  with  potassium  bromide  as  an  adjuvant.  The 
same  alkaline  and  antiseptic  spray  which  is  recommended  for  folliculous  ton- 
sillitis should  be  used  every  hour  or  half-hour,  and  in  the  same  manner,  spray- 
ing through  the  mouth,  and  to  a  less  extent  through  the  nose.  In  the  early 
stage  of  the  affection  the  application  of  cold  externally  by  means  of  Leiter's 
coil  would  assist  in  aborting  the  suppurative  inflammation  were  it  as  feasible 
with  restless  children  as  with  adults.     As  soon  as  it  becomes  evident  that  sup- 


422    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

puration  must  occur,  a  hot  poultice,  applied  externally  over  the  corresponding 
part  of  the  neck,  will  both  ease  the  pain  and  hasten  the  formation  of  pus. 

At  the  earliest  moment  that  pus  is  indicated  with  reasonable  certainty  by 
fluctuation  or  an  effort  at  ''pointing  "  the  abscess  should  be  punctured,  prefer- 
ably by  a  long,  slightly  curved,  double-edged  bistoury  devised  for  the  purpose, 
or,  in  the  absence  of  this  instrument,  by  an  ordinary  sharp-pointed  bistoury. 
The  puncture  should  not  be  made  into  or  through  the  tonsil  itself,  but  some- 
what" above  and  to  the  outer  side  of  the  gland  into  the  anterior  surface  of  the 
velum,  where  the  pus  actually  is  located,  in  the  cellular  tissue  of  the  velum 
palati  and  palato-glossal  fold  (Fig.  3). 

Fig.  3. 


Peritonsillar  Abscess :  a,  point  for  puncture. 


VI.  Hypertrophy  of  the  Tonsils. 

The  exact  function  and  size  of  normal  tonsils  are  questions  of  interest 
which  are  answerable  only  in  a  general  way.  Histologically,  they  possess  the 
structure  of  both  a  lymphatic  and  a  mucous  gland,  and,  anatomically,  they  are 
in  close  connection  by  lymph-channels  with  the  cervical  lymphatic  glands. 
The  inference  is  that  they  are  lymphatic  glands,  possessing  the  function  of 
similar  glands  elsewhere  located,  which  by  virtue  of  their  position  in  the  fauces 
have  been  endowed  also  with  mucous  elements  for  lubricating  purposes.  The 
natural  size  approximates  that  of  an  almond-kernel. 

Etiology  and  Pathology. — The  predisposing  cause  of  enlargement  of  the 
tonsils  is  a  peculiar  diathesis  now  termed  "lymphatism,"  the  local  manifestations 
of  Avhich  include  also  enlargement  of  the  naso-pharyngeal  tonsil,  or  "adenoids," 
and  of  the  muco-lymphoid  glands  of  the  pharynx  and  base  of  the  tongue.  This 
diathesis  is  certainly  not  identical  with  scrofula,  even  in  the  limited  sense  to 
which  that  term  is  now  restricted,  for  lymphatism  frequently  manifests  itself 
in  children  who  are  otherwise  robust,  yet  the  condition  seems  allied  to,  and 
often  conjoined  with,  scrofula.  Climatic  inequalities  furnish  adequate  exciting 
causes. 

In  the  usual  form  of  the  disease,  that  of  mere  hypertrophy,  there  is  simply 
an  overgrowth,  both  in  size  and  number,  of  all  the  natural  elements  of  the 
gland — the  lymphoid  bodies,  crypts  and  follicles,  mucous  glands,  and  connec- 
tive tissue. 

Another  variety  of  hypertrophy  of  the  tonsils,  named  by  Bosworth  the 
hyperplastic  form,  which  is  rare  in  children,  but  common  in  adults,  results  from 
repeated  attacks  of  acute  inflammation  and  consists  chiefly  of  hyperplasia  of 


DI8EASE8  OF  THE  PHARYNX  AND  NA80-PHABYNX.     423 

the  fibrous  connective-tissue  element,  with  a  less  degree  of  enlargement  and 
multiplication  of  the  lymphoid  bodies.  Such  tonsils  are  dense  and  fibrous, 
while  those  of  the  first  type  are  soft  and  friable.  Between  these  two  types, 
exist  all  degrees  of  variation,  both  in  contour  and  texture. 

Symptoms. — Moderate  enlargement  only  will  occasion  a  tendency  to  recur- 
rent attacks  of  acute  tonsillitis,  and  any  degree  of  hypertrophy  unquestionably 
predisposes  the  child  to  diphtheritic  infection  and  increases  the  gravity  of  the 
latter  disease  when  it  occurs. 

The  effects  of  mechanical  obstruction  to  respiration  occasioned  by  enlarged 
tonsils,  either  alone  or  especially  in  conjunction  with  enlargement  of  the  naso- 
pharyngeal tonsil,  will  be  described  in  the  article  on  Naso-pharyngeal  Adenoid 
Hypertrophy,  and  I  need  only  mention  here  the  more  prominent  features. 

Mouth-breathing  can  be  caused  even  by  enlarged  faucial  tonsils  alone — by 
their  projection  backward  and  upward  into  the  pharynx  in  such  a  way  as  to 
interfere  with  the  passage  of  air  inspired  through  the  nose.  Mouth-breathing 
in  turn  causes  deformed  development  of  the  facial  bones  and  muscles  and  an 
idiotic  expression  of  countenance  and  mental  stupidity ;  also,  deformed  develop- 
ment of  the  chest  and  thoracic  weakness.  The  recumbent  position  and  absence 
of  voluntary  muscular  control  to  keep  the  throat  open  aggravate  the  obstruc- 
tion to  both  nasal  and  oral  respiration  at  night,  so  that  the  patient  is  frequently 
awakened  or  thrown  into  a  nightmare  by  a  sense  of  dyspnoea.  Deglutition 
and  mastication  are  impaired  in  proportion  to  the  extent  of  the  disease,  although 
it  is  probable  that  deficient  oxygenation  of  the  blood  and  disturbed  rest  at 
night,  together  with  subsequent  thoracic  deformity,  are  the  chief  factors  in 
seriously  stunting  the  development  of  the  child. 

Treatment. — Abscission  is  the  only  satisfactory  method  of  treatment  when 
the  enlargement  is  sufficient  to  occasion  the  symptoms  of  mechanical  obstruc- 
tion. 

It  is  probable  that  the  syrup  of  iodide  of  iron  so  far  tends  to  correct  the 
underlying  constitutional  dyscrasia  as  to  prevent  recurrence  after  operation, 
and  even  to  cause  partial  reabsorption  of  very  slight  and  recent  overgrowths; 
but  we  have  never  been  able  to  discern  therefrom  any  permanent  reduction  of 
tonsils  which  were  greatly  or  even  moderately  enlarged.  Local  astringents  are 
wholly  inadequate.  Ignipuncture  or  galvano-cautery  puncture  affords  only 
palliation  for  the  milder  cases.  We  have  repeatedly'  found  it  necessary  to 
abscise  tonsils  after  months  had  been  spent  with  this  somewhat  painful  and 
ineffective  mode  of  treatment. 

The  wire  snare  is  an  excellent  means  of  abscission  when  the  child  is  anaesth- 
etized, as  when  combining  this  operation  with  that  for  "  adenoids; "  but  other- 
wise it  is  slow  and  painful,  and,  like  the  galvano-cautery  snare,  it  requires  more 
time  and  quietude  for  adjustment  than  are  available  with  young  children  when 
not  anaesthetized.  An  ansesthetic  is  not  usually  necessary  when  the  faucial  ton- 
sils alone  are  to  be  abscised,  although  it  is  decidedly  best  to  administer  ether 
when  the  combined  operation  for  removal  of  the  faucial  tonsils  and  naso-pharyn- 
geal "  adenoids"  is  to  be  made.  Also,  with  unusually  excitable  or  obstreperous 
children  ether  may  be  administered. 

The  tonsillotome  is  still  the  best  implement  for  children  who  are  not  anaes- 
thetized, because  of  the  rapidity,  precision,  and  comparative  ease  with  which 
this  method  can  be  practised.  With  older  children  it  is  best  to  use  a  prelim- 
inary spray  of  5  per  cent,  cocaine  solution.  Younger  children  are  apt  to  be 
terrified  by  spraying,  and  it  is  best  to  omit  it.     The  pain  is  not  really  great. 

The  Mathieu  tonsillotome  is  well  adapted  to  the  purpose,  especially  for 
children,   and   it  is  the  one  now  in  general    use.      The   mechanism  is  very 


424    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ingenious,  being  fitted  with  a  fork  attachment  which  is  designed  to  transfix 
the  tonsil,  and  withdraw  it  from  its  bed  by  the  same  motion  of  the  operator's 
fingers  which  draws  the  ring-knife  home.  The  much- vaunted  Mackenzie  ton- 
sillotome  is  an  unnecessarily  cumbersome  instrument. 

The  author  has  described  elsewhere  a  simplified  instrument  which  he  has 

Fig.  4. 


Mathieu's  Tonsillocome. 

used  for  years  with  the  utmost  satisfaction.     It  is  the  Mathieu  guillotine,  so 
constructed  as  to  do  away  with  the  fork  attachment  (Fig.  5). 

In  place  of  the  fork  he  uses,  held  in  the  other  hand,  a  specially  con- 
structed vulsellum  (Fig.  5),  by  which  the  tonsil  can  be  grasped,  drawn 
out  of  its  bed,  and  abscised  at  the  point  desired  with  much  greater  accu- 
racy than  by  the  fork  attachment  (Fig.  6).  He  has  found  the  action  of  the 
fork  to  be  largely  accidental,  dependent  on  the  size  and  shape  of  the  tonsil 
and  the  amount  of  gagging  by  the  patient — that  now  it  determines  too  deep  an 

Fig.  5. 


The  Author's  Tonsillotome  and  Tonsil  Vulsellum. 


abscission,  and,  again,  misses  the  tonsil  entirely,  especially  if  this  happens  to 
be  rather  small  or  flat.  In  other  words,  the  new  instrument,  assisted  by  the 
vulsellum,  will  abscise  many  tonsils  that  could  not  be  satisfactorily  grasped  by 
the  old  mechanism,  and  it  will  abscise  all  tonsils  with  a  reasonable  degree  of 
accuracy  at  the  proper  line. 

One  can  also  by  this  instrument  more  easily  avoid  wounding  the  anterior 
and  posterior  pillars,  which  eliminates  one  of  the  sources  of  persistent  haemor- 
rhage. The  instrument  therefore  conduces  to  safety  by  virtue  of  greater  pos- 
sible precision  in  operating.  It  is  less  formidable  in  appearance  and  is  easy  to 
use.  No  tongue-depressor  is  necessary,  the  body  of  the  tonsillotome  answering 
this  purpose,  at  the  same  time  that  the  vulsellum  prongs  grasp  the  tonsil  to 
draw  it  from  its  bed  into  the  ring  of  the  tonsillotome. 

The  proper  line  or  point  for  abscission  I  believe  to  be  close  to  the  base  of 
the  gland,  but  not  so  close  as  to  constitute  a  total  extirpation.  A  stump 
should  be  left,  but  one  not  much  larger  than  the  normal  gland,  and  not  of  suf- 


DISEASES  OF  THE  PHARYNX  AND  NASO-PHABYNX.     425 

ficient  size  to  protrude  from  or  T^-idely  separate  the  pillars  of  the  fauces.  A 
total  extirpation  would  seem  unnecessarily  hazardous  on  account  of  difficulty  of 
access  to  bleeding  vessels  should  hsemorrhage  occur,  and  I  cannot  think  that 
heemorrhao-e  is  any  less  prone  to  occur  after  tot  al  extirpation,  as  recently  stated, 
than  after  abscission. 

On  the  other  hand,  when  a  considerable  portion  of  the  gland  is  left,  only 
the  cortical  laver  being  removed,  redevelopment  of  the  growth  is  common. 

Very  larc^e  and  densely  fibrous  tonsils  in  older  children  are  best  removed 

Fig.  6. 


The  Author's  Method  of  Tonsillotomy. 

by  the  galvano-cautery  snare,  since  they  are  especially  apt  to  bleed  if  cut, 
and  are  difficult  to  abscise  by  a  cold  wire.  In  rare  instances  haemorrhage 
even  then  occurs,  either  primarily  when  the  wire  is  overheated,  or  second- 
arily on  the  separation  of  the  slough.  The  chief  objection  to  the  method 
for  general  use  is  the  intense  inflammation  of  the  fauces  which  is  liable  to 
follow  it.  This  can  be,  in  part,  but  not  wholly,  obviated  if  one  is  careful 
not  to  singe  the  pillars,  which,  however,  are  not  so  easily  avoided  in  the  use 
of  the  cautery  snare.  To  this  end,  Dr.  Jonathan  "Wright  has  adapted  the 
frame  of  the  Mackenzie  tonsillotome  to  galvano-cautery  purposes  by  substi- 
tuting for  the  steel  blade  a  wire  mounted  on  compressed  paper  and  to  be  con- 
nected with  a  battery. 

Consideration  of  this  subject  would  not  be  complete  without  reference  to 
the  views  of  Dr.  Harrison  Allen  of  Philadelphia,  as  advanced  in  a  recent  essay 
before  the  American  Laryngological  Association.  He  believes  "  that  abscis- 
sion should  be  restricted  to  the  removal  of  the  superficial  or  cortical  part  of 
the  tonsil,  and  in  preference  to  the  treatment  by  amputation  of  the  whole  mass; 
that  after  removal  of  such  cortex,  should  the  crypts  be  closed,  he  would  search 


426    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

for  hidden  canals,  and  when  found  pass  a  probe  or  director  through  them  and 
freely  divide  the  overlying  tissues,  incising  thus  the  tonsil  in  any  direction  and 
to  any  required  depth.  After  this  is  done  the  separate  coarse  lobules  can  be 
severally  taken  up  by  forceps  and  removed,  care  being  taken  to  avoid  touching 
enveloping  folds  of  mucous  membrane."  It  is  evident  that  this  would  be  an 
impossible  method  with  most  young  children,  because  of  tediousness,  but  it  may 
be  advantageously  utilized  with  older  patients. 

The  only  serious  objection  to  abscission  of  the  tonsils  is  the  rare  possibility 
of  troublesome  haemorrhage,  which  has  seemed  to  a  fcAV  extreme  conservatives 
to  justify  avoidance  of  the  operation;  but  a  greater  risk  is  assumed  in  every 
phase  of  life,  in  travel,  and  in  pursuit  of  business  and  pleasure.  It  is  stated 
that  Elsberg  made  the  operation  eleven  thousand  times  Avith  but  two  cases  of 
even  alarming  haemorrhage,  and  Morell  Mackenzie,  whose  experience  must 
have  been  enormous,  only  once  met  with  a  case  in  which  the  bleeding  appeared 
actually  to  endanger  life.  Only  one  authentic  case  of  death  of  a  child  from 
haemorrhage  after  tonsillotomy  is  recorded  in  modern  literature,  and  it  is  prob- 
able that  this  case  need  not  have  ended  fatally  but  for  a  deception  of  the  ope- 
rator relative  to  the  seriousness  of  the  haemorrhage,  by  reason  of  the  blood  being 
swallowed  by  the  young  child  and  not  expectorated;  which  caused  the  adoption 
of  a  less  vigorous  treatment  than  otherwise  would  have  been  used. 

When  one  considers  the  number  of  cases,  beyond  computation,  of  tonsil- 
lotomy in  children,  and  the  few  reported  cases  of  haemorrhage,  one  must  regard 
it  as  among  the  safest  of  even  minor  operations. 

The  treatment  of  severe  haemorrhage  may  consist,  first,  of  a  trial  of  the 
astringents  and  styptics.  The  most  popular  of  these  is  Mackenzie's  mixture 
of  tannic  and  gallic  acids: 

I^.  Acidi  tannici 3vj. 

Acidi  gallici Sij- 

Aquae f|j.— M. 

Sig.  Sip  and  swallow  half-teaspoonful  quantities  at  short  intervals. 

If  this  fail,  it  is  probable  that  any  simple  astringent  or  vaso-contractor  will 
fail. 

Ice,  held  in  the  mouth  and  swallowed,  is  also  an  efficient  remedy. 

Pressure  may  be  successfully  applied  by  grasping  the  tonsil  firmly  between 
the  thumb,  held  within  the  mouth  and  enveloped  in  three  or  four  layers  of  linen, 
and  the  fingers  held  over  the  corresponding  part  of  the  neck.  It  must  be  main- 
tained sometimes  for  an  hour  or  more. 

When  the  simpler  expedients  fail,  then  the  bleeding  points  and  surfaces 
should  be  accurately  located  and  thoroughly  seared  by  the  actual  cautery,  or 
the  galvano-cautery  if  at  hand.  For  this  purpose  one  needs  several  small 
sponges  mounted  on  long  sponge-holders,  which,  if  not  at  hand,  may  be  sub- 
stituted by  wooden  sticks  (sponges  are  much  more  effective  than  absorbent 
cotton) ;  also,  a  small  surgical  retractor,  like  a  tracheotomy  retractor,  in  the 
absence  of  which  a  palate  hook,  or  even  a  bent  pro])e,  will  serve.  An  assist- 
ant is  desirable  to  hand  and  clean  the  sponges. 

Under  the  illumination  of  a  head  reflector,  the  throat  should  first  be  well 
sprayed  with  a  5  per  cent,  solution  of  cocaine,  and  sponged  clear  of  clotted  blood ; 
the  bleeding  surface  can  then  be  exposed  to  view  by  holding  aside  the  anterior 
pillar  by  means  of  the  retractor,  when  by  rapid  sponging  the  bleeding  points 
can  be  discerned  and  then  cauterized. 

As  a  substitute  for  the  galvano-cautery  one  may  use  a  thick  wire  heated 


DISEASES  OF  THE  PHARYNX  AND  NASO-PHABYNX.     427 

to  redness  over  a  gas-flame.  We  have  used  this  means  successfully  with  adults, 
but  have  never  had  occasion  to  apply  it  with  children.  If  necessary,  however, 
we  would  endeavor  to  do  so  with  young  children  by  first  administering  chloro- 
form and  inserting  a  Whitehead  gag,  as  in  operation  for  cleft  palate,  placing 
the  patient  with  the  shoulders  elevated  and  the  head  pendent,  so  that  blood 
could  not  gravitate  into  the  trachea. 

When  the  haemorrhage  is  comparatively  slight  exact  cauterization  of  the 
bleeding  points  by  solid  nitrate  of  silver  is  effective.  Torsion  is  applicable 
only  when  a  spurting  artery  can  be  seen. 

As  a  last  resort,  may  be  mentioned  ligation  of  the  external  carotid  artery, 
as  advised  by  Delavan,  in  preference  to  ligation  of  the  common  carotid,  which 
latter  might  permit  haemorrhage  to  continue  by  collateral  circulation  through 
the  circle  of  Willis. 

Vn.   Retro-pharyngeal   Abscess    (Retro-pharyngeal    Lymph- 
adenitis). 

It  is  now  well  established  that  retro-pharyngeal  abscess  arises  ordinarily 
not  in  caries  of  the  cervical  vertebrae,  but  in  suppurative  inflammation  of  the 
lymphatic  glands  which  are  imbedded  in  the  posterior  pharyngeal  wall.  In 
harmony  with  accepted  views  of  the  origin  of  pus  elsewhere,  the  source  of  this 
inflammation  must  be  infection,  either  from  within  or  without  the  body,  by 
some  one  or  more  of  the  pathogenic  micro-organisms  which  produce  sup- 
puration. 

Children  are  especially  prone  to  inflammations  of  the  lymphatic  system. 
Cervical  lymphadenitis  is  common  among  them.  Frequently  it  is  tuberculous, 
but  often  it  is  not,  and  usually  the  acute  suppurative  variety  results  from  infec- 
tion by  a  previously  existing  tonsillitis.  So  also  with  retro-pharyngeal  abscess : 
it  is  most  reasonable  to  regard  it  as  a  secondary  infection  of  the  pharyngeal 
lymphatics  from  inflammation  of  exposed  and  associated  muco-lymphoid  glands, 
like  the  faucial  and  naso-pharyngeal  tonsils.  But,  whatever  the  source  of 
infection,  whether  primary  or  secondary,  the  initial  stage  of  retro-pharyngeal 
abscess  is  retro-pharyngeal  lymphadenitis.  Moreover,  the  lymphadenitis  may 
be  of  a  non-suppurative  type,  or  the  disease  become  arrested  in  this  stage, 
undergoing  resolution  without  the  formation  of  an  abscess. 

Bokai  reports  a  case  of  retro-pharyngeal  lymphadenitis  in  a  child  eight 
months  old,  in  which  tracheotomy  was  necessitated  by  the  supervention  of 
alarming  symptoms  of  suffocation.  The  posterior  wall  of  the  pharynx  showed 
diffuse  hard  swelling  without  fluctuation,  and  a  deep  incision  into  the  mass  had 
yielded  no  pus.  After  the  tracheotomy  resolution  was  quickly  established. 
This  simple  lymphadenitis  has  been  but  rarely  observed  in  this  country,  but 
Bokai,  in  addition  to  400  cases  of  abscess,  mentions  112  cases  of  simple  retro- 
pharyngeal lymphadenitis  as  having  passed  under  his  observation  in  the  Pester 
Kinderspital.     (See  note  at  end  of  this  chapter.) 

In  rare  instances  the  source  of  infection  may  be  rhinitis,  communicated 
through  the  nasal  lymph-channels,  or,  still  more  rarely,  a  suppurative  otitis ; 
but,  as  previously  intimated,  folliculous  and  suppurative  forms  of  tonsillitis,  as 
well  as  those  forms  of  tonsillitis  and  pharyngitis  which  are  symptomatic  of  the 
exanthemata,  may  reasonably  be  regarded  as  the  most  frequent  causes  of  retro- 
pharyngeal lymphadenitis,  which  in  turn  may  proceed  to  the  formation  of  an 
abscess.  Cases  which  originate  in  any  of  these  ways  are  grouped  by  Bokai 
under  the  term  "  idiopathic  ;"  and  of  204  cases  analyzed,  he  placed  189  in  this 
class,  in  contradistinction  to  only  7  cases  secondary  to  caries  of  the  vertebrae, 


428    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

7  cases  from  burrowing  of  pus  from  abscess  in  the  neck,  and  1  case  of  trau- 
matic origin. 

Symptoms. — The  disease  may  commence  quite  insidiously  or  it  may  cul- 
minate rapidly.  Attention  is  directed  to  the  throat  by  a  deep-seated  pain, 
dysphagia,  and,  later,  by  dyspnoea.  When  located  low  down  in  the  laryngo- 
pharynx,  a  comparatively  small  abscess  may  speedily  occasion  suffocative  symp- 
toms. Critical  inspection  or  palpation  of  the  throat  will  disclose  a  swelling 
of  the  posterior  pharyngeal  wall,  which  may  be  either  in  the  median  line  or 
somewhat  to  one  side. 

Diag-nosis. — The  disease  is  distinguished  from  oedema  of  the  glottis  by 
inspection,  which  reveals  pharyngeal  instead  of  laryngeal  swelling,  and  from 
both  diphtheritic  and  spasmodic  laryngitis  in  the  same  manner ;  moreover,  in 
both  forms  of  croup  the  voice  is  impaired,  which  is  not  the  case  in  retro- 
pharyngeal abscess. 

Prognosis. — The  affection  usually  terminates  in  recovery  in  from  five  to 
fifteen  days,  the  abscess  discharging  spontaneously  in  many  instances.  In  a 
considerable  proportion  of  cases,  however,  prompt  recognition  of  the  disease 
and  evacuation  of  the  pus  is  necessary  to  avert  a  rapidly-fatal  issue  by  suffo- 
cation, or,  in  rarer  cases,  to  prevent  burrowing  of  the  pus  into  the  oesophagus, 
larynx,  mediastinum,  or  pleural  cavity. 

Treatment. — As  soon  as  pus  has  formed  it  should  be  evacuated  by  making 
an  incision  as  near  the  median  line  as  possible,  and  then  the  head  of  the  child 
should  be  inclined  well  forward  to  prevent  the  pus  from  running  into  the  larynx. 
An  ordinary  bistoury  will  suffice  for  the  incision.  An  exploratory  puncture 
may  be  made  at  any  time  to  determine  the  presence  of  pus.  In  Bokai's  expe- 
rience tracheotomy  has  been  but  rarely  necessary,  but  it  should, be  promptly 
performed  if  puncture  of  the  swelling  does  not  relieve  the  suffocative  symptoms 
by  evacuation  of  pus. 

The  syrup  of  iodide  of  iron  and  nutritive  tonics  are  indicated. 

Viii.  Naso-pharyngeal  Adenoid  Hypertrophy. 

This  disease,  which  is  variously  known  as  "adenoid  hypertrophy  in  the 
naso-pharynx,"  "adenoid  vegetations,"  and  "third  tonsil,"  in  multiplicity  of 
cases  and  gravity  of  consequences  will  bear  comparison  with  any  other  affec- 
tion of  the  upper  respiratory  tract.  In  the  normal  state  isolated  and  aggre- 
gated muco-lymphoid  follicles  of  the  same  adenoid  structure  as  those  in  the 
pharynx  are  imbedded  throughout  in  the  mucous  and  submucous  tissues  of  the 
naso-pharynx.  Histologically,  each  in  its  simplest  form  consists  of  a  depression 
of  the  mucous  membrane  lined  Avith  its  epithelium  and  enveloped  in  a  stratum 
of  reticular  connective  tissue,  entangled  in  which  are  numerous  lymphoid 
cells,  lymphoid  bodies  (closed  follicles),  and  lymphatic  and  other  vessels. 
Morphologically,  they  are  closely  related  to  the  faucial  tonsils,  which  are  com- 
pound aggregations  of  the  same.  At  the  vault  of  the  pharynx  a  number  of 
these  follicles  are  grouped  together,  forming  a  compound  gland  analogous  to 
the  tonsils,  and  known  as  the  third  tonsil,  the  pharyngeal  tonsil,  or  the  tonsil 
of  Luschka.  In  the  normal  state  this  is  not  of  sufficient  size  to  desei've  such 
appellation,  but  when  hypertrophied,  as  it  frequently  is,  it  bears  some  resem- 
blance to  the  faucial  tonsil  in  a  state  of  enlargement.  Several  sorts  of  aggre- 
gation are  distinguishable  clinically  by  rhinoscopic  inspection.  Of  these  the 
more  common  are :  (1)  the  fimbriated  variety,  in  which  the  growth  is  composed 
of  several  cock's-comb-like  masses  closely  packed  together  ;  (2)  the  stalaetitic 
form,  in  which  multiple  pear-shaped  bodies  are  pendent,  like  stalactites,  from 


DISEASES  OF  THE  PHARYNX  AND  NASO-PHABYNX.     429 


the  vault  of  the  pharynx,  and  to  which  the  name  "  adenoid  vegetations"  is  most 
truly  applicable ;  (3)  the  individuate  variety,  in  which  the  mass  is  made  up,  in 
large  part,  of  but  a  single  neoplasm,  of  firmer  consistency,  smoother  surface, 
and  more  or  less  irregular  contour  according  to  size  and  degree  of  impaction. 

Regarding  consistency,  this  is  found  to  vary  in  accordance  with  the  amount 
of  fibrous  tissue  in  its  composition.  In  the  fimbriated  and  stalactitic  forms  the 
adenoid  element  predominates,  rendering  them  friable  and  soft  to  the  touch, 
while  the  individuate  variety  often  contains  much  fibrous  tissue,  which  gives  it 
greater  density  and  tenacity.  Between  these  forms  are  encountered  all  degrees 
of  variation  both  in  contour  and  texture. 

Etiology. — Children  of  syphilitic  and  tuberculous  parents  and  those  other- 
wise the  victims  of  scrofulosis  are  predisposed  to  it,  but  children  in  other 
respects  robust  are  also  aff'ected. 

The  term  "  lymphatism  "  has  been  introduced  as  a  recognition  of  an  under- 
lying dyscrasia  which  is  characterized  by  hyperplasia  of  this  and  other  muco- 
lymphoid  structures,  including  the  faucial  tonsils.  Climatic  inequalities  fur- 
nish adequate  exciting  causes. 

Symptoms. — The  space  of  the  naso-pharynx  is  designed  to  serve  as  a 
common  area  of  air-communication  between  the  five  openings  which  enter  it. 
The  Eustachian  tubes  open  into  it,  one  on  each  lateral  wall  posterior  to  the 
nasal  choanee,  and  upon  perfect  patency  of  these  openings,  together  with  free 
nasal  respiration,  the  power  of  hearing  is  dependent ;  for  ventilation,  with  nor- 
mal air-pressure  in  the  cavity  of  the  middle  ear,  is  essential  to  correct  auditory 
The  adenoid  excrescences,  when  large,  are  forcibly  compressed  between 


sense. 


Fig.  7. 


Naso-pharyngeal  Obstruction  by  Adenoids. 


the  lateral  walls  of  the  naso-pharynx  or  they  overlap  the  tuber  of  the  Eustach- 
ian orifice  from  above,  acting  in  either  case 
as  a  stopper  to  one  or  both  openings ;  or 
else  the  vegetations  which  are  crowded  in 
above  and  behind  the  Eustachian  tubes  de- 
form and  close  the  orifice  by  forcing  its 
upper  projecting  lip  downward  to  meet  the 
lower  border  of  the  rim.  Fig.  7,  accurately 
drawn  from  nature,  is  a  typical  representa- 
tion of  an  average  case,  in  which  the  naso- 
pharynx is  seen  to  be  occupied  by  a  fim- 
briated adenoid  mass  which  occludes,  in 
large  part,  the  posterior  nasal  choanse,  and 
so  presses  downward  the  upper  lip  of  the 
tuber  of  the  left  Eustachian  orifice  as  to  practically  close  the  channel  to  the 
middle  ear. 

Again,  even  with  lesser  hypertrophy,  the  accompanying  catarrhal  state  is 
prone  to  extend  by  continuity  of  surface  along  the  Eustachian  tube,  and  to 
excite  exudation  or  suppurative  infiammation  of  the  middle  ear.  Deafness, 
therefore,  is  frequently  a  deplorable  symptom,  and  one  which  is  liable  to 
become  permanent  unless  speedy  relief  be  afibrded. 

Into  this  space  open  also  the  posterior  nares,  the  natural  respiratory  pas- 
sage being  via  the  nose  and  naso-pharynx.  Adenoid  hypertrophy,  therefore, 
serves  as  a  plug  to  the  posterior  nasal  openings,  and  obstructs  nasal  respiration 
completely  or  in  part  according  to  the  degree  of  glandular  enlargement.  From 
this  point  we  find  it  a  matter  of  exceeding  interest  to  trace  the  origin  and 
development  of  each  successive  step  in  the  series  of  deformities  consequent  upon 
this  condition.  The  plugging  up  of  the  posterior  nares  necessitates  oral  breath- 
ing, and  the  constantly  open  mouth  interferes  with  the  normal  adaptation  of 


430    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


certain  facial  muscles,  which  in  turn  effects  radical  changes  in  the  contour  of 
the  soft  and  developing  bones  of  the  face,  the  whole  resulting  in  a  physiognomy 
characterized  by  a  vacant,  stupid,  almost  idiotic  expression  of  countenance,  which 
can  be  better  illustrated  by  a  photograph  from  nature  than  described  (Fig.  8). 
Fig.  8.  The  hanging  lower  jaw  causes  the  face 

to  appear  elongated.  The  nose  is  pinched 
or  its  alje  distended,  while  the  angles  of 
the  mouth  and  eyes  have  a  drawn  appear- 
ance. 

Moreover,  the  air-cavities  in  commu- 
nication with  the  nose,  as  the  frontal, 
maxillary,  sphenoidal,  and  ethmoidal  sin- 
uses, which  are  essential  to  the  proper  ex- 
pansion of  their  respective  bones,  cease 
to  develop  when  the  circulation  of  air 
through  the  nose  is  interfered  with,  thus 
altering  nature's  intent  regarding  the 
dimensions  of  the  face  and  head,  and  still 
further  deforming  the  physiognomy.  Aug- 
mentation of  atmospheric  pressure  upon 
the  buccal  surface  of  the  palate  process, 
and  the  impact  of  air-currents  to  and  fro 
during  mouth-breathing,  together  with  the 
diminution  of  intra-nasal  air-pressure  inci- 
dent to  nasal  obstruction,  gradually  force 
upward  the  centre  of  the  hard  palate,  and 
change  thus  the  obtusely  rounded  Romanesque  arch  into  one  of  Gothic  shape 
— the  pointed  or  high-arched  palate  commonly  existing  in  association  with  long- 

FiG.  9. 


Characteristic  Physiognomy  of  Adenoid  Vege- 
tations (from  a  photograph  by  the  author). 


High-arched  Palate. 


DISEASES  OF  THE  PHARYNX  AND  NASO-PHABYNX.     431 


continued  and  excessive  adenoid  development  during  childhood  (Fig.  9).  Ele- 
vation of  the  palatal  arch  lessens  the  traverse  diameter  of  the  j  aw,  and  causes 
it  to  grow  pointed  in  front — the  so-called  V-shaped  indenture ;  and  with  the 
resulting  contraction  of  the  alveolar  process,  the  teeth,  especially  those  near  the 
point,  are  crowded  into  various  grotesque  aggregations  or  are  rotated  on  their 
axes — a  condition  depicted  in  Fig.  9,  drawn  from  a  typical  case,  in  which  the 
two  central  incisors  overlap,  and  the  two  lateral  incisors  undergo  a  quarter  rota- 
tion and  stand  at  right  angles  to  the  alveolar  process. 

It  is  proper  to  state  that  this  relation  of  mouth-breathing  to  deformed 
indentures  is  questioned  by  some  dental  authorities,  who  attribute  the  elevation 
of  the  palatal  arch  solely  to  a  perverted  production  of  the  permanent  teeth. 
The  association  between  the  adenoid  hypertrophy  as  a  cause  of  mouth-breath- 
ing and  the  high-arched  palate  is,  however,  so  constant  that  an  etiological 
relationship  is  most  probable. 

Next,  elevation  of  the  palatal  arch  must  produce  contortion  within  the  nose, 
for  the  septum,  composed  of  the  vomer,  the  perpendicular  plate  of  the  ethmoid 
bone,  and  its  cartilaginous  portion,  is  unequal  in  power  of  resisting  compression 
to  the  bones  by  which  it  is  incased.     Designed  by  nature  to  fill  vertically  the 

Fia.  10. 


Fig. 11. 


natural  space  between  the  roof  of  the  nose  and  its  floor,  the  abbreviation  of 
this  space  by  elevation  of  the  palatal  arch  through  the  instrumentality  of  naso- 
pharyngeal adenoid  hypertrophy  cannot  result  otherwise  than  in  forcing  the 
septum  to  provide  for  itself  by  bending  and  curving 
laterally  in  various  directions — a  condition  which  is  dia- 
grammatically  represented  in  Fig.  10. 

The  septal  deflection  acts  as  an  additional  impedi- 
ment to  nasal  respiration  and  drainage,  and  becomes 
a  potent  factor  in  the  evolution  of  hypertrophic 
rhinitis  or  that  form  of  nasal  catarrh  characterized 
by  enlargement  of  the  turbinated  bodies  (Fig.  11). 

Headache  is  also  complained  of,  although  a  sense 
of  mental  obtundity  and  heaviness  is  more  usual  than 
absolute  pain  in  the  head. 

Finally,  not  only,  as  before  said,  do  these  un- 
fortunates looh  stupid,  but  they  really  are  stupid,  and 
exhibit  abundant  evidence  of  mental  hebetude,  with 
inability  to  fix  the  attention,  to  learn,  to  memorize,  or 
to  reason. 

Three  varieties  of  thoracic  deformity  are  observed  to  accompany  obstmc- 


432    AMEBIC  AN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tive  naso-pharyngeal  adenoid  hypertrophy,  the  association  of  one  or  other  form, 
in  advanced  cases,  being  so  constant  that  a  direct  causal  relationship,  although 
difficult  of  absolute  demonstration,  can  reasonably  be  assumed. 

For  the  induction,  hoAvever,  of  two  of  these  forms,  the  "pigeon-breast" 
deformity  and  the  "  barrel -shaped"  chest,  the  intermediation  of  still  another 
symptom,  bronchitis,  seems  essential ;  but  adenoid  hypertrophy  is  an  etiological 
factor  in  the  production  of  chronic  bronchitis.  Especially  in  neurasthenic 
individuals  it  is  exquisitely  sensitive  to  reflex-producing  impressions,  and  its 
irritation  may  result,  reflexly,  in  spasm  of  the  glottis,  cough,  asthma,  and  pare- 
tic vaso-motor  bronchitis. 

The  third  variety  of  thoracic  deformity,  the  "flat  chest,"  is  due  directly 
to  obstruction  by  the  adenoid  growth  itself,  and  is  an  indrawing  of  the  chest- 
walls,  especially  a  shortening  of  the  antero-posterior  diameter,  which  results 
from  an  insufficient  air-supply  to  the  lungs.  The  chest  becomes  flat  and  thin 
(Fig.  12),  has  a  sunken  appearance  over  the  lower  part  of  the  sternum,  perhaps 
a  deep  concavity  at  the  ensiform  cartilage,  with  depressed  intercostal  spaces. 

Fig.  12. 


Flat-chest  Deformity  (Hooper). 


Rachitis,  so  often  associated  with  depraved  nutrition,  is  doubtless  the  pre- 
disposing condition  to  all  of  these  forms  of  chest  deformity. 

Treatment. — For  pronounced  hypertrophy  the  only  satisfactory  method 
of  treatment  is  removal  by  surgical  means.  Many  methods  by  cautery,  snare, 
curette,  and  forceps,  without  general  anaesthesia,  have  been  described.  With 
older  children  it  makes  little  difference  which  of  these  methods  is  employed,  so 
that  the  object  is  thoroughly  accomplished.  With  young  children,  however, 
who  will  not  hold  still,  most  of  them  are  inapplicable,  and  others  border  on 
the  barbarous.  The  young  child  should  be  completely  anaesthetized  by  etlier^ 
and  then  placed  in  the  sitting  position  on  the  lap  of  an  assistant,  with  its  head 
against  the  left  shoulder.  The  mouth  is  kept  open  by  a  gag  similar  to  those 
furnished  with  sets  of  intubation  instruments.  Three  or  four  pairs  of  forceps, 
either  the  author's  (Fig.  13)  or  other  modification  of  Lbwenberg's  instrument, 
being  in  readiness,  the  left  index  finger  is  passed  behind  the  velum,  followed 
by  forceps  held  in  the  other  hand ;  a  portion  of  growth  is  located,  grasped,  and 


I)I8EASES  OF  THE  PHARYNX  AND  NASO-PHABYNX.    433 

Fig.  13. 


Author's  Forceps. 

removed,  when,  without  withdrawing  the  guiding  finger,  quickly  a  second, 
third,  and  even  fourth  pair  of  forceps  are  used,  and  thus  several  pieces 
extracted  before  active  hgemorrhage  ensues.  Instantly,  then,  the  patient  is 
tilted  well  forward  with  the  head  pendent  to  permit  the  blood,  while  flowing 
actively,  to  escape  by  the  nose  and  mouth.  In  a  few  seconds  the  gush  is 
over,  the  patient  can  be  raised,  the  remaining  blood  cotton-swabbed  from 
the  pharynx,  and  the  procedure  repeated,  and  still  again  repeated,  until  the 
naso-pharynx  is  completely  cleared.  As  a  final  stage  remaining  shreds  are 
thoroughly  scraped  by  the  finger-nail. 

Little  fear  need  be  entertained  of  blood  running  down  the  trachea. 
That  which  trickles  slowly  will  course  along  the  oesophagus  into  the  stomach, 
and  at  times  of  rapid  flow  this  danger  will  be  obviated  by  the  method  of 
tilting  the  child  well  forward  to  permit  of  escape  through  the  nose.  Other- 
wise the  blood  is  liable  to  gush  into  the  trachea  rather  than  to  be  swallowed, 
assertions  to  the  contrary  notwithstanding ;  for  the  function  of  deglutition 
during  profound  anaesthesia  is  suspended.  Rapid  and  persistent  cotton- 
swabbing  may  sufiice,  but  is  not  so  completely  effective,  and  it  prevents  the 
reapplication  of  the  anaesthetic  during  the  bleeding  interval,  so  prolonging 
the  operation.  The  patient  should  be  kept  in  bed  until  the  following  day, 
and  during  healing  the  parts  should  be  cleansed  by  syringing  through  the 
anterior  nares  with  an  antiseptic  alkaline  solution. 

When  the  adenoids  are  small  and  soft,  sufiicient  palliation  perhaps,  but  not 
an  absolute  cure,  can  be  effected  by  thorough  and  rapid  scraping  with  the 
cleansed  finger-nail,  used  as  a  curette,  without  the  administration  of  ether. 
Gottstein's  knife  and  Hartmann's  curette,  when  deftly  plied,  can  also  be  made 
effective  without  anaesthesia,  but  are  apt  to  terrorize  both  the  child  and  its 
parents. 

Syrup  of  iodide  of  iron,  internally,  tends  to  correct  the  underlying  dyscrasia 
— lymphatism. 

IX.  Cleft  Palate. 

True  cleft  palate  is  a  congenital  fissure  in  the  roof  of  the  mouth,  of  variable 
extent.  The  so-called  acquired  cases  differ  therefrom  in  presenting  an  unequal, 
ragged,  or  incomplete  cleft,  such  as  would  be  produced  by  the  destructive  ulcer- 
ations of  syphilis.  The  extent  of  congenital  cleft  may  vary  from  the  slightest 
manifestation,  that  of  a  bifid  uvula,  to  the  grossest  form  of  conjoined  cleft 
palate  and  hare-lip,  in  which  the  fissure  involves  not  only  the  velum  palati  and 
hard  palate,  but  penetrates  one  or  both  sides  of  the  alveolar  arch  and  upper 
lip,  with  the  presence  of  a  separate  intermaxillary  structure.     This  article, 

28 


434     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

however,  will  not  embrace  the  subject  of  hare-lip  except  incidentally  (Figs. 

Fig.  16. 
Fig.  15. 
Fig.  14. 


Bifid  Uvula. 


Cleft  Palate 


Cleft  Palate    and    Hare-lip  con- 
joined. 


Etiology  and  Pathology. — Nature  fails  to  complete  her  design  as  origin- 
ally intended,  and  the  defect  doubtless  dates  from  an  early  period  of  intra-uterine 
life.  It  is  a.ssumed  that  the  same  causes  which  produce  rickets  in  children  are 
prone  to  effect  cleft  palate.  A  deficient  supply  of  phosphates  in  the  diet  of  the 
mother,  or  failure  on  her  part  to  thoroughly  assimilate  the  phosphatic  elements, 
may  be  regarded  as  an  exciting  cause. 

Vander  Veer  states  that  "  several  years  ago  the  lions  in  the  Zoological  Gar- 
dens of  London  were  fed  upon  flesh  containing  too  large  bones  for  them  to 
break  and  swallow,  as  is  their  custom.  The  young  born  while  this  method  of 
feeding  was  pursued  were  observed  to  have  cleft  palates,  and  lived  but  a 
short  time.  The  lions  were  then  fed  upon  small  animals,  whose  bones  they 
could  break  easily,  and  the  young  born  afterward  had  perfectly-formed 
palates." 

Intermarriage  and  unfortunate  "  maternal  impressions  "  are  also  stated  to 
be  exciting  causes.  Whatever  may  have  been  the  causes  of  the  original  in- 
ception of  the  malformation  in  previous  generations,  there  can  be  no  doubt  that 
heredity  now  serves  as  a  potent  predisposing  cause.  In  my  own  cases  I  have 
nearly  always  been  able  to  elicit  histories  of  other  cases  in  other  branches  of 
the  family.  Vander  Veer,  Lawson  Tait,  and  Gurdon  Buck  emphasize  this  fact. 
It  will  often  reappear  after  skipping  one  or  more  generations,  or  it  will  diverge 
into  collateral  branches. 

Symptoms. — The  symptoms  consist  of  an  inability  to  nurse  or  to  swallow 
perfectly,  and,  later,  to  talk  properly — disabilities,  of  course,  which  vary  in 
accordance  with  the  extent  of  the  cleft.  A  peculiar  nasal  intonation  ot  the  voice 
is  occasioned,  wliich,  if  the  cleft  be  an  extended  one,  will  first  attract  attention 
to  the  defect  in  the  crying  of  the  infant,  and  later  in  life  will  characterize  the 
speech.     In  swallowing,  fluids  regurgitate  through  the  nose. 

On  inspection  in  marked  cases  the  parts  appear  as  if  there  were  no  soft 
palate,  the  side  flaps  being  retracted  by  muscular  tension,  leaving  a  wide, 
inverted  V-shaped  opening,  through  which  are  visible  the  posterior  and  supe- 
rior walls  of  the  naso-pharynx  with  their  covering  of  adenoid  glandular 
tissue. 

Treatment. — This  may  be  considered  in  three  divisions  :  prophylaxis,  pal- 
liative measures,  and  operative  treatment. 


DISEASES  OF  THE  PHARYNX  AND  NASO-PHABYNX.    435 

Prophylaxis. — Whenever  any  hereditary  tendency  to  cleft  palate,  however 
remote,  can  be  established,  it  would  be  a  rational  precaution  to  provide  in 
abundance  for  the  mother  those  articles  of  diet  which  are  rich  in  phosphates — 
e.  g.  oatmeal — and  to  administer  precipitated  phosphate  of  calcium  in  powder, 
five  to  ten  grains  twice  daily.  It  should  be  given,  however,  without  the  know- 
ledo-e  of  the  mother  concerning  the  end  in  view,  in  order  not  to  excite  in  her 
a  ''mental  impression  "  toward  cleft  palate.  For  the  same  reason,  in  order  to 
avoid  directino-  the  mother's  thoughts  into  this  channel,  she  should  not  person- 
allv  be  questioned  relative  to  heredity,  or  the  subject  be  given  prominence  in 
any  way  in  conversation  with  her  during  the  period  of  gestation. 

Palliative  Measures. — If  the  cleft  be  large,  some  provision  will  be  neces- 
sary to  facilitate  nursing.  A  large  rubber  nipple  or  one  which  is  large  and 
flat,  so  as  to  serve  at  the  same  time,  while  nursing,  as  a  temporary  obturator  to 
close  the  cleft  and  permit  of  suction,  is  generally  the  best  device.  Such  a 
nipple  can  be  attached  to  the  glass  shield  of  an  ordinary  artificial  nipple,  com- 
monly used  to  protect  the  mother's  nipple  when  nursing  is  painful,  thus  ena- 
bling the  child  to  nurse  indirectly  from  the  breast,  or  it  can  be  used  with  a 
nursing-bottle.  In  this  latter  case  the  bottle  can  be  supplied  with  mother's 
milk,  at  least  for  a  time,  by  the  preliminary  use  of  a  breast-pump.  In  extreme 
cases,  especially  those  which  are  conjoined  with  the  worst  forms  of  hare-lip,  it 
becomes  necessary  to  feed  the  child  by  a  spoon  or  feeding-cup,  which  is  a 
laborious  undertaking,  but  one  likely  to  result  successfully  if  it  be  properly 
carried  out.  Vander  Veer  mentions  two  cases,  "son  and  daughter  in  one  family, 
where  the  mother,  for  nearly  two  years  in  each  instance,  was  obliged  to  give 
nearly  her  entire  time  to  their  care  as  regards  feeding  before  they  could  help 
themselves." 

Later  in  life,  if  for  any  reason  the  operative  treatment  be  not  adopted  or  if 
operations  should  fail,  much  may  be  done  to  lessen  the  disability  by  the  skil- 
ful adaptation  of  an  obturator — a  dental  plate  so  constructed  as  to  cover  as 
much  as  possible  of  the  cleft.  A  skilful  dentist  will  fashion  one  to  fit  accu- 
rately and  to  extend  quite  far  posteriorly,  made  of  firm  material,  such  as  hard 
rubber  or  gold,  furnishing  thus  a  substitute  for  the  hard  palate  and  to  a  slight 
degree  for  the  velum  palati.  But  an  obturator  at  best  is  but  a  poor  substitute 
for  a  natural  palate  ;  it  mitigates,  but  does  not  remedy,  the  defect ;  and  to 
adopt  permanently  the  use  of  one  in  lieu  of  a  radical  surgical  operation  is  but 
to  condemn  the  patient  for  life  to  the  employment  of  a  more  or  less  trouble- 
some and  incomplete  appliance. 

A  radical  surgical  operation,  if  it  be  skilfully  managed,  will  be  ultimately 
successful  in  a  large  maj  ority  of  cases,  and  its  dangers  are  slight  in  comparison 
with  the  disadvantage  of  a  perpetuation  of  cleft  palate  for  a  lifetime. 

Ojjerative  Treatment. — On  account  of  the  difficulty  in  phonation  the 
operation  for  closure  of  the  cleft  should  always,  when  possible,  be  performed 
early,  before  the  child  has  learned  to  talk  in  an  imperfect  manner ;  otherwise, 
even  though  the  cleft  be  closed  later,  much  difficulty  is  experienced  in  teach- 
ing correct  articulation.  It  should  therefore  be  performed  between  the  ages  of 
one  and  a  half  and  three  years. 

The  operation  is  known  as  staphylorraphy  when  the  cleft  involves  the  soft 
palate  only  or  extends  but  little  into  the  hard  palate ;  and  osteoplasty  when  the 
palate  process  of  the  superior  maxilla  is  so  deficient  as  to  necessitate  the  Fer- 
gusson  procedure  of  drilling  off"  edges  of  bone  to  bring  together  in  the  centre. 

It  is  not  my  purpose  to  speak  of  this  operation  in  detail.  It  is  one  which 
has  interested  the  greatest  surgeons  of  the  day,  and  which  will  be  found 
described  at  length  in  all  text-books  of  surgery.     But  there  are  certain  points 


436    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

essential  to  obtain  a  good  result — that  is,  perfect  primary  union  of  the  two 
sides — and  these  salient  features  of  the  operation  will  be  described. 

It  is  important  that  the  general  condition  of  the  patient  be  good,  and  that 
the  season  of  the  year  be  favorable;  that  is,  preferably,  not  during  the  heated 
term  of  summer.  The  bowels  should  be  opened  freely  the  day  before  the 
operation  by  the  administration  of  castor  oil  the  night  preceding  this.  Special 
care  should  be  taken  to  avoid  vomiting,  caused  by  the  anaesthetic,  by  forbidding 
any  breakfast  on  the  morning  of  the  operation.  One  can  readily  understand 
that  the  whole  success  of  this  long  and  tedious  operation  will  depend  upon 
securing  primary  union,  and  that  this  preliminary  treatment  is  calculated  to 
insure  a  condition  of  health  favorable  to  such  union. 

For  anaesthesia  in  operations  about  the  mouth  chloroform  is  often  preferred 
to  ether,  because  its  administration  can  be  more  interrupted ;  but  children  with 
cleft  palate  are  apt  to  be  generally  feeble,  so  one  must  consider  ether  the  safer 
anaesthetic  for  prolonged  use ;  but  one  can  commence  with  chloroform,  because 
of  its  greater  rapidity  and  pleasantness  of  action,  and  continue,  as  soon  as 
unconsciousness  is  secured,  with  ether. 

As  with  most  other  operations  on  the  mouth  and  throat,  the  patient  should 
be  placed  in  Rose's  position ;  that  is,  with  the  head  pendent  from  the  edge  of 
the  table,  and  the  shoulders  elevated  by  a  small  hard  pillow,  so  that  blood  will 
gravitate  into  the  naso-pharynx  and  not  into  the  windpipe.  In  this  position, 
at  times  when  haemorrhage  is  freest,  the  patient  can  be  rolled  upon  the  abdo- 
men and  the  blood  allowed  to  flow  from  the  mouth  and  the  nose. 

The  most  suitable  gag  is  Mussey's  modification  of  the  Whitehead  gag.  It 
has  a  tongue-depressor  attached, — a  matter  of  importance  as  it  is  absolutely 
necessary  that  the  tongue  be  held  depressed  at  the  same  time  that  the  mouth 
is  gagged  open.  The  tongue-depressor  of  the  Whitehead  gag  is  attached  by  a 
hinge-and-ratchet  joint,  which  easily  gets  out  of  order,  and  detracts  from  the 
value  of  the  mechanism.  In  the  Mussey  gag  the  tongue-depressor  is  a  part 
of  the  same  piece,  but  by  force  it  can  be  bent  to  a  different  angle  if  required. 

Many  and  complicated  needles  have  been  devised  for  the  purpose,  among 
which  may  be  mentioned  Prince's  needle  as  ingenious,  but  rather  complicated. 
All  that  is  necessary  is  a  curved  needle  mounted  in  a  handle,  as  illustrated  in 
Fig.  17.    This  needle  is  often  kept  in  the  shops,  but  the  curve  should  be  much 

Fig.  17. 


Author's  Modified  Stapbylorraphy  Needle  (half  size). 


more  acute  than  is  usually  supplied,  and  the  eye  of  the  needle  as  near  as  possi- 
ble to  its  point.  These  may  seem  like  small  details,  but  the  selection  of  the 
needle  is  one  of  the  most  important  points  to  insure  a  successful  operation, 
inasmuch  as  it  is  sufficiently  difficult  to  place  the  sutures  with  a  perfect  needle, 
and  with  a  faulty  one  it  may  be  impossible. 

The  patient  being  thoroughly  under  the  influence  of  the  anaesthetic,  the 
first,  and  absolutely  necessary,  step  is  the  division  of  certain  muscles.  This 
should  be  the  first  step  of  the  operation,  and  not  the  last,  for  the  reason  that 
firm  and  accurate  coaptation  of  the  edges  can  be  made  only  after  the  perfect 
relaxation  of  the  muscles  thereby  produced.  Having  introduced  the  gag,  one 
will  notice  the  wide  aperture  in  the  roof  of  the  mouth,  and  that  it  is  seemingly 
impossible  to  draw  together  the  two  sides  of  the  palate.  This  is  by  reason  of 
the  constant  contraction  of  the  palatal  muscles.     If  one  were  to  draw  the  two 


DISEASES  OF  THE  PHARYNX  AND  NASO-PHABYNX.     437 

sides  together  forcibly  by  means  of  stitches  under  the  partial  relaxation  pro- 
duced by  the  anaesthetic,  they  would  only  be  ripped  out  again  at  the  first  effort 
of  the  child  in  crying  or  coughing  or  swallowing.  Only  perfect  relaxation  of 
the  velum  can  assure  complete  primary  union  of  the  parts.  The  muscles  to 
be  divided  on  each  side  are  the  tensor  palati,  the  levator  palati,  the  palato- 
glossus, and  one  of  the  palato-pharyngei.  The  last-named  muscles  constitute 
the  anterior  and  posterior  pillar  of  the  fauces  respectively.  The  tensor  palati 
arises  on  each  side  at  the  base  of  the  internal  pterygoid  process,  and,  descend- 
ing, its  tendon  winds  around  the  hamular  process,  which  can  be  felt  by  the 
tongue  just  to  the  inner  side  of  the  upper  third  molar  tooth,  and  then  spreads 
through  the  body  of  the  velum.  The  levator  palati  has  its  fibres  distributed 
just  behind  the  tensor.  A  puncture,  therefore,  through  the  velum,  com- 
mencing at  the  point  of  the  hamular  process,  and  following  its  curve  about 
three  millimetres  upward,  will  sever  the  tendon  of  the  tensor.  Then  the  knife, 
with  its  cutting  edge  directed  upward,  should  have  its  handle  depressed,  with- 
drawn, reintroduced  (in  the  same  opening),  the  cutting  edge  directed  downward 
and  handle  elevated,  cutting,  in  this  manner,  the  posterior  surface  of  the  velum 
more  widely  than  the  anterior  surface,  and  so  severing  as  many  fibres  as  possible 
of  the  levator.  Having  done  this,  one  will  notice  how  much  more  easily  the 
two  sides  can  be  approximated. 

Next  raise  the  velum  on  each  side  and  snip  with  scissors  the  anterior  pillar, 
and,  on  one  side  only,  the  posterior  pillar,  in  order  to  guard  against  atrophy  of 
the  palate  by  leaving  the  arterial  supply  intact  on  the  opposite  side. 

The  haemorrhage  which  is  caused  by  these  punctures  is  not  likely  to  be 
dangerously  profuse,  although  a  small  artery  is  severed,  but  the  galvano-cau- 
tery  point-electrode  subsequently  introduced  would  serve  to  arrest  an  excessive 
bleeding. 

The  edges  of  the  cleft  should  be  thoroughly  pared,  as  merely  splitting  them 
does  not  result  in  the  same  satisfactory  raw  surface,  and  then  provision  can  be 
made  for  closing  the  cleft  in  the  hard  palate.  If  this  part  of  the  fissure  be  not 
very  extensive,  the  Warner-Langenbeck  method  is  best.  Loosen  tissue  to  slide 
to  the  median  line  by  making  lateral  incisions  through  the  mucous  membrane 
and  periosteum,  and  by  incision  around  and  behind  the  anterior  end  of  the  cleft, 
extending  to  the  bone  both  on  the  buccal  and  nasal  surface ;  then,  by  means 
of  a  periosteal  elevator  raising  the  periosteum  from  the  bone  from  the  lateral 
incisions  to  the  edges  of  the  cleft,  which  part  of  the  edge  must  also  be  well 
detached  from  the  underlying  bone  and  fascia,  and  properly  freshened  wherever 
it  is  to  join  the  one  of  the  opposite  side  (Fig.  18).  These  two  flaps  can  then 
be  brought  together  in  the  median  line. 

For  extensive  bony  clefts  Fergusson  advocated  the  separation,  by  boring 
and  chiselling,  of  sufficient  of  the  bony  edges  to  bring  together  in  the  centre 
to  close  the  cleft.  This  procedure  appears  unnecessarily  formidable,  apart  from 
the  fact  that  with  very  wide  cleft — the  cases  with  which  the  ordinary  flap  ope- 
ration is  inadequate — the  bony  edges  are  likewise  too  scanty  to  afford  a  reason- 
able prospect  of  success.  For  such  wide  clefts  the  soft  flap  method  recently 
proposed  by  Davies-Colley,  of  Guy's  Hospital,  commends  itself.  Figs.  19  and 
20  will  convey  his  idea. 

Next,  the  introduction  of  the  sutures,  by  far  the  most  difficult  part  of  the 
operation.  I  prefer  silk  sutures,  and  consider  them  much  superior  to  silver  wire 
and  shot,  as  they  are  softer  in  the  mouth,  and  seemingly  do  not  produce  the 
same  amount  of  irritation  and  annoyance  to  the  child.  Two  colors,  white  and 
black,  should  be  used,  as  all  the  stitches  should  be  passed  before  tying,  and  if 
these  colors  alternate  confusion  of  the  ends  need  not  occur.     The  well-curved 


438    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

Fig.  13. 


Wamer-Langenbeck  Method  of  Closing  Small  Bony  Clefts,  flap  prepared  on  one  side  only. 


Figs.  19  and  20. 


Method  of  Closing  a  Wide  Cleft  of  the  Hard  Palate  (after  Davies-Colley). 


DISEASES  OF  THE  PHARYNX  AND  NASO-PHABYNX.    439 

needle,  having  been  threaded,  is  introduced  on  one  side  (the  patient  being 
recumbent),  from  below  upward,  or  what  would  be,  if  the  patient  were  upright, 
from  behind  forward  (Fig.  21).  To  facilitate  passing  the  needle  the  flap  is  held 
and  drawn  tense  by  forceps.  The  thread  is  then  caught  from  the  eye  of  the 
needle  by  a  blunt  tenaculum  (Fig.  21),  one  end  drawn  all  the  way  through,  and 
the  needle  passed  back  and  drawn  off  the  other  end. 

Fig.  21. 


Fig.  22. 


End  of  suture,  a,  is  next  passed  through  loop,  b, 
•which  is  used  only  to  draw  end  a  through  the 
flap  of  that  side.  Ends  a  and  c  are  subsequently 
tied. 


Passing  a  Suture. 


This  procedure  is  easier  than  if  the  needle  were  previously  passed  in  the 
reverse  direction,  as  is  usually  recommended.  Having  passed  the  suture  on 
one  side,  one  must  pass  a  double  thread  on  the  opposite  side,  drawing  up  in 
like  manner  with  a  tenaculum  the  two  free  ends,  which  leaves  the  loop  below 
(Fig.  22);  the  needle  is  then  drawn  back  as  before  and  disengaged.  Then 
through  the  loop  is  passed  the  lower  end  of  the  single  suture,  and,  by  means 
of  the  double  thread,  it  is  pulled  through  the  opposite  side.  In  passing  the 
stitches  great  care  should  be  taken  to  engage  sufficient  tissue,  not  getting  them 
too  near  the  edge,  and  also  to  have  them  passed  as  nearly  as  possible  at  points 
opposite  each  other. 

Before  tying  the  sutures  special  care  should  be  observed  to  see  that  the  edges 
of  the  flaps  are  clean  and  free  from  clotted  blood.  Then,  commencing  anteriorly, 
the  sutures  are  tied  first  by  means  of  a  slip-knot  pushed  down  by  the  finger, 
the  suture  well  tightened,  and  again  tied  by  an  ordinary  knot.  As  the  sutures, 
one  after  another,  are  thus  tied,  see  that  the  edges  are  not  turned  in  so  as 
to  bring  mucous-membrane  surfaces  together  instead  of  freshened  edges. 

Failure  to  unite  by  primary  union  is  probably  due  to  incomplete  division  of 
the  muscles  more  frequently  than  to  any  other  one  cause  ;  but  the  good  health  of 
the  child,  the  careful  paring  of  the  edges,  and  placing  of  the  sutures  are  also 
essential  points.  If,  however,  complete  union  should  not  result  at  the  first  oper- 
ation, we  certainly  should  operate  a  second  or  a  third  time. 

It  is  rare  indeed,  with  ordinary  care  and  skill,  that  partial  union  will  not  be 
produced  at  the  first  trial,  and  this  will  encourage  both  parents  and  surgeon  to 
persevere  to  a  complete  result. 


440    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Concerning  now  tlie  subsequent  treatment  of  the  patient :  At  the  completion 
of  the  operation,  before  the  patient  has  revived  from  the  ansesthetic,  a  hypo- 
dermic of  morphine  should  be  administered.  This  to  prevent,  as  far  as  possible, 
vomiting  and  excessive  crying — in  other  words,  to  maintain  quietude  of  the 
parts.  I  consider  it  best,  although  all  authorities  will  not  be  in  accord  with 
this  opinion,  to  keep  the  patient  partially  under  the  influence  of  morphine 
during  the  first  three  days,  for  the  same  reason.  The  stitches  may  be  removed 
from  the  sixth  to  the  tenth  day.  Some  of  them  by  the  sixth  day  will  have 
ulcerated  out  on  one  or  both  sides,  but  this  matters  not  when  primary  union  is 
secured  ;  and  if  primary  union  is  not  secured,  the  stitches  will  not  hold  the  parts 
together  after  the  third  or  fourth  day.  But  as  a  matter  of  precaution,  to  give 
some  strength  to  the  newly -formed  union,  the  stitches  may  be  left  until  the 
time  stated.     To  facilitate  their  removal  an  anaesthetic  should  be  administered. 

[Note. — Since  going  to  press  the  author  has  observed  an  instructive  case  of  retro- 
pharyngeal lymphadenitis  in  an  infant  four  months  of  age.  The  child  was  convalescing 
from  infectious  pseudo-membranous  tonsillitis  (folliculous)  when  dyspnoea  commenced, 
and  increased  for  two  weeks,  wlien  suffocation  was  imminent.  Voice  was  unimpaired 
and  inspection  of  the  fauces  negative,  but  palpation  disclosed  a  hard  tumor  projecting 
from  the  posterior  pharyngeal  wall  in  the  median  line,  low  down  and  pressing  upon  the 
opening  of  the  larynx.  Three  punctures  into  this  tumor  failed  to  evacuate  pus.  Trache- 
otomy was  immediately  performed.  Eesolution  was  complete ;  at  the  end  of  two  weeks 
the  tube  was  withdrawn,  and  the  child  recovered.] 


GASTRIC  CATARRH  AND  GASTRIC  ULCER. 


By  a.  D.  BLACKADER,  M.  D., 

Montreal. 


I,  Acute  Gastric  Oatabrh. 

Acute  gastric  catarrh,  otherwise  known  as  acute  gastritis,  gastro-aden- 
itis,  acute  dyspepsia,  or  gastric  fever,  is  an  acute  inflammation  of  the  glandular 
tissue  of  the  stomach  interfering  with  its  digestive  functions,  and  generally  due 
to  the  presence  of  irritating  ingesta.  The  attack  is  attended  with  pain,  ano- 
rexia, and  nausea  or  vomiting;  frequently  also  by  general  pyrexia.  It  is 
occasionally  complicated  by  reflex  nervous  symptoms  of  a  more  or  less  serious 
character.  Associated  disorder  in  other  portions  of  the  alimentary  canal  may 
be  met  with.  While  occurring  at  any  age,  artificially  reared  infants  and  deli- 
cate children  are  especially  prone  to  this  disorder. 

Etiology. — During  infancy  the  stomach  appears  to  be  peculiarly  liable  to 
disturbance  of  its  functions.  It  is  the  period  of  its  most  rapid  development, 
and  not  only  does  it  increase  in  size,  but  it  has  to  assume  more  varied  duties. 
At  the  same  time,  the  demands  upon  it,  incident  to  the  very  rapid  growth  of 
the  body  at  this  period  of  life,  are  proportionately  larger  than  at  a  more 
advanced  age.  Infants  fed  at  the  breast  generally  escape,  but  not  always. 
Occasionally  errors  in  diet  on  the  part  of  the  mother,  violent  disturbance  of 
the  nervous  system,  or  the  appearance  of  the  catamenia,  may  produce  such 
changes  in  maternal  milk  as  to  render  it  less  digestible,  and  thus  bring  about 
an  attack  of  acute  catarrh  in  the  infant.  It  is,  however,  among  those  who 
have  been  artificially  fed  from  the  early  days  of  infancy  that  disturbances  of 
this  character  most  frequently  occur.  The  essentials  of  artificial  feeding  in  in- 
fancy,— a  milk,  practically  sterile,  containing  the  proper  amount  of  albuminoids, 
fats,  and  sugars,  fed  to  the  infant  in  proper  amounts,  at  a  proper  temperature, 
and  at  due  intervals,  so  as  to  permit  perfect  digestion  with  a  short  period  of  rest 
for  .the  stomach, — have  not  yet  been  generally  attained,  even  in  our  more  intel- 
ligent families;  while,  among  the  poorer  classes,  how  often  does  the  infant's  food 
fail  in  every  one  of  these  details !  During  infancy,  also,  appear  the  reflex  nerve- 
disturbances  generally  attributed  to  dentition.  Certainly  at  this  period  acute 
disturbances  of  the  stomach  are  more  frequently  met  with  than  either  before  or 
after. 

By  the  end  of  two  years  the  powers  of  the  stomach  are  more  developed; 
the  demands  of  the  system  less  exorbitant;  any  irritation  accompanying  denti- 
tion is  past ;  and,  under  a  careful  dietary,  attacks  of  acute  catarrh  should  be 
infrequent.  The  rich  and  varied  table  diet  often  injudiciously  allowed  after 
this  age  may,  however,  conduce  to  an  attack. 

Generaliz-ing,  we  may  say  that  any  excess  in  the  amount  of  food,  too  great 
variety  in  its  character,  the  use  of  such  stimulating  food  as  highly-spiced  dishes, 
pickles,  or  sauces,  irregularity  in  the  meal  hours,  or  the  unregulated  and  un- 
limited eating  of  fruits,  cakes,  or  sweetmeats,  especially  between  meals,  may  in 

441 


442  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

children  bring  on  an  attack  of  acute  indigestion.  Food  or  drink,  too  hot 
or  too  cold,   quickly  taken,  may  also  occasionally  be  an  exciting  cause. 

Closely  associated  with  errors  in  the  dietary  as  an  etiological  factor  is  the 
imperfect  mastication  so  often  given  to  food.  Children  require  to  be  taught  to 
masticate,  and  their  teeth  from  the  time  of  their  first  appearance  should  claim 
the  careful  attention  of  the  attendants. 

There  is  not,  however,  in  all  children  an  equal  susceptibility  to  disturb- 
ance. Some  appear  to  have  particularly  vigorous  stomachs  which  tolerate 
much  abuse,  while  it  is  only  with  the  greatest  care  that  attacks  can  be  averted 
in  others.  In  some  a  predisposition  to  weak  digestion  is  distinctly  hereditary. 
An?emic  children  are  peculiarly  prone  to  attacks.  The  close  association  be- 
tween rickets  and  disorders  of  digestion  has  long  been  recognized.  The 
scrofulous  and  rheumatic  diatheses  are  also  predisposing  factors.  Unsanitary 
conditions  of  life  markedly  impair  the  digestive  powers,  and  thus  favor  an  acute 
disturbance  ;  especially  is  this  true  of  want  of  exercise  in  the  open  air. 

The  acute  ailments  and  specific  fevers  of  childhood  frequently  leave  the 
mucous  membrane  of  the  alimentary  canal  in  a  weakened  condition,  from 
which  it  takes  time  and  a  very  careful  dietary  to  thoroughly  recover.  Of  this 
class  of  disease  Ewald  says:  "  Although  the  gastric  symptoms  are  relegated  to 
the  background  by  other  manifestations,  yet  in  those  cases  with  dyspeptic  dis- 
turbances, in  which  we  are  enabled  to  examine  the  organ  soon  after  death,  we 
will  find  the  anatomical  changes  of  acute  gastritis." 

In  some  children  the  sudden  checking  of  the  cutaneous  circulation,  by  chill 
from  imprudent  exposure,  may  occasionally  interfere  with  the  process  of  diges- 
tion and  bring  about  an  attack.  Eustace  Smith  thinks  this  a  very  frequent 
cause  of  trouble.  In  our  more  severe  climate  children  are  more  perfectly 
clothed  in  flannel  than  in  England,  but  in  children  with  weak  stomachs  I  have 
frequently  noticed  an  attack  of  gastric  catarrh  brought  on  by  getting  the  feet 
damp.     Unless  due  care  be  exercised,  one  attack  may  predispose  to  others. 

Pathology. — Our  knowledge  of  the  minute  changes  in  the  mucous  mem- 
brane in  acute  gastric  catarrh  has,  until  lately,  been  very  limited  ;  so  much  so, 
that  some  writers  have  questioned  the  propriety  of  admitting  this  among  the  list 
of  actual  diseases.  In  his  recent  work  Ewald  protests  against  the  use  of  the 
word  "  catarrh  "  as  creating  an  erroneous  conception.  "  The  structure,"  he  says, 
"  of  the  gastric  mucosa,  better  designated  the  glandular  layer,  ttmiea  glandularis, 
is  such  that  it  is  out  of  the  question  to  call  it  a  mucous  membrane  in  the  ordi- 
nary meaning   of   the  term It  is   simply  a  peculiar  feature  of  the 

inner  layer  that  the  protoplasm  of  the  epithelium  of  the  excretory  ducts  pos- 
sesses in  a  remarkable  degree  the  property  of  being  converted  into  mucus.  . 
.  .  .  Dr.  Beaumont's  investigations  on  his  patient,  St.  Martin,  showed  that 
every  catarrh,  even  the  mildest,  was  accompanied  by  a  disturbance  of  the 
secretion  of  gastric  juice  ;  consequently  by  an  affection  of  the  glands  them- 
selves. The  inflammation  is  thus  not  catarrhal,  but  parenchymatous  and  inter- 
stitial. It  has  nothing  in  common  with  a  catarrh  except  the  "flow,"  the  secre- 
tion of  a  moi-e  or  less  abundant,  but  always  alkaline,  transudate  into  the  cavity 
of  the  stomach.  Misled  by  the  term  "catarrh,"  we  are  too  prone  to  under- 
estimate the  importance  of  these  processes,  particularly  when  they  are  chronic, 
and  by  thinking,  for  example,  of  a  chronic  pharyngeal  catarrh,  we  lose  all 
proper  standards  of  comparison." 

Macroscopically,  the  mucous  membrane  in  acute  catarrh  appears  swollen  and 
reddened.  In  severe  cases  slight  haBmorrhages,  or  even  small  erosions,  may 
occur ;  the  submucosa  may  be  oedematous.  Microscopically,  there  appears  an 
infiltration  of  the  interstitial  tissue  with  leucocytes  ;  the  differentiation  between 


GASTBIC    CATARRH  AND    GASTRIC    ULCER.  443 

the  parietal  and  the  principal  cells  can  no  longer  be  made  out,  while  all  the  cells 
may  alike  be  seen  to  have  become  granular  and  cloudy,  and  in  part  separated 
from  the  memhrana  propria  of  the  glands.  The  mucous  cells  are  especially 
abundant  in  the  pyloric  region,  and  extend  down  deeply  into  the  ducts  of  the 
glands. 

Symptoms. — Cases  of  acute  gastric  catarrh  have  been  divided  into  two 
classes,  the  fehrile  and  the  afebrile,  according  as  they  are,  or  are  not,  accom- 
panied by  pyrexia.  The  division  is  a  convenient  one.  The  febrile  are  much 
the  more  severe.  The  afebrile  run  a  short,  mild  course,  and  are  as  a  rule 
unaccompanied  by  serious  symptoms. 

The  onset  of  an  attack  is  generally  sudden.  Within  an  hour  or  two  after 
the  error  in  diet  the  child  shows  signs  of  being  unwell.  If  an  infant,  after  a 
short  sleep  it  awakes  crying  and  apparently  in  pain.  Its  thighs  are  flexed  on 
the  abdomen.  It  moves  restlessly  from  side  to  side,  and  whines  piteously  or 
cries  bitterly.  The  temperature  will  be  found  more  or  less  elevated,  102  °  to 
104°,  the  pulse  and  respiration  quickened,  the  tongue  furred,  the  abdomen 
distended,  and  pressure  on  it  evidently  increases  the  child's  distress.  The 
bowels  at  this  time  may,  or  may  not,  show  signs  of  disturbed  action.  Vomiting 
generally  occurs  early,  with  some  temporary  relief.  After  this  the  infant,  if 
allowed,  may  eagerly  take  the  breast  or  its  food  again,  only  to  reject  it,  curdled 
and  sour-smelling,  after  a  short  interval.  If  the  ejecta  be  carefully  examined, 
there  will  be  found  a  marked  deficiency  of  hydrochloric  acid,  and  in  its  place 
the  presence  of  lactic  and  butyric  acids.  Vomiting  may  recur  several  times  ; 
at  the  last,  watery,  sour-smelling  mucus,  perhaps  more  or  less  bile-stained, 
being  ejected.  There  is  now  complete  anorexia.  The  infant  is  restless  and 
feverish,  if  not  actually  crying  with  pain,  and  its  sleep  is  much  broken  and 
disturbed.  Under  proper  treatment  the  attack  is  generally  of  short  duration, 
and  in  twenty-four  or  forty-eight  hours  a  few  loose  movements  carry  away  any 
of  the  offending  material  that  has  escaped  into  the  bowel ;  the  fever  subsides  ; 
the  infant  again  sleeps  quietly  ;  but  for  a  few  days  it  is  less  eager  for  its  food, 
which  it  is  inclined  to  take  more  slowly  and  in  smaller  quantity. 

In  older  children  the  attack  manifests  itself  by  a  feeling  of  listlessness, 
with  more  or  less  drowsiness.  The  child  will  give  up  its  play  and  prefer  to 
lie  down.  Uneasy  pain  in  the  epigastrium  is  soon  complained  of,  with  a  feel- 
ing of  nausea  and  headache.  If  the  child  fall  asleep,  it  is  a  very  disturbed 
sleep,  from  which  it  frequently  awakes  in  a  fright,  complaining  of  bad  dreams. 
Dark  circles  may  now  be  noticed  under  the  eyes ;  the  face  is  generally  pallid 
unless  the  fever  runs  high.  In  that  case  a  peculiar  pallor  about  the  upper  lip 
and  the  alse  nasi  is  very  distinctive  of  irritation  of  the  stomach.  The  tongue 
is  coated  heavily  toward  the  base,  but  the  tip  and  the  edges  are  red ;  the  skin 
is  dry  ;  the  pulse  is  quickened  ;  the  temperature  may  be  high — 103°  to  104° 
— but  if  so  it  reaches  its  height  early  ;  the  abdomen  is  distended,  pressure  over 
the  epigastrium  increasing  the  uneasiness ;  and  the  breath  is  generally  heavy  or 
sour-smelling.  The  secretion  of  saliva  is  increased,  so  that  during  sleep  it  may 
dribble  on  the  pillow.  Vomiting  may  occur,  but  not  so  generally  as  in  infants. 
When  it  does,  there  is  usually  much  retching,  and  toward  the  close  biliary 
matters,  with  watery  mucus,  are  ejected  with  much  straining.  The  bowels  are 
constipated  and  the  urine  scanty  and  high-colored,  with  an  abundant  sediment 
of  lithates.  The  headache  is  generally  frontal,  although  sometimes  temporal. 
In  some  cases  an  associated  pharyngitis  may  be  noticed ;  in  others  a  few 
herpetic  vesicles  appear  on  the  lips.  In  mild  cases  the  attack  subsides  in  a  day 
or  two,  but  in  the  more  severe  forms  the  fever  may  persist  for  four  or  five  days, 
leaving  the  child  in  an  exhausted  state,  from  which,  however,  under  careful 


444  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

dietary,  it  generally  recovers  rapidly.  Occasionally  an  attack  of  acute  gastric 
catarrh  is  followed  in  a  few  days  by  catarrhal  jaundice.  The  inflammation 
has  probably  extended  down  the  duodenum,  blocking  the  common  bile-duct. 
Such  cases  are  usually  of  short  duration. 

Although,  in  general,  an  attack  of  acute  gastric  catarrh  may  give  us  little 
anxiety,  at  times  we  have  associated  reflex  symptoms  of  a  very  alarming  char- 
acter. The  convulsive  seizures  of  infancy,  dependent  so  frequently  upon 
gastric  or  intestinal  irritation,  are  familiar  to  all  and  require  prompt  treat- 
ment. The  danger  of  cerebral  haemorrhage  during  such  an  attack  should 
always  be  borne  in  mind. 

In  older  children  more  alarming,  because  more  unusual,  symptoms  of  reflex 
irritation  are  occasionally  met  with.  In  some  instances  localized  or  difl"use 
clonic  muscular  movements  have  their  origin  in  gastric  irritation.  Symptoms 
closely  resembling  those  of  meningitis  have  been  reported  by  Seibert.  Fraen- 
kel  relates  the  case  of  a  child  four  years  old  who  shortly  after  eating  a  large 
amount  of  table  food  lost  the  power  of  movement  and  sensation  on  the  right 
side.  Complete  recovery  followed  on  the  next  day.  Henoch  records  a  case  of 
complete  aphasia  in  a  child  which  passed  away  an  hour  later  after  the  vomiting 
of  some  undigested  fruit.  Such  cases,  however,  are  rare,  and  should  alwa^^s 
receive  the  most  careful  attention  on  the  part  of  the  physician,  lest,  instead  of 
being  reflex,  they  arise  from  a  distinct  and  all-important  lesion. 

Diagnosis. — In  most  instances,  with  a  distinct  history  of  some  error  in 
diet,  no  serious  diflSculty  will  be  experienced  in  arriving  at  a  guarded  conclu- 
sion. The  sudden  onset,  the  tenderness  over  the  epigastrium,  the  relief  afforded 
by  vomiting,  and  the  rapid  subsidence  of  the  symptoms  will  in  a  day  or  two 
enable  us  to  assure  the  parents  that  no  more  serious  trouble  need  be  appre- 
hended. In  cases  attended  with  fever,  however,  it  is  always  wise  to  speak 
more  or  less  guardedly  at  the  first.  The  onset  of  scarlet  fever  should  always 
be  excluded.  In  this  disease  we  have  as  an  early  symptom  a  definite  amount 
of  congestion  of  the  fauces,  followed  frequently  by  some  enlargement  of  the 
glands  at  the  angle  of  the  jaw.  The  irregular  erythema,  sometimes  appearing 
for  a  few  hours  in  disorders  of  the  stomach,  should  be  distinguished  from  the 
scarlatinal  eruption  with  its  more  regular  development  and  longer  duration.  In 
doubtful  cases,  for  such  will  arise,  isolation  for  twenty-four  or  forty-eight  hours 
will  solve  the  problem.  Tonsillitis  and  diphtheria  may,  with  care,  be  easily 
excluded.  An  attack  of  acute  catarrh  may  closely  resemble  the  onset  of  pneu- 
monia. J.  Lewis  Smith  relates  a  case  in  which  the  high  temperature  and  ex- 
piratory moan  simulated  a  pulmonary  inflammation,  but  was  promptly  relieved 
by  the  expulsion  of  some  orange-pulp.  In  cases  such  as  these  careful  attention 
must  be  paid  to  the  pulse,  the  respiration,  and  the  temperature.  In  typhoid 
fever  the  rise  is  more  gradual ;  we  frequently  meet  with  an  initial  bronchitis, 
the  prodromata  are  more  marked,  and  some  enlargement  of  the  spleen  may  be 
made  out.  In  acute  gastric  catarrh  the  onset  is  more  sudden,  and  the  disten- 
tion of  the  abdomen  more  marked,  than  is  general  in  typhoid  fever  at  an  early 
stage,  while  tenderness  is  noted  in  the  epigastrium,  not  in  the  iliac  region,  and 
the  temperature  falls  after  a  few  days.  In  delicate  children  the  possibility  of 
tuberculosis  must  always  give  us  anxiety.  We  have  no  absolute  symptoms  by 
which  we  can  exclude  this  disease.  A  slow  pulse  may  occasionally  be  met  with 
in  gastric  disorder  from  irritation  of  the  vagus.  The  vomiting  of  meningitis  is, 
in  general,  indistinguishable  in  its  character  from  the  vomiting  of  mere  gastric 
irritation,  and  the  condition  of  the  tongue  is  no  certain  guide.  Under  these 
circumstances  a  careful  watch  for  localizing  symptoms  will  be  required,  and  a 
very  guarded  opinion  must  be  given. 


GASTRIC   CATABBH  AXD    GASTBIC    ULCEB.  445 

Prognosis. — The  prognosis  of  acute  gastric  catarrh  must  be  regarded  as 
very  favorable.  Onlv  in  delicate  infants,  whose  hold  on  life  is  extremely  frail, 
will  the  disturbance  of  nutrition  or  the  gastric  irritation  threaten  immediate 
serious  results.  Such  an  attack  may  be  the  beginning,  however,  of  a  gastro- 
enteritis, which  may  prove  fatal.  Convulsive  seizures  are  always  serious. 
Relapses  are  common  in  artificially-fed  infants  and  in  older  children  unless 
due  care  be  exercised. 

Treatment. — In  acute  gastric  catarrh  the  first  important  indication  for 
treatment  would  appear  to  be  the  removal  of  the  offending  material  in  the 
stomach.  Nature  in  many  cases  effects  this  spontaneously  by  the  induction  of 
vomiting.  Should  we  see  the  case  early,  before  vomiting  has  taken  place,  we 
may  favor  it  by  the  administration  of  ipecacuanha,  either  in  the  form  of  a 
powder,  or  of  the  wine  or  syrup.  If  some  hours  have  elapsed,  however,  a 
large  portion  of  the  offending  stomach-contents  may  have  escaped  through  the 
pylorus,  and  a  gentle  but  prompt  purgative  is  then  called  for.  The  following 
are  suitable  prescriptions  under  the  circumstances : 

^.   Hydrarg.  chloridi  mitis gr.  ij-iv. 

Sodii  bicarbonatis gr.  xij. — M. 

In  pulv.  iv.  divid. 
Sig.   One   every   three  hours  until   a  free   evacuation  of  the   bowels  is 
secured  (for  a  child  of  three  years). 

Or,          !^.   Hydrarg.  cum  creta g^*  "^j* 

Sodii  bicarbonatis gr.  viij. 

Pulv.  rhei gr.  viij. — M. 

In  pulv.  ii.  divid. 
Sig.   One  to  be  given  immediately  (for  a  child  of  three  years). 

Or,          !^.   Sodii  et  potassii  tartratis gr.  xxx. 

Sodii  bicarbonatis gr.  iij. — M. 

In  pulv.  vj.  divid. 
Sig.  One  to  be  given  every  hour  in  a  wineglassful  of  hot  water  until 
a  free  evacuation  is  secured  (for  a  child  of  three  years). 

In  those  cases  where  vomiting  is  troublesome  and  persistent  minute  doses 
of  calomel,  or  of  calomel  and  soda,  may  be  given  dry  on  the  tongue.  My  own 
preference  is  for  the  triturate  of  a  tenth  of  a  grain,  or  of  the  tenth  of  a  grain 
of  calomel  with  a  grain  of  soda,  to  be  given  hourly  until  eight  or  ten  doses 
have  been  taken.  This  generally  checks  vomiting  and  secures  a  free  evacua- 
tion of  the  bowels  within  twelve  or  twenty-four  hours.  It  probably  serves  also 
to  check  to  some  extent  the  development  of  bacteria  in  the  stomach.  Should 
pain  in  the  epigastrium  be  complained  of,  a  warm  poultice  of  linseed-meal, 
either  pure  or  with  a  proportion  of  mustard,  applied  over  this  region,  will  be  a 
source  of  much  comfort.  After  the  first  acute  symptoms  have  passed  off,  a 
mixture  containing  sodium  bicarbonate,  with  a  minute  dose  of  nux  vomica,  will 
distinctly  favor  a  return  to  healthy  secretion : 

^.   Sodii  bicarbonatis gr.  xlviij. 

Tr.  nucis  vomicae TTlvj. 

AquEe  carui adfsiij. — M. 

Sig.   One  dessertspoonful  to  be  given  four  times  daily  (for  a  child  of  three 
years). 


446   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

As  the  case  progresses  and  the  inflammatory  action  subsides,  the  amount 
of  the  nux  vomica  may  be  increased. 

The  dietetic  treatment  is  even  more  important  than  the  medicinal.  After 
the  stomach  is  emptied  it  should  have  complete  rest  for  some  hours.  Water  in 
small  quantities  or  small  pieces  of  ice  should  be  all  that  is  allowed  until  the 
inflammatory  action  has  sufficiently  subsided  to  permit  the  secretion  of  gastric 
juice.  Any  attempt  to  give  the  child  food  before  this  will  only  increase  the 
existing  hypersemia.  In  general,  after  about  twelve  hours  of  abstinence,  milk 
diluted  with  either  Vichy  or  lime-water,  may  be  allowed  in  small  quantities 
at  a  time.  Should  it  disagree,  a  weak  broth  with  barley-  or  rice-water  may  be 
tried.  The  recourse  to  solid  food  must  be  gradual.  Starchy  food,  which  is 
principally  digested  in  the  small  intestine,  may  first  be  given,  while  stronger 
nitrogenous  food  is  withheld  for  a  few  days  longer. 

Should  nervous  symptoms,  such  as  sudden  twitchings  or  startings,  make 
their  appearance,  great  quiet  should  be  maintained  in  the  sick-room,  Avhich 
should  be  moderately  darkened.  At  the  same  time  an  enema,  containing 
bromide  of  potassium  or  chloral,  or  both,  in  a  little  starch-  or  gum-water,  may 
be  given  to  relieve  the  nervous  irritability,  and,  if  possible,  to  ward  off  any 
convulsive  seizure. 

As  long  as  the  pulse  is  quickened  or  the  temperature  elevated  the  child 
should  be  kept  in  bed.  Afterward  over-fatigue  should  be  avoided,  as  tending 
to  a  relapse. 

When  the  gastric  irritation  has  quite  subsided,  the  tongue  become  clean, 
and  the  appetite  has  to  some  extent  returned,  the  administration  of  some  fer- 
ruginous tonic,  with  a  daily  drive  in  the  open  air,  will  generally  prove  of  dis- 
tinct value. 

n.  Chronic  Gastric  Catarrh. 

This  disease,  also  called  chronic  glandular  gastritis,  or  chronic  vomiting,  is 
a  chronic  inflammatory  condition  of  the  glandular  tissue  of  the  stomach,  giving 
rise  to  a  diminution  in  both  the  quantity  and  the  quality  of  the  true  glandular 
secretion  (hydrochloric  acid  and  pepsinogen),  but  attended  with  the  secretion, 
sometimes  in  large  quantities,  of  an  alkaline  mucus  which  possesses  no  digest- 
ive powers.  As  a  result  of  this  condition  we  meet  with,  in  time,  an  enfeeble- 
ment  of  the  muscular  coat  of  the  stomach  leadi-ng  to  the  undue  retention  of 
food.  Chronic  gastric  catarrh  is  undoubtedly  the  condition  most  frequently 
encountered  in  the  chronic  digestive  disorders  of  childhood.  Only  very  seldom 
at  this  period  of  life  can  such  disorders  be  referred  to  a  distinct  neurosis. 

Etiology. — The  causes  leading  to  the  condition  of  chronic  gastric  catarrh 
in  childhood  are  closely  allied  to  those  already  mentioned  as  inducing  an  acute 
catarrh.  The  continued  irritation  of  the  gastric  mucous  membrane  by  the 
ingestion  of  large,  imperfectly  masticated  and  insalivated  morsels  of  food ;  by 
the  habitual  use  of  food,  indigestible  or  improperly  cooked,  such  as  hot  bread 
or  cakes,  pastry,  and  fried  dishes ;  or  by  the  habit  of  eating  sweetmeats  at  all 
hours  of  the  day,  may  occasion  this  condition,  either  directly  or  indirectly,  by 
producing  acrid  fermentation  in  the  contents  of  the  stomach.  Another  source 
of  irritation  is  the  continued  contamination  of  the  food  by  off'ensive  discharges 
from  ulcerations  in  the  nose,  throat,  or  mouth  :  from  decaving  teeth  ;  and  from 
the  muco-purulent  discharges,  often  very  considerable  in  amount,  from  adenoid 
growths.  Repeated  attacks  of  an  acute  or  subacute  form  are  very  liable  to 
lead  to  this  condition,  especially  in  children  with  lowered  vitality  living  under 
imperfect  sanitary  conditions.     The  presence  of  ansemia,  rachitis,  or  scrofula 


GASTRIC    CATARRH  AND    GASTRIC    ULCER.  447 

may  be  regarded  as  distinctly  predisposing ;  also  prolonged  convalescence  from 
an  acute  inflammatory  or  specific  fever. 

Any  engorgement  of  the  gastric  veins  due  to  valvular  heart  disease  or  to 
chronic  inflammatory  disorder  in  the  liver  and  lungs  will,  of  course,  distinctly 
predispose  to  this  condition. 

Pathology. — The  conditions  in  chronic  catarrhal  gastritis  are  but  an  exten- 
sion of  those  referred  to  under  the  heading  of  Acute  Gastric  Catarrh.  The 
whole  organ  is  usually  enlarged.  The  mucous  membrane,  usually  thickened, 
is  of  a  pale-gray  or  slate-gray  color,  with  insular  deeply  injected  areas,  and  is 
covered  with  a  closely  adherent  layer  of  mucus.  In  places,  especially  in  the 
vicinity  of  the  pylorus,  the  hypertrophied  mucous  membrane  may  form  small 
papillary  projections,  the  so-called  etat  mamelonne.  In  more  advanced  stages 
this  condition  may  give  rise  to  distinct  polypoid  outgrowths.  The  minute 
anatomy,  says  Dr.  Ewald,  is  that  of  a  parenchymatous  and  interstitial  inflam- 
mation,' most  noticeable  in  the  pyloric  region.  The  gland-cells  may  be  found 
partly  destroyed,  partly  granular,  and  partly  shrivelled  up.  The  differentia- 
tion between  the  principal  and  parietal  cells  is  impossible.  In  many  places 
the  ducts  have  lost  their  regular  form  and  show  an  atypical  ramification. 
There  is  an  abundant  small-celled  infiltration,  most  marked  near  the  surface 
of  the  mucosa.  The  superficial  layer  of  the  epithelium  of  the  mucosa  is  loos- 
ened, and  can  be  separated  in  adherent  shreds.  The  mucoid  transformation 
of  the  cells  of  the  tubules  is  a  prominent  feature,  and  may  be  observed  to 
extend  down  to  the  base  of  the  glands.  Whether  this  degeneration  may  to 
any  extent  retrograde,  or  whether  it  is  permanent.  Dr.  Ewald  has  not  been  able 
to  decide. 

As  the  disease  advances  changes  in  nutrition  produce  a  progressive  fatty 
degeneration  of  the  cells,  with  finally  complete  atrophy  of  the  mucous  mem- 
brane. To  this  condition  Dr.  E^vald  proposes  to  give  the  name  of  anadenia 
of  the  stomach.  This  atrophic  process  may  advance  in  two  ways  :  (1)  by  pro- 
gressive destruction  of  the  glandular  parenchyma,  so  that  finally  nothing  is 
left  but  a  layer  of  small  round  cells,  in  which  appear  isolated  remnants  of  the 
former  parenchyma ;  (2)  by  a  mai'ked  activity  of  the  interstitial  connective 
tissue,  leading  to  hypertrophic  proliferation,  with  much  thickening  of  the  walls, 
but  with  great  contraction,  so  that  the  capacity  of  such  a  stomach  becomes  very 
limited. 

In  either  form  it  is  a  severe  irreparable  process,  which  specially  involves  the 
glandular  layer  of  the  stomach,  and  which  is  characterized  by  a  complete  dis- 
appearance of  the  secretory  parenchyma. 

Symptoms. — The  symptoms  at  first  are  those  of  impaired  digestion.  The 
appetite  is  lessened,  except  at  occasional  intervals,  Avhen  it  may  appear  in- 
creased. Ill-defined  gastric  distress  and  colicky  pains,  with  distention  of  the 
abdomen,  indicate  the  presence  of  fermentation.  Nervous  symptoms,  such  as 
headache,  listlessness,  irritable  temper,  and  disturbed  sleep,  owing  in  great 
measure  to  reflex  irritation,  become  manifest.  General  nutrition  sooner  or 
later  begins  to  show  signs  of  impairment.  The  child  looks  pallid,  dark  circles 
appear  under  the  eyes,  the  muscular  system  is  badly  nourished,  the  pulse  is 
wanting  in  tone,  and  slight  exertion  produces  signs  of  fatigue.  The  indi- 
cations of  digestive  disorder  now  become  more  prominent :  the  appetite  fails  at 
the  regular  meal-hours,  but  during  the  intervals  there  may  be  cravings  for 
unsuitable  food.  The  breath,  especially  in  the  early  morning,  is  heavy-smell- 
ing ;  eructations  occur  during  the  day ;  pain,  referred  to  the  epigastrium,  is 
frequently  complained  of;  nausea,  recognized  by  sudden  pallor  of  the  coun- 
tenance, recurs  occasionally,  but  vomiting  in  older  children  is  infrequent.     In 


448  AlfEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

infants  vomiting  is  often  a  most  pronounced  feature ;  hence  the  title,  "  chronic 
vomiting,"  often  given  to  the  disease.  Constipation  is  generally  pronounced, 
and  is  very  difficult  to  relieve.  The  motions  consist  of  hard  rounded  masses, 
of  offensive  smell  and  variable  color,  passed  with  much  straining,  and  generally 
associated  with  an  increased  amount  of  mucus.  Occasionally  an  evening  rise 
in  temperature  may  be  observed,  exciting  suspicions  of  typhoid  fever  or  tuber- 
culosis. In  the  more  severe  cases,  after  the  disorder  has  run  a  prolonged 
course,  and  the  failure  in  general  nutrition  has  become  very  marked,  "  the 
patient  either  literally  pines  away  like  a  lamp  the  oil  of  which  has  not  been 
replenished,"  or  falls  an  easy  victim  to  some  intercurrent  disease. 

Such  may  be  said  to  be  a  general  picture  of  this  disease.  Its  course, 
always  very  prolonged,  is  perhaps  more  irregular  than  that  of  most  chronic 
affections.  The  stimulus  of  a  season  at  the  seaside,  or  in  bracing  mountain-air, 
may  for  a  time  make  an  improvement  in  such  children,  especially  in  the  early 
stages  of  the  disease,  but  unless  we  can  secure  the  necessary  watchfulness  over 
the  dietary  and  general  hygiene,  a  fresh  exacerbation  is  easily  induced,  with 
renewal  of  all  the  unfavorable  symptoms. 

In  infancy  symptoms  of  indigestion  occasionally  appear  shortly  after  birth. 
Frequently  the  fault  in  such  cases  lies  in  the  character  of  the  nutriment  sup- 
plied to  the  infant ;  but  sometimes  a  feeble  power  of  digestion  appears  to  be 
inherited.  Should  disturbances  of  the  digestive  functions  persist,  the  infant 
becomes  restless,  fretful,  and  colicky.  Attacks  of  vomiting  occur  frequently  ; 
sometimes  shortly  after  the  food  is  taken,  on  some  slight  movement,  the  greater 
portion  of  the  meal  will  be  rejected,  curdled  and  sour-smelling.  At  other  times 
vomiting  takes  place  some  hours  after  the  meal,  and  consists  of  watery  mucus 
and  lumps  of  hard  curd  or  other  undigested  food.  The  appetite  is  variable  ;  at 
times  the  breast  or  the  bottle  may  be  refused  absolutely,  and  again  food  may  be 
taken  eagerly  at  first,  but  is  shortly  pushed  aside  with  evident  signs  of  distress. 
The  face  is  pale,  and,  instead  of  the  normal  expression  of  placid  content,  it 
frequently  puts  on  a  pained  look.  The  tongue  is  generally  furred,  but  in  infancy 
this  is  not  so  reliable  a  symptom  as  in  older  children.  Sleep  is  fitful,  much 
disturbed,  and  for  short  intervals  only.  Nutrition  distinctly  fails.  Instead  of  the 
normal  increase  of  from  four  to  eight  or  ten  ounces  per  week,  the  infant  may 
scarcely  hold  its  own  or  may  even  lose  weight.  The  skin,  along  with  the  other 
tissues,  suffers  from  lack  of  nutrition,  the  subcutaneous  fat  is  absorbed,  and 
the  superficial  veins  show  distinctly  through  its  more  delicate  structure  ;  the 
muscles  are  small  and  flabby  ;  the  extremities  are  with  difiiculty  kept  warm ; 
the  fontanelles,  if  open,  will  be  found  depressed  ;  and  the  coronal  suture  may 
be  prominent,  owing  to  depression  of  the  frontal  bones.  Constipation  is  a 
frequent  symptom,  but  occasional  attacks  of  diarrhoea  occur,  with  the  passage 
of  undigested  food  and  some  mucus.  Various  forms  of  skin  rashes  frequently 
make  their  appearance,  such  as  erythema,  urticaria,  and  lichen.  Vomiting  in 
such  infants,  especially  if  there  be  much  failure  in  general  nutrition,  is  always 
a  symptom  requiring  much  attention.  In  my  own  experience  it  has  almost 
invariably  yielded  to  patient  and  careful  treatment,  but  it  quickly  reduces  the 
strength,  and  hydrocephaloid  symptoms  may  supervene.  PaTasitic  stomatitis 
is  apt  to  prove  a  troublesome  and,  in  a  few  cases,  a  serious,  complication.  If 
symptoms  of  indigestion  persist  and  wasting  becomes  extreme,  all  our  measures 
seem  to  fail,  and  the  infant  sinks  into  the  condition  known  as  simple  atrophy. 

A  few  of  the  symptoms  met  with  in  older  children  require  more  extended 
notice.  Pain  and  uneasiness,  referred  to  the  epigastric  region,  is  a  very  com- 
mon complaint.  In  general,  the  distress  becomes  more  pronounced  shortly 
after  taking  food,  but  occasionally  it  seems  to  be  more  felt  when  the  stomach  is 


GASTRIC    CATARRH  AXD    GASTRIC    ULCER.  449 

empty.  In  all  cases  distinct  tenderness  is  elicited  by  pressure  on  the  epigas- 
trium. The  tongue  is  usually  large  and  flabby,  with  heavy  yellowish  fur 
toward  the  base.  The  tip  is  red,  and  its  papilliis  reddened  and  prominent. 
Occasionally  we  meet  with  a  comparatively  clean  tongue,  or  one  marked  by 
crescentic  and  wandering  rashes.  Too  much  importance  must  not  be  placed 
upon  its  appearance.  The  appetite  is  whimsical,  variable,  or  sometimes  alto- 
gether wanting.  In  some  it  is  satisfied  after  a  few  mouthfuls,  and  afterwards 
requires  much  coaxing.  Although  a  feeling  of  nausea  is  not  an  infrequent 
symptom,  vomiting  seldom  takes  place  except  on  the  occurrence  of  an  acut« 
exacerbation. 

The  sleep  of  such  children  is  generally  much  disturbed.  They  toss  about 
from  side  to  side,  dream,  and  talk  in  their  sleep.  Occasionally  they  may  awake 
suddenly  in  great  terror,  and  remain  for  some  fcAv  minutes  screaming  wildly 
under  the  influence  of  fright,  unable  to  recognize  their  attendants.  Somnam- 
bulism in  children  is  generally  due  to  this  same  cause. 

The  amount  of  interference  with  nutrition  that  may  take  place  is  variable. 
Some  appear  to  grow  fairly  Avell,  though  they  remain  pale;  their  frame  is  well 
developed,  but  the  muscles  are  deficient  in  tone.  In  others  nutrition  is  markedly 
defective.  They  are  small  for  their  age,  their  muscular  tissue  is  poorly  devel- 
oped, and  their  pulse  small,  weak,  and  occasionally  intermitting.  Such  chil- 
dren are  liable  to  suff"er  from  neuroses.  Headaches,  chiefly  frontal,  are  fre- 
quently complained  of;  the  temper  is  uncertain,  and  generally  very  irritable. 
Local  muscular  twitchings  of  choreic  character  are  not  infrequent.  Syncopal 
attacks,  closely  resembling  those  of  petit  mal^  are  sometimes  met  with.  Dis- 
turbances afiecting  the  heart's  action,  or  the  respiration,  have  been  reported. 

The  nutrition  of  the  skin  in  such  children  is  always  impaired.  Their  skin 
is  never  clear,  but  is  generally  sallow  in  appearance. 

A  reflex  irritation,  referred  to  the  nostrils  or  the  anus,  manifested  by  a 
constant  pickino:;  of  the  nose  or  scratchins;  at  the  seat,  is  very  common  and  is 
extremely  troublesome.  A  "stomach  cough,"  generally  due  to  an  accompany- 
ing pharyngeal  catarrh,  is  a  not  infrequent  symptom.  As  a  rule,  it  is  most 
troublesome  during  the  hours  of  sleep. 

The  course  of  chronic  gastric  catarrh  in  children  varies  much,  xlfter  it 
has  persisted  for  some  time  there  is  always  a  marked  tendency  to  distention  of 
the  stomach,  with  impaired  muscular  action.  This,  if  not  checked,  may  go  on  to 
the  production  of  actual  dilatation,  especially  in  those  cases  where  the  abdom- 
inal parietes  are  much  relaxed.  In  some  the  large  secretion  of  mucus  becomes 
a  prominent  symptom,  the  disease  extends  to  the  lower  portion  of  the  aliment- 
ary canal,  and  general  nutrition  becomes  still  more  rapidly  lowered.  (See 
article  on  '•  Mucous  Disease.")  In  the  severer  forms  of  atrophy  of  the 
glandular  tissue  of  the  stomach  the  clinical  picture  may  l)e  that  of  a  pernicious 
anaemia. 

Diag-nosis. — In  the  diagnosis  of  chronic  gastric  catarrh  there  should  rarely 
be  much  difficulty.  The  long  history,  the  epigasti'ic  tenderness,  the  disturbed 
digestion,  and  impaired  nutrition,  after  the  exclusion  of  organic  trouble  in  the 
lungs,  heart,  or. kidneys,  will  indicate  clearly  the  character  of  the  trouble  with 
which  we  have  to  deal.  If  possible,  however,  an  exact  determination  should 
be  made  by  examination  of  the  stomach-contents  one  hour  after  a  test  break- 
fast, which  in  older  children  should  consist  of  bread  and  milk.  The  examina- 
tion may  be  easily  managed  in  infants  by  passing  a  soft  rubber  stomach-tube 
and  withdrawing  some  of  the  contents.  In  older  children  this  is  more  difficult, 
but  may  sometimes  be  managed.  Advantage  may  be  taken  of  any  ejecta,  or 
artificial  means  may  be  used  to  produce  emesis.     By  this  measure  three  forms 

29 


450  AMERTCAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  chronic  gastritis  may  be  distinguished:  1.  Simple  gastritis,  in  which,  after 
the  test  breakfast,  hydrochloric  acid  is  found  in  diminished  quantity,  while 
lactic  and  butyric  acids  are  usually  present.  2.  Mucous  gastritis,  which  differs 
from  simple  gastritis  chiefly  by  the  presence  of  a  large  amount  of  mucus. 
3.  Atrophic  gastritis,  in  which  the  secretion  of  hydrochloric  acid  and  pepsin  is 
almost  entirely  absent. 

In  some  cases  of  impaired  digestion  in  infants  it  is  necessary  to  exclude 
the  presence  of  hereditary  syphilis  and  tuberculosis.  In  the  former  possi- 
bility a  decision  should  be  arrived  at  without  having  recourse  to  medicines,  as 
in  simple  gastric  disorder  a  course  of  antisyphilitic  remedies  may  do  harm 
(Pepper).  In  older  children  the  presence  of  pyrexia,  with  the  symptoms  of 
chronic  gastric  catarrh,  should  always  suggest  the  possibility  of  typhoid 
fever.  The  same  considerations  should  influence  us  in  forming  a  diagnosis  in 
the  case  of  chronic,  as  in  that  of  acute  gastric  catarrh. 

Popular  opinion  generally  refers  many  of  the  symptoms  of  chronic  gastritis 
to  the  presence  of  intestinal  worms.  In  suitable  cases  it  may  be  desirable  to 
give  a  few  doses  of  mild  vermifuge  to  exclude  their  presence. 

Prognosis. — The  prognosis  of  chronic  gastric  catarrh  in  childhood,  if 
placed  under  careful  dietetic  and  hygienic  treatment  before  the  atrophic 
changes  have  proceeded  too  far,  may  be  regarded  as  good.  In  infancy  there 
is  always  danger  of  extension  of  the  trouble  to  other  portions  of  the  aliment- 
ary canal.  This  is  especially  the  case  during  the  summer  months.  The 
continued  interference  with  nutrition  renders  children  more  prone  to  the 
development  of  some  intercurrent  disease. 

"  While  the  dyspepsias  of  children  are  not  of  themselves  often  fatal,  they 
are  serious  on  account  of  the  vulnerability  of  system  they  induce.  They  are 
prone  to  recur.  They  are  apt  to  interfere  with  normal  development,  and  to 
entail  subsequent  debility  of  digestion,  of  nerve,  or  of  the  entire  nutrition  " 
(Pepper). 

Treatment. — The  treatment  of  chronic  gastric  catarrh  is  in  many  instances 
one  of  the  most  unsatisfactory  that  we  can  undertake.  The  disease  is  apt  to 
run  a  prolonged  course  and  to  have  many  relapses.  The  families  in  which  we 
meet  our  more  severe  cases  are  frequently  those  who  can  only  with  much  diffi- 
culty be  impressed  with  the  importance  of  strict  attention  to  the  details  of 
treatment,  and  when  Ave  finally  succeed  in  .convincing  the  parents  of  the 
necessity  of  our  rules,  we  find  that  the  children  refuse  to  be  controlled. 

Our  first  step  in  each  case  must  be  to  investigate  carefully  all  the  factors, 
exciting  and  predisposing,  tending  to  impair  the  functions  of  the  stomach. 
The  character  of  food  taken  by  the  child  must  receive  our  most  careful  atten- 
tion, and,  making  due  allowance  for  the  idiosyncrasies  of  digestion  so 
frequently  met  with  among  children,  a  systematically  arranged  dietary  for  the 
week  should  be  drawn  up,  and  rigidly  adhered  to,  in  each  case.  Instructions 
should  be  given  that  the  attendant  insist  on  proper  mastication  of  the  food. 
Nervous  children  especially  are  very  apt  to  bolt  it.  Should  the  teeth  be  so 
defective  as  seriously  to  interfere  with  mastication,  all  food  requiring  it  should 
be  minced  before  giving  it  to  the  child.  The  amount  also  should  be  carefully 
regulated.  I  am  convinced  that  many  children  accustomed  to  a  richly-spread 
table  have  a  tendency  to  overfeed  themselves.  Dinner,  the  heaviest  meal  of 
the  day,  should  be  taken  about  noon.  The  evening  meal  should  be  a  light 
one.  The  general  hygiene  of  the  child  will  also  demand  the  most  careful 
attention  if  our  efforts  are  to  be  successful.  The  child  should  live  a  quiet, 
regular  life ;  it  should  retire  early  to  bed,  and  its  sleeping  apartment  should 
be  cool  and  airy.     The  morning   bath  should  be  of  a  stimulating  character. 


GASTRIC    CATARRH  AND    GASTRIC    ULCER.  451 

For  these  children  I  prefer  the  bath  recommended  by  Wiederhofer.  The 
child  on  getting  out  of  bed  first  receives  a  general  rub  down  with  a  somewhat 
rough  towel.  It  then  steps  into  the  bath,  which  contains  warm  water  to  the 
depth  of  three  or  four  inches.  It  is  afterward  sponged  down  quickly  with 
cool  salt  water,  of  which  half  a  gallon  or  more  is  to  be  emptied  over  the  chest 
and  shoulders.  When  the  sponging  is  finished,  the  child  is  then  at  once 
wrapped  in  a  large  towel  and  is  briskly  dried  and  dressed. 

Children  suifering  from  chronic  gastric  disorder  are  easily  fatigued,  and 
under  the  influence  of  excitement  may  readily  over-tire  themselves.  This  is 
to  be  avoided.  At  the  same  time,  regular  moderate  exercise  in  the  open  air 
is  to  be  insisted  on. 

There  are  several  indications  that  should  be  considered  in  our  administra- 
tion of  medicine  : 

1.  The  deficiency  of  gastric  juice,  which  is  generally  met  with  in  these  chil- 
dren, may  sometimes  with  advantage  be  supplied  by  the  administration  shortly 
after  meals  of  hydrochloric  acid  with  pepsin.  In  those  cases  where  the  tongue  is 
coated  with  a  white  creamy  fur  an  alkali,  such  as  sodium  bicarbonate,  given 
shortly  before  the  meal,  appears  to  act  as  a  sedative  to  the  mucous  membrane, 
while  at  the  same  time  it  stimulates  to  more  active  secretion  the  cells  elabo- 
rating hydrochloric  acid. 

2.  In  almost  all  cases  there  is  a  deficient  tone  in  the  muscular  coat  of  the 
stomach  which  calls  for  the  administration  of  one  of  the  vegetable  bitters. 
My  own  preference  is  for  nux  vomica,  in  smaller  or  larger  doses  as  the  case 
may  require.  Columbo,  gentian,  or  quassia  may  also  be  employed,  either  in 
the  form  of  infusion  or  tincture. 

3.  In  many  cases,  owing  to  the  large  amount  of  mucus,  fermentation  either 
in  the  stomach  or  small  bowel  becomes  a  prominent  feature,  and  the  distention 
thus  induced  may,  if  allowed  to  persist,  lead  to  a  more  or  less  paretic  condition 
of  their  muscular  walls.  To  relieve  this  aromatics  may  be  added  with  advan- 
tage to  our  remedies,  but  some  reliance  may  also  be  placed  on  antiseptics. 
Salol  under  these  circumstances  has,  I  think,  given  me  very  satisfactory 
results. 

Should  diarrhoea  supervene,  a  combination  of  bismuth  and  salol  will  prove 
very  serviceable.  To  relieve  the  colicky  pains  often  complained  of  by  these 
children  some  anodyne  may  occasionally  have  to  be  employed.  I  have  also 
used  with  much  benefit  large  enemata  of  warm  water,  as  recommended  by 
Ashby. 

In  infants,  and  sometimes  in  older  children,  vomiting  becomes  occasionally 
a  troublesome  feature,  persisting  in  spite  of  treatment.  Absolutely  no  food, 
under  these  circumstances,  should  be  given  by  the  mouth,  all  extraneous 
sources  of  irritation  should  be  removed,  and  sedative  enemata,  containing 
small  doses  of  either  opium  or  bromide  with  chloral  hydrate,  may  be  given  twice 
daily  to  subdue  the  nervous  erethism.  In  these  cases  lavage  of  the  stomach 
has  sometimes  proved  a  successful  therapeutic  measure.  Dr.  Booker,  after  a 
large  experience  in  the  Thomas- Wilson  Sanitarium,  says  :  "  I  believe  stomach- 
washing  is  of  undoubted  advantage  in  the  treatment  of  the  digestive  disorders 
of  infancy.  It  has  proved  with  me  the  quickest  and  most  effective  means  for 
the  relief  of  the  vomiting,  which  I  found  generally  relieved  after  the  first 
w^ashing  ;  in  only  one  case  was  it  found  necessary  to  stop  milk  food.  The 
contra-indications  to  the  use  of  the  measure  are  heart  disease  and  serious  bron- 
chitis or  other  pulmonary  trouble.  When  the  tube  continues  to  excite  vomit- 
ing and  strong  resistance,  it  is  doubtful  if  advantage  follows  its  use.  A  feeble 
condition  of  the  infant  does  not  necessarily  contra-indicate  the  operation."     In 


452  A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

older  children  lavage  is  rendered  extremely  difficult,  owing  to  tlieir  determined 
resistance.  Possibly  results  less  efficient,  but  somewhat  similar,  may  be  obtained 
by  the  administration  of  warm  alkaline  drinks  on  an  empty  stomach.  A  com- 
bination of  the  potassio-tartrate  of  soda  with  a  small  amount  of  the  bicarbon- 
ate, dissolved  in  hot  water,  may  be  given  early  every  morning,  or  equal  parts 
of  Vichy  and  hot  water  may  be  taken  once  or  twice  daily.  Sufficient  time 
should  be  allowed  for  this  to  pass  out  of  the  stomach  before  food  is  taken. 

In  cases  associated  Avith  constipation  a  determined  effort  should  be  made  to 
secure  a  regular  movement  of  the  boAvels  once  a  day,  Avith  the  least  possible 
amount  of  irritation  to  the  gastric  mucous  membrane.  Some  preparation  of 
cascara  may  be  given  regularly  at  bed-time  in  doses  sufficient  to  secure  a  daily 
motion  of  fair  consistence.  The  action  of  the  medicine  should  be  favored  by 
daily  gentle  massage  of  the  large  bowel,  and  by  regularity  in  the  time  of  solicit- 
ing a  movement. 

In  children  suffering  from  chronic  gastric  disorder  any  sudden  chill  of  the 
surface  should  be  prevented  by  the  habitual  use  of  a  Hannel  binder  over  the 
abdomen.  The  extremities  should  l)e  efficiently  covered ;  the  feet  and  ankles 
especially  should  be  always  dry  and  warm.  Although  ferruginous  tonics,  if 
symptoms  of  any  acute  exacerbation  are  present,  may  disagree,  they  may  be 
given  to  many  of  these  children  Avith  advantageous  results. 

ni.  Gastric  Ulcer. 

Gastric  ulcer  is  a  lesion  affecting  the  mucous  membrane  of  the  stomach, 
characterized  by  the  formation  of  an  ulcer  of  varying  size  and  depth,  and  of 
uncertain  position  on  the  gastric  wall.  The  disease  in  childhood  may  be  indi- 
cated by  symptoms  similar  to  those  met  with  in  the  adult — namely,  epigastric 
tenderness,  pain  increased  by  the  ingestion  of  food,  and  luiematemesis.  Occa- 
sionally the  symptoms  are  very  obscure,  and  a  diagnosis  is  impossible  until 
an  autopsy  reveals  the  cause  of  death.  It  is  an  exceedingly  rare  affection  in 
childhood,  and  very  few  cases  have  been  reported. 

Etiology. — Gastric  ulcer  in  children  is  generally  associated  with  some  con- 
stitutional disorder,  such  as  tuberculosis,  struma,  and  antemia.  Pneumonia  and 
purpura  haemorrhagica  are  also  mentioned  as  predisposing.  Colgan  reports 
a  case  in  a  child  of  two  years  and  a  half,  due  apparently  to  chronic  gastric 
catarrh.      Tuberculous  ulcers  are  often  multiple. 

Symptoms. — According  to  Descroizelles,  anorexia  develops  early  and  is 
steadily  progressive.  Vomiting  may  come  on,  but  sometimes  nausea  only  is 
complained  of.  Eructations  and  pain  are  frequently  present,  and  the  ingestion 
of  food  is  orenerallY  followed  bv  an  exacerbation  of  the  suffering.  In  some 
cases  the  symptoms*  are  by  no  means  distinctive.  In  one  case  reported  the 
physical  signs  simulated  those  of  pericarditis ;  in  another,  those  of  pneumo- 
thorax. In  the  case  related  by  Colgan  a  well-nourished  child  had  been  in 
fair  health  up  to  the  morning  of  the  attack,  when  she  complained  of  feeling 
unwell.  Toward  the  evening  she  Avas  seized  with  convulsions.  When  seen  by 
Dr.  Colgan  her  temperature  Avas  106  °  ;  the  pulse  loO,  rather  full  and  tense ; 
and  the  breathing  stertorous.  The  convulsions  Avere  general,  and  there  had 
been  involuntary  evacuations  from  both  bladder  and  rectum.  The  convulsions 
were  temporarily  controlled,  and  consciousness,  Avhich  had  been  lost  from  the 
beginning  of  the  attack,  was  beginning  to  return,  when  a  second  attack 
occurred  and  terminated  fatally.  At  the  autopsy  a  perforating  ulcer  was  found, 
with  consequent  peritonitis.  The  gastric  mucous  membrane  Avas  in  a  chronic 
catarrhal  condition. 


GASTRIC    CATARRH  AND    GASTRIC    ULCER.  453 

Gastric  ulcer,  dependent  upon  emboli  from  thrombosis  in  the  umbilical  vein, 
is  said  to  be  a  frequent  cause  of  haemorrhage  in  the  new-born. 

Prognosis  is  very  unfavorable. 

Treatment. — The  treatment,  too,  is  generally  unsatisfactory.  If  a  diag- 
nosis be  made,  the  child  should  be  confined  to  bed,  and,  if  possible,  it  should  for 
some  days  be  fed  only  by  the  rectum  with  artificially  digested  food.  After- 
Avards,  a  gradual  return  should  be  made  to  milk  or  bland  starchy  food,  given  in 
small  quantities  and  frequently  repeated.  Of  drugs,  nitrate  of  silver  in  small 
repeated  doses  is  probably  one  of  the  most  satisfactory.  Small  doses  of  opium 
should  be  given  to  relieve  pain.  Gentle,  soothing  applications  may  be  made 
over  the  epigastrium.     If  vomiting  occur,  bismuth  is  indicated. 

Gastro-malacia. 

This  term  is  applied  to  the  softened,  and  sometimes  ulcerated,  condition  of 
the  stomach  occasionally  found  after  death  in  children.  It  is  dependent  upon 
the  action  of  the  gastric  juice,  which  may  happen  to  be  present  in  the  stomach 
at  the  time  of  death,  upon  the  walls  of  the  stomach  itself,  now  dead  and  unpro- 
tected. Goodhart  believes  that  an  action  may  commence  just  prior  to  death, 
owing  to  a  very  defective  circulation  insufficiently  protecting  the  tissues.  Even 
if  such  be  the  case,  it  is  the  result  of  ebbing  life,  not  a  disease  causing  death, 
and  as  such  it  calls  for  no  further  remark. 


MUCOUS  DISEASE. 

By    WILLIAM  A.    EDWARDS,    M.  D., 

San  Diego. 


The  fact  that  many  different  names  and  many  etiological  factors  have  been 
advanced  to  designate  the  train  of  symptoms  and  explain  the  pathology  of 
the  disease  under  consideration,  serves  to  show  that  as  yet  there  is  not  an  entire 
consensus  of  opinion  as  to  the  proper  classification  of  this  condition. 

Space  forbids  a  complete  recapitulation  of  the  host  of  synonyms  under 
which  this  disease  appears  in  medical  Avritings.  We  cite  but  a  few :  Chronic 
gastro-intestinal  catarrh  ;  Intestinal  desquamative  catarrh  ;  Mucous  disease ; 
Chronic  muco-colitis ;  Chronic  croup  of  the  intestines ;  Chronic  follicular  inflam- 
mation of  the  intestinal  mucous  membrane  ;  Chronic  pseudo-membranous  gastro- 
enteritis ;  Mucous  or  Gelatinous  diarrhoea  :  Mucous  casts. 

The  term  membranous  enteritis  has  recently  become  somewhat  restricted  to 
a  particular  form  of  intestinal  disorder  characterized  by  irregularly  recurring 
paroxysms-  of  abdominal  pain,  unaccompanied  by  fever  and  relieved  by  the 
passage  of  membranous  shreds  or  tubes,  which  for  the  most  part  are  composed 
of  mucin. 

The  present  chapter  will  be  restricted  to  a  consideration  of  mucous  disease 
as  described  by  Eustace  Smith  of  London,  who  defines  it  as  an  increased 
secretion  of  mucus  from  the  whole  internal  surface  of  the  alimentary  canal :  it 
is  a  mucous  flux  which  interferes  mechanically  with  digestion  and  absorption 
of  the  food,  and  by  its  influence  in  impeding  general  nutrition  often  excites 
suspicion  of  the  existence  of  tubercle.  This  disease,  unlike  its  analogue, 
membranous  enteritis,  is  a  very  frequent  condition  among  children,  in  Avhom  it 
is  most  usually  met  with  between  the  ages  of  three  and  twelve  years. 

Etiology. — The  infectious  diseases,  particularly  measles  and  scarlatina,  but 
above  all  pertussis,  may  be  followed  by  mucous  disease — indeed  Smith  considers 
that  pertussis,  of  all  others,  is  the  one  to  which  this  derangement  can  com- 
monly be  traced.  It  must  not  be  forgotten  that  the  mucous  membrane  of  the 
alimentary  canal  in  the  child  is  naturally  very  active,  and  that  the  healthy 
stool  in  the  young  infant  contains  a  large  proportion  of  mucus;  so  that  we  can 
readily  understand  that  if  the  child  be  nabitually  fed  on  indigestible  food, 
thus  presenting  a  constant  source  of  intestinal  irritation,  the  normal  mucus 
may  appear  in  abnormal  amounts. 

We  must  also  remember  that  the  stool  of  the  healthy  infant  contains  many 
bacteria  and  micrococci.  Osier  says  that  the  most  important  are  the  bacterium 
lactiL  aerogenes  and  the  bacterium  coli  commune. 

In  diarrhceal  conditions  the  number  is  greatly  increased.  Booker  has 
isolated  forty  varieties,  and  his  conclusions  are.  that  in  the  diarrhoea  of  infants 
not  one  specific  kind,  but  many  different  kinds,  of  bacteria  are  concerned,  and 
that  their  action  is  manifest  more  in  the  alteration  of  the  food  and  intestinal 

454 


MUCOUS  DISEASE.  455 

contents  and  in  the  production  of  injurious  products,  than  in  a  direct  irritation 
upon  the  intestinal  wall.  So  that  from  the  authority  of  this  careful  observer, 
together  with  that  of  Jeifries  and  Baginsky,  we  may  conclude  that  mucous 
disease  is  not  bacterial  in  origin  and  does  not  arise  from  the  presence  of  a 
specific  micro-organism. 

We.  however,  must  state  that  Cornil  considers  that  the  peculiarities  in  all 
foi"ms  of  membranous  enteritis,  mucous  disease,  and  the  like  are  not  oAvinuf  to 
different  anatomical  lesions,  but  to  the  difference  in  the  nature  of  the  micro- 
organisms :  he  considers  that  all  forms  are  due  to  special  micro-organisms  intro- 
duced with  the  food. 

Heredity  does  not  merit  consideration  among  the  etiological  factors,  nor  does 
climate,  as  the  disease  is  seen  in  all  countries  and  in  all  climes  :  it  is  perhaps 
more  frequent  in  England  than  elsewhere,  although  this  may  be  due  to  the  fact 
that  Eno-lish  observers  have  more  carefully  recorded  their  observations.     It  is 

O  ^  ...  .       *■' 

usually  seen  in  association  with  other  diseases  of  the  intestinal  tract :  an  ante- 
cedent dyspepsia  or  a  diarrhoea  alternating  with  constipation  is  frequently 
noted  before  mucous  disease  becomes  firmly  established. 

Day  agrees  with  Meigs  and  Pepper  that  whether  diarrhoea  be  caused  by 
improper  food,  summer  heat,  dentition,  or  epidemic  influences,  the  complaint,  if 
it  becomes  chronic,  is  apt  to  terminate  in  mucous  disease.  It  has  been  observed 
in  children  to  follow  typhoid  fever,  enteralgia,  haemorrhoids,  and  intestinal 
tuberculosis. 

We  ourselves  have  always  accepted  the  statement  of  DaCosta  that  the 
disease  was  a  manifestation  of  disordered  nervous  supply,  which  may  be  either 
general  or  local,  and  that  the  nerves  presiding  over  nutrition  and  secretion  are 
primarily  at  fault. 

Wales  is  of  the  opinion  that  the  primary  seat  of  the  disorder  is  in  the  gan- 
glionic nerves  of  the  intestines. 

Certain  it  is  that  all  of  our  cases  presented  marked  evidences  of  deranged 
nervous  action,  and  we  agree  with  Goodhart,  who  considers  the  class  of  diseases 
that  are  the  subject  of  this  article  under  the  title  of  "abdominal  neuroses," 
and  further  states  that  he  "is  persuaded  that  although  they  may  seem  to  be 
caused  by  temporary  conditions — such  as  errors  in  diet — these  varying  pains 
and  aches  are  often  but  the  expression  of  a  constitutional  build.  They  are  an 
evidence  of  nervous  instability,  and  they  are  foun(^  in  nervous  children  or  in 
nervous  families."  In  this  observer's  experience  the  children  who  are  the  sub- 
jects of  mucous  disease  are  the  offspring  of  those  whose  nervous  systems  are 
feeble  or  diseased,  or  who  are  closely  related  to,  or  have  themselves  been,  the 
subjects  of  fits,  insanity,  hysteria,  neuralgia,  rheumatism,  or  gout;  or  if  not, 
have  in  themselves  given  other  evidence  of  unstable  nerves  in  the  convulsions 
of  infancy,  passionateness,  morbid  timidity,  chorea,  or  rheumatism. 

Louis  Starr,  the  American  editor  of  Goodhart's  book,  favors  the  views  of 
Eustace  Smith. 

Symptoms. — In  the  more  chronic  cases  of  mucous  disease  there  is  an 
almost  constant  sequence  of  symptoms.  A  coated,  anemic,  flabby,  and  fissured 
tongue  is  usually  observed.  Avith  aphthous  ulcers  of  the  mouth  and  tonsillar 
derangements. 

Smith  considers  the  appearance  of  the  tongue  to  be  absolutely  characteristic : 
it  appears  to  him  as  if  brushed  over  with  a  solution  of  gum  :  this  slimy  look 
may  be  generally  limited  to  a  small  spot  in  the  centre  of  the  dorsum.  In  my 
experience  the  whole  tongue  is  more  apt  to  be  clean,  stripped  of  epithelium, 
glazed  or  glossy.     See  accompanying  Plate   (XII). 

All  the  stools  do  not  contain  mucus,  but  its  passage  may  be  paroxysmal,  or 


456    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

there  may  be  an  accumulation  of  mucus,  and  the  discharges  for  several  daj's 
may  be  made  up  ahnost  entirely  of  this  substance,  or  a  great  mass  may  be 
passed  at  a  single  stool ;  constipation  may  exist  or  this  condition  may  alternate 
with  diarrhoea.  The  patient  may  have  only  one  mucous  stool  a  day,  or,  as  I 
have  seen  them,  twelve  to  fifteen  in  twenty-four  hours ;  after  an  attack  of  this 
kind  the  discharges  are  usually  free  from  mucus  for  several  days,  or  even  for 
weeks,  and  the  child  apparently  improves  for  a  time,  but  only  to  sufter  another 
exacerbation  in  a  shorter  or  longer  period.  A  simple  enema  or  a  mild  aperient 
usually  brings  away  large  quantities  of  clear  mucus  or  mucus  stained  by  fseces. 
These  children  rarely  pass  a  normal  faecal  evacuation:  the  fieces  are  apt  to  be 
soft,  mushy,  light-colored,  and  mixed  Avith  or  coated  over  by  mucus.  The  stools 
occasionally  contain  Avorms. 

Some  cases  present  certain  premonitory  symptoms  before  one  of  these  large 
discharges  of  mucus  occurs,  as  chilliness,  blueness  of  the  nails,  tingling  or  pain 
at  the  finger-tips,  dyspeptic  symptoms,  and  a  sense  of  uneasiness  usually  referred 
to  the  umbilical  region.  Smith  has  also  observed  that  a  most  fre((uent  seat  of 
pain  is  over  the  left  hypochondrium,  and  explains  this  by  calling  attention  to 
the  fact  that  at  this  point  the  colon  makes  a  very  abrupt  turn,  and  the  angle 
thus  formed  presents  a  site  for  the  accumulation  of  flatus. 

During  an  acute  attack  the  former  sense  of  uneasiness  may  become  true 
pain ;  in  some  instances  it  is  most  severe ;  tenderness  may  extend  over  the 
entire  abdomen,  or  it  may  be  localized  and  developed  only  by  firm  pressure. 
Nausea  or  vomiting,  in  my  experience,  does  not  often  occur,  although  it  is 
mentioned  by  some  writers. 

The  breath  is  usually  most  unpleasant,  heavy  and  fetid ;  the  tonsils  are  apt 
to  be  diseased,  and  no  doubt  contribute  their  share  to  this  unpleasant  odor. 

The  temperature  is  rarel}'  above  normal  except  perhaps  at  the  height  of  a 
painful  paroxysm  ;  indeed  an  abnormal  temperature  Avould  lead  one  to  suspect 
some  other  and  more  serious  condition,  as  phthisis.  The  surface  temperature  to 
the  touch  seems  to  be  below  normal,  although  the  thermometer  will  probably 
not  so  record  it. 

The  nervous  system  is  early  affected,  and  presents  many  evidences  of 
derangement ;  hysteria  in  some  of  its  many  forms  may  exist,  and  night-terror 
with  its  peculiar  concomitants,  nocturnal  incontinence  of  urine,  somnambulism 
or  the  insomnia  of  gastro-intestinal  origin,  irregular  muscular  tremors,  paresis, 
hysterical  tetanus,  neuralgia,  hypergesthesia,  anaesthesia,  convulsions,  syncope, 
and  stammering,  have  all  been  observed.  Tinnitus  aurium,  transient  defects 
in  vision,  as  squinting,  a  disordered  sense  of  taste,  haemorrhoids,  prolapse  of 
the  rectum,  and  anal  fissure  have  also  been  noted.  The  child's  nature  seems 
to  have  undergone  a  radical  change:  he  is  irritable  and  exacting;  he  sufiers 
from  mental  depression,  faulty  memory,  and  hypochondriasis.  In  the  older 
child  melancholia  may  be  noted. 

Furuncles  or  carbuncles  may  arise,  and  sore  mouth  or  herpes  of  the  genitals 
are  not  unusual. 

The  appetite  is  at  first  increased,  then  becomes  capricious,  and  finally  almost 
complete  anorexia  exists ;  food  produces  distress  by  flatulent  distention  of 
the  bowels,  and  it  isonh'  by  the  exercise  of  good  tact  that  the  little  patient  can 
be  induced  to  eat  at  all.  This,  however,  is  not  true  of  all  cases:  some  children 
maintain  their  appetite  throughout  the  disease,  but,  notwithstanding  the  enor- 
mous quantity  of  food  consumed,  the  emaciation  is  extreme.  The  skin  ma}- 
have  the  characteristic  hue  of  ansemia  or  the  sallow  tint  of  jaundice;  it  may  be 
harsh,  rough,  and  scaly.  The  urine  is  apt  to  be  acid  and  to  contain  an  excess 
of  urates.     I  have  not  observed  that  the  lymphatic  glands  in  the  neck  are  pecu- 


MUCOUS  DISEASE.  457 

liarly  liable  to  become  enlarged  on  the  slightest  irritation,  as  stated  by  Smith, 
who  also  adds  that  they  do  not,  however,  necessarily  suppurate  or  remain  per- 
manently swollen ;  the  enlargement,  after  persisting  for  a  variable  time,  may 
disappear  completely. 

It  must  be  remembered  that  the  little  patient  who  is  the  subject  of  mucous 
disease  does  not  present  a  regular  sequence  of  symptoms,  so  that  it  is  a  diffi- 
cult matter  to  present  a  didactic  picture  of  the  derangement ;  the  symptoms 
are  as  erratic  as  the  child  itself.  As  Goodhart  aptly  remarks,  such  children 
are  essentially  angular  in  their  moral  nature  and  are  an  "odd  lot."  In  this 
connection  attention  may  be  called  to  a  paper  by  Ayres  {Med.  News,  vol.  lix.. 
No.  1,  1891,  p.  1)  on  chronic  gastro-intestinal  catarrh  in  relation  to  the  etiology 
of  some  cases  of  insanity. 

Microscopic  Appearance  of  Matters  Passed. — They  are  very  similar 
to  the  masses  passed  in  cases  of  membranous  enteritis,  and  are  made  up  of 
opaque  white  solid  masses,  moulded  or  flattened,  and  small  flocculent  pieces  of 
semi-translucent  membrane.  The  tubes,  branching  membranes,  casts,  and  fine 
network  membranes  are  not  seen  in  mucous  disease.  The  description  I  have 
elsewhere  given  of  membranous  enteritis  (in  Keating's  Cyclopaedia,  vol.  iii. 
p.  166)  also  applies  to  the  mucous  masses  voided  in  chronic  gastro-intestinal 
catarrh. 

Under  a  low-power  objective  the  masses  are  seen  to  be  due  to  the  formation 
of  mucous  and  epithelial  matter  (the  cells  having  undergone  fatty  degeneration), 
and  granular  ddbris.  H.  B.  Hare  states  that  these  matters  are  similar  in 
chemical  reaction  to  pharyngeal  mucus,  that  they  may  possibly  contain  a  trace 
of  albumin,  but  no  fibrin.  Their  surface  may  be  seen  to  be  composed  of  opaque 
and  translucent  parts ;  the  former  appear  as  rounded  ridges  marking  off  the 
latter  into  regularly  arranged  hexagonal  or  polygonal  crypts. 

Clark  has  observed  that  the  product  of  diseased  action  on  mucous  mem- 
branes occurs  in  three  varieties:  first,  clear,  jelly  like,  and  imperfectly  mem- 
branous ;  second,  yellowish,  semi-opaque,  flaky,  and  usually  membranous ; 
third,  yellowish-white,  dense,  opaque,  distinctly  membranous,  tough,  and  rather 
adherent  to  the  subjacent  surface. 

Morbid  Anatomy. — The  morbid  anatomy  of  the  disease  seems  to  be  a 
thickening  of  the  intestinal  mucous  membrane ;  there  may  be  evidences  of 
ulceration  or  enlargement  of  the  glandular  follicles  of  the  colon  or  small  intes- 
tine, the  sigmoid  flexure,  and  the  descending  colon,  together  Avith  the  lower  part 
of  the  ileum. 

Diagnosis. — As  I  have  elsewhere  remarked,  if  mistakes  arise  in  the  diag- 
nosis of  the  affection,  they  are  in  all  probability  due  to  the  carelessness  of  the 
observer  rather  than  to  any  obscurity  in  the  manifestations  of  the  usual  clinical 
phenonema  of  the  disease. 

The  mucous  masses  may  resemble  and  have  been  mistaken  for  ascaris  lum- 
bricoides;  indeed,  the  parasite  may  be  present  in  the  discharges,  as  it  finds  in  the 
mucus-loaded  intestine  a  peculiarly  acceptable  habitat.  The  white,  shining, 
detached  pieces  have  been  mistaken  for  segments  of  the  various  tape-worms, 
taenia  mediocanellata,  tsenia  solium,  and  bothriocephalus  latus. 

The  lienteric  discharges  of  dysentery  have  also  been  erroneously  considered 
as  illustrations  of  this  disease;  in  scarlatina  and  tubercular  disease  mucous 
deposits  are  sometimes  passed  per  anum. 

The  disease,  however,  of  all  others,  with  which  we  are  apt  to  confound 
mucous  disease  is  general  or  pulmonary  tuberculosis :  here  it  is  that  a  carefully 
recorded  series  of  temperature  records  is  invaluable.  In  tuberculosis  we  find 
a  continued  elevation  of  temperature,  while  in  mucous  disease  the  temperature  is 


458    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

usually  normal ;  at  all  events,  it  is  only  elevated  during  the  height  of  a  paroxysm, 
remaining  high  for  two  or  three  days  and  returning  quickly  to  the  normal. 

Smith  makes  the  statement  that  in  some  cases  the  temperature  rises  and 
remains  elevated,  perhaps  permanently,  although  the  symptoms  in  other  respects 
correspond  to  those  of  mucous  disease.  I  have  never  met  such  cases.  He  con- 
siders that  these  subjects  are  peculiarly  prone  to  pneumonia,  and  that  the  deposit, 
only  partially  absorbed,  undergoes  cheesy  transformation  and  forms  the  so-called 
pneumonic  phthisis.  Under  these  conditions  I  must  confess  that  the  differen- 
tial diagnosis  between  mucous  disease,  pneumonic  phthisis,  and  tuberculosis 
would  indeed  be  a  difficult  problem  to  solve. 

Prognosis. — Most  cases  run  a  prolonged  and  tedious  course,  with  many 
recurrent  attacks  and  exacerbations,  extending  sometimes  into  adult  life.  Abso- 
lute recovery  rarely  occurs. 

Treatment. — The  child  that  is  the  subject  of  mucous  disease  must  submit 
to  a  constant  supervision  of  its  daily  life.  Its  diet,  regimen,  and  personal 
hygiene  are  of  vital  importance.  The  little  patient  must  have  a  daily  bath, 
first  with  castile  soap  and  warm  water,  then  a  general  sponging  with  alcohol, 
followed  by  an  inunction  of  olive  oil.  In  this  way  the  peculiarly  harsh,  dry, 
and  scaly  skin  can  be  restored  to  its  normal  function  as  one  of  the  excreting 
organs  of  the  body. 

The  diet  always  merits  the  most  painstaking  care;  indeed,  without  a  correct 
and  suitable  diet  all  other  methods  of  treatment  will  inevitably  fail.  All  sources 
of  irritation  are  to  be  removed;  easily-digested  or  even'pre-digested  food  should 
be  supplied,  and  the  medical  attendant  should  satisfy  himself  that  undigested 
particles  of  food  are  not  irritating  the  alimentary  canal. 

The  following  diet-table  is  taken  from  Eustace  Smith  (fifth  edition,  1888), 
and  is  applicable  to  a  child  of  seven  years  of  age  and  upward : 

Breakfast,  8  A.  M.  Three-quarters  of  a  pint  of  fresh  milk  alkalinized  by 
twenty  drops  of  the  saccharated  solution  of  lime;  a  thin  slice  of  well-toasted 
bread ;  fresh  butter ;  a  fresh  egg  lightly  boiled  or  poached. 

Dinner,  noon.  A  mutton  chop  without  fat,  broiled ;  well-boiled  cauliflower 
or  French  beans,  according  to  season;  a  thin  slice  of  av ell-toasted  bread;  half 
to  one  wineglassful  of  sound  sherry,  diluted  with  twice  its  bulk  of  water. 

Tea,  4-  J^'  ^^-     Same  as  breakfast. 

Supper,  7  P.  M.  A  breakfast-cupful  of  beef-tea  (a  pound  to  the  pint) ; 
a  thin  slice  of  dry  toast. 

Or  we  can  adopt  a  diet-table  that  I  suggested  in  a  lecture  before  the  tl niver- 
sity  Training-School  for  Nurses,  which  is  that  of  the  North-eastern  Hospital 
for  Children,  London: 


Breakfast,  7  a.  m. 
Dinner,  12  m.  .  . 


Tea,  3.30  p.  m.  . 
Supper,  6  p.  m. 


Milk  Diet. 


Milk,    K   pint;    bread,    2 
ounces,  with  butter. 

Milk,  y^  pint ;  rice  or  other 
milk  pudding. 


Milk,    y^   pint;    bread,   2 
ounces,  with  butter. 

Biscuit  (cracker)  or  slice 
of  bread  and  butter. 


Fish  Diet. 


Milk    or   cocoa,    l^  pint; 

bread,  25^  ounces,  with 

butter. 
Fish,  boiled,  2}/,  ounces; 

potatoes,        mashed,      3 

ounces ;  bread,  1  ounce ; 

milk  pudding. 


Milk,  ]4  pint;  bread,  2)4 
ounces,  with  treacle  of 
butter. 

Bread,  2  ounces,  with  but- 
ter, or  cracker. 


Full  Diet. 


Milk  or  cocoa,  "%  pint;  bread, 
2)A  ounces,  with  butter. 

Roast,  boiled,  or  minced  mut- 
ton, or  roast  or  minced  beef, 
2!/^  ounces;  mashed  potatoes, 
4  ounces,  to  alternate  witli 
green  vegetables;  bread,  1 
ounce;  milk  pudding. 

Bread,  2>$  ounces,  with  butter, 
treacle,  or  dripping;  milk,  % 
pint. 

Bread,  2  ounces,  with  butter,  or 
cracker. 


In  the  more  serious  forms  Jacobi  adheres  to  a  very  strict  diet.    He  says :  "No 


MUCOUS  DISEASE.  459 

raw  milk,  no  boiled  milk,  no  milk  at  all  in  any  mixture,  in  bad  cases."  In 
the  very  worst  cases  total  abstinence  is  recommended  by  this  Avriter  for  from 
one  to  six  hours;  afterward  the  following  combination  is  allowed:  Five  ounces 
of  barley-water,  one  to  two  drachms  of  brandy  or  whiskey,  the  white  of  one 
egg,  salt,  and  cane-sugar ;  a  teaspoonful  every  five  or  fifteen  minutes,  accord- 
ing to  age  or  case. 

Jacobi  in  his  terse  way  remarks:  "That  never  are  the  common  sense  and 
tact  of  the  intelligent  practitioner  more  thoroughly  taxed ;  no  printed  rule  ever 
supplies  or  substitutes  brains." 

If  the  appetite  be  capricious,  these  strict  dietetic  rules  cannot  of  course  be 
adhered  to ;  Ave  must  then  endeavor  to  supply  such  a  variety  as  will  tempt  the 
appetite  and  check  the  tissue  waste.  If  the  stools  shoAv  a  mass  of  milk  curds, 
milk  must  be  diluted,  predigested,  or  altogether  prohibited. 

The  various  preparations  of  predigested  food  may  now  be  resorted  to  :  milk, 
milk-gruel,  milk-punch,  effervescing  milk-punch,  beef-tea,  and  oysters  may  all 
be  prepared  in  this  manner.  Raw  beef-juice,  beef-tea,  consomme,  chicken, 
mutton,  or  veal  broth  are  preparations  upon  which  we  may  often  place  absolute 
dependence.  Farinacea  as  a  rule  must  be  excluded,  although  we  occasionally 
have  to  allow  a  little  rice  pudding,  tapioca,  or  flour-ball  by  Avay  of  a  variety. 
It  is  somewhat  odd  to  note  in  this  connection  that  Burnet  in  his  valuable  little 
book  on  Foods  and  Dietaries  recommends  the  farinaceous  substances  as  a  suit- 
able diet  in  mucous  diarrhoea. 

Alcohol  is  not  by  any  means  contraindicated,  and  may  be  administered  as 
wine-whey  or  a  combination  of  milk,  egg  and  brandy.  English  writers  advise 
well-diluted  light  sherry  or  light  claret. 

Among  medicinal  agents  many  and  varied  plans  of  treatment  have  been 
suggested.  Recently  much  attention  has  been  paid  to  intestinal  antisepsis,  but 
it  is  interesting  to  note  that  so  recent  and  reliable  a  writer  as  Osier,  in  his 
Practice  of  Medicine,  considers  that  "  we  are  still  without  a  reliable  intes- 
tinal antiseptic.  Neither  naphthaline,  salol,  resorcin,  salicjdates,  nor  mercury 
meets  the  indications." 

This  has  not  been  our  clinical  experience,  nor  indeed  has  it  been  that  of  the 
general  practitioner. 

Dujardin-Beaumetz  recommends  the  following  formula  as  a  satisfactory 
intestinal  antiseptic  : 

^.  Salol 

Bismuthi  salicylatis 

Sodii  bicarbonatis aa  gr.  cl. 

Sig.  Divide  in  capsul.  Xo.  xxx.      One  capsule  before  breakfast  and  before 
dinner. 

Droixhe  considers  salol  as  a  remedy  easily  administered  and  without  toxic 
action,  and  ranks  it  among  the  approved  intestinal  antiseptics. 
Carreras  suggests  resorcin  in  the  following  formula  : 

!^'.  Resorcin gr.  ij— vij. 

Syr.  aurantii f^j. 

Aq.  citronellge q.  s.  ad  fiiv. — M. 

Sig.   Three  teaspoonfuls  every  three  hours. 

The  same  author    suggests  that  when  the  child   is   fed  exclusively  upon 


460    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

milk  the  dejecta  may  be  very  acid ;  in  this  case  some  such  mixture  should  be 
given  as — 

I^.  Bismuth,  phosphat.  aut  subnitrat gr.  xxx. 

Sodii  bicarbonat gr.  xv. 

Pepsinse gr.  vij. 

Pulv.  ipecac,  comp gr.  j— iv. — M. 

Divide  in  chart.  No.  iij. 
Sig.   One  every  hour  or  two. 

Creolin  has  been  recommended  in  the  following  combination : 

Bf,.   Creolin lUviij- 

Sacchari gr.  Ixxv. — M. 

Divide  in  chart.  No.  x. 
Sig.  One  every  two  or  three  hours. 

"Sf.  Creolin gtt.  i-ij. 

Syrupi f5j. 

Aq.  menthae  pi})erit fgij. — M. 

Sig.   Teaspoonful  every  two  hours. 

Schwinz  also  endorses  creolin. 

Naphthaline  may  be  given  to  young  children  in  doses  of  ten  centigrammes 
every  two  hours.  Pure  naphthaline  never  causes  accidents  even  when  used  in 
large  doses.  It  may  be  given  per  rectum  in  a  mucilaginous  mixture  which 
will  hold  it  in  suspension  but  not  dissolve  it.  Bouchard  thinks  naphthol  is 
superior  in  its  action  to  naphthaline. 

Constipation  may  exist  sometimes  to  a  stubborn  degree :  mild  saline  laxa- 
tives may  be  exhibited,  or  a  simple  enema  may  occasionally  be  administered, 
and  will  usually  cause  the  expulsion  of  large  masses  of  mucus. 

Irrigation  of  the  stomach  is  generally  agreed  upon  by  all  Avriters  to  be  a 
most  efficacious  method  of  dealing  with  the  more  chronic  examples  of  the 
disease.  Osier  speaks  of  it  in  the  warmest  terms  in  cases  of  the  most  obstinate 
gastro-intestinal  catarrh  in  children.  This  method  must  be  combined  with  the 
irrigation  of  the  large  bowel.  The  last-quoted  authority  states  that  a  pint  will 
thoroughly  irrigate  the  colon  of  a  child  aged  six  months,  and  a  quart  that  of  a 
child  of  two  years.  When  the  temperature  is  high,  ice-cold  water  may  be  used 
for  this  purpose. 

Booker  has  had  a  large  experience  in  stomach-washing.  His  apparatus  is 
the  one  proposed  by  Epstein.  A  soft  Nelaton's  catheter,  No.  8,  9,  or  10,  is 
attached  by  a  short  glass  tube  to  a  common  rubber  tube  two  feet  long,  with  a 
2  ounce  (62  grammes)  glass  funnel  fitted  into  the  distal  end  ;  a  pitcher  contain- 
ing a  half-gallon  (2  litres)  of  tepid  water  is  placed  in  a  convenient  position. 

It  is  only  within  a  short  time  that  the  plan  of  washing  out  the  stomach, 
which  was  inaugurated  by  Kussmaul  for  diseases  of  that  organ  in  adults,  has 
been  applied  to  children.  The  difficulties  connected  w4th  its  application  are 
few,  and  the  dangers,  even  for  the  j^oungest  and  weakest  infants,  easily  avoided. 
Kussmaul's  apparatus  for  irrigating  the  stomach  consists  merely  of  a  Nelaton's 
catheter,  a  long  rubber  tube,  and  a  funnel,  and  this  simple  apparatus  will 
accomplish  all  that  is  necessary.  Escherich's  apparatus  has  greater  advantages, 
however,  and  is  preferred.      The  time  required  for  irrigation  of  the  stomach  is 


3IUC0US  DISEASE.  461 

usually  four  or  five  minutevS,  from  half  a  litre  to  a  litre  and  a  half  of  water  being 
usually  required  before  the  return  flow  is  clear.  If  there  is  gastric  or  intes- 
tinal catarrh,  a  few  drops  of  a  6  per  cent,  solution  of  benzoate  of  sodium  and 
a  few  drops  of  tincture  of  opium  may  be  given  hourly  after  each  irrigation. 
Irrigation  is  contraindicated  only  in  very  feeble  children  and  when  collapse  is 
impending.  The  same  apparatus  is  also  used  for  intestinal  irrigation,  except- 
ing that  a  larger  and  stifFer  catheter,  with  much  larger  lateral  opening,  is 
employed.  It  may  be  introduced,  if  necessary,  to  a  distance  of  27  centi- 
metres, and  the  entire  large  intestine  washed  out. 

Ehring's  experience  in  this  method  of  treatment  in  850  cases  has  been 
rapid  cure  in  68.7  per  cent,  of  cases,  moderate  success  in  14.58,  failure  or 
death  in  16.73.  This  writer  further  considers  that  the  indications  for  this 
treatment  exist  in  all  cases  of  intestinal  catarrh.  Riemschneider  reports  the 
results  obtained  in  140  cases  by  this  method,  and  is  favorably  impressed  with 
the  results  obtained  by  washing  out  the  stomach  with  Escherich's  apparatus ;  he 
follows  the  irrigation  of  plain  water  by  an  irrigation  of  a  3  per  cent,  solution 
of  benzoate  of  sodium.  Of  these  cases  a  quickly  favorable  result  was  obtained 
in  89,  a  sloAvly  favorable  one  in  31 ;  in  20  the  result  was  fatal. 

Seibert  in  treatino-  1404  cases  of  gastro-intestinal  catarrh  used  stomach- 
washing  in  521  cases,  and  states  that  the  results  were  most  gratifying  both  in 
stomach-  and  bowel-washing.* 

Von  Ziemssen  recommends  cutaneous  electrization  of  the  stomach  with  very 
large  electrodes,  for  half  an  hour  before  meals.  This  treatment  is  supple- 
mented by  faradizing  for  a  short  time  with  the  wire  brush  the  skin  of  the 
abdomen,  cheek,  and  back.  Massage  of  the  stomach  and  intestines  is  also  of 
value,  although  of  less  importance  than  electricity. 

Electrization  of  the  intestines  is  accomplished  with  large  electrodes,  one 
occupying  the  entire  abdominal  surface,  the  other  the  entire  dorsal  surface  ;  and 
the  electricity  must  be  of  increased  intensity,  owing  to  the  great  size  of  the 
electrodes.  The  subjective  results  of  this  treatment  are  increased  appetite 
and  loss  of  abnormal  abdominal  sensations. 

When  the  excretion  of  mucus  is  excessive  the  a-lkalies  will  assist  materially 
in  arresting  its  secretion :  we  usually  select  the  bicarbonate  of  sodium  ;  this  may 
be  combined  with  twenty-drop  doses  of  tincture  of  myrrh,  as  suggested  by 
Smith,  or  the  powdered  myrrh  which  Maxson  speaks  so  highly  of,  given  in 
divided  doses  of  from  9  to  12  grains  a  day,  either  in  capsules  or  with  mucil- 
age of  acacia,  glycerin,  and  liquorice.     Podophyllin  and  aloes  are  much  lauded 

^  Dr.  W.  Soltau  Fenwick  cites  the  dangers  of  -washing  out  the  stomach  :  1.  Convulsions  and 
tetany.  Probably  because,  in  a  case  predisposed  to  convulsive  seizures  by  the  chronic  absorption 
of  certain  morbid  products  from  the  dilated  stomach,  the  irritation  of  a  gastric  tube  may  con- 
stitute an  efficient  exciting  cause.  2.  Syncope  and  sudden  death.  Any  sudden  alteration  in  the 
gastric  pressure  can,  in  certain  cases,  bring  about  a  reflex  condition  of  shock.  3.  Perforation. 
The  using  of  a  gastric  catheter  for  the  purpose  of  investigating  the  chemical  contents  of  the 
stomach  in  cases  of  acute  gastric  ulcer  is  a  useless  and  mischievous  procedure.  4,  Haemorrhage. 
Danger  may  arise  from  a  too  rapid  evacuation  of  the  contents  of  a  dilated  stomach.  5.  Injury 
to  the  cesophagus  or  to  the  walls  of  the  stomach.  6.  Poisoning.  From  the  use  of  antiseptics 
thi'ough  the  tube.  Cases  are  cited  illustrating  each  division.  He  concludes  that  the  stomach 
is  washed  out  for  all  sorts  of  symptoms,  some  of  which  are  manifestly  not  to  be  benefited  by 
this  procedure.  And  in  cases  in  which  it  fails  to  do  good  it  is  likely  to  be  productive  of  harm 
in  removing  products  of  digestion  whose  manufacture  lias  caused  the  stomach  a  considerable 
amount  of  labor.  The  indiscriminate  ase  of  this  method  in  every  case  of  disordered  digestion 
will  prove  to  be  a  curse  rather  than  a  benefit,  and  will  eventually  throw  discredit  upon  tiie 
whole  method  of  treatment. 

Booker  says  stomach-washing  is  contraindicated  in  children  affected  with  heart  disea.se, 
serious  bronchitis,  or  pulmonary  trouble.  If  the  tube  continues  to  excite  vomiting  and  strong 
resistance,  it  is  doubtful  if  advantage  follows  its  use. 


462    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

by  the  English  writers ;  our  preference  has  been  for  some  of  the  milder  laxatives. 
We  have  obtained  good  results  from  the  following  combination  : 

^.  Pulv.  rhei 3J. 

INIagnesii  carb 3iij. 

Pulv.  zingiber 3ss. 

Elixir  simp q.  s.  ad  fsviij. — M. 

S.   Teaspoonful  night  and  morning  for  child  of  five  years. 

Some  cases  do  well  upon  the  acids,  nitric,  hydrochloric,  or  nitro-muriatic. 
Strychnine,  ipecacuanha,  and  gentian  in  pill  is  sometimes  a  happy  com- 
bination. 

Belladonna,  Dover's  powder,  quinine,  subnitrate  and  subcarbonate  of 
bismuth  have  all  been  suggested.  Quinine  may  be  given  in  tAvo-grain  sup- 
positories combined  with  a  sixth  of  a  grain  of  opium,  as  suggested  by  J.  C. 
AVilson. 

When  the  gastro-intestinal  tract  is  in  condition  to  receive  it,  iron  becomes 
a  valuable  adjunct:  we  select  either  the  tincture  of  the  chloride  combined  with 
nux  vomica  and  dilute  phosphoric  acid,  or  the  dried  sulphate  of  iron  wdth  aro- 
matic syrup  of  rhubarb.  Arsenic,  copaiba,  bromide  of  potassium,  turpentine, 
cod-liver  oil,  oxide  or  nitrate  of  silver  by  mouth  or  by  high  injection  into  the 
bowel,  chloride  of  ammonium,  sulphate  of  zinc,  bichloride  of  mercury,  chlorate 
of  potassium,  oxide  of  zinc,  blisters,  nux  vomica,  ergot,  are  among  the  drugs 
recommended  by  various  writers.     Gold  has  been  suggested  as  follows : 

IBf.  Auri 20  grammes. 

Mellis 125  grammes. — M. 

Sig.   One  coifeespoonful  in  the  morning  and  two  in  the  afternoon. 

Antiquedad  states  that  hydrotherapy,  sulphate  of  quinine,  chlorate  of 
potassium,  and  revulsion  are  the  means  Avhich  will  be  found  most  efficient  in 
the  treatment  of  intestinal  catarrh  in  children. 

It  is  quite  useless  toorder  cod-liver  oil  while  the  alimentary  canal  is  covered 
with  mucus ;  when  we  have  modified  the  mucous  discharges,  oil  then  becomes 
a  valuable   drug.     These   children,   however,   cannot    assimilate  large   doses. 

Much  is  to  be  gained  by  a  residence  in  a  suitable  climate.  We  can  for- 
mulate no  rules,  hoAvever,  as  to  the  locality  to  be  chosen ;  each  case  is  a  rule  unto 
itself.  My  practice  has  been  to  leave  the  matter  of  selection  of  a  climate  to 
a  great  extent  to  the  patients  themselves,  with,  hoAvever,  a  promise  that  the  local- 
ity must  be  such  as  to  permit  of  an  almost  constant  out-door  life,  the  greatest 
number  of  clear  sunny  days,  and  the  least  variability  of  thermometric  range. 
It  must  also  be  understood  that  the  patient  will  spend  several  years  at  the 
place  of   selection. 


DIARRHCEAL  DISEASES. 

By  VICTOR  C.  VAUGHAN,  M.  D., 

Ann  Arbok. 


There  are  many  difficulties  in  the  way  of  a  satisfactory  classification  of  the 
diarrhoeal  affections  of  infancy.  The  gravest  symptoms  in  the  most  speedily 
fatal  cases  are  often  accompanied  by  the  most  superficial  lesions ;  while,  on  the 
other  hand,  symptoms  so  mild  that  no  anxiety  is  awakened  may  result  from 
marked  and  extensive  pathological  changes.  Cases  which  are  apparently  iden- 
tical clinically  often  reveal  diverse  lesions.  It  is  therefore  apparent  that  the 
pathological  alterations  do  not  form  a  suitable  basis  of  classification.  The 
variations  from  the  normal  condition  found  after  death  are  dependent  more 
upon  the  length  of  the  continuance  of  the  diarrhoea  than  upon  the  primary 
exciting  causes.  The  majority  of  cases  of  infantile  diarrhoea  which  continue 
for  four  days  or  longer  might  be  designated,  in  a  classification  founded  upon 
morbid  anatomy,  as  entero-colitis,  and,  moreover,  the  extent  of  the  inflam- 
matory changes  is  measured  largely  by  the  duration  of  the  diarrhoea.  In 
cases  terminating  fatally  within  four  days,  in  previously  healthy  children,  even 
the  superficial  epithelium  may  be  normal,  while  in  other  of  these  cases 
there  may  be  some  desquamation  of  this  layer.  The  cases  which  terminate 
fatally  after  from  seven  to  ten  days  usually  show  more  marked  inflammatory 
changes.  The  mucous  membrane  is  swollen,  the  villi  are  prominent  and  pur- 
plish, and  the  solitary  and  agminated  follicles  are  congested  and  projecting. 
In  more  protracted  cases  the  inflammatory  process  involves  the  deeper  layers, 
and  ulcerations  in  every  degree,  from  the  most  superficial  to  those  extending 
down  to  the  muscular  coat,  may  appear. 

It  would  be  as  unscientific  to  attempt  a  classification  of  the  diarrhoeas  of 
infancy  founded  upon  pathological  anatomy  as  it  would  be  to  designate  acute, 
subacute,  and  chronic  arsenical  poisoning  as  desquamative,  catarrhal,  and 
ulcerative  gastro-enteritis. 

Having  thus  discarded  all  classifications  founded  upon  morbid  anatomy. 
what  shall  we  select  as  a  basis  for  the  differentiation  of  the  various  forms  of 
diarrhoea  in  infancy  ?  The  fundamental  object  in  any  classification  must  be  to 
enable  the  physician  to  treat  his  patient  most  successfully.  The  giving  of 
names  to  diseased  conditions  enables  us  to  group,  systematize,  and  most 
advantageously  use  the  information  which  we  may  possess,  or  may  in  the 
future  acquire,  concerning  the  etiology,  symptomatology,  and  treatment.  Cer- 
tainly in  the  class  of  diseased  conditions  now  under  consideration  a  classi- 
fication founded  upon  etiological  factors  will  be  of  greatest  service  in  treat- 
ment. But  the  question  which  arises  here  is  this :  Do  we  at  present  know 
enough  of  the  causes  of  these  diseases  to  attempt  a  classification  based  upon 
etiology  ?  In  answer  to  this  I  reply  that,  while  there  is  yet  much  to  learn 
on  this  point,  I  propose  to  offer  a  provisional  classification  founded  upon  what 
I  believe  to  be  the  most  important  factors  in  the  causation  of  the  diarrhoeas 

463 


464    AM£IiICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  infancy,  because  I  believe  that  such  a  classification,  imperfect  as  it  must  at 
present  be,  will  be  of  greater  service  to  the  practitioner  than  one  ba^sed  upon 
the  morbid  anatomy,  which,  as  we  have  seen,  is  determined  more  largely  by  the 
duration  of  the  diarrhoea  than  by  the  nature  of  the  exciting  cause. 

In  attempting  this  classification  we  have  the  following  facts  to  aid  us:  (1) 
Some  of  these  diarrhoeas  are  independent  of  seasonal  influence.  They  occur 
as  frequently  in  winter  as  in  summer,  while  the  prevalence  of  other  forms  is  so 
plainly  limited  to  the  hot  season  that  they  are  now  quite  universally  designated 
as  "summer  diarrhoeas."  (2)  Those  which  are  apparently  independent  of  sea- 
sonal influence  do  not  differ  from  similar  diseases  in  adult  life,  save  in  the 
greater  susceptibility  of  the  infant  and  in  the  greater  delicacy  of  its  organiza- 
tion, thus  rendering  the  disease  of  more  serious  import  in  the  child  than  in  the 
adult.  On  the  other  hand,  the  so-called  ''summer  diarrhoeas"  are  so  generally 
limited  to  the  first  two  or  three  years  of  life  that  they  may  be  regarded  as 
peculiar  to  that  age. 

Improper  or  excessive  feeding,  acting  upon  the  delicate  organization  of  the 
child  s  digestive  apparatus,  may  cause  diarrhoea  even  when  there  are  no  toxi- 
cogenic  micro-organisms  present.  A  small  quantity  of  some  indigestible  sub- 
stance in  the  intestines  may  increase  the  peristaltic  movements  and  lead  to 
frequent  stools.  Taube  and  Escherich  have  shown  that  in  the  young  child 
stomachic  digestion  is  of  less  importance  than  intestinal  digestion,  and  that  the 
stomach  is  more  of  a  receptacle  into  which  the  milk  is  received  for  coagulation 
than  a  digestive  orgfan :  thus  we  have  the  most  favorable  conditions  for  the 
growth  and  activity  of  the  bacteria  which  are  introduced  with  the  food.  The 
same  investigators  find  that  the  younger  the  child  the  less  active  is  digestion 
in  the  stomach,  and  that  in  this  organ  the  milk  is  coagulated  and  passed  through 
the  pylorus  undigested.  Hammarsten  has  shown  that  this  is  the  case  in  Jiup- 
pies  and  Toung  rabbits,  and  Hofmeister  and  Tappeiner  showed  that  the  stomach 
does  not  absorb  soluble  substances  as  rapidly  as  does  the  mucous  membrane  of 
the  small  intestines.  Zweifel  states — and  in  this  he  is  supported  by  Hammar- 
sten— that  the  proteolytic  activity  of  the  pancreatic  juice  is  relatively  well 
developed  in  the  new-born.  The  absorption  of  fats  is  dependent  upon  the 
pancreatic  juice  and  the  bile,  and  the  teaching  of  Frerichs,  that  the  milk- 
sugar  is  absorbed  from  the  stomach,  is  now  known  to  be  erroneous.  This 
constituent  of  milk,  as  has  been  shown  by  Dastre.  is  digested  by  a  ferment 
found  in  the  mucus  of  the  small  intestine.  These  experiments  convince  us 
that  the  digestion  of  milk  by  the  infant  is  nearly,  if  not  quite,  altogether  accom- 
plished in  the  small  intestine,  and  explain  why  indigestion  in  the  infant  induces 
diarrhoea. 

The  diarrhoea  which  results  from  temporary  indigestion  will  be  described 
under  the  title  of  Acute  Intestinal  Indigestion. 

The  continued  ingestion  of  material  indigestible  in  character  will  produce 
inflammatory  processes  leading  to  pathological  lesions,  and  this  condition  will 
be  considered  in  this  paper  under  the  head  of  Chronic  Intestinal  Indigestion. 

It  must  now  be  admitted  that  the  so-called  ''summer  diarrhoeas"  of  infancy 
are  due  to  the  growth  and  multiplication  of  bacteria  and  the  formation  <jf 
chemical  poisois  by  these  low  forms  of  vegetable  life.  Since  these  harmful 
organisms  are.  m  the  great  majority  of  cases,  taken  into  the  body  in  the  milk 
which  constitutes  the  sole  or  chief  food  of  the  infant.  I  will  describe  the  symp- 
toms and  lesions  due  to  these  causes  under  the  title  of  Milk  Infection,  and  this 
will  be  subdivided,  according  to  the  severity  and  duration  of  the  symptoms, 
into  Acute  and  Subacute  Milk  Infection. 

I  would  prefer  the  term  "milk-poisoning"  for  the  last  two  of  these  forms 


DIABBHCEAL   DISEASES.  465 

of  diarrhoea,  but,  bearing  in  mind  the  fact  that  "milk-poisoning"  has  long 
been  used  to  cover  another  affection,  I  have  been  debarred  from  using  it. 
There  are,  moreover,  certain  advantages  in  the  adoption  of  the  words  "milk 
infectiono"  These  bring  out  more  prominently  the  part  played  by  bacteria  in 
the  causation.  I  wish  to  positively  deny  that  I  have  been  led  to  drop  the  old 
nomenclature  and  adopt  a  new  one  for  the  sake  of  introducing  a  novelty.  I 
believe  that  the  advance  in  our  knowledge  of  the  causation  of  these  diarrhceas 
justifies  the  change,  and  that  the  use  of  the  terms  here  suggested  will,  in  the 
first  place,  give  the  physician  a  better  idea  of  the  cause  and  nature  of  the 
trouble  Avith  which  he  is  dealing,  and,  secondly,  it  Avill  tend  to  make  parents 
more  attentive  to  the  character  of  the  food  supplied  their  children. 

This  simple  classification  will,  as  a  whole,  I  believe,  be  of  most  service  to 
the  practitioner,  and  the  object  of  this  paper  is  to  aid  the  physician  in  treat- 
ment, and  not  to  instruct  the  pathologist  in  morbid  anatomy.  It  must  not  be 
supposed,  however,  that  the  writer  believes  that  this  classification  is  perfect, 
or  that  a' diarrhoea  originating  in  one  of  the  above-mentioned  causes  may  not 
be  influenced  by  other  etiological  factors.  A  child  with  a  simple  irritative 
diarrhoea  is  by  no  means  immune  to  milk  infection,  and  every  physician  knows 
that  the  intestines  of  an  improperly-fed  child  furnish  the  best-known  culture- 
tubes  for  the  growth  of  certain  harmful  bacteria.  For  these  reasons  the  prog- 
nosis in  a  case  of  intestinal  indigestion  will  be  influenced  by  the  greater  or  less 
probability  of  there  being  engrafted  upon  this  abnormal  condition  the  more 
serious  element  of  bacterial  poisoning. 

Acute  Intestinal  Indigestion. 

Synonyms. — Simple  diarrhoea ;  Irritative  diarrhoea  ;  Mechanical  diarrhoea. 

The  number  of  cases  of  this  disease  is  large,  but,  unfortunately,  the  physi- 
cian is  not  frequently  consulted  concerning  them  until  they  have  become 
chronic  or  until  the  supervention  of  bacterial  poisoning  renders  the  symptoms 
more  grave  and  excites  alarm.  The  idea  that  frequent  stools  are  beneficial 
during  teething  has' led  to  neglect  of  these  cases,  and  has  been  an  important 
factor  in  increasing  infantile  mortality.  The  prompt  recognition  and  treat- 
ment of  acute  intestinal  indigestion  are  most  valuable  prophylactic  measures 
against  the  more  serious  intestinal  disorders.  Measured  by  the  good  which 
can  be  accomplished  by  proper  treatment,  this  disease  is  second  to  none  of  the 
diarrhoea!  affections  in  importance. 

Etiology. — Excessive  feeding  is  a  frequent  cause  of  intestinal  indigestion. 
Children  fed  artificially  are  more  likely  to  be  overfed  than  those  nursing  from 
the  breast,  for  two  reasons :  In  the  first  place,  the  supply  is  not  so  easily 
exhausted,  and,  in  the  second  place,  the  child  obtains  the  food  more  easily ; 
indeed,  the  milk  is  often  poured  into  the  child's  stomach  ad  nauseam.  To 
these  might  be  added  the  fact  that  the  child  is  often  given  the  nursing-bottle 
when  the  busy  mother  would  not  stop  to  nurse  it  herself.  Again  the  system 
needs  so  much  water,  and  too  many  mothers  and  nurses  seem  to  be  wholly 
ignorant  of  the  fact  that  a  babe  might  relish  a  little  water  at  times.  The  over- 
loading of  the  stomach  throws  upon  the  digestive  organs  more  work  than  they 
can  do,  and  the  undigested  portions  act  as  foreign  bodies. 

Improper  feeding  is  another  fertile  source  of  mischief.  This  is  not  the 
place  to  discuss  infant-feeding,  and  readers  are  referred  to  the  special  section 
upon  that  subject.  It  may  be  remarked,  however,  that  the  custom  of  giving 
the  babe  a  taste  of  various  things  on  the  table  is  a  pernicious  one.  The  milk 
of  the  healthy  mother  contains   all  the  nourishment   needed  by  the  nursing 

.30 


466     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

infant,  and  should  constitute  its  sole  food  at  this  period  of  life.  But,  unfor- 
tunately, the  mother  is  not  always  healthy,  and  she  may  on  account  of  sick- 
ness, excessive  menstruation,  or  other  causes  be  unable  to  supply  the  demand 
either  in  proper  quality  or  quantity.  In  these  cases  the  knowledge  of  the 
most  intelligent  physician  is  often  found  to  be  too  limited. 

The  cause  of  the  imperfect  digestion  may  be  in  the  child  itself.  It  may 
have  tuberculosis  or  some  other  wasting  disease,  or  the  digestive  organs  may  be 
functionally  incapacitated  by  some  temporary  ailment.  The  employment  of 
predigested  food  may  be  resorted  to  for  the  time,  but  its  continued  use  is  not 
wise.  The  digestive  organs,  like  all  the  organs  of  the  body,  are  enfeebled 
if  relieved  of  their  physiological  duties.  The  too  rapid  absorption  of  peptones 
may  be  harmful,  and  physiologically  it  is  questionable  whether  proteids  which 
have  been  completely  converted  into  peptones  are  ever  largely  utilized  in  the 
body  in  building  up  tissue.  It  is  probably  fortunate  that  in  the  great  majority 
of  instances  artificial  digestion  is  incomplete  and  the  su])posed  peptones  are 
actually  albumoses. 

Symptoms. — Restlessness,  flatulency  with  abdominal  pain,  and  sometimes 
vomiting,  are  the  first  symptoms  of  this  form  of  diarrhoea.  Then  frequency 
of  stool,  often  accompanied  by  griping  pain,  follows™  The  appearance  and 
other  physical  characters  of  the  discharges  vary  with  the  severity  and  con- 
tinuance of  the  attack.  At  first  they  appear  quite  normal,  and  their  frequency 
is  the  only  thing  to  attract  attention.  Then  they  become  more  watery,  but  are 
not  mucous,  as  they  are  when  the  disease  becomes  chronic  and  inflammatory, 
nor  serous,  as  they  often  are  in  acute  milk  infection.  The  stools  are  sometimes 
green,  and  this  may  give  rise  to  alarm,  but  this  color  is  often  due  to  trivial 
causes,  and  too  much  importance  has  sometimes  been  attached  to  it.  After  a 
free  discharge  the  child  becomes  less  restless,  and  may  fall  into  a  quiet  sleep, 
from  which,  however,  it  is  soon  aroused  by  abdominal  pain,  which  continues 
until  the  bowels  are  again  relieved.  A  few  hours  of  this  pain  tells  upon  the 
features ;  the  countenance  becomes  pale,  and  its  continuance  for  a  few  days 
lessens  the  rotundity  of  the  limbs  and  makes  the  muscles  soft  and  flabby.  If 
the  intestinal  irritation  be  severe,  convulsions  may  occur.  Elevation  of  tem- 
perature is  seldom  observed  in  this  form  of  diarrhoea,  or  if  it  does  appear  it  is 
evanescent.  The  pulse  is  accelerated  during  the  paroxysms  of  pain,  but  is 
usually  normal  during  the  intervals.  Thirst  is  an  accompaniment,  and  may  be 
great  when  the  stools  are  frequent  and  watery. 

Prognosis. — This  form  of  diarrhoea  is  not  in  and  of  itself  fatal.  Unless 
the  cause  of  the  irritation  be  removed,  inflammatory  processes  are  induced  in 
the  intestine,  and  a  chronic  diarrhoea  results,  or  bacterial  invasion,  finding 
favorable  soil,  may  speedily  develop  an  alarming  condition. 

Treatment. — The  prompt  and  judicious  treatment  of  this  form  of  diar- 
rhoea is  in  the  majority  of  instances  highly  satisfactory.  The  administration 
of  all  food  should  be  forbidden  for  a  number  of  hours.  The  exact  period  of 
this  prohibition  may  vary  with  the  symptoms  in  the  individual  case,  biit,  as  a 
rule,  twenty-four  hours  will  not  be  too  long.  The  child  will  be  restless  and 
will  cry  from  thirst,  which  should  be  provided  for  by  suspending  bismuth  sub- 
nitrate  in  sterilized  water,  from  two  to  five  grains  to  the  drachm,  and  ordering 
that  this  be  given  in  doses  of  a  teaspoonful  or  more  every  hour  when  the  child  is 
awake.  The  undigested  food  remaining  in  the  intestines  should  be  removed, 
and  the  best  agent  for  the  accomplishment  of  this  purpose  is  castor  oil,  a  tea- 
spoonful  of  which  should  be  given  to  a  child  one  year  of  age.  Some  physi- 
cians prefer  rhubarb  (one  to  two  drachms  of  the  syrup),  and  others  recommend 
magnesium  sulphate,  but  I  am  sure  that  there  is  nothing  which  is  more  certain 


DIABRHGEAL    DISEASES.  467 

and  pleasant  in  its  action  than  castor  oil.  It  may  be  asked  whether  or  not  the 
administration  of  the  laxative  is  regarded  as  essential  in  every  instance.  I  have 
seen  many  children  improve  rapidly  without  it.  In  these  the  irritating  sub- 
stance has  been  swept  out  of  the  intestines  by  the  diarrhoeal  discharges,  and  a 
small  dose  of  opiate  is  all  that  is  needed ;  but  it  is  impossible  to  tell  in  a  given 
case  whether  this  fortunate  removal  has  been  accomplished  by  unaided  nature 
or  not,  and  the  more  certain  method  is  to  administer  the  laxative. 

After  the  laxative  has  had  its  effect,  earlier  if  there  be  great  pain,  an 
opiate  in  very  small  doses,  to  be  repeated,  if  desirable,  after  each  evacuation, 
is  generally  beneficial.  The  opiate  may  be  given  in  the  form  of  the  tincture, 
the  deodorized  or  the  camphorated  tincture.  The  custom  of  introducing  opium 
into  compound  prescriptions  ordered  for  children  is  to  be  condemned.  It  is  a 
common  practice  with  many  physicians  to  write  a  prescription  containing  an 
opiate,  bismuth  subnitrate,  pepsin,  and  chalk  mixture.  The  pepsin  is  use- 
less, because  the  administration  of  food  has  been  prohibited,  and  it  cannot  have 
any  digestive  effect  upon  that  which  is  already  in  the  intestines.  The  syrup  in 
the  mixture  may  ferment  and  be  harmful,  and  the  chalk  is  without  value,  while 
the  bismuth  should  be  given  more  freely  than  the  opiate.  For  these  rea- 
sons the  opiate  should  not  be  incorporated  in  a,mixture,  but  should  be  prescribed 
by  itself;  and  this  holds  good  whenever  opium  is  employed  in  any  form  of 
diarrhoea  in  infants.  I  have  said  that  the  dose  of  the  opiate  should  be  small 
— simply  enough  to  allay  the  abnormal  peristalsis  of  the  intestines.  From  five 
to  ten  drops  of  the  camphorated  tincture  or  a  half  minim  of  either  of  the  other 
tinctures  will  usually  suffice  for  a  dose  for  a  child  one  year  of  age.  After  twelve 
hours  of  this  treatment  the  condition  of  the  child  will  usually  be  found  to  be 
much  improved,  but  the  diarrhoea  will  return  as  soon  as  the  improper  feeding 
begins.  It  is  well  to  order  the  continuation  of  bismuth  subnitrate  at  longer 
intervals  for  some  days,  and  the  physician  must  give  his  attention  to  the  cha- 
racter of  the  food,  which  must  now  be  resumed.  He  must  endeavor  to  ascertain 
wherein  the  feeding  was  at  fault,  and  thus  avoid  a  repetition  of  the  trouble. 
If  the  child  is  nursing  and  the  harm  has  come  from  the  giving  of  additional 
food,  such  addition  must  be  forbidden.  If  the  mother's  milk  is  at  fault,  and 
if  this  cannot  be  improved,  the  selection  of  a  good  wet-nurse  is  the  best  thing 
that  can  be  done.  If  neither  of  these  is  practicable,  or  if  the  child  has  been 
artificially  fed,  the  selection  and  preparation  of  the  best  food  suited  to  the  case 
must  be  undertaken.  For  aid  upon  this  point  the  reader  is  referred  to  the  sec- 
tion on  infant-feeding. 

Chronic  Intestinal  Indigestion. 

Synonyms. — Chronic  diarrhoea;  Chronic  irritative  diarrhoea ;  Chronic 
intestinal  catarrh  ;   Chronic  entero-colitis. 

Etiology. — Chronic  intestinal  indigestion,  with  consequent  diarrhoea,  is  a 
common  affection  of  infancy.  The  undigested  food  ferments,  and  the  products 
of  this  fermentation,  acting  as  irritants  upon  the  sensitive  mucous  membrane, 
induce  a  catarrhal  condition  which  is  most  marked  in  the  ileum  and  colon, 
where  ulceration  not  infrequently  results.  All  this  may  occur  without  the  aid 
of  toxicogenic  germs,  and  probably  without  the  intervention  of  any  adven- 
titious bacteria  whatever,  since  those  normally  present  are  capable  of  accom- 
plishing these  results  when  digestion  is  arrested  or  markedly  retarded.  Chronic 
intestinal  indigestion  may  occur  at  any  season  of  the  year,  but  it  becomes  of 
more  serious  import  during  the  hot  months,  when  toxicogenic  germs  abound 
and  the  chances  of  their  invasion  are  greatly  increased.     It  is  self-evident  that 


468    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tliis  affection  is  more  common  among  those  infants  artificially  fed  than  among 
those  who  draw  their  sole  and  sufficient  nourishment  from  the  breast  of  a  healthy 
mother.  It  is  equally  plain  that  it  is  most  prevalent  among  those  suffering 
from  debilitating  and  wasting  disorders,  either  inherited  or  acquired,  such  as 
syphilis,  tuberculosis,  rickets,  or  chronic  broncho-pneumonia;  and  among  those 
who  liave  had  their  vitality  impaired  by  an  acute  infectious  disease,  such  as 
pertussis,  scarlatina,  or  measles.  Children  who  suffer  from  neglect,  insufficient 
clothing,  and  exposure  to  cold  are  also  prone  to  this  affection.  Some  children 
seem  to  be  born  with  an  inability  on  the  part  of  the  intestines  to  properly 
digest  and  absorb  food.  I  have  seen  such  a  child  Aveighing  less  when  sixteen 
months  of  age  than  at  the  time  of  birth,  and  yet  recovery  resulted,  and  the 
child,  now  eight  years  of  age,  weighs  as  much  and  is  as  robust  as  the  average. 
Frequent  attacks  of  acute  indigestion  lead  to  the  chronic  form,  though  it  is 
probably  true  that  the  majority  of  cases  of  chronic  indigestion  develop  insidi- 
ously and  without  any  marked  prelirainary  acute  attack. 

Symptoms.  — The  discharges  from  the  bowels  become,  as  a  rule,  gradually 
more  frequent,  increasing  from  one  to  two,  to  from  four  to  six  or  more  per  day. 
The  child  usually  becomes  nervous,  fretful,  and  fails  to  sleep  well.  Flatulency 
is  a  more  or  less  marked  symptom,  and  when  great  the  distention  of  the  bowels 
may  cause  severe  pain.  The  stools  are  generally  quite  characteristic  in  certain 
particulars.  In  consistency  they  may  be  semi-solid  or  more  watery,  or  they 
may  vary  in  this  respect  from  time  to  time.  The  odor  is  quite  invariably  dis- 
tinctly offensive.  So  marked  and  common  is  this  that  the  stools  are  frequently 
designated  as  putrid.  The  presence  of  undigested  food  is  indicated  by  the 
color.  Lumps  of  coagulated  casein  and  masses  of  unchanged  fat  may  be  seen. 
With  the  progress  of  the  disease  and  the  development  of  inflammatory  changes, 
mucus  appears,  pus  may  be  detected  with  the  microscope,  and,  Avhen  hard  lumps 
are  present,  they  may  be  streaked  with  blood.  The  color  will  vary  with  the 
kind  of  food  and  the  extent  to  which  it  fails  to  digest.  Pale,  putty-like  stools 
are  common,  while  the  presence  of  a  large  amount  of  fat  may  render  the  excre- 
tions gray  or  even  white.  The  green  stools  are  quite  common  in  this  affection, 
and  in  some  instances  at  least  this  coloration  is  due  to  the  growth  of  chromo- 
genic  bacteria.  There  are  likely  to  be  periods  of  exacerbation,  when  the 
number  of  evacuations  becomes  much  greater  and  their  consistency  thinner 
and  mor6  watery.  At  these  times  the  pain  usually  becomes  more  severe,  and 
fever,  with  vomiting  and  increased  restlessness,  makes  the  case  more  alarming. 
The  diarrhoea,  more  or  less  marked,  may  continue  for  weeks.  In  rare  instances 
the  increased  frequency  of  the  discharges  may  be  borne  by  the  child  for  a  long 
time  in  a  surprising  manner.  The  rotundity  of  the  limbs  is  not  lost,  and  the 
infimt  may  not  only  hold  its  own,  but  may  gain  slightly  in  Aveight.  Such  cases, 
however,  make  the  exceptions.  Usually  the  child  loses  day  by  day.  Emacia- 
tion becomes  marked,  the  muscles  of  the  limbs  and  the  trunk  melt  away,  and 
the  head  appears  by  contrast  to  be  abnormally  large.  The  gradual  loss  of  sub- 
stance and  strength  may  end  in  exhaustion  and  death.  However,  this  is  not 
common,  death  in  the  majority  of  instances  resulting  not  from  the  disease 
itself,  but  from  the  intercurrence  of  milk  infection. 

In  cases  terminating  favorably  recovery  is  usually  a  slow  and  gradual  pro- 
cess, liable  to  many  partial  relapses.  The  child  becomes  less  fretful  and  gives 
less  evidence  of  pain.  The  stools  decrease  in  number,  and  become  more  like 
the  normal  in  form  and  color.  The  putrid  odor  is  likely  to  be  the  most  per- 
sistent evidence  of  the  diseased  condition. 

Throughout  the  course  of  a  chronic  intestinal  indigestion  it  often  happens 
that  the  appetite  is  unimpaired.     The  child,  while  it  is  losing  weight  and  after 


BIARRHCEAL    DISEASES,  469 

it  has  been  reduced  to  a  mere  shadow  of  its  former  self,  may  take  more  food 
than  it  did  when  well.  It  has  often  been  observed  that  while  such  a  child 
does  not  give  any  evidence  of  craving  food,  and  while  its  restlessness  is  not 
increased  by  prolonging  the  intervals  between  feeding,  it  readily  and,  possibly, 
voraciously  swallows  any  food  oiFered ;  and  it  may  seem  that  the  larger  the 
quantity  of  food  taken,  the  more  rapidly  do  the  tissues  melt  away.  Indeed, 
this  is  not  altogether  a  merely  apparent  thing ;  it  may  be  a  reality.  When 
the  food  is  not  digested,  excessive  feeding  increases  the  irritation,  deepens 
the  inflammatory  processes,  multiplies  the  number  of  stools,  draws  upon  the 
vital  resources,  and  hastens  the  period  of  exhaustion. 

The  stomach  often  remains  surprisingly  free  from  involvement  in  this  aiFec- 
tion,  and  vomiting  seldom  occurs  save  during  the  exacerbations  already  referred 
to.  The  tongue  is  usually  dry  and  red,  though  it  may  be  covered  heavily  with 
a  yellowish  or  brownish  coat.  Thrush  and  follicular  stomatitis  are  not  rarely 
seen,  and  the  teeth  may  rapidly  decay.  These  are,  however,  by  no  means 
constant  symptoms.  The  vexatious  cases  of  prolapsus  ani  in  infants  are  most 
common  among  those  suffering  from  chronic  intestinal  indigestion.  The  general 
vitality  of  the  little  patient  is  often  so  low  that  the  replaced  bowel  is  not 
retained,  and  when  it  becomes  inflamed  and  swollen  it  may  cause  great  pain. 
The  skin  with  which  the  discharges  come  in  contact  may  become  highly 
inflamed,  and,  unless  attention  be  given  to  fi-equent  changes  and  the  employ- 
ment of  protective  powders,  the  inflammatory  process  may  lead  to  ulceration. 

The  temperature  is  usually  normal,  though  it  may  be  elevated  during  the 
periods  of  exacerbation.  A  subnormal  temperature  persisting  for  some  days 
is  an  alarming  indication,  and  is  usually  followed  by  death.  However,  in 
cases  of  marked  debility  and  exhaustion  the  extremities  are  generally  cool, 
and  need  warm  clothing  and  at  times  the  application  of  artificial  heat.  The 
pulse  becomes  weak,  and  the  respiration  is  often  irregular  and  shallow.  The 
ankles  may  become  oedematous,  and  this  condition  does  not  necessarily  imply 
nephritis,  though  structural  changes  in  the  kidney,  Avith  albuminuria,  may 
occur. 

Diagnosis. — The  history  of  the  case  and  careful  inspection  of  the  stools, 
which  should  always  be  made,  will  seldom  leave  any  doubt  in  the  mind  of  the 
intelligent  physician  concerning  the  correctness  of  his  diagnosis.  There  is  one 
point,  however,  which  should  always  be  considered  in  reaching  a  correct  esti- 
mate of  the  nature  and  gravity  of  the  individual  case.  I  refer  to  the  necessity 
of  a  careful  examination  of  the  child  in  every  part  of  its  anatomy.  If  atten- 
tion is  given  exclusively  to  the  bowels,  important  conditions  may  be  over- 
looked. In  some  instances — and  the  number  of  these  is  not  small — the  failure 
of  the  digestive  organs  to  perform  their  functions  properly  is  due  to  the  exist- 
ence of  some  constitutional  disease  and  to  the  eff"ects  of  poisons  generated  in 
such  an  afi'ection.  On  the  other  hand,  the  wastins;  Avhich  follows  lono;-con- 
tmued  intestinal  indigestion  renders  the  child  highly  susceptible  to  the  invasion 
of  specific  germs,  and  especially  to  those  of  tuberculosis.  The  diagnosis  must 
therefore  embrace  any  constitutional  coexistent  affection.  Otherwise  the  phy- 
sician is  likely  to  be  led  astray  in  his  pi'ognosis  and  treatment. 

Prognosis. — This  will  be  influenced  largely  by  the  parentage  of  the  child, 
by  the  cause  of  the  indigestion,  by  the  duration  of  the  disease,  by  the  season 
of  the  year,  and  by  the  presence  or  absence  of  constitutional  disease.  In  some 
families  the  children  are  prone  to  digestive  troubles ;  especially  is  this  true 
when  one  or  both  parents  are  tuberculous  or  syphilitic.  This  is  also  likely  to 
be  the  case  when  a  child  is  born  to  very  youthful  parents.  If  the  cause  of  the 
indigestion  can  be  traced  to  some  special  error  in  diet,  the  chance  of  curing 


470    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHIIDREN. 

the  disease  after  the  removal  of  the  cause  is,  of  course,  greatly  increased.  The 
greater  possibility  of  the  supervention  of  milk  infection  leads  to  a  less  hopeful 
prognosis  when  this  form  of  indigestion  occurs  during  the  hot  months ;  and  the 
coexistence  of  chronic  broncho-pneumonia,  tuberculosis,  scorbutus,  syphilis,  or 
rachitis  mav  render  temporary  improvement  doubtful  and  permanent  recovery 
impossible.  Still  another  and  most  important  subject  to  be  considered  in 
forming  a  prognosis  is  the  sanitary  surroundings  of  the  patient  and  the  prob- 
ability of  securing  improvement  when  needed. 

Treatment. — So  long  as  the  cause  of  the  indigestion  is  unknown,  the 
treatment  is  likely  to  be  wrongly  directed  and  ineffective.  Some  error  in  diet 
is  suspected.  If  the  child  nurses,  does  it  obtain  all  its  food  from  this  source  ? 
If  the  answer  to  this  be  in  the  affirmative,  then  the  health  of  the  mother  must 
be  investigated.  Is  she  pregnant  ?  is  she  exhausted  by  excessive  menstru- 
ation, prolonged  lactation,  by  care  and  loss  of  sleep,  or  by  some  constitutional 
disease  ?  If  any  of  these  be  demonstrated  to  be  the  real  cause,  the  enijtloy- 
ment  of  a  suitable  wet-nurse,  when  such  a  rare  and  valuable  aid  in  treatment 
can  be  found,  is  the  best  thing  that  can  be  done.  However,  it  is  far  better  to 
take  the  chances  with  artificial  feeding  than  to  trust  the  child  to  a  dishonest, 
vicious,  or  diseased  wet-nurse.  I  have  known  of  more  than  one  instance  of 
the  children  of  respectable  parents  contracting  syphilis  from  such  a  woman. 
When  the  infint  is  artificially  fed.  it  is  not  enough  for  the  physician  to  merely 
inquire  about  the  character  of  the  food,  but  he  must  know  how  it  is  prepared 
and  in  what  quantities  and  how  frequently  it  is  administered.  The  source  of 
the  food  mav  be  exceptionally  good,  but  if  it  is  kept  in  unclean  vessels,  in  a 
contaminated  atmosphere,  or  if  it  is  administered  in  excessive  quantities,  the 
doctor's  drugs  will  be  of  little  service  until  the  fault  is  discovered  and  removed. 
The  phvsician  who  depends  solely  upon  his  prescriptions,  and  neglects  the  more 
important  matter  of  diet,  will  not  have  reason  to  congratulate  himself  upon  the 
success  of  his  treatment.  The  child  will  often  improve  and  gain  in  flesh  when 
the  quantitv  of  its  food  is  diminished.  When  the  stools  contain  lumps  of 
coaf^ulated  casein  and  masses  of  fat,  or  when  they  are  acid  from  the  fermenta- 
tion of  the  sugar  of  milk,  it  is  best  to  wholly  discontinue  the  use  of  milk  for 
some  davs  and  feed  the  child  solely  upon  meat  broths  and  egg-albumin.  On 
the  other  hand,  if  the  stools  be  alkaline  and  putrid,  barley  gruel,  rice-water, 
and  solutions  of  dextrin  or  soluble  starch  obtained  by  roasting  or  boiling 
wheat  flour,  may  be  used.  As  a  rule,  the  indigestion  is  confined  to  the  inability 
of  the  digestive  fluids  to  act  upon  either  the  carbohydrates  or  the  proteids.  If 
the  trouble  lies  in  the  former,  the  stools  are  likely  to  be  acid  and  the  formation 
of  gas  in  the  intestines  marked.  In  such  cases  a  diet  consisting  exclusively 
of  proteids  should  be  tried  and  continued,  unless  it  should  prove  positively 
harmful,  for  three  or  four  days,  and  if  beneficial  eff"ects  follow  it  may  be  longer 
continued.  Proteid  indigestion  is  likely  to  produce  fetid,  alkaline  stools,  and 
a  diet  of  carbohydrates  will  prove  beneficial.  I  do  not  claim  that  any  absolute 
rules  can  be  founded  upon  the  above-mentioned  facts,  because  fermentation  of 
one  of  these  food-constituents  natui'ally  and  necessarily  prevents  the  complete 
digestion  of  the  other ;  but  I  do  hold  that  the  physician  gains  no  information 
by  continuing  a  mixed  diet,  and.  although  he  may  be  in  error  in  his  first  trial, 
he  has  made,  as  it  were,  a  physiological  test,  and  he  is  now  better  prepared  to 
treat  the  case  rationally.  Many  physicians  recommend  the  employment  of 
artificially  digested  milk,  but  my  experience  has  led  me  to  prefer  the  selection 
of  an  exclusive  diet  of  either  carbohydrates  or  proteids  :  and  by  this  I  do  not 
mean  the  employment  of  halfway  measures,  but  the  exclusion  of  one  of  these 
food-principles  should   be  complete.     Moreover,  there  are,  as   I  have  stated. 


DIARRHCEAL    DISEASES.  471 

grave  physiological  doubts  about  the  capability  of  the  organism  to  utilize  pep- 
tones in  the  repair  of  -w'asted  tissue. 

The  physician  must  never  lose  sight  of  the  fact  that  chronic  intestinal  indi- 
gestion is  accompanied  and  may  be  caused  by  lowered  vitality  and  general  loss 
of  tone.  Tonics  are  indicated,  and  the  best  of  these  is  an  abundant  supply  of 
pure,  fresh  air.  Removal  from  the  crowded  city  and  its  contaminations  to  the 
better  air  of  the  country,  and  especially  to  that  of  the  mountains,  is  often  of 
the  greatest  service,  and  should  be  urgently  recommended  to  parents  who  are 
able  to  provide  for  such  a  change.  Arsenic  and  nux  vomica  may  be  used,  but 
they  are  poor  substitutes  for  fresh  air  and  improved  sanitary  surroundings. 
Alcohol  in  the  form  of  port  or  sherry  is  often  advantageous,  and  cod-liver  oil 
is  of  service  in  protracted  cases. 

The  occasional  administration  of  laxative  doses  of  castor  oil  or  from  two 
to  three  grrains  of  calomel  will  be  of  service. 

Opiates  are  to  be  avoided  as  far  as  possible,  and  are  never  indicated  save 
in  the  painful  exacerbations  which  may  occur.  , 

Much  has  been  written  concerning  the  use  of  intestinal  antiseptics,  but 
only  a  few  of  these  are  of  any  real  value.  The  same  is  true  of  astringents. 
Bismuth  subnitrate  has  both  antiseptic  and  astringent  properties  in  a  mild 
degree,  and  of  all  such  drugs  it  has  best  preserved  its  reputation.  It  should  be 
given  in  large  doses,  fifteen  grains  or  more,  six  or  eight  times  per  day,  and,  as 
in  acute  indigestion,  it  should  be  kept  free  from  combination  with  opiates. 
Sodium  salicylate  and  salol  in  some  cases  seem  to  be  of  benefit. 

The  lesions  in  the  small  intestines  are  best  reached  by  the  administration 
of  the  large  doses  of  bismuth  subnitrate,  while  those  of  the  large  intestine  are 
most  successfully  treated  by  enemata.  These  should  be  employed  three  or  four 
times  per  week.  First,  the  bowels  should  be  irrigated  with  warm  water  con- 
taining a  little  castile  soap  until  they  are  completely  emptied.  This  must  be 
thoroughly  done,  and  in  order  to  secure  this  thoroughness  the  physician  must 
either  do  it  himself  or  trust  it  only  to  a  trained  nurse  or  assistant.  The  hips 
should  be  elevated,  and  a  large-sized  flexible  catheter  attached  to  a  fountain 
syringe  should  be  passed  into  the  colon.  The  passage  of  the  catheter  will  be 
facilitated  by  allowing  the  water  to  flow  at  the  time.  From  three  to  four  quarts 
of  water  should  be  used,  the  excess  returning  by  the  side  of  the  tube.  After 
the  large  intestines  have  been  cleansed  in  this  manner,  one-half  pint  of  water, 
containing  from  one  to  two  drachms  of  bismuth  subnitrate  in  suspension,  should 
be  injected  and  left  in  the  bowel.  Instead  of  the  bismuth,  thirty  grains  of 
tannic  acid  may  be  used.  The  temperature  of  the  water,  both  that  used  in  the 
irrigation  and  for  the  injection,  should  be  that  of  the  body. 

The  possibility  of  the  intercurrence  of  serious  complications  should  always 
be  borne  in  mind  and  place  the  medical  attendant  on  his  guard.  The  frequency 
with  which  relapses  occur  necessitates  continued  attention  to  the  diet,  sanitary 
surroundings,  and  general  health  of  the  little  patient  for  weeks  and  months 
after  apparent  recovery. 


MILK  INFECTION. 

The  diarrhoeas  which  prevail  among  infants  during  the  summer,  especially 
in  cities  and  among  the  poorer  classes,  produce  a  fearful  mortality;  conse- 
quently, they  have  given  rise  to  much  discussion  concerning  their  nature  and 
causation.  The  theories  which  have  been  advanced  to  explain  the  origin  of 
these  diarrhoeas  have  included  nearly  everything  which  a  lively  imagination 


472    AlfEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

could  suggest.  Learned  arguments  have  been  made  to  show  that  the  most 
important  etiological  factors  lie  in  mysterious  and  unknowable  meteorological  or 
telluric  conditions;  while,  on  the  other  hand,  the  keen  perception  of  a  medical 
genius  detects  "that  the  fatality  of  the  disease  has  been  appreciably  increased 
by  the  introduction  and  universal  use  of  the  child's  carriage. 'i  The  limit  set 
upon  the  writer  of  this  paper  by  the  editor  will  not  permit  indulgence  in  an 
historical  sketch  of  these  varied  theories,  nor  will  it  allow  of  any  argumentative 
discussion.  I  shall  have  to  content  myself  with  a  bare  statement  of  those  etio- 
logical factors  the  existence  of  which  has,  in  my  opinion,  been  demonstrated. 

These  diarrhoeas  are  due  to  toxicogenic  (poison-producing)  bacteria.  There 
is  not  a  specific  micro-organism,  as  there  is  in  tuberculosis,  but  any  one  or 
more  of  a  large  class  of  germs,  the  individual  members  of  which  differ  from 
one  another  sufficiently  morphologically  to  be  regarded  as  distinct  species,  may 
be  present  and  may  produce  the  symptoms. 

Only  a  very  brief  summary  of  our  knowledge  concerning  the  intestinal  bac- 
teria can  be  given  here,  while  the  reader  is  referred  for  more  extended  informa- 
tion to  the  works  of  Escherich,  Booker,  Baginsky,  and  Jeffries.  The  intestinal 
contents  during  foetal  life  are  sterile,  and  remain  so  for  a  short  time  after  birth. 
However,  Avithin  a  few  hours  after  birth  bacteria  find  their  way  into  the  intes- 
tines. The  meconium  contains  quite  constantly  two  species  of  bacilli  and  a 
micrococcus.  One  of  these  bacilli  is  a  long,  slender  rod  with  a  bright,  glisten- 
ing spore,  and  is  known  as  the  "head-bacillus."  The  other  appears  to  be 
identical  with  bacillus  subtilis.  The  micrococcus  is  a  large  circular  or  ellip- 
tical organism.  Breslau  taught  that  this  is  taken  in  with  the  air  which  the 
child  swallows  immediately  after  birth,  but  Escherich  thinks  that  these  bacilli 
found  in  the  rectum  find  entrance  through  the  anus.  However,  these  bacteria 
wholly  disappear  with  the  last  passage  of  meconium. 

The  normal  bacterial  flora  of  the  healthy  nursing  child  is  yet  more  limited, 
so  ffir  as  species  are  concerned,  the  number  being  two — the  bacterium  lactis 
aerogenes  and  the  bacterium  coli  commune.  These  are  known  as  obligatory 
"  milk-fifioes  "  bacteria,  and  are  constantly  present.  The  upper  part  of  the 
duodenum  is  quite  free  from  bacteria.  Lower  down,  the  small  intestines  con- 
tain large  numbers  of  the  bacterium  lactis  aerogenes,  while  in  the  lower  part 
of  the  ileum  the  bacterium  coli  commune  appears,  and  grows  more  abundant  in 
the  colon,  throughout  the  whole  length  of  Avhich  this  germ  is  found.  Other 
"inconstant"  bacterial  forms  are  found  in  the  large  intestines  of  the  bealthy 
milk-fed  child.  Both  the  bacterium  lactis  aerogenes  and  the  coli  commune  ai'e 
pathogenic  to  some  of  the  lower  animals  when  injected  subcutaneously. 
Whether  either  of  these  ever  develop  pathogenic  properties  in  diseased  con- 
ditions or  not  is  a  question  which  has  been  much  discussed,  but  which  cannot 
be  considered  as  positively  settled  at  present. 

The  contents  of  the  intestines  in  the  so-called  summer  diarrhoeas  of  infancy 
swarm  with  bacteria  of  many  species,  and  some  of  these  produce  most  power- 
ful poisons.  These  bacteria  multiply  outside  of  the  body,  and  are  disseminated 
widely  and  abundantly  only  when  the  atmospheric  temperature  reaches  60°  F. 
or  higher.  This  is  the  reason  for  the  restriction  of  these  diarrhoeas  to  the  hot 
months  of  summer. 

The  most  suitable  culture-medium  for  the  groAvth  of  these  bacteria  is  milk, 
and  this  is  the  food  with  which  they  most  commonly  find  tlieir  way  into  the 
intestines  of  the  child.  A  knowledge  of  these  facts  has  led  to  the  employment 
of  the  most  effective  pi'ophylactic  measures  for  these  diarrhoeas.  These 
measures  may  be  grouped  into  (a)  those  which  prevent  the  contamination  of 
milk,  and  (6)  those  which  destroy  any  germs  with  which  the  milk  has  already 


DIABBHCEAL   DISEASES.  473 

been  contaminated.  Since  these  diari'hoeas  are  limited  to  children  artificially 
fed  ia  whole  or  in  part,  our  prophylactic  measures  are  devoted  exclusively  to 
cow's  milk.  Some  years  ago  I  formulated  the  following  rules  concerning  the 
care  necessary  to  prevent  milk  undergoing  these  putrefactive  changes : 

{a)  The  cows  should  be  healthy,  and  the  milk  of  any  animal  which  seems 
indisposed  should  not  be  mixed  with  that  from  the  healthy  animals. 

(6)  Cows  must  not  be  fed  upon  swill  or  the  refuse  from  breweries  or  glucose- 
factories,  or  upon  any  other  fermented  food. 

(c)  Milk  cows  must  not  be  allowed  to  drink  from  stagnant  pools,  but  must 
have  access  to  fresh,  pure  water. 

[d)  The  pasture  must  be  freed  from  noxious  weeds,  and  the  barn  and  yard 
must  be  kept  clean. 

(g)  The  udders  should  be  washed,  then  wiped  dry,  before  each  milking. 

(/)  The  milk  must  be  at  once  thoroughly  cooled.  This  is  best  done  in  the 
summer  by  placing  the  milk-can  in  a  tank  of  cold  water  or  ice-water,  the  water 
being  of  the  same  depth  as  the  milk  in  the  can.  It  would  be  well  if  the  water 
in  the  tank  could  be  kept  flowing,  and  this  will  be  necessary  unless  ice-water 
is  used.  The  tank  should  be  thoroughly  cleansed  each  day  to  prevent  bad 
odors.  The  can  should  remain  uncovered  during  the  cooling,  and  the  milk 
should  be  gently  stirred.  The  temperature  should  be  reduced  to  60°  F.  or 
lower  within  an  hour.  The  can  should  remain  in  the  cold  water  until  ready 
for  delivery. 

{g)  Milk  should  be  delivered  during  the  summer  in  refrigerator  cans  or  in 
bottles  about  which  ice  is  packed  during  transportation. 

(Ji)  When  received  by  the  consumer  it  must  be  kept  in  a  clean  place  and  at 
a  temperature  some  degrees  below  60°  F. 

If  all  the  milk  used  in  the  artificial  feeding  of  infants  could  be  obtained 
and  marketed  with  the  care  demanded  by  the  above  rules,  milk  infection  would 
be  practically  unknown  and  the  sterilization  of  the  infant's  food  would  be 
unnecessary.  However,  since  it  is  impossible  for  the  city  consumer  to  know 
that  the  milk,  which  has  been  transported  through  a  long  distance  and  has 
passed  through  the  hands  of  several  dealers,  has  been  kept  from  infection,  the 
only  safe  plan  for  him  to  adopt  consists  in  the  sterilization  of  all  of  that  which 
is  fed  to  children.  There  is  no  doubt  in  the  mind  of  the  writer  that  whole- 
some, uninfected  milk  in  the  raw  state  is  a  better  food  for  the  infant'  than 
cooked  milk.  The  heat  of  sterilization  robs  the  nuclein  of  the  milk  of  its 
vital  properties,  as  can  be  demonstrated  by  experiments.  But  I  am  equally 
positive  that  it  is  better  to  feed  the  city  child  upon  sterilized  milk  than  it  is  to 
use  that  which,  with  the  prevailing  ignorance  and  carelessness  of  dairymen 
and  dealers,  is  likely  to  be  infected.  The  risk  in  using  unsterilized  milk  is 
too  great,  and  the  question  with  the  parent  or  physician  is  not.  Am  I  giving 
the  child  the  best  food  ?  but.  Am  I  giving  it  a  poison  ?  The  choice  is  easily 
made  when  the  matter  is  looked  at  in  this  light. 

The  toxicogenic  germs  grow  and  multiply  in  the  milk  both  before  and  after 
it  has  been  taken  into  the  alimentary  canal  of  the  child,  and  elaborate  chemical 
poisons  which  induce  the  diarrhoea  and  other  untoward  symptoms.  The  num- 
ber of  these  poisons  is  probably  as  great  as  that  of  the  bacteria  which  produce 
them.  While  they  may  differ  in  the  intensity  of  their  toxic  properties,  all  are 
gastro-intestinal  irritants,  just  as  we  have  a  number  of  metallic  poisons  which 
act  in  a  similar  manner.  Some  of  these  poisons  have  been  isolated  and  their 
effects  upon  the  lower  animals  have  been  studied.  Tyrotoxicon,  first  found  in 
poisonous  cheese,  later  in  ice-cream  and  other  milk-products,  has  been  isolated 
from  a  sample  of  milk  a  part  of  which  had  been  administered  to  a  healthy  child 


474    AMERICAN  TEXT-BOOK  OE  DISEASES  OF  CHILDREN. 

and  had  caused  a  severe  choleriform  diarrhoea.  This  is  a  most  potent  poison, 
inducing  severe  and  continued  vomiting  and  purging  with  speedy  prostration, 
and  death  Avithin  a  few  hours  if  the  quantity  administered  is  sufficient.  Post- 
mortem examination  shows  but  little  change.  The  mucous  membrane  of  the 
small  intestine  is  bleached  and  softened,  and  possibly  deprived  here  and  there 
of  its  superficial  epithelium.  These  are  the  symptoms  and  the  post-mortem 
appearances  in  the  choleriform  diarrhoea  of  infants. 

In  1890  proteid  poisons  were  isolated  by  the  writer  from  cultures  of  three  of 
the  toxicogenic  germs  found  by  Booker  in  the  intestines  of  infants  suffering 
from  milk  infection.  These  proteids  are  highly  poisonous,  and  when  injected 
under  the  skin  of  kittens  or  puppies  they  cause  vomiting  and  purging,  and, 
when  employed  in  sufficient  quantity,  collapse  and  death.  Post-mortem 
examination  shows  the  small  intestine  pale  throughout  and  constricted  in 
places.  The  heart  has  been  invariably,  so  far,  found  in  diastole  and  filled 
with  blood. 

A  small  amount  of  the  proteid  from  bacillus  x,  dissolved  in  water,  was 
injected  under  the  skin  on  the  back  of  a  kitten.  Within  one  half  hour  the 
animal  began  to  vomit  and  purge,  and  death  resulted  within  eighteen  hours. 
The  small  intestines  were  pale,  contracted  in  places,  and  contained  a  frothy 
mucus.  The  stomach  was  distended  with  gas,  and  contained  mucus  stained 
yellow  with  bile.  The  liver  was  normal,  the  spleen  and  kidneys  were  congested, 
and  the  heart  was  distended. 

Another  kitten  was  treated  Avith  the  proteid  from  bacillus  a,  dissolved  in 
water.  The  vomited  and  faecal  matter's  in  this  case  were  green.  The  animal 
died  after  fifteen  hours,  and  presented  appearances  practically  identical  Avith 
those  mentioned  above. 

A  third  kitten  Avas  treated  Avith  some  of  the  proteid  from  bacillus  A,  sus- 
pended in  Avater,  and  presented  substantially  the  same  symptoms  and  post- 
mortem appearances. 

Concerning  the  amount  of  one  of  these  proteids  necessary  to  produce  a 
fatal  result  in  the  animals  experimented  upon  the  folloAving  tests  Avere  made: 
Fifteen  milligrammes  of  the  dry  proteid  from  bacillus  a  w-as  injected  under  the 
skin  of  the  back  of  a  guinea-pig.  This  caused  death  Avithin  tAvelve  hours.  Of  tAvo 
kittens  treated  Avith  fifteen  milligrammes  of  the  a  proteid,  one  died  after  forty- 
eight  hours,  and  the  other  recovered  after  tAvo  days  of  vomiting  and  purging. 
Two  puppies  of  about  five  pounds  weight  had  each  forty  milligrammes,  anxl  after 
serious  illness  of  two  days  speedily  recovered.  During  these  tAA'o  days  of  vomit- 
ing and  purging  these  dogs  were  constantly  shivering  as  Avith  cold,  but  the 
rectal  temperature  stood  at  from  102.5°  to  103.5°  F. 

Baginsky  and  Stadthagen  have  isolated  from  cultures  of  the  "white  lique- 
fying germ"  obtained  by  the  former  from  diarrhoeal  stools  a  poisonous  proteid 
Avhich  produces  in  mice,  after  about  five  hours,  slight  dyspnoea.  The  coat 
becomes  rough,  the  animal  sits  with  drooping  head,  and  when  forced  to  move 
does  so  sluggishly,  butw^ithout  any  evidence  of  paralysis.  The  marked  apathy 
increases,  and  death  results  after  tAvo  or  three  days.  Section  shows  an  infiltra- 
tion about  the  place  of  injection,  congestion  of  the  spleen,  liver,  and  perito- 
neum. The  intestine  is  hyperaemic  throughout  its  entire  length,  and  its  upper 
portion  contains  a  reddish-brown  fluid.  The  same  bacterium  produces  a 
poisonous  base. 

With  our  present  knowledge  of  infected  milk  and  the  chemical  poisons 
which  may  be  generated  therein  the  causation  of  the  summer  diarrhoeas  in 
infancy  has  been  divested  of  the  mystery  Aviiich  formerly  obscured  our  views. 
Uninfected  milk  improperly  administered  may,  as  Ave  have  seen,  cause  intestinal 


BIABRHCEAL    DISEASES.  475 

indigestion,  and  thus  prepare  the  way  for  milk  infection  ;  but  it  can  never 
directly  induce  the  severer  forms  of  diarrhoea  which  make  infantile  mortality 
so  alarmingly  great.  The  relation  between  these  forms  of  diarrhoea  may  be 
likened  to  that  between  catching  cold  and  infection  with  tuberculosis.  The 
popular  idea  is  that  tuberculosis  originates  in  frequent  colds,  but  the  physician 
knows  that  this  is  not  true,  and  that  the  only  causal  relation  between  the  two 
is  that  which  grows  out  of  the  lowered  vitality,  lessened  resistance,  and  greater 
susceptibility.  If  parents  were  willing  to  pay  for  wholesome,  uninfected  milk 
half  the  fancy  price  which  they  readily  give  for  some  prepared  baby  food, 
their  children  would  be  better  nourished  and  disease  among  them  would  be  less 
frequent. 

Acute  Milk  Infection. 

Synonyms. — Cholera  infantum  ;   Choleriform  diarrhoea. 

Etiolog-y. — Fortunately,  this  foito  of  milk  infection  is  not  so  common  as 
those  of  a  milder  type.  It  practically  never  occurs  among  children  fed  exclu- 
sively from  the  breast.  The  exceptions  to  this,  if  there  be  such,  must  arise 
from  the  introduction  of  powerful  toxicogenic  germs  into  the  alimentary  canal 
in  some  unusual  manner.  There  are  recorded  cases  in  Avhich,  after  a  night 
of  debauch,  the  milk  of  a  wet-nurse  has  proved  intensely  poisonous  to  the 
child.  It  may  possibly  happen  that  an  infant  creeping  about  a  filthy  apart- 
ment, and  investigating  every  object  upon  which  it  can  lay  its  hands,  by 
the  sense  of  taste  or  by  sucking  its  dirty  fingers,  may  thus  infect  itself.  It 
may  also  happen  that  a  like  misfortune  may  result  from  bacteria  taken  from 
the  exterior  of  the  breast  of  a  filthy  mother.  However,  as  stated  above,  these 
are  unusual  methods  of  infection,  and  the  rule  holds  good  that  choleriform 
diarrhoea  is  limited  to  the  artificially  fed. 

The  diligent  researches  of  able  bacteriologists — among  whom  Booker  and 
Jefi"ries  in  this  country  and  Escherich  and  Baginsky  in  Germany  deserve  men- 
tion— have  failed  to  discover  a  specific  micro-organism  in  cholera  infantum. 
Booker  found  bacteria  belonging  to  the  proteus  group  most  frequent  in  these 
cases. 

As  has  been  stated,  the  writer  found  tyrotoxicon  in  one  sample  of  milk, 
the  administration  of  which  to  a  healthy  child  was  followed  within  two  hours 
by  the  development  of  a  most  violent  form  of  this  kind  of  poisoning.  This 
demonstrates  that  the  poison  may  exist  preformed  in  the  milk  at  the  time  of  its 
administration.  Holt  has  observed  that  cholera  infantum  "  is  most  frequently 
engrafted  upon  a  mild  dyspeptic  diarrhoea."  This  is  undoubtedly  often  the 
case,  but  it  so  happens  that  in  the  writer's  experience  the  violent  symptoms  have 
suddenly  appeared  in  previously  healthy  children,  and  Christopher  makes  a 
similar  observation.  It  certainly  is  an  error  to  say  that  acute  milk  infection 
begins  as  a  mild  diarrhoea.  The  former  may  supervene  on  the  latter,  but  one 
is  no  part  of  the  other. 

Choleriform  diarrhoea  never  occurs  save  in  tlie  hot  months  of  summer,  at  a 
time  when  poison-producing  germs  are  most  abundantly  distributed.  The  cause 
is  invariably  in  the  food,  and  the  poisons  which  induce  the  symptoms  are  not 
known  to  originate  in  any  other  food  than  milk  or  some  milk  preparation.  I  saw 
one  case  in  a  child  fed  upon  condensed  milk,  and  the  mother  noticed  when  she 
opened  the  can  that  the  ends  were  distended  by  accumulated  gases,  and  the  first 
feeding  from  this  can  was  folloAved  by  severe  vomiting  and  purging.  Bacteria 
were  abundant  in  the  contents  of  the  can.  Another  case  resulted  from  the  first 
feeding  from  a  can  of  a  baby-food  preparation.  Every  case  of  this  afiection  is 
one  of  poisoning  from  the  elaboration  of  chemical  products  by  the  growth  of 


476    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

bacteria  in  milk.  There  may  be  enough  of  the  poison  in  the  food  at  the  time 
of  its  administration  to  develop  the  symptoms  as  quickly  as  they  would  result 
from  the  giving  of  a  poisonous  dose  of  arsenic,  or  the  greater  part  of  the  toxic 
substance  may  be  generated  by  the  growth  of  the  bacteria  in  the  alimentary 
canal. 

Symptoms. — No  one  can  see  a  little  patient  suffering  from  acute  milk 
infection  without  .being  deeply  impressed  with  the  similarity  of  the  symptoms 
with  those  induced  by  some  powerful  gastro-intestinal  irritant.  The  child, 
which  may  have  been  perfectly  well  or  suffering  from  some  mild  form  of  diar- 
rhoea, suddenly  begins  to  vomit  and  purge.  These  symptoms  may  continue 
almost  incessantly  until  death  results  within  a  few  hours.  The  color  leaves 
the  face,  and  a  deathly  pallor  spreads  over  the  countenance.  The  eyes  sink 
into  their  sockets,  while  anxiety  and  alarm  make  themselves  visible  in  every 
feature.  Any  food-contents  of  the  stomach  are  soon  removed  by  the  vomiting, 
but  this  distressing  symptom  continues,  and  mucus  colored  with  bile  is  thrown 
off.  The  frequency  of  the  vomiting  is  increased  by  the  administration  of  food 
or  drink.  The  stools  at  first  contain  formed  faecal  matter  and  undigested  food; 
then  they  become  more  watery  and  copious,  and  at  last  they  are  composed  almost 
solely  of  blood-serum.  At  first  they  are  yellow  or  green,  but  as  they  become 
more  abundant  they  lose  all  color.  The  odor  is  peculiar  and  musty.  Thirty 
or  more  stools  may  be  passed  in  the  severer  cases  within  twenty-four  hours. 
So  long  as  the  stools  contain  undigested  food  they  may  be  acid,  but  the  serous 
passages  are  alkaline.  The  flesh  rapidly  disappears,  and  there  is  no  other  dis- 
ease, with  the  exception  of  Asiatic  cholera,  in  which  the  wasting  proceeds  more 
speedily  and  exhaustion  results  more  quickly.  The  skin  is  usually  cool  and 
clammy,  but  the  rectal  temperature  is  elevated,  usually  from  102°  to  104°  F., 
and  in  the  severer  cases  it  may  read  as  high  as  107°  or  108°  before  death.  The 
pulse  is  weak,  thready,  and  rapid.  The  respirations  are  shallow,  irregular, 
and  hurried.  At  first  the  child  cries,  then  only  moans,  and  later  falls  into  a 
comatose  condition,  but  there  may  be  great  restlessness,  wild  delirium,  and  con- 
vulsions. Thirst  is  usually  great,  and  everything  offered  is  swallowed  and 
almost  immediately  vomited.  The  abdomen  is  not  distended,  but  is  usually 
retracted.  Sometimes  the  vomiting  and  purging  suddenly  cease,  and  the  parents 
are  rejoiced  at  this  apparently  favorable  turn.  However,  it  may  be  but  the 
precursor  of  death.  The  physician  is  not  cheered  by  the  cessation  of  these 
symptoms  if  the  child  remains  in  a  stupor,  for  this  is  most  likely  to  deepen 
into  coma. 

In  rare  instances  the  child  quickly  passes  into  an  algid  state  in  which  the 
temperature  is  subnormal.  This  indicates  that  the  amount  of  the  poison 
absorbed  is  large  and  the  chances  of  recovery  are  small.  In  these  cases  the 
child  lies  in  a  stupor,  with  the  eyelids  half  open  and  the  eyes  apparently  cov- 
ered with  a  film.  The  angles  of  the  mouth  are  retracted  and  the  lips  open. 
The  fontanelle  is  depressed,  the  pulse  weak,  and  the  respiration  irregular.  The 
urine  is  scanty  and  there  may  be  complete  suppression. 

In  other  cases  the  symptoms  are  not  so  grave  as  those  indicated  above. 
The  stools  are  not  so  frequent  and  copious,  and  the  vomiting  not  so  incessant. 
The  little  patient  may  brighten  up  at  intervals,  and  sufficient  of  the  poison  may 
be  removed  by  the  vomiting  and  purging  to  give  great  relief  and  lead  to 
speedy  recovery. 

Cases  of  acute  milk  infection  terminate  either  in  death  or  in  marked  im- 
provement within  forty-eight  or  at  the  most  seventy-two  hours.  The  improve- 
ment may  be  rapid  and  complete,  or  it  may  reach  a  certain  point  and  there 
remain  comparatively  stationary. 


BIARRHCEAL    DISEASES.  477 

Diagnosis. — There  is  only  one  disease  which  presents  symptoms  with  which 
those  resulting  from  acute  milk  infection  can  be  confounded.  This  is  Asiatic 
cholera,  and  at  times  of  the  prevalence  of  this  foreign  scourge  a  diiferential 
diagnosis  between  the  two  cannot  be  made  without  the  aid  of  a  bacteriological 
study  of  the  stools.  At  all  other  times  the  suddenness  of  the  onset,  the  inces- 
sant vomiting,  the  frequent  and  copious  watery  stools,  and  the  speedy  prostra- 
tion are  so  striking  and  characteristic  that  there  can  be  no  hesitancy  in  making 
a  diagnosis.  It  is  true  that  some  writers  have  tried  to  confound  acute  milk 
infection  and  sunstroke.  The  points  of  similarity  are  the  suddenness  of  the 
prostration  and  the  high  temperature,  but  in  the  former  of  these  there  is  a  dif- 
ference. The  prostration  of  sunstroke  is  like  a  lightning  flash,  while  in  milk 
infection  it  develops  only  after  a  few  hours.  In  thermic  fever  there  may  be 
one  or  two  copious  discharges  from  the  bowels,  but  frequent  pui'ging  does  not 
occur  and  the  stools  are  never  serous.  The  attempt  to  make  acute  milk  infec- 
tion identical  with  thermic  fever  arose  from  our  former  ignorance  of  the  exist- 
ence of  the  powerful  poisons  which  may  be  elaborated  in  milk,  and  the  idea 
does  not  now  find  any  support. 

Prog-nosis. — It  is  quite  necessary  that  the  physician  appreciate  the  gravity 
of  these  cases  of  acute  milk  infection.  The  usual  termination  is  in  death. 
The  physician  who  speaks  too  hopefully  in  the  first  hours  of  the  attack  is 
likely  to  find  himself  disappointed  in  a  very  short  time.  The  more  persistent 
the  vomiting  and  purging,  and  the  more  marked  the  nervous  symptoms,  the 
less  are  the  chances  of  recovery.  If  the  stools  become  less  frequent  and  less 
watery,  and  if  at  the  same  time  the  pulse  grows  less  frequent  and  stronger  and 
the  nervous  symptoms  improve,  hope  may  be  indulged  in,  but  in  the  most 
favorable  cases  there  is  always  the  possibility  of.  a  relapse  into  the  subacute 
form,  and  so  long  as  this  continues  danger  is  imminent.  Unfortunately,  the 
name  "cholera  infantum"  has  been  made  to  cover  all  the  diarrhoeas  prevail- 
ing during  hot  months,  and  the  physician  must  not  be  led  astray  by  the  reported 
success  of  various  methods  of  treatment. 

Treatment. — These  are  cases  of  acute  poisoning,  and  prompt,  energetic 
treatment  is  demanded  as  truly  as  if  the  child  had  swallowed  a  toxic  dose  of 
arsenic  or  antimony.  It  is  certainly  ti'ue  that  the  physician  who  hesitates  or 
temporizes  loses  his  patient. 

The  first  thing  to  be  done  is  to  positively  forbid  the  further  administration 
of  the  poison.  Not  a  drop  of  milk  should  be  given.  This  is  a  sine  qud  non  in  the 
treatment.  This  prohibition  of  milk  must  be  absolute.  Sterilized  milk  is  not 
to  be  thought  of,  and  even  the  breast  of  the  mother  or  wet-nurse  must  be  denied. 
Prepared  baby  foods  should  be  thrown  out  of  the  window.  The  most  danger- 
ous foe  with  whom  the  doctor  has  to  contend  in  the  treatment  is  the  grand- 
mother or  other  good-hearted  old  lady,  who  knows  just  what  will  agree  with 
the  baby,  and  who  persists  in  giving  it  food  as  soon  as  the  doctor  turns  his 
back.  The  most  valuable  ally  that  he  can  have  is  a  trained,  conscientious 
nurse  who  will  carry  out  directions  to  the  letter. 

The  second  thing  to  do  is  to  remove  so  far  as  is  possible  the  poison  already 
in  the  alimentary  canal.  Take  a  lesson  from  nature.  The  vomiting  and 
purging  are  attempts  to  eliminate  the  harmful  substance,  but,  like  many  other 
attempts  on  the  part  of  nature,  they  are  ineffectual  and  exhausting.  Wash  out 
the  stomach  and  intestines  on  the  first  appearance  of  the  symptoms.  Do  not 
postpone  these  measures  in  the  hope  that  resort  to  them  may  not  be  necessary. 
What  would  be  thought  of  the  physician  who  when  called  to  see  a  person  who 
had  swallowed  a  drachm  of  white  arsenic  vshould  say,  ''  Well,  the  symptoms  are 
not  at   present  alarming ;  I  will  call  around  after  a  few  hours,  and  if  it  be 


478    A3IEBICAy  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

necessary  I  will  then  wash  out  the  stomach ""  ?  Acute  milk  infection  is  poison- 
ing with  a  substance  more  powerful  and  deadly  than  white  arsenic.  The  wash- 
ing of  the  stomach  and  intestine  will  not  exhaust  the  little  patient  half  so  much 
as  the  continued  vomiting  and  purging,  and  the  artificial  measures  are  much 
more  eflFective.  The  bowels  should  be  thoroughly  irrigated  with  warm  water 
and  castile  soap,  not  less  than  a  gallon  of  the  water  being  used.  After  the 
large  intestine  has  been  cleansed  in  this  manner,  an  injection  of  cool  water,  con- 
taining fifteen  to  thirty  grains  of  tannic  acid  to  the  pint,  should  immediately 
follow.  Some  of  the  poisons  formed  are,  as  we  have  seen,  proteids  which  are 
precipitated  b}'  tannic  acid,  but  until  the  great  mass  of  proteid  in  the  large 
intestine  has  been  removed  no  good  can  be  expected  from  this  agent.  The 
object  of  the  tannic-acid  irrigation  is  to  render  inert  any  soluble  poisonous  pro- 
teids Avhich  may  remain  in  the  intestines  after  the  first  washing. 

The  stomach  should  be  washed  with  warm  water  containing  a  teaspoonful  of 
common  salt  to  the  pint.  After  this  organ  has  been  thoroughly  cleansed,  from 
three  to  five  grains  of  calomel  should  be  administered. 

These  irrig;^tions  should  be  repeated  as  soon  as  the  vomiting  or  purging 
retui-ns.  These  may  appear  to  be  heroic  measures,  but  the  strength  of  the 
patient  is  conserved  thereby  to  the  extent  to  which  the  vomiting  and  purging 
are  allayed. 

The  calomel  is  given  for  its  antifermentative  action  and  in  order  to  reach 
the  small  intestines,  which  are  inaccessible  by  the  processes  of  irrigation. 

After  the  vomiting  has  been  allayed  by  irrigation,  stimulants  may  be  given 
by  the  mouth.  I  prefer  whiskey  to  all  other  alcoholic  stimulants.  Brandy,  if 
pure,  would  be  equally  good,  possibly  better,  but  unadulterated  brandy  is  a  rare 
article  in  this  country,  Avhile  good  Avhiskey  is  easily  obtainable.  The  stimulant 
is  best  given  in  ice-cold  water  (the  water  should  be  boiled,  and  then  ice-packed 
about  the  container  ;  the  ice  should  not  be  put  in  the  water)  containing  0.1  per 
cent,  of  hydrochloric  acid.  This  dilute  acid  may  be  used  at  any  time  to  allay 
thirst. 

I  agree  with  Holt  that  the  hypodermatic  use  of  very  small  doses  of  morphine 
and  atropine  (one-hundredth  of  a  grain  of  the  former  and  one  eight-hundredth 
of  the  latter)  may  be  of  benefit  as  a  heart  stimulant,  but  the  dose  must  not  be 
repeated  too  frequently.  I  have  feared  digitaline  too  much  to  try  it  in  these 
cases,  nor  have  I  employed  sparteine. 

When  the  temperature  is  above  103°,  an  ice-cap  on  the  head  is  desirable, 
and  in  some  instances  it  seems  to  favorably  affect  the  vomiting.  When  the  tem- 
perature goes  up  to  104°  or  higher,  some  more  efficient  means  of  reducing  it 
should  be  resorted  to.  The  use  of  the  coal-tar  derivatives  for  this  purpose  is  not 
to  be  considered,  and  the  same  may  be  said  of  all'  drugs.  Frequent  sponginor 
and  friction  with  cloths  wet  with  cold  water  may  be  sufficient.  The  friction  is 
important  on  account  of  the  coldness  of  the  surface.  When  the  temperature  is 
more  alarming,  the  child  should  be  placed  in  warm  water,  and  the  temperature 
of  this  gradually  lowered  by  the  addition  of  ice  to  85°,  the  child  being  rubbed 
all  the  while  it  is  in  the  bath.  It  should  not  be  kept  in  the  bath  more  than  ten 
minutes  after  the  temperature  has  been  lowered  to  the  above-mentioned  point. 
Bathing  the  extremities  in  hot  mustard-water  and  the  use  of  friction  are  bene- 
ficial in  the  state  of  collapse. 

With  the  exception  of  the  above-mentioned  stimulants  the  child  should 
have  no  food  for  twenty-four  hours  or  even  longer.  Then  warm  meat  broths, 
given  a  teaspoonful  at  a  time,  and  to  be  discontinued  if  they  provoke  vomiting, 
are  most  likely  to  be  borne.  The  absolute  prohibition  of  milk  should  hold 
good  for  several  days. 


DIARRHCEAL   DISEASES.  479 

There  is  scarcely  a  drug  which  has  been  shown  to  have,  or  supposed  to 
have,  germicidal  properties  that  has  not  been  used  in  this  disease.  Among 
others,  mercuric  chloride,  carbolic  acid,  creasote,  salicylate  of  sodium,  benzo- 
ate  of  sodium,  salol,  naphthalin,  and  resorcin  may  be  mentioned.  These  and 
others  may  be  given  by  the  mouth  and  by  the  rectum.  Much  harm  and  no 
good  can  be  obtained  from  them.  To  attempt  to  disinfect  the  alimentary  canal 
by  means  of  these  agents  is  a  waste  of  time  and  energy  which  might  be  given 
to  the  more  rational  treatment  outlined  above. 

The  diapers  from  children  suifering  from  milk  infection  should  always  be 
disinfected,  and,  what  is  of  more  importance,  the  nurse's  hands  should  be  disin- 
fected after  she  has  removed  the  diaper. 

■   Subacute  Milk  Infection. 

Synonyms. — Summer  diarrhoea ;  Gastro-intestinal  catarrh  ;  Infectious 
diarrhoea ;  Entero-colitis. 

Etiolog-y. — This  is  the  disease  which  carries  off  so  many  thousands  of 
children  in  the  large  cities  every  summer.  It  prevails  only  during  the  hot 
months,  when  the  atmospheric  temperature  stands  above  60°  F.  for  several  con- 
secutive days.  It  is  due  to  the  action  of  poisons  generated  by  the  growth  and 
multiplication  of  bacteria.  These  germs  are  certainly  more  widely  distributed 
than  those  which  induce  the  symptoms  described  under  Acute  Milk  Infection, 
but  the  chemical  poisons  produced  by  the  former  are  less  powerfully  toxic  than 
those  of  the  latter.  However,  the  milder  poisons  induce  the  greater  number 
of  deaths,  on  account  of  the  greater  number  of  individuals  invaded  by  the 
germs  which  produce  them.  There  are  also  greater  variations  in  the  symptoms 
of  subacute  cases.  When  the  chemical  poisons  have  been  studied  more 
thoroughly,  these  variations  will  doubtless  be  better  understood  and  a  more 
exact  classification  of  them  can  be  made. 

Symptoms. — In  the  milder  forms  the  symptoms  gradually  develop.  The 
movements  of  the  bowels  increase  in  frequency  and  become  more  watery. 
Thev  consist  largely  of  undigested  food,  and  contain  lumps  of  coagulated 
casein  and  masses  of  fat.  The  color  may  be  brown,  yellow,  or  green,  and  the 
odor,  though  it  may  be  disagreeable,  has  not  the  peculiar  putrid  property 
characteristic  of  chronic  intestinal  indigestion.  J.  Lewis  Smith  has  made  a 
microscopical  study  of  the  faeces,  and  has  the  following  to  say  concerning  them : 
"  In  addition  to  undigested  casein,  I  have  found  epithelial  cells,  single  or  in 
clusters  (sometimes  regularly  arranged  as  if  detached  in  mass  from  the  villi), 
fibres  of  meat,  crystalline  formations,  mucus,  and  occasionally  blood.  In  one 
instance  I  observed  an  appearance  resembling  three  or  four  crypts  of  Lieber- 
kiihn  united,  probably  thrown  ofi"  by  ulceration.  If  the  stools  are  green, 
colored  masses  of  various  sizes,  but  mostly  small,  are  also  seen  under  the 
microscope." 

The  continuance  of  the  intestinal  fermentation  sets  up  inflammatory  pro- 
cesses, and  the  stools  then  contain  mucus.  This  condition  may  go  on  for  weeks, 
and  the  anatomical  changes  in  the  intestines  become  gradually  more  serious. 
Ulcerations  may  occur,  especially  in  the  ileum  and  colon.  The  general  nutri- 
tion of  the  child  becomes  impaired,  the  appetite  is  not  good,  the  tongue  is 
covered  with  a  white  or  grayish  coat,  and  there  is  a  gradual  loss  of  flesh.  The 
temperature  is  the  best  indication  of  the  rapidity  with  which  inflammatoxy 
changes  are  occurring  in  the  intestines.  There  is  always  fever,  at  least  during 
some  portion  of  the  twenty-four  hours,  but  in  the  milder  cases  it  may  be  so 
slight  that  it  is  likely  to  escape  detection.     These  cases,  in  the  earlier  stages 


480    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  before  marked  inflammatory  changes  have  occurred  in  the  intestines,  are 
often  readily  amenable  to  treatment,  especially  to  proper  change  in  food,  and 
marked  improvement  may  be  produced  in  a  short  time.  Other  cases  are  more 
obstinate  and  drag  on  for  weeks,  and  are  likely  to  terminate  fatally  from  some 
exacerbation,  from  exhaustion,  or  from  some  intercurrent  disease.  Children 
who  have  suffered  from  this  slow  poisoning  during  the  summer  are  likely  to 
fall  victims  to  pneumonia  the  succeeding  winter. 

In  these  protracted  cases  there  is  usually  more  or  less  vomiting.  This  may 
be  an  early  symptom,  in  which  case  it  is  due  to  fermentation  in  the  stomach  ; 
or  it  may  appear  later  when  stomachic  digestion  is  impaired  by  the  general 
failure  in  nutrition.  The  vomiting  is  not  .so  incessant  as  it  is  in  acute  milk 
infection. 

During  the  progress  of  the  protracted  cases  there  are  likely  to  be  many 
exacerbations,  or  acute  infection  ma}'  result  from  the  introduction  of  more 
virulent  toxicogenic  germs. 

■  1  rill 

In  other  instances  the  development  of  these  symptoms  is  more  abrupt.  I  he 
child  becomes  restless,  and  cries  with  pain  due  to  distention  of  the  intestines 
with  gas,  and  there  may  be  convulsions.  Vomiting  occurs  early,  and  the  tem- 
perature may  rise  to  103°.  The  diarrhoea  begins,  and  the  expulsion  of  the 
stools  is  accompanied  by  large  quantities  of  gas.  This  gives  relief  from  the 
pain,  the  nervous  symptoms  disappear,  and  the  child  falls  asleep,  from  which  it 
is  soon  awakened  by  new  accumulations  of  gas.  In  these  cases  unaided  nature 
is  frequently  successful  in  removing  the  offending  contents  of  the  intestines, 
and  unless  the  administration  of  infected  food  is  continued  a  speedy  return  to 
health  may  follow.  Under  other  conditions  the  severe  initial  symptoms  abate, 
but  putrefactive  processes  continue  in  the  intestines  for  an  indefinite  pei'iod  of 
time. 

Whether  the  symptoms  come  on  gradually  or  begin  more  abruptly,  the  con- 
tinuance of  bacterial  fermentation  in  the  intestines  leads  to  the  development 
of  those  anatomical  changes  which  constitute  Avhat  is  generally  designated 
as  entei'o-colitis.  That  the  fermented  intestinal  contents  are  irritant  in  their 
action  is  shown  by  the  erythema  which  appears  on  the  buttocks  and  thighs 
when  frequentlv  soiled  by  the  discharges,  and  which  may  develop  into  super- 
ficial ulceration  of  the  skin.  It  is  generally  believed  that  tlie  structural  changes 
in  the  intestines  are  due  to  the  direct  action  of  the  bacteria  on  the  intestines, 
but  these  alterations  are  more  probably  due  to  the  irritating  action  of  the 
chemical  products  of  the  germs.  The  upper  parts  of  the  small  intestines,  the 
duodenum  and  the  jejunum,  are  generally  free  from  inflammatory  changes, 
which  are  marked  in  the  lower  part  of  the  ileum.  This  is  easily  explained  by 
the  fact  that  the  contents  of  the  small  intestines  accumulate  here  before  passing 
through  the  ileo-c£ecal  valve.  If  the  destructive  processes  in  the  intestinal  walls 
were  due  to  the  direct  action  of  the  bacteria  burrovring  into  the  tissue,  the 
explanation  of  the  location  of  the  catarrhal  inflammation  and  the  ulceration  in  the 
lower  ileum  Avoukl  not  be  easy.  Inflammatory  changes  in  the  colon  are  invari- 
ably present  in  protracted  cases,  and  they  are  generally  more  marked  than 
those  of  the  small  intestines,  due  to  the  fact  that  the  intestinal  contents  become 
more  irritating  the  longer  they  are  subjected  to  the  fermentative  action  of  the 
bacteria.  While  the  anatomical  changes  are  frequently  found  along  the  entire 
course  of  the  colon  from  the  ileo-coecal  valve  to  the  sigmoid  flexure,  they  are 
most  marked  just  above  the  last-mentioned  point.  This  is  again  explained  by 
the  delay  which  occurs  here  in  the  passage  of  the  irritating  substance.  Tbe 
rectum  is  usually  free  from  inflammatory  lesions,  or  shows  only  those  of  the 
most  superficial  character. 


DIABBHCEAL    DISEASES.  481 

The  extent  to  which  these  anatomical  lesions  are  developed  depends  upon 
the  character  and  quantity  of  the  irritating  substances  formed,  but  most  of  all 
upon  the  duration  of  the  diarrhoea.  A  milder  irritant  acting  through  a  longer 
time  may  cause  deeper  and  more  dangerous  tissue-changes  than  a  more  power- 
ful ao-ent  actino-  for  a  shorter  time.  The  character  and  extent  of  these  lesions 
may  be  to  some  extent  judged  by  the  contents  of  the  stools.  There  may  be 
much  fluid  mucus  in  the  passages,  and  in  such  cases  it  is  customary  to  say  that 
the  child  is  suffering  from  "  catarrhal  diarrhoea,"  or  there  may  be  lumps  or 
clots  of  mucus  stained  with  blood,  and  this  is  designated  as  "  dysenteric 
diarrhoea."  The  presence  of  shreds  of  mucous  membrane  has  led  to  the  use 
of  the  term  "croupous  diarrhoea,"  and  the  detection  of  considerable  pus  is 
deemed  sufficient  to  pronounce  the  case  one  of  "follicular  ulceration.''  How- 
ever, as  all  of  these  changes  may  result  from  one  and  the  same  poison  in  differ- 
ent degrees  of  concentration  or  acting  through  varying  periods  of  time,  a 
classification  based  on  the  anatomical  lesions  is  wholly  irrational.  It  must  not 
be  concluded  from  this  repudiation  of  an  anatomical  basis  of  classification  that 
the  physician  should  pay  no  attention  to  the  stools.  Careful  inspection  should 
be  made  frequently,  and  the  statements  of  attendants  should  not  be  relied  upon 
to  the  extent  of  failing  to  give  this  matter  personal  attention.  Because  one 
knows  that  his  patient  is  poisoned  with  arsenic,  this  is  no  reason  why  he  should 
shut  his  eyes  to  the  amount  and  extent  of  gastro-intestinal  irritation  caused 
by  the  poison,  or  even  to  the  condition  of  the  circulation,  respiration,  and 
nervous  functions.  Learn  all  you  can  about  your  patient,  and  you  will  often 
find  yourself  even  then  knowing  too  little  to  effect  a  cure. 

Complications. — Erythema  of  the  buttocks  and  thighs  from  the  irritation 
of  the  discharges  is  frequent,  and,  as  has  been  stated,  superficial  ulceration 
may  be  developed  and  may  form  a  very  distressing  complication.  Thorough 
cleansing,  the  use  of  a  mild  soap,  and  subsequent  dusting  with  starch  or  other 
protective  powder  should  be  advised. 

Boils  over  the  head  and  face  often  appear,  and  the  destruction  of  tissue 
may  be  so  deep  that  permanent  scars  are  formed. 

In  strumous  children  the  lymphatic  glands  in  the  inguinal  region,  more 
rarely  those  about  the  throat,  may  enlarge  and  possibly  suppurate.  I  once 
saw  a  case  in  which  the  suppuration  from  the  glands  of  the  neck  was  so  pro- 
fuse that  it  endangered  life.  The  urine,  which  was  normal  before  the  glands 
began  to  swell,  contained  a  considerable  quantity  of  blood,  and  the  hgematuria 
continued  for  more  than  a  week.  The  glands  were  freely  opened  and  antisep- 
tically  treated,  and  the  child  ultimately  recovered  completely. 

In  the  great  majority  of  these  cases  the  stomach  remains  surprisingly  free 
from  any  lesion,  and  this  is  true  even  when  there  has  been  frequent  vomiting. 
In  a  small  number  some  hypersemia  of  the  mucous  membrane  of  this  organ  is 
found  after  death,  and  in  rare  instances  minute  ulcers  have  been  observed. 

Stomatitis  is  frequently  a  complication,  and  aphthous  ulceration  an  occa- 
sional one. 

Hypostatic  congestion  of  the  lungs  is  frequent,  and  a  subacute  broncho- 
pneumonia is  a  common  complication  of  this  form  of  diarrhoea.  It  is  most 
marked  in  the  posterior  and  dependent  portions  of  the  lungs,  and  it  often  con- 
stitutes the  immediate  cause  of  death.  The  condition  of  the  patient  in  pro- 
tracted cases  renders  it  specially  susceptible  to  specific  micro-organisms,  and 
tuberculosis  is  sometimes  developed. 

Holt  thinks  that  the  frequency  of  nephritis  as  a  complication  has  been  over- 
estimated since  the  writings  of  Kj  ell  berg  called  attention  to  it,  and  J.  Lewis 
Smith  doubts  the  correctness  of  generally  attributing  the  vomiting  to  ursemic 

31 


482    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

poisoning.     My  own  observation  and  belief  support  the  views  of  these  Amer- 
ican authorities. 

Diagnosis. — Subacute  milk  infection  is  distinguished  from  the  acute  form 
by  the  milder  character  of  the  former.  The  vomiting  and  purging  are  less 
violent,  the  temperature  does  not  rise  so  high,  the  prostration  is  not  so  great, 
and  the  large  serous  stools,  so  characteristic  of  the  acute  form,  are  wanting. 
From  chronic  intestinal  indigestion  there  may  be  great  difficulty  in  making  a 
differential  diagnosis.  The  season  of  the  year,  the  character  of  the  food,  and 
the  hygienic  surroundings  must  be  taken  into  consideration.  The  temperature 
is  also  another  valuable  indication,  as  an  elevation  is  exceptional  in  indigestion 
except  during  periods  of  exacerbation.  From  intussusception,  subacute  milk 
infection  is  to  be  distinguished  by  the  suddenness  and  violence  of  the  attack, 
the  tenesmus  and  pain,  tlie  absence  of  fever,  and  the  stercoraceous  vomiting 
which  characterize  the  former. 

Prognosis. — As  in  the  case  of  chronic  intestinal  indigestion,  the  prognosis 
will  be  influenced  by  the  parentage  of  the  child,  by  its  sanitary  surroundings, 
and  by  the  period  of  time  through  which  the  poisoning  has  continued,  and  con- 
sequently by  the  extent  and  character  of  the  anatomical  lesions.  Cases  develop- 
ing at  the  beginning  of  a  hot  summer,  especially  when  the  parents  are  not  able 
to  transfer  the  child  from  the  crowded  and  possibly  filthy  quarter  of  a  city  to  a 
salubrious  country  place,  are  less  likely  to  recover  than  those  occurring  among 
the  same  classes  late  in  the  fall.  The  probability  of  relapses,  when  the  sur- 
roundings remain  unfavorable,  should  always  be  borne  in  mind. 

Treatment. — Preventive  treatment  intelligently  carried  out  would  save 
thousands  of  lives  annually  in  our  large  cities.  The  best  of  all  these  measures 
is  that  the  mother  should  nurse  the  child,  and  the  mother  who  allows  anything 
short  of  absolute  inability  to  prevent  her  doing  so  places  the  life  of  her  child 
in  jeopardy.  Daily  bathing  should  be  practised;  and  again  I  must  call  atten- 
tion to  the"  desirability  of  having  nurses  disinfect  their  hands  after  they  have 
changed  the  diapers  of  the  infant.  This  should  be  done  whether  the  child  is 
sick  or  well.  Reports  showing  that  all  the  children  in  a  hospital  fed  by  a  certain 
nurse  have  simultaneously  developed  a  diarrhoea,  while  those  fed  with  tlie  same 
food  by  other  nurses  have  remained  well,  are  given  by  some  writers  in  order  to 
prove  the  contagious  character  of  the  disease.  It  is  more  than  likely  that  these 
cases  were  due  to  direct  infection  of  the  food  from  the  hands  of  the  nurse  or  from 
the  use  of  unclean  receptacles.  Soiled  diapers,  even  those  from  healthy  infants, 
should  not  be  allowed  to  dry  in  the  air  which  children  breathe.  When  the 
mother  cannot  nurse  her  infant,  the  fresh,  uncooked,  uninfected  milk  of  a 
healthy  cow  is  the  best  substitute.  AVhen  this  cannot  be  obtained  Avith  any 
certainty,  sterilized  milk  is  the  next  best  food  from  a  prophylactic  standpoint. 
Fresh  air,  and  plenty  of  exercise  in  it,  are  essential  to  the  proper  growth  of 
the  child. 

When  we  come  to  the  curative  treatment  the  question  of  feeding  is  one  of 
the  most  perplexing  with  wliich  the  physician  has  to  deal,  and  the  writer  rejoices 
that  for  the  details  on  this  point  he  can  refer  the  reader  to  the  high  authority 
who  deals  with  the  subject  of  Infant-feeding  in  this  volume.  However,  it  is 
not  fair  to  shirk  all  responsibility  in  this  matter,  and  a  brief  statement  of  the 
dietetic  treatment  will  be  given. 

We  will  assume  that  the  child  has  been  artificially  fed  in  wliole  or  in  part. 
All  milk  food  should  be  prohibited  for  from  two  to  four  days,  possibly  longer. 
Escherich  has  shown  that  the  bacterial  flora  of  the  infant's  intestines  changes 
radically  and  speedily  when  milk  is  excluded  from  the  diet.  In  fact,  this  is 
one  of  the  most  potent  agents  at  our  command  for  destroying  toxicogenic  germs 


DIARBHCEAL   DISEASES.  483 

in  the  intestines.  Their  best  culture-medium  is  milk,  and  in  this  thev  will 
thrive  and  multiply  most  abundantly.  Exclude  milk  from  the  food,  and  these 
bacteria  give  place  to  others  Avhich,  if  toxicogenic  at  all,  are  less  powerfully  so. 
The  proteids  of  the  milk  may  be  replaced  by  animal  broths  and  solutions  of 
egg-albumin,  which  should  always  be  freshly  prepared.  The  meat  extracts  of 
trade  are  worse  than  worthless  in  these  cases.  Their  nutritive  value  is  prac- 
tically zero.  They  contain  extractives  which  may  be  used  as  stimulants,  but 
these  are  not  specially  indicated  in  the  cases  now  under  discussion.  The  carbo- 
hydrates are  best  supplied  in  the  form  of  soluble  starch  and  dextrin,  obtained 
by  boiling  rice  or  arrow-root  or  by  baking  these  or  other  foods  rich  in  starches. 
A  return  to  a  milk  diet  should  be  made  cautiously:  sterilized  milk  should  be 
employed,  and  at  first  in  very  small  quantities,  the  greater  part  of  the  food  still 
consisting  of  the  articles  mentioned  above. 

Shall  the  medicinal  treatment  be  begun  by  the  administration  of  a  laxative? 
The  answer  to  this  depends  upon  the  period  in  the  development  of  the  disease 
when  the  physician  first  sees  the  patient.  In  dispensary  work,  and  often  in 
private  practice,  the  physician  does  not  see  these  cases  until  the  diarrhoea  has 
persisted  for  days,  possibly  for  weeks,  and  after  the  little  one  has  been  dosed 
with  domestic  remedies,  Avhich  are  practically  unlimited  in  number  and  variety. 
If  the  child  is  seen  early,  give  from  one  to  two  teaspoonfuls  of  castor  oil,  fol- 
lowed by  one  or  two  drops  of  the  tincture  of  opium.  If,  on  the  other  hand, 
the  child  is  already  exhausted  from  the  continuance  of  the  diarrhoea,  begin  at 
once  the  administration  of  stimulants,  whiskey  or  brandy,  and  give  opium  in 
small  doses,  which  may  be  repeated  sufficiently  to  allay  any  pain  and  lessen  the 
peristaltic  action  of  the  intestines,  but  never  sufficiently  to  induce  constipation. 
Irrigation  of  the  intestines,  as  before  described,  should  be  resorted  to  in  all 
cases.  After  the  large  intestine  has  been  cleansed  by  irrigation,  from  two  to 
three  drachms  of  bismuth  subnitrate  should  be  suspended  in  from  six  to  eight 
ounces  of  water  and  retained  as  long  as  possible.  The  irrigation  of  the  intes- 
tines, with  the  subsequent  injection,  may  be  practised  from  two  to  four  times 
per  Aveek  so  long  as  the  stools  remain  abnormal.  Tannic  acid,  ten  to  fifteen 
grains  to  the  ounce  of  Avater,  may  be  used  instead  of  the  bismuth.  Irrigation 
of  the  stomach  is  seldom  indicated — never  unless  the  vomiting;  be  a  marked 
symptom.  Bismuth  subnitrate  suspended  in  water  or  in  some  mucilaginous 
drink  should  be  given  by  the  mouth  in  quantities  of  one  or  tAvo  drachms  per 
day. 

Antiseptics  are  practically  Avithout  value,  and.  as  unnecessary  dosing  is  cer- 
tainly to  be  avoided,  medication  should  bcAvithout  them.  The  astringents, 
both  vegetable  and  mineral,  such  as  catechu,  coto-bark,  silver  nitrate,  and  lead 
acetate,  which  are  so  frequently  found  in  diarrhoea  mixtures,  are  not  only 
valueless  when  given  by  the  mouth,  but  they  are  likely  to  interfere  Avith  the 
digestive  action  of  the  stomach,  which,  as  Ave  have  seen,  usually  escapes  involve- 
ment in  the  diseased  process,  and  consequently  they  are  harmful. 

In  protracted  cases  general  tonic  treatment  is  often  of  great  A^alue.  Dilute 
nitro-hydrochloric  acid,  three  or  four  drops  in  as  many  ounces  of  water,  is  one 
of  the  best  in  the  list  of  tonics.  FoAvler's  solution,  two  or  three  drops  three 
times  per  day,  may  be  of  service,  and  the  tincture  of  nux  vomica  has  been 
much  praised.  Iron  and  cod-liver  oil  are  most  appropriate  after  the  digestive 
disturbances  have  disappeared. 

In  the  more  acute  forms,  where  tenesmus  is  marked,  relief  may  be  obtained 
by  the  use  of  suppositories  containing  one-fourth  of  a  grain  of  cocaine.  Hot 
applications  over  the  abdomen  may  also  be  of  value. 

I  must  again  emphasize  the  need  of  attention  to  the  local  sanitary  con- 


484    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

(litions  in  all  cases  of  milk  infection.  These  are  of  more  importance  than  the 
climatic  influences;  and,  moreover,  the  former  can  be  improved,  while  the 
latter  can  be  bettered  only  by  a  change  in  residence.  Unhygienic  surround- 
ings tell  most  unfavorably  upon  the  young  child,  whose  organism  requires  time 
in  order  to  adapt  itself  to  its  environment. 


dysentery; 

By  SAMUEL  S.  ADAMS,  M.  D., 

WASsrsGToy.  D.  C. 


Dysentery  is  an  inflammation  of  the  mucous  membrane  of  the  large 
intestine.  In  retaining  the  term  "  dysentery  "  in  the  nomenclature  of  diseases 
of  the  intestines  it  is  not  because  it  is  recognized  as  a  distinct  form  of  disease, 
but  because  it  is  a  convenient  term  to  express  the  most  prominent  symptoms 
resulting  from  the  lesions  in  the  colon  and  rectum. 

There  are  three  varieties — the  catarrhal,  the  diphtheritic,  and  the  amoebic. 

I.  Catarrhal  Dysentery. 

This  affection  may  be  acute  or  chronic,  sporadic,  endemic,  or  epidemic. 

Etiology. — Catarrhal  dysentery  may  occur  at  any  age  from  birth  to 
puberty,  but  it  is  most  frequent  bet-n-een  the  first  and  tenth  year  as  an  inde- 
pendent affection.  Sex  exerts  no  influence,  as  it  occurs  as  frequently  in  boys 
as  in  girls  ;  and  the  same  statement  is  true  of  race ;  so  if  it  happen  to  occur 
more  generally  among  any  particular  nationality  in  a  community,  it  must  be 
attributed  to  other  than  racial  influence.  It  occurs  under  all  social  conditions 
from  the  highest  to  the  loTvest,  and,  while  it  is  more  prevalent  among  the 
pauper  and  laboring  classes,  its  severity  is  not  tempered  by  high  social  stand- 
ing. It  is  more  frequent  in  the  city  than  in  the  country,  but  occurs  in  the 
latter  with  as  great  severity  as  in  the  former.  Neglect,  poverty,  ill-ventilated 
and  uncleanly  apartments,  and  insuflScient  and  foul  clothing  act  as  predisposing 
causes  by  depressing  the  general  resisting  powers  of  the  child.  Hence  it  is 
met  with  more  frequently  among  the  inhabitants  of  the  tenement-houses  than 
among  those  in  sanitary  dwellings.  The  liability  to  dysentery  is  increased  by 
such  vices  of  constitution  as  tuberculosis,  congenital  syphilis,  rickets,  and 
athrepsia,  which  enfeeble  the  general  health. 

As  dysentery  frequently  occurs  during  the  period  of  the  eruption  of  the 
deciduous  teeth,  there  is  a  popular  belief  that  it  is  the  direct  result  of  dentition. 
After  careful  observation  and  study  of  the  relation  of  dentition  to  diseases  of 
the  alimentary  tract  in  288  infants,  the  author  feels  free  to  assert  that  neither 
the  evolution  nor  eruption  of  the  teeth  was  found  to  be  an  etiological  factor  in 
any  of  them.  Similar  investigations  may  convince  the  skeptical  that  improper 
alimentation,  and  not  "teething,"  is  the  most  potent  etiological  factor  in  the 
disorders  of  the  alimentary  tract  of  infants.  So  in  order  to  establish  a  direct 
relation  between  dentition  and  dysentery  every  other  etiological  factor  must  be 
excluded. 

The  most  frequent  as  Avell  as  the  most  powerful  causative  factor  is  improper 

^  At  the  meeting  of  the  American  Pediatric  Society,  held  at  West  Point  in  May  1893,  it 
was  agreed  to  drop  the  term  "Dysentery"  from  the  nomenclature  of  diseases  and  substitute 
for  it  "  Ileo-Colitis." 

485 


486    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

feeding.  The  food  may  be  faulty  in  quality  or  quantity,  or  in  both.  Pure 
food  may  act  deleteriously  if  given  in  too  large  quantities ;  and  the  correct 
amount  of  impure  food  will  certainly  prove  injurious.  It  occurs  most  often  in 
the  artificially  fed,  although  the  nursling  is  not  exempt.  The  former  is  not 
only  subjected  to  the  perils  of  impure  or  ill-prepared  cow's  milk,  but  also  to 
the  dangers  of  the  indiscriminate  use  of  indigestible  "table-food."  We  fre- 
quently  see  a  baby  lying  in  its  crib  or  carriage  with  a  half-filled  bottle  of 
decomposed  cow's  milk,  or,  still  worse,  a  concoction  of  some  patent  "infant 
food,"  lying  beside  him,  to  the  foul  fly-infected  tip  of  which  he  applies  his  lips 
for  comfort  day  and  night.  Changing  the  drinking-water,  whether  it  be  impreg- 
nated with  harmful  germs  or  not,  may  irritate  the  intestinal  canal.  The  author 
has  in  his  possession  records  of  at  least  fifty  children  who  undoubtedly  con- 
tracted dysentery  by  drinking  the  water  from  an  impure  city  well.  In  this 
instance  the  disease  prevailed  very  generally  among  the  children  in  an  area 
of  several  blocks,  but  those  who  did  not  use  that  pump-water  were  almost 
entirely  exempt.  Seeds,  uncooked  vegetables,  unripe  or  decayed  fruit,  toys, 
coins,  and  many  other  indigestible  substances  may  induce  dysentery  by  injuring 
the  intestines  in  their  passage  through  them.  Weaning  has  been  noted  by 
some  as  an  etiological  factor,  but  it  must  be  remembered  that  coincident  Avith  it 
is  the  introduction  of  artificial  food — a  recognized  factor.  Sudden  changes  of 
temperature,  particularly  sudden  and  rapid  falls,  or  exposure  to  draughts  of 
air,  may  chill  the  body  and  cause  dysentery.  It  is  now  very  generally  accepted 
that  bacteria  play  an  important  part  in  the  production  of  this  disease,  but  as  yet 
experimentation  has  failed  to  detect  a  specific  germ  for  the  catarrhal  form. 
Finally,  the  anatomical  lesions  of  catarrhal  dysentery  vary  so  much  that  we 
are  forced  to  the  inevitable  conclusion  that  no  single  etiological  factor  will 
cause  them. 

Morbid  Anatomy. — The  lesions  of  catarrhal  dysentery  are  usually  con- 
fined to  the  lower  part  of  the  colon  and  rectum,  but  in  some  cases  may  extend 
along  the  upper  part  of  the  colon,  and  even  into  the  ileum.  They  are  charac- 
terized by  more  or  less  intense  hypersemia  of  the  mucous  membrane,  either 
general  or  confined  to  circumscribed  areas,  and  there  may  be  slight  punctiform 
haemorrhages  into  the  mucosa  or  submucosa.  The  congested  mucous  mem- 
brane  varies  in  color  from  bright-red  to  dark-purple,  and  is  never  uniform  ;  it 
is  usually  covered  with  thick,  tenacious  mucus.  The  large  intestine  is  usually 
empty,  while  the  small  is  distended  with  gas  and  contains  a  thin  greenish  fluid. 
The  mucous  membrane  is  commonly  swollen  and  grayish  in  color.  The' solitary 
lymph -follicles  along  the  colon  are  swollen,  sometimes  to  the  size  of  a  small 
bean,  and  surrounded  by  an  area  of  hypercemia.  Between  these  inflamed 
areas  the  mucous  membrane  is  normal  in  appearance.  Ulceration  may  take 
place.  The  ulcers  at  first  are  round  and  superficial,  but  soon  enlarge,  two  or 
more  coalescing  and  forming  ulcers  from  one-half  to  one  inch  in  diameter,  often 
exposing  the  muscular  coat  of  the  intestine.  Their  edges  are  everted  and  flat- 
tened, and  they  assume  an  irregular,  serpentine,  or  rodent  shape.  Ulcerations 
in  different  stages  of  development  may  often  be  found  in  the  same  individual. 
Patches  resembling  pseudo-membrane  may  also  be  found.  Cicatrization  begins 
upon  the  floor  of  the  ulcer,  its  edges  being  drawn  toward  the  base.  Perfora- 
tion and  peritonitis,  which  are  seldom  seen  in  children,  may  result  from  the 
ulcerative  process  extending  through  the  intestinal  coats.  The  liver,  which  is 
usually  congested,  may  be  the  seat  of  multiple  abscesses.  The  mesenteric 
glands  are  enlarged  and  softened  and  dark  blue  in  color. 

Bouchut  found  thrombi  in  the  sinuses  of  the  dura  mater  in  35  of  the  38 
children  who  had  died  of  "dysenteric  convulsions,"  and  in  the  other  3,  en- 


DYSENTERY. 


487 


cephalitis.  Busey  verified  by  his  cases  the  results  obtained  by  Bouchut.  Cere- 
bral aniemia,  which  is  the  commonly  accepted  cause  of  convulsions  or  death, 
may  be  found  alone  or  coexisting  with  thrombosis  of  the  sinuses  of  the  dura 
mater.  Busey  has  also  observed,  in  a  few  fatal  cases  in  very  young  children, 
oedema  of  the  loAver  extremities  and  discoloration  of  the  skin  of  the  feet  and 
legs,  which  he  attributes  to  the  formation  of  thrombi  in  the  pelvic  veins, 
causino-  venous  stasis  and  serous  transudation  into  the  subcutaneous  tissues. 
The  following  reports  of  necropsies  illustrate  some  of  the  principal  macro- 
scopic lesions  of  dysentery  : 

Child,  aged  fourteen  month?>,  great  emaciation,  muscles  flabby,  and  rigor  mortis 
deficient.  Lungs. — Hypostatic  congestion  of  lower  lobes.  Heart. — Large  ante-mortem 
clot  in  right  auricle,  and  a  smaller  one  in  left  auricle.  Glands. — Mesenteric  glands 
enlarged  and  congested.  Intestines. — Patches  of  congestion  in  lower  part  of  small  intes- 
tine. Large  intestine  much  thickened  and  deeply  congested  throughout  its  course.  A 
few  superficial  ulcers,  especially  near  the  ileo-ca^cal  valve. 

Busey's  case.  Necropsy  twenty-four  hours  after  death.  Aged  two  years,  emaciated, 
abdominal  walls  retracted,  and  rigidity  slight.  Brain. — "Weight  2  pounds  5ii-  ounces, 
anfemic,  effusion  into  arachnoid  cavity  (estimated)  1  pint,  slight  in  ventricles.  Black 
clots  in  all  the  sinuses,  and  a  large  white  fibrinous  thrombus  at  the  junction  of  the  right 
lateral  with  the  petrosal  sinus.  Heart. — Weight  1]  ounces  ;  eflusion  into  pericardium; 
white  fibrinous  clot  in  superior  vena  cava  extending  into  right  auricle  and  firmly 
attached  to  base  of  tricuspid  valve.  No  blood  in  either  ventricle,  and  valves  intact. 
Lungs. — Weight  7j  ounces,  float  in  water  ;  left  normal,  right  contained  in  middle  lobe  a 
cheesy  mass  as  large  as  a  hen's  egg  ;  this  lobe  was  firmly  attached  to  pleura.  No  tuber- 
cular deposits.  A  cheesy  bronchial  gland  as  large  as  a  pigeon's  egg.  Abdomen. — 
Abdominal  walls  thin  and  destitute  of  fat.  Omentum  contains  but  little  fat.  Mesen- 
teric glands  slightly  enlarged  and  congested.  Small  intestines  contain  faeces,  and 
nothing  abnormal  noted.  Patches  of  intense  inflammation  all  along  the  tract  of  large 
intestine  from  csecum  to  anus.  Liver  anaemic,  bufl'-colored ;  gall-bladder  distended. 
Large  deposits  of  pus  at  lower  extremity  of  either  kidney.     AVeight  Ij  ounces  each. 

Fig.  1. 


fchowiii     I 


c  f  C  olon 


Microscopical  Appearaxces. — There  is  considerable  loss  of  surface  epi- 
thelium and  of  that  lining  the  tubular  glands.  The  glands  frequently  contain 
pus-cells  and  degenerated  epithelium.     The  interglandular  tissue  is  infiltrated 


488    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

with  serum  and  pus-cells.  The  mucous  membrane  softens,  and  necrosis  extends 
for  a  considerable  distance  into  it.  Here  the  glands  are  broken  down,  their 
confines  are  lost  and  they  may  fall  out  or  remain  incarcerated  in  cast-oflF 
epithelium,  mucus,  and  pus.  There  may  be  ulceration  accompanying  these 
changes.  The  ulcers  are  shallow  and  without  well-defined  borders.  They 
result  from  softening,  suppuration,  and  exfoliation  of  the  tissues  into  the  sub- 
mucosa  or  even  down  to  the  muscular  coat.  The  solitaiy  follicles  are  swollen 
to  the  size  of  two  or  three  millimetres  in  diameter,  and  vary  in  color  from 
transparent  gray  to  opaque  white.  The  swelling  is  due  to  an  increase  of  round- 
cells  or  hyperplasia  of  lymphatic  tissue.  Large  epithelial  and  pus-cells, 
mingled  with  lymphocytes,  may  be  seen  in  the  nodules.  If  the  destructive 
process  continue,  the  epithelium  over  the  lymph-nodules  breaks  down  and  an 
ulcer  is  formed.  The  Ijmpli-nodules  then  appear  elevated,  with  a  central 
depression. 

Symptoms. — The  onset  may  be  sudden,  without  premonitory  symptoms, 
accompanied  by  one  or  more  chills  or  preceded  by  diarrhoea.  The  tempera- 
ture is  usually  elevated  two  or  three  degrees,  depending  upon  the  intensity 
of  the  inflammation ;  the  pulse  soon  becomes  rapid,  small,  and  compressible ; 
the  strength  is  rapidly  diminished  ;  and  the  face  presents  a  pinched,  pallid,  and 
anxious  expression.  The  tongue  is  moist  and  covered  with  a  whitish  fur. 
There  is  seldom  abdominal  pain  or  tenderness  on  pressure.  There  is  constant 
desire  to  go  to  stool,  with  pain  and  straining  during  and  after  evacuation.  The 
stools,  which  at  first  contain  fiscal  matter,  soon  become  small,  frequent,  odor- 
less, and  consist  of  blood,  mucus,  and  pus.  Sloughs  are  rarely  seen.  The 
stools  vary  in  number  from  eight  or  ten  to  forty  or  fifty  in  the  twenty-four 
hours.  As  the  inflammatory  process  advances  to  ulceration  the  stools  contain 
shreds,  resembling  "  washed  raAv  meat,"  mingled  with  blood  and  pus,  and  may 
be  passed  involuntarily.  The  straining  now  becomes  more  severe,  and  prolapse 
of  the  rectum  frequently  results  from  it.  The  abdomen  becomes  tympanitic, 
and  tenderness  marked  along  the  entire  course  of  the  colon.  •  The  tongue 
becomes  dry,  with  brown  centre  and  red  margin.  Vomiting  may  supervene, 
and  prove  to  be  intractable.  The  pulse  becomes  rapid,  thready,  and  intermit- 
tent, and  syncope  threatening.  The  respirations  become  sighing  and  the  voice 
inaudible.  The  eyelids  are  partially  closed,  and  the  pupils  are  widely  dilated. 
The  child  becomes  restless,  and  tosses  from  one  side  of  the  bed  to  the  other, 
and  delirium  or  convulsions  may  be  present.  The  urine  is  high-colored  and 
scanty,  or  there  ma}^  be  total  suppression.  Avith  vesical  tenesmus. 

If  examined  microscopically,  the  typical  "dysenteric  stool"  contains  traces 
of  ingesta,  various  kinds  of  bacteria,  fat,  epithelial  cells,  round  cells,  mucus, 
blood-corpuscles,  and  pus-corpuscles  mingled  together. 

Cases.     Nellie  E ,  aged  eighteen  months,  had  been  suffering  several  days  v,-ith 

loose  bowels.  The  evacuations  becoming  frequent,  small,  bloody,  and  slimy,  the  parents 
called  in  a  physician.  He  found  that  she  had  a  dozen  or  more  dysenteric  stools  daily, 
accompanied  by  great  tenesmus,  and  that  there  was  marked  prostration.  The  disease 
yielded  to  treatment,  and  she  recovered  in  three  days. 

John  B ,  aged  twenty-two  months,  had  had  frequent  bloody  discharges  for  sev- 
eral days,  and  had  been  dosed  with  numerous  remedies  for  "summer  complaint"  which 
had  been  prescribed  by  other  physicians  for  other  people's  children.  As  he  rapidly  grew 
worse,  I  was  summoned.  Found  him  running  about  the  room,  but  he  would  frequentlv 
assume  the  squatting  position  and  strain.  He  had  had  twenty  bloody,  slimv,  olfensive 
stools,  and  as  many  of  "  a  stain  of  blood  and  slime,"  during  the  previous  twenty-four 
hours.  The  pain  did  not  seem  to  be  so  severe,  but  he  would  strain  until  drenched  with 
perspiration.  He  could  not  be  kept  in  bed.  Finally,  his  symptoms  became  so  much 
worse  that  he  was  held  by  one  of  his  parents,  but  not  in  recumbency.  This  modified 
rest  did  but  little  good,  as  the  rectum  was  soon  prolapsed  to  about  half  an  inch.     After 


DYSENTERY.  489 

exhausting  the  usual  methods  of  treatment  the  disease  succumbed  to  suppositories  of 
cocaine  and  ergotin,  on  the  eighth  day  of  my  service. 

Lottie  E— — ,  aged  four  years,  was  seen  forty  hours  after  the  dysenteric  symptoms 
began.  She  was  now  having  frequent,  offensive,  muco-sanguinolent  stools,  accompanied 
by  exhausting  tenesmus.  The  pulse  was  frequent  and  small,  and  the  temperature  was 
not  100°  F.  The  symptoms  rapidly  grew  worse  and  she  seemed  liable  to  die  at  any 
moment  from  cardiac  failure.  The  rectum  protruded,  became  oedematous,  and  blood 
exuded  from  the  mucous  membrane.  The  prolapsed  gut  seemed  to  be  about  two  inches 
in  length.  On  the  ninth  day  of  the  disease  the  dysentery  yielded  to  treatment,  but  the 
prolapse  lasted  for  a  week  longer. 

Dimple  G ,  aged  seven  years,  had  been  sick  for  five  days  with  dysentery.     The 

bloody  discharges  had  increased  in  number,  the  pain  had  become  more  intense,  the  desire 
to  stool  more  imperative,  and  the  evacuations  were  characterized  as  small,  bloody,  and 
slimy.  She  was  suffering  from  strangury  produced  by  turpentine  stupes,  which  had  been 
used  for  several  days.  She  had  had  two  hundred  and  eighty-one  bloody,  slimy  stools  in 
thirty-six  hours  (four  hundred  and  sixty-three  during  the  five  days  of  her  illness). 
Dr.  D.  obtained  this  history,  and  the  following  day  called  me  in  consultation.  She  now 
had  the  appearance  of  being  extremely  ill.  Her  pulse  was  small,  frequent,  and  com- 
pressible ;  the  eyes  were  sunken  and  the  pupils  dilated ;  the  cheeks  were  pale  and  sunken, 
and  the  lips  livid  and  pinched;  the  tongue  was  slightly  coated  and  very  dry,  and  thirst 
was  intense;  there  was  nausea,  but  not  vomiting,  although  she  had  vomited  in  the  early 
part  of  the  illness;  the  abdominal  walls  were  flabby,  and  there  was  no  pain  upon  pres- 
sure over  the  abdomen.  She  had  not  slept  for  several  days,  and  was  continually  begging 
for  sleep.  The  discharges  were  involuntary  and  had  become  so  frequent  that  cloths  were 
kept  under  the  nates  to  catch  them  ;  they  were  small,  bloody,  and  offensive.  There  was 
great  pain  and  straining.  The  voice  was  almost  inaudible,  and  the  respiration  was  sigh- 
ing. Cerebral  ansemia  was  well  marked.  She  had  frequent  attacks  of  syncope,  although 
not  permitted  to  raise  her  head  from  the  pillow.  Her  condition  was  so  critical  that  a 
physician  remained  in  her  room.  Stimulants  and  food  were  systematically  given  until 
the  stomach  and  rectum  reftised  to  retain  them,  when  brandy  and,  finally,  ether  were 
given  hypodermatically.  The  attacks  of  syncope  became  more  and  more  frequent,  and 
she  died  of  exhaustion  and  heart  failure  seventy-two  hours  after  the  first  consultation. 

Diagnosis. — In  sporadic  cases  of  dysentery  there  may  be  some  difficulty 
in  differentiating  it  in  its  early  stage  from  acute  intestinal  catarrh,  but  when 
the  characteristic  stools  have  once  made  their  appearance  all  doubt  will  dis- 
appear. In  dysentery  the  stools  contain  mucus,  blood,  pus,  and  small  masses 
of  ffecal  matter,  and  are  odorless  or  have  a  '"fresh-meat  odor;"  tenesmus  is 
always  present,  a  small  quantity  is  expelled  from  the  bowel  after  a  violent 
effort,  and  the  patient  is  bathed  in  a  cold,  clammy  sweat,  is  exhausted,  and 
probably  faints.  In  acute  intestinal  catarrh  the  evacuations  are  larger;  the 
blood,  w^hen  present,  is  in  streaks  and  not  mixed  wdth  mucus;  the  pain  is  more 
intense  and  paroxysmal ;  and  tenesmus  is  seldom  present. 

The  differentiation  of  sporadic  from  epidemic  dysentery  can  be  made  by 
the  prevalence  of  the  latter  in  the  communitv. 

Prognosis. — The  prognosis  in  acute  catarrhal  dysentery  in  children  is 
usually  favorable.  The  ordinary  duration  is  from  eight  to  ten  days,  but  it 
may  prove  fatal  in  twelve,  twenty-four,  forty-eight,  or  seventy-two  hours. 
The  favorable  symptoms  are  absence  of  foul  odor,  diminution  in  frequency 
and  improvement  in  the  character  of  the  stools,  and  disappearance  of  tormina 
and  tenesmus ;  the  absence  of  nervous  depression  and  of  anxious  and  care- 
worn expression  of  countenance  ;  and  increase  of  heart-power  and  arterial 
tension. 

The  unfavorable  symptoms  are  increased  blood-loss,  ashy  aspect  of  counte- 
nance, nausea,  vomiting,  hiccough,  tympanitic  and  tender  abdomen,  nervous 
depression,  sleeplessness,  tossing  about  the  bed,  moaning,  delirium,  convul- 
sions or  other  marked  cerebral  disturbances,  and  suppression  of  urine.  When 
convulsions  appear,  death  is  not  far  distant.  Busey  observes  that  in  many 
cases  death  takes  place  under  exactly  similar  circumstances* — viz.,  one,  two.  or 


490    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

three  convulsions,  followed  by  coma  and  death,  and  in  none  of  his  cases  did 
consciousness  return  after  the  first  convulsion. 

II.  Amcebic  Dysentery.' 

This  form,  which  is  also  known  as  tropical  dysentery,  is  characterized  by 
the  presence  in  the  stools  of  the  amoeba  coli  (Loscli),  amoeba  dtjse7iterice  (Coun- 
cilman and  Lafleur).  It  is  this  form  which  occurs  in  such  fatal  epidemics  in 
the  tropics.  "  The  amoeba  is  a  unicellular,  protoplasmic,  motile  organism, 
from  ten  to  twenty  micro-millimetres  in  diameter,  consisting  of  a  clear  outer 
zone,  ectosarc,  and  a  granular  inner  zone,  endosarc,  containing  a  nucleus  and 
one  or  more  vacuoles.  It  was  first  described  by  Lambl  in  1859,  and  subse- 
quently by  Lbsch,  who  considered  it  the  cause  of  the  disease  " — (Osier).  The 
disease  is  not  infrequently  seen  in  Europe  and  North  America,  but  its  home  is 
in  tropical  and  subtropical  countries.  The  most  frequent  source  of  infection  is 
unquestionably  the  drinking-water. 

Morbid  Anatomy. — Like  the  other  varieties,  the  lesions  are  situated  in 
the  colon,  but  in  some  cases  they  are  also  found  in  the  lower  portion  of  the 
ileum.  These  lesions  consist  in  ulcers,  which  result  from  infiltration  into  the 
submucosa.  At  first  small  elevations  appear  along  the  mucosa ;  the  mucous 
membrane  covering  them  sloughs  off,  exposing  an  ulcer  with  a  grayish -yellow 
floor.  Councilman  divides  these  ulcers  into  four  forms  :  (1)  "  Ulcers  character- 
ized by  cellular  infiltration,  softening,  and  cavity-formation  in  the  submucosa ; 
these  have  a  small  opening  in  the  mucous  membrane  and  often  communicate 
with  neighboring  ulcers  by  passages  in  the  submucosa.  (2)  Ulcers  with  slight 
undermining  of  the  edges,  representing  simple  excavations  in  the  thickened 
submucous  tissue.  (3)  Ulcers  with  smooth  sides  and  clean  bases.  (4)  Ulcers 
with  extensive  adhering  sloughs."  These  simply  represent  different  stages  of 
the  same  process.     The  non-adjacent  mucosa  remains  unaffected. 

Osier  says  the  '*  microscopical  examination  shows  a  notable  absence  of  the 
products  of  purulent  inflammation.  In  the  infiltrated  tissues  polynuclear 
leucocytes  are  seldom  found,  and  never  constitute  purulent  collections.  On 
the  other  hand,  there  is  proliferation  of  the  fixed  connective-tissue  cells. 
Amoeb?e  are  found  more  or  less  abundantly  in  the  tissues  at  the  base  of, 
and  around,  the  ulcers,  in  the  lymphatic  spaces,  and  occasionally  in  the  blood- 
vessels. 

"  The  lesions  in  the  liver  are  of  two  kinds :  firstly,  local  necroses  of  the 
parenchyma,  scattered  throughout  the  liver  and  possibly  due  to  the  action  of 
chemical  products  of  the  amoeb?e  ;  and,  secondly,  abscesses.  These  may  be 
single  or  multiple.  When  single  they  are  generally  in  the  right  lobe,  either 
toward  the  convex  surface  near  its  diaphragmatic  attachment  or  on  the  concave 
surface  in  proximity  to  the  bowel.  Multiple  abscesses  are  small  and  generally 
superficial.  In  an  early  stage  the  abscesses  are  grayish-yellow,  wath  sharply 
defined  contours,  and  contain  a  spongy  necrotic  material,  with  more  or  less 
fluid  in  its  interstices.  The  larger  abscesses  have  ragged,  necrotic  walls,  and 
contain  a  more  or  less  viscid,  greenish-yellow  or  reddish-yellow  purulent 
material  mixed  with  blood  and  shreds  of  liver-tissue.  The  older  abscesses  have 
fibrous  walls  of  a  dense,  almost  cartilaginous  toughness.  A  section  of  the 
abscess-wall  shows  an  inner  necrotic  zone,  a  middle  zone  in  Avhich  there  is 
great  proliferation  of  the  connective-tissue  cells  and  compression  and  atrophy 

'  The  writer  has  depended  almost  entirely  upon  the  valuable  contributions  of  L.  Emmett 
Holt,  Osier,  and  Lafleur  and  Councilman  in  preparing  the  sections  on  amoebic  and  diphtheritic 
dysentery. 


DYSENTERY.  491 

of  the  liver-cells,  and  an  outer  zone  of  intense  hypersemia.  There  is  the 
same  absence  of  purulent  inflammation  as  in  the  intestine,  except  in  those 
cases  in  which  a  secondary  infection  with  pyogenic  organisms  has  taken  place. 
The  material  from  the  abscess-cavity  shows  chiefly  fatty  and  granular  detritus, 
few  cellular  elements,  and  more  or  less  numerous  amoebae.  Amoeba  are  also 
found  in  the  abscess- walls,  chiefly  in  the  inner  necrotic  zone.  Cultures  ai-e 
usually  sterile.  Lesions  in  the  lungs  are  seen  when  an  abscess  of  the  liver — as 
so  frequently  happens — points  toward  the  diaphragm  and  extends  by  con- 
tinuity through  it  into  the  lower  lobe  of  the  right  lung.  The  gross  and  micro- 
scopical appearances  are  similar  to  those  of  the  liver."' 

Symptoms. — Sometimes  the  onset  is  sudden  and  at  other  times  gradual. 
The  severer  forms  are  characterized  by  a  sudden  onset.  The  diarrhoea  inter- 
mits, while  loss  of  strength  and  emaciation  are  progressive.  Moderate  fever  is 
usually  present,  although  some  cases  are  unattended  by  this  symptom.  In 
some,  tormina  and  tenesmus  and  nausea  and  vomiting  are  marked  at  the  onset, 
while  in  others  they  are  not  observed.  Twelve  or  fourteen  grayish-yellow 
stools,  containing  blood  and  mucus  are  voided  daily.  This  condition  persists 
for  weeks.  The  amoebae  are  found  in  great  numbers  in  the  stools  during  the 
diarrhoeal  attacks,  bat  gradually  decrease,  and  finally  disappear  as  the  attack 
subsides. 

Diagnosis. — This  form  is  difi"erentiated  from  the  catarrhal  by  the  frequent 
exaggeration  and  remission  of  the  diarrhoeal  symptoms,  but  more  especially  by 
the  presence  of  amoebae  in  the  stools. 

Prognosis. — The  duration  varies  from  six  to  twelve  weeks.  The  progno- 
sis is  not  as  favorable  as  in  the  catarrhal  form  ;  and  convalescence  is  slow, 
owing  to  the  depletion,  the  relapses,  and  the  chronic  tendency. 

in. — Diphtheritic  Dysentery. 

Diphtheritic  or  croupous  inflammation  of  the  intestinal  tract  is  the  most 
fatal  variety.  It  usually  begins  in  the  intestine,  but  may  result  from  diphtheria 
situated  in  the  mouth,  pharynx,  or  nose. 

Morbid  Anatomy. — Macroscopically,  there  is  nothing  significant  in  the 
appearance  of  the  intestinal  contents  unless  patches  of  pseudo-membrane  are 
found  upon  washing.  The  stools  vary  in  color  from  yellowish-green  to  greenish- 
brown,  and  consist  of  mucus,  ftecal  matter,  occasionally  digested  blood — seldom 
pure  blood — and  perhaps  pieces  of  pseudo-membrane. 

The  lesions  are  situated  over  the  entire  colon  and  the  lower  portion  of  the 
ileum,  but  are  most  numerous  near  the  c?ecum.  The  intestinal  Avail  is  greatly 
thickened  and  the  rugae  are  obliterated.  Small  grayish-white,  opaque  masses 
are  seen  upon  the  congested  mucosa.  These  masses  cling  to  the  surface,  and 
can  only  be  removed  by  tearing  off"  a  portion  of  the  mucous  membrane.  These 
small  areas  may  coalesce  and  form  a  patch  which  involves  the  greater  part  of 
the  intestine,  converting  it  into  a  thick,  inflexible  tube.  AVhere  the  membrane 
is  extensive  it  is  marked  by  numei'ous  transverse  and  longitudinal  fissures, 
which  give  it  the  appearance  of  separate  patches.  The  mucous  membrane 
devoid  of  the  patch  is  intensely  congested  and  roughened,  or  the  only  changes 
may  be  confined  to  the  diphtheritic  areas. 

Microscopical  Appearances. — There  is  infiltration  of  the  mucosa,  and  in 
some  cases,  of  the  submucosa.  The  pseudo-membrane  is  composed  of  fibrin, 
necrotic  cells,  and  sometimes  blood-corpuscles.  The  tubular  glands  are  usually 
unrecognizable,  but  their  remains  may  often  be  detected  in  the  necrotic  masses. 
The  thickening  of  the  intestine  is  due  to  the  infiltration  of  the  submucosa.  the 


492     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

dense  mass  of  fibrin,  the  engorged  blood-vessels,  and  extravasations  of  red 
blood-corpuscles.  Ulcers  are  seldom  present  in  children,  but  Avhen  found  are 
usually  of  the  follicular  variety. 

Symptoms. — This  form  is  not  seen  in  infants  and  is  uncommon  in  children. 
In  some  cases  the  onset  is  insidious,  and  may  be  mistaken  for  the  catarrhal, 
while  in  others  it  is  abrupt  and  alarming.  The  symptoms  are  similar  to,  but 
more  severe  than,  those  of  the  catarrhal  or  amoebic.  The  pathognomonic 
symptom  is  the  presence  of  pseudo-membrane  in  the  stools. 

Treatment  of  Dysentery. 

PROPHYLAXif^. — Acute  catarrhal  dysentery  may  often  be  avoided  by 
promptly  and  energetically  treating  the  simpler  forms  of  intestinal  disease. 
It  too  often  happens  that  disorders  of  digestion  are  regarded  as  trifling,  and 
skilled  assistance  is  only  summoned  when  the  signs  of  severe  anatomical 
lesions  become  manifest. 

Hygieiie. — Personal  and  domiciliary  hygiene  should  be  carefully  supervised. 
The  child  should  be  bathed  at  least  once  a  day,  and  in  very  hot  weather  twice. 
His  clothing  should  be  changed  sufficiently  often  to  protect  him  from  sudden 
variations  in  temperature ;  especially  is  this  true  during  the  cool  nights  of 
autumn.  If  not  already  too  ill,  he  should  be  removed  from  the  heat  of  the  city 
to  some  salubrious  resort  in  the  mountains  or  at  the  seashore.  If  circumstances 
compel  him  to  remain  at  home,  he  should  be  placed  in  a  room  where  pure,  fresh 
air  Avill  be  admitted  freely.  An  occasional  sponge-bath  of  equal  parts  of  alcohol 
or  bay-rum  and  water  will  prove  to  be  grateful,  and  will  reduce  the  body  heat 
as  well  as  allay  nervous  irritability.  The  infant's  diapers  should  be  removed 
and  placed  in  a  disinfecting  solution  as  soon  as  soiled,  and  in  older  children  the 
evacuations  should  be  immediately  disinfected.  For  this  purpose  solutions  of 
carbolic  acid,  1 :  20,  corrosive  sublimate,  1 :  500,  milk  of  lime,  or  some  other 
germicidal  drug  must  be  kept  in  some  convenient  place. 

It  is  none  the  less  important  that  the  hygiene  of  the  premises  should  be 
scrupulously  watched  and  every  means  possible  used  to  prevent  the  accumula- 
tion of  filth. 

Jlest. — Rest  in  the  recumbent  posture  must  be  enjoined  from  the  start. 
The  stools  should  be  passed  in  this  posture,  as  any  other  will  increase  the  pain 
and  straining. 

Dietetic. — The  diet  should  be  prescribed  in  the  very  beginning,  and  but 
little  discretion  given  to  parent  or  nurse.  The  nursing  infant  should  continue 
at  the  breast  unless  some  condition  of  the  mother,  or  of  her  milk,  contraindicates 
it.  In  all  others  sterilized,  Pasteurized,  or  peptonized  milk,  beef-tea,  beef- 
juice,  or  mutton-broth,  or  all  alternately,  should  be  given  in  small  quantities 
at  frequent  intervals.  Care  should  be  taken  not  to  overfeed,  lest  harm 
be  done.  When  the  l)lood  and  mucus  have  disappeared  from  the  stools,  we 
may  gradually  but  cautiously  return  to  a  more  liberal  and  mixed  diet.  A 
liberal  supply  of  natural  mineral  water,  distilled  water,  or  boiled  city  water 
must  be  allowed.  If  the  child  refuse  or  is  unable  to  SAvallow,  food  must  be 
administered  by  gavage — a  method  not  at  all  difficult,  and  attended  with 
satisfactory  results. 

Medicinal. — There  are  no  specifics  for  this  disease,  although  different 
remedies  have  been  specially  recommended  by  different  Avriters.  Some  believe 
the  best  results  are  to  be  obtained  from  ipecacuanha,  others  from  opium,  pur- 
gatives, or  vegetable  or  mineral  astringents,  while,  latterly,  many  rely  upon 
the  administration  of  intestinal  antiseptics,  as  salol,  mercuric  chloride,  naph- 


DYSENTERY. 


493 


thol,  and  sulpliocarbolate  of  zinc.  While  it  may  be  admitted  that  all  of  these 
methods  have  their  advantages  in  individual  cases,  still,  no  one  has  proved  to 
be  uniformly  successful  in  the  hands  of  those  who  treat  the  greatest  number 
of  cases. 

Usually  the  first  indication  for  treatment  is  the  removal  of  undigested  or 
indigestible  food  from  the  alimentary  tract.  For  this  purpose  the  mild  saline 
purgatives  are  especially  indicated,  or  a  stronger  purgative,  as  for  a  child  aged 
6  years : 

]^.   Pulv.  ipecac gr.  ss. 

Mass.  hydrarg gi"-  '  " 

Pulv.  aromatic,  comp gr. 

Sacchar.  alb gr. 

Ft.  chart.  No.  X. 
Sig.   One  every  two  hours. 


"J- 

V. 

XV. — M. 


^.  Tinct.  opii  deodorat gtt.  xij. 

Olei  ricini fSss. 

Pulv.  acaciae q.  s. 

Aqu8e  rosse q.  s.  adfsij. — M. 

Sig.  Tablespoonful  every  two  hours. 

As  soon  as  the  scybala  and  undigested  masses  have  been  removed  this 
treatment  should  be  suspended. 

Of  the  mineral  astringents  the  subnitrate  of  bismuth,  in  large  doses,  holds 
the  highest  rank.  The  author  has,  at  times,  received  benefit  from  the  folloAv- 
ing,  which  is  both  astringent  and  antiseptic : 

i^.  Plumbi  acetatis gr.  iv. 

Acidi  acetic q.  s. 

Acidi  carbolic g^'-  ij- 

Liquor,  calcis q.s.  adfsij. 

Mix  the  first,  third,  and  fourth,  and  add  enough  of  the  second  to  make  a 

perfectly  clear  solution. 
Sig.   Teaspoonful  every  three  hours. 

If  the  pain  and  straining  are  intense,  relief  may  be  derived  from  the 
followinor : 


^.   Cocain.  muriat 

Ext.  ergot,  aq 

Ext.  opii  aq 

Aristol 

Olei  theobrom 

gi--  J- 

....  gr.  X. 
.    .    .    .  gr.  ij. 
....  gr.  V. 
.    .    .    .  q.  s. — M 

Sig. 

Ft.  Suppos.  No.  X. 
One  every  two  or  three  hours. 

Stimulants  are  imperative,  but  should  be  administered  with  great  care. 
The  dose  of  whiskey  or  brandy  must  be  regulated  by  the  age  of  the  child  and 
the  exigencies  of  the  case.  .When  these  fail,  the  more  powerful  and  difiusible 
cardiac  stimulants  should  be  given,  perhaps  hypodermatically. 

Local. — In  the  light  of  modern  science  the  most  rational  treatment  of 
dysentery  is  intestinal  irrigation.  By  it  the  irritating  contents  of  the  colon 
and  rectum  are  washed  out  and  the  pain  and  straining  are  mitigated,  and  in 


494    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

some  cases  entirely  relieved.  A  distinction  has  been  drawn  by  Dr.  W.  W. 
Johnston,  of  "Washington,  D.  C,  between  intestinal  irrigation  and  injection. 
The  former  is  more  correctly  the  application  of  a  running  stream  to  the  inflamed 
gut,  in  which  the  fluid  has  free  egress,  while  in  the  latter  the  fluid  is  intro- 
duced to  painful  distention.  In  the  former  a  second  tube  permits  a  free  out- 
l)ouring  and  in  the  latter  the  fluid  must  escape  between  the  nozzle  of  the 
syringe  and  the  anal  sphincter  or  be  forcibly  expelled  by  the  disabled  intestine 
after  the  tube  is  withdrawn.  The  former  is  preferable  when  the  lesions  are 
below  the  sigmoid  flexure,  and  the  latter  when  they  are  above  it. 

To  irrigate  the  rectum  a  double  injection-tube,  attached  to  a  fountain 
syringe,  should  be  passed  from  three  to  five  inches  into  the  boAvel,  through 
which  a  current  of  water  is  kept  flowing  at  the  pleasure  of  the  operator.  As 
the  passing  of  such  an  instrument  is  nearly  always  attended  with  great  pain, 
it  is  better  to  use  two  soft  rubber  catheters,  well  oiled ;  the  larger  is  attached 
to  the  tube  of  the  syringe,  while  the  smaller  is  used  as  the  escape-pipe.  Pres- 
sure on  the  flexible  tubes  by  the  operator's  fingers  will  regulate  the  inflow  and 
outflow  of  the  fluid. 

To  irrigate  the  entire  colon  in  a  child  of  eight  or  ten  years  it  is  necessary 
to  inject  one  or  two  pints  immediately  after  a  stool,  but  an  infant  requires  much 
less.  The  author  has  never  succeeded  in  injecting  such  large  quantities  into 
the  bowel,  but  has  obtained  very  satisfactory  results  from  small  quantities  by 
forcing  it  to  be  retained  for  a  short  time,  by  pressing  a  napkin  against  the 
anus.  This  fluid  must  be  sloAvly  injected,  so  as  to  allow  the  inflamed  and 
infiltrated  coats  to  adapt  themselves  to  the  increased  tension. 

The  irrigating  apparatus  being  ready,  the  child  is  placed  on  his  left  side, 
with  the  hips  on  a  plane  higher  than  the  body,  or,  still  better,  in  the  knee- 
chest  posture,  so  as  to  favor  the  inflow.  The  first  irrigation  should  be  given 
by  the  physician,  who  will  thus  instruct  the  nurse  to  follow  his  particular 
method.  When  the  pain  and  tenesmus  are  severe,  and  the  introduction  of  the 
tube  intensifies  both,  the  rectum  may  be  partially  or  completely  anaesthetized 
by  suppositories  of  ice,  aristol,  europhen,  or  cocaine,  or  by  the  injection  of  a 
2  or  4  per  cent,  solution  of  cocaine  or  carbolic  acid. 

The  frequency  of  irrigation  is  best  determined  by  the  number  of  stools, 
the  object  being  to  prevent  the  patient  from  having  stools  by  washing  out  the 
intestinal  contents  through  the  tube.  At  first  the  irrigation  should  be  given 
after  every  stool ;  then,  as  the  pain  and  tenesmus  lessen  and  the  blood  and 
mucus  decrease,  it  must  be  given  at  longer  intervals ;  and,  finally,  when  the 
movements  border  on  the  natural,  a  daily  irrigation  for  a  few  days  may  prevent 
a  relapse. 

Hot  or  cold  water,  either  plain  or  holding  in  solution  one  of  the  numerous 
antiseptics,  may  be  used  as  the  irrigatinir  fluid.  In  some  cases  very  hot  water 
will  afford  marked  benefit,  while  a  large  number,  in  the  author's  experience, 
have  received  almost  immediate  relief  from  cold  or  ice-Avater.  The  temperature 
of  the  Avater  must  be  srraduallv  loAvered  Avhen  irrinratincj  the  infant's  boAvel,  as 
the  shock  from  ice-Avater  might  prove  fatal. 

Every  writer  has  a  favorite  antiseptic  for  dysentery,  but  mercuric  chloride, 
1 :  10,000,  is  most  extensively  employed.  The  bowel  must  be  quickly  and 
thoroughly  emptied  of  this  fluid  to  insure  protection  against  its  poisonous 
eff"ects  from  absorption.  Some  of  the  other  antiseptics  are  carbolic  acid, 
boracic  acid,  hydrochloric  acid,  salicylic  acid,  aseptol,  thymol,  sulphocarbolate 
of  zinc,  nitrate  of  silver,  alum,  quinine,  and  creolin.  While  it  is  advisable  to 
use  some  antiseptic  solution  in  the  graver  forms,  the  great  benefit  to  be  derived 
from  irrigation  in  catarrhal  dysentery  is  the  cleansing. 


DYSENTERY.  495 

In  amoebic  dysentery,  Councilman  and  Lafleur  have  used  solutions  of  qui- 
nine, 1 :  5000,  1 :  2500,  1 :  1000,  in  five  cases.  In  3  cases  improvement  Avas 
marked,  in  1  the  injections  were  suspended  owing  to  a  fatal  complication,  and 
in  the  other  the  amoebae  did  not  decrease  during  the  quinine  injections.  Lbsch 
found  by  experimentation  that  solutions  of  quinine,  1 :  5000,  would  kill  amoebae 
outside  of  the  body,  so  Councilman  and  Lafleur  were  led  to  use  it  by  intes- 
tinal irrigation.  The  patient  should  be  placed  in  the  knee-chest  posture,  and 
a  half-pint  or  a  pint  of  the  quinine  solution  injected  thrice  daily,  the  enema 
being  retained  for  fifteen  minutes.  These  writers  claim  that  the  enemata/kill 
the  amoebae  in  the  intestine,  but  have  little  or  no  effect  upon  those  in  the 
tissues. 

In  diphtheritic  dysentery  the  same  rules  of  treatment  that  are  recommended 
in  the  other  forms  are  applicable,  but  must  be  more  vigorously  employed. 
Irrigation  with  solutions  of  mercuric  chloride,  silver  nitrate,  or  hydrogen 
peroxide  seems  to  be  the  most  rational  procedure. 


CHRONIC  CONSTIPATION. 

By  J.  HENRY  FRUITNIGHT,  A.  M.,  M.  D., 

New  York. 


Chronic  Constipation,  or  the  absence  of  a  regular,  periodical  expulsion 
of  fiEcal  excrement  from  the  bowels,  is  very  prevalent  in  infancy  and  early 
childhood.  In  childhood  a  daily  evacuation  should  be  the  rule,  whilst  in 
infancy  two,  three,  and  sometimes  even  four,  motions  are  usual. 

Excluding  acute  bronchitis,  habitual  constipation  is  the  most  common  ail- 
ment met  with  in  early  life.  It  is  rather  an  aberration  from  the  normal  func- 
tional activity  of  the  bowels  than  an  essential  disease,  but  if  not  relieved  may 
in  time  seriously  aifect  the  general  health  of  the  patient  by  interfering  with  the 
functions  of  other  organs  and  with  the  processes  of  nutrition,  and,  as  an  ulti- 
mate result,  life  even  may  be  endangered.  It  often  proves  a  very  intractable 
disorder,  and,  despite  all  that  is  done,  it  may  continue  throughout  the  period 
of  childhood,  interfering  with  healthy  development  as  well  as  with  comfort. 
Children  who  are  artificially  fed  are  more  prone  to  constipation  than  those  who 
are  suckled  at  the  breast. 

Btiolog-y. — The  cause  of  the  constipation  may  exist  in  the  person  of  the 
patient,  or  the  condition  may  be  the  result  of  some  extraneous  influence.  We 
will  first  speak  of  the  former. 

In  the  child  the  small  intestine  is  comparatively  longer  and  its  lumen  nar- 
rower than  in  the  adult,  and  its  walls  are  feeble  and  not  so  thick.  Again,  the 
ascending  and  the  transverse  colon  are  shorter,  while  the  descending  colon  is 
longer  relatively  than  in  the  adult.  Finally,  the  many  curves  of  the  intestinal 
canal,  the  deep  cul-de-sac  in  the  sigmoid  flexure  just  above  the  rectum,  and  the 
contracted  conformation  of  the  pelvis  in  children,  with  the  consequent  crowding 
of  the  intestines  into  a  relatively  small  space,  are  Avell  known.  All  of ^these 
anatomical  peculiarities  act  as  causal  factors.  Another  element  of  importance 
in  infancy,  but  Avhich  lessens  in  force  as  the  child  develops,  is  feeble  peristalsis, 
due  to  the  imperfectly-developed  state  of  the  muscular  coat  of  the  intestines. 

A  diminution  in  the  amount  of  intestinal  secretions,  especially  of  the  bile, 
favors  the  occurrence  of  constipation,  for  under  such  conditions  the  faecal  mass 
becomes  hard  and  scybalous,  and  is  apt  to  be  too  long  retained.  Then,  too,  if 
fermentable  food  be  taken,  large  quantities  of  flatus  are  generated  and  pain  and 
abdominal  distention  attend  the  constipation 

Certain  pathological  conditions,  obstructive  in  nature,  are  often  present. 
Among  such  conditions  are  tumors,  congenital  malformations,  and  uterine  retro- 
flexions; constricting  bands  resulting  from  acute  or  chronic  peritonitis;  intes- 
tinal displacements,  stenosis  at  the  ileo-caecal  valve,  and  a  nest  of  lumbricoid 
worms.  Local  disorders  seated  in  the  rectum  may  also  cause  constipation. 
Chief  among  these  is  fissure  of  the  anus,  for  in  this  disease,  as  pain  is  produced 
when  defecation  is  attempted,  the  patient  refrains  from  the  act  of  evacuation 
and  the  constipated  habit  is  gradually  formed. 

496 


CHRONIC   CONSTIPATION.  497 

In  diseases  of  the  central  nervous  system,  as  tubercular  meningitis,  hydro- 
cephalus. micTocephalus,  and  myelitis,  whicli  interfere  with  the  innervation  of 
the  abdominal  and  intestinal  structures  or  which  produce  a  spastic  contraction 
of  these  parts,  constipation  is  generally  present.  The  various  constitutional 
dyscrasiee,  as  tuberculosis,  rachitis,  syphilis,  and  the  like,  may,  by  weakening 
the  muscles  encraored  in  the  act  of  defecation,  act  as  causes. 

Any  condition  depriving  the  organism  of  water  in  large  quantities  renders 
the  faeces  dry  and  predisposes  to  sluggish  bowels  :  profuse  perspiration  and  the 
polyuria  of  diabetes  come  under  this  head.  Want  of  attention  in  infancy  and 
the  neglect  to  respond  to  the  calls  of  nature  on  the  part  of  older  children  are 
potent  factors,  for  by  repeated  stimulation  and  over-distention  of  the  rectum  by 
its  contents,  its  muscular  activity  is  worn  out  and  an  atonic  condition  is  the 
result.  Constipation  sometimes  results  from  diarrhoea.  In  such  cases  it  is  due 
to  atony  and  paresis  of  the  muscular  envelope  of  the  intestines  caused  by 
excessive  and  persistent  irritation.  Insufficient  peristalsis,  accumulation  of 
faeces,  dilatation  of  the  entire  bowel  or  of  certain  parts,  accompanied  by  reflex 
symptoms  due  to  interference  with  other  functions  of  the  body,  are  additional 
factors  conducing  to  this  result.  Some  authors  say  that  all  cases  of  habitual 
constipation  are  accompanied  by  a  considerable  amount  of  chronic  irritation 
and  subacute  inflammation  of  the  caecum  and  colon  and  neighboring;  cellular 
tissue.     The  effect  of  this  is  to  reflexly  arrest  peristalsis. 

We  will  now  consider  what  may  be  called  the  extrinsie  causes  of  constipa- 
tion, or  those  which  operate  from  without  the  body.  Constipation  in  infants  at 
the  breast  may  be  the  consequence  of  a  constipated  habit  on  the  part  of  the 
mother.  In  such  cases  the  maternal  milk  may  be  deficient  in  fat,  sugar,  or 
salt.  In  older  children  improper  food  is  a  very  frequent  cause.  On  the  one 
hand,  food  may  be  given  to  the  child  which  after  digestion  leaves  very  little 
residue  in  the  bowel,  so  that  no  stimulation  of  the  intestines  is  produced  for  the 
expulsion  of  its  contents.  On  the  other,  too  coarse  foods  may  be  given,  and  the 
residue  may  be  so  great  that  by  constant  over-stimulation  of  the  muscular 
coats  of  the  intestines  their  tonicity  is  exhausted.  Excess  of  farinaceous  foods 
will  act  in  this  manner,  and  all  foods  that  are  prone  to  fermentation  by  pro- 
ducing accumulations  of  gas  will  hinder  free  action  of  the  bowels.  Lack  of 
moisture  in  the  intestinal  contents,  resultincf  from  scantv  ingestion  of  water,  is 
another  factor ;  and  still  more  potent  are  the  indiscriminate  use  of  medicinal 
agents,  especially  castor  oil  and  spiced  syrup  of  rhubarb — laxatives  having  a 
secondary  astringent  action — and  the  repeated  use  of  enemata,  wliich  destroy 
the  natural  sensibility  and  reflex  activity  of  the  rectum. 

In  older  children  an  in-door,  sedentary  life,  negligence  in  regard  to  the  for- 
mation of  a  regular  habit  of  evacuating  the  bowel,  and  a  faulty  posture  at  stool 
are  active  in  producing  the  constipated  habit.  In  regard  to  the  last  element, 
it  may  be  said  that  in  the  physiological  act  of  defecation  the  individual  should 
assume  such  an  attitude  that  every  muscle  of  the  back  and  abdomen  Avhich 
causes  the  bowel  to  be  quickly  and  thoroughly  emptied  of  its  contents  may  be 
brought  into  action. 

Pathology. — The  pathological  condition  to  be  found  in  constipation  varies 
from  a  simple  hyperemia  to  a  catarrhal  or  even  ulcerative  condition  of  the 
mucous  membrane  of  the  intestines.  Yet  in  many  cases  nothing  whatever  is 
to  be  discovered  in  the  intestinal  canal.  The  intestinal  walls  are  apt  to  become 
thin,  and  some  authors  maintain  that  fatty  degeneration  of  the  muscular  coat 
of  the  intestines  supervenes,  resulting  in  a  loss  of  contractility  and  expulsive 
power.  A  swollen  and  distended  condition  of  the  bowels  and  a  chronic  inflam- 
mation, with  induration  and  thickening  in  the  region  of  the  c^cum.  are  occa- 

.32 


498    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

sionally,  met  with.  Hernine,  particularly  umbilical,  pi'olapsus  ani,  varicocele, 
fissure,  cystitis,  and  haemorrhoids  may  be  the  results  of  the  violent  and  oft- 
repeated  straining,  and  the  liver  may  be  pressed  upward  and  congested  from 
interference  with  the  portal  circulation. 

Symptoms. — When  constipation  is  due  to  obstruction,  fsecal  matter  accu- 
mulates above  the  occluded  point  and  produces  distention  of  the  abdomen,  accom- 
panied by  eructations  of  gas,  vomiting,  impaired  appetite,  and  a  consequent 
deterioration  of  the  general  health.  If  the  intestinal  contents  be  composed  of 
hard  masses  or  contain  coarse,  undigested  material,  there  is  danger  of  complete 
obstruction  which  will  place  the  patient  in  a  very  perilous  position. 

In  mild  cases  of  functional  constipation  there  is  simply  a  retention  of 
the  faeces  in  the  rectum  or  lower  bowel;  then  there  are  no  marked  symptoms 
with  the  exception  of  a  sensation  of  fulness,  distention,  and  weight  in  these 
parts. 

Generally  speaking,  the  symptoms  vary  in  degree  according  to  the  grada- 
tion from  the  mild  to  the  very  grave  forms  of  the  disorder,  but  it  is  surprising 
how  frequently  even  severe  cases  of  constipation  are  unattended  by  serious 
symptoms.  Very  often,  in  consequence  of  local  irritation  from  the  retained 
faeces,  a  conservative  purging  is  excited,  and  the  patient  suffers  alternately 
from  diarrhoea  and  constipation.  The  boAvel,  however,  is  not  always  fully 
emptied  of  its  contents  when  such  a  diarrhoea  occurs,  and  the  retained  faeces 
in  time  undergo  decomposition,  with  the  generation  of  noxious  gases,  which  in 
turn  distend  and  irritate  the  bowels  and  cause  severe  colic.  Fiscal  and  gase- 
ous disitention  also  interferes  with  the  action  of  the  diaphragm,  and  produces 
labored  respiration  or  even  great  dyspnoea;  it  may  also  obstruct  the  venous 
circulation  in  the  viscera  and  interfere  with  the  cardiac  action  and  the  circula- 
tion in  the  thoracic  cavity,  leading  to  palpitation  of  the  heart,  irregular  pulse, 
and  vertigo.  Again,  pressure  upon  the  abdominal  and  portal  venous  systems 
hinders  the  return  circulation  from  the  lower  extremities,  and  produces  slight 
oedema  of  the  ankles  and  feet;  finally,  .obstruction  of  the  portal  ducts  and 
vessels,  with  attendant  resorption  of  bile,  may  give  rise  to  jaundice.  In  aggra- 
vated cases  of  chronic  constipation  the  pressure  of  the  retained  faeces  may 
cause  inflammation  of  the  mucous  lining  of  the  gut,  when  abdominal  tender- 
ness and  fever  will  be  noted.  Sometimes  the  inflammation  extends  to  ulcera- 
tion, or  even  perforation,  with  their  attendant  symptoms. 

When  a  constipated  patient  attempts  to  evacuate  his  bowels,  he  will  expe- 
rience great  tenesmus,  and  the  expelled  mass  may  be  streaked  with  blood  and 
smeared  with  mucus,  indicating  that  the  lining  membrane  of  the  rectum  has 
suff'ered  in  the  violent  effort  at  expulsion. 

In  infants  constipation  is  accompanied  by  fretfulness ;  the  little  patient  draws 
up  his  legs  in  pain,  and,  if  he  be  nervously  irritable,  is  very  prone  to  an  attack 
of  eclampsia. 

In  all  cases  of  long-standing  retention  the  fluid  elements  of  the  fiieces  are 
reabsorbed,  to  be  eliminated  from  the  body  by  other  emunctories.  When  this 
occurs  the  blood  becomes  contaminated,  and  there  is  impairment  of  the  gene- 
ral health,  with  the  production  of  such  symptoms  as  languor,  a  foul  breath 
and  furred  tongue,  headache,  nausea,  and  more  or  less  complete  anorexia;  irri- 
tability of  temper  or  hypochondriasis  and  moroseness.  The  abdominal  ner- 
vous plexuses  also  are  affected,  and  the  sufferer,  when  old  enough,  complains 
of  formication,  fatigue,  and  pain  in  the  abdomen  and  lower  extremities. 

Diagnosis. — While  the  recognition  of  the  existence  of  constipation  is  of 
course  very  easy,  it  is  often  a  difficult  problem  to  detect  the  condition — the 
actual  disease — leading  to  the  functional  disorder  of   the  bowels ;    and  this 


CHRONIC   CONSTIPATION.  499 

problem  must  be  correctly  solved  before  successful  treatment  can  be  inaugu- 
rated. 

Such  conditions  as  hernia,  haemorr-hoids,  and  continued  tenesmus  should 
always  lead  one  to  expect  the  presence  of  the  constipated  habit.  On  the  other 
hand,  all  children  who  have  small  or  infrequent  faecal  evacuations  are  not  con- 
stipated, as  such  features  may  be  noticed  Avhen  the  food  is  too  concentrated  or 
is  allowed  in  insufficient  quantity. 

Prognosis. — Simple  idiopathic  chronic  constipation  never  endangers  life. 
If,  however,  the  condition  depends  upon  some  structural  abnormality,  the 
prognosis  is  more  grave.  In  its  consequences,  both  immediate  and  remote, 
constipation  is  of  serious  import.  It  Avill  lead,  as  has  been  said,  to  fissures, 
hgemorrhoids,  and  other  local  troubles ;  it  impairs  the  general  health,  and  if 
not  attended  to  early  a  lifelong  habit  is  formed. 

Treatment. — To  secure,  if  possible,  the  removal  of  its  cause  should  be  our 
first  consideration  in  the  treatment  of  constipation.  If,  on  account  of  struc- 
tural or  pathological  reasons,  this  be  impossible,  our  efforts  must  be  directed  to 
the  minimization  of  its  ill  eff"ects.  In  nurslings  drugs  should,  as  far  as  possi- 
ble, be  avoided,  attention  being  paid  to  the  food  and  to  the  diet  of  the  mother 
or  nurse.  If  the  mother's  milk  be  deficient  in  fat,  sugar,  or  salts,  her  diet 
should  be  so  modified  that  a  larger  quantity  of  these  principles  are  presented 
for  assimilation ;  she  should  also  partake  of  laxative  foods.  If  the  child  be 
nourished  by  a  wet-nurse,  the  same  ends  may  be  accomplished  by  a  change  to 
one  who  is  in  an  earlier  stage  of  lactation  and  whose  milk  contains  more  fat 
and  less  albumin.  When,  in  spite  of  these  measures,  the  constipation  con- 
tinues, some  simple  laxative  is  indicated.  I  frequently  use  a  little  molasses  or 
melted  sugar  and  butter  or  sweet  oil  in  teaspoonful  doses.  If  the  constipation 
be  due  to  an  insufficiency  of  fluids,  as  indicated  by  dry  and  brittle  motions,  it 
is  Avise  to  insist  upon  the  child's  being  given  water  several  times  daily — an  item 
often  overlooked  by  parents  and  nurses.  Sometimes  oatmeal-water  may  be 
substituted  for  plain  water  with  advantage,  particularly  in  older  children  taking 
a  mixed  diet. 

When  these  simple  measures  fail,  the  next  resort  is  to  suppositories  or 
enemata,  which  act  by  local  stimulation  of  the  rectal  muscles.  Suppositories 
should  be  conical  in  shape  and  made  either  of  soap  or  molasses  candy,  or  should 
contain  either  gluten  or  glycerin.  I  prefer  those  containing  glycerin,  as  being 
most  prompt  and  efficient  in  action.  But  whatever  variety  is  selected,  it  should 
be  well  oiled  before  insertion,  and  then  gently  introduced  and  pushed  up  well 
beyond  the  internal  sphincter.  Glycerin  may  also  be  used  by  injection,  in 
the  proportion  of  ten  to  twenty  drops  to  two  fluidrachms  of  water.  Such  an 
injection  is  followed  in  from  five  to  ten  minutes  by  a  full  and  painless  motion. 
The  efficiency  of  the  glycerin  is  due  to  its  hygroscopic  action ;  it  abstracts 
water  from  the  mucous  membrane  of  the  rectum,  inducing  hyperaemia  of  the 
part  and  increasing  peristaltic  action  through  nervous  excitation.  Cold-water 
injections  are  also  recommended.  These  may  be  given  at  first  three  times, 
then  twice,  and  finally  once,  daily  until  a  cure  is  effected.  The  addition  of  a 
little  table  salt  increases  the  activity  of  these  enemas.  As  to  the  bulk  of  the 
injection,  one  or  two  fluidrachms  will  usually  suffice  in  infants.  Too  large 
enemata  not  only  dilate  the  bowel  and  paralyze  its  muscular  coats,  but  may 
also  give  rise  to  much  pain,  and  even  interfere  with  the  respiration  and  circu- 
lation. 

If  it  be  necessary  to  resort  to  drugs,  the  most  simple  are  to  be  chosen,  as 
small  doses  of  calomel,  castor  oil,  solution  of  citrate  of  magnesium,  carbonate 
of  magnesium,  and  phosphate  of  sodium,  in  properly  graded  doses.     The  last 


500    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

remedy  has  given  me  great  satisfaction  in  doses  of  one  to  five  grains  according 
to  the  age  of  the  patient.  I  frequently  administer  it  in  the  following  com- 
bination : 

"Sf.   Sodii  phosphatis gr.  xxiv. 

Syr.  mannae fsiiss. 

Aq.  anisi q.s.  ad  fsiij- — M. 

Sig.  One  teaspoonful  three  times  daily,  for  a  child  under  one  year  old. 

Calomel  may  ])e  given  in  one-sixth  grain  doses  several  times  daily,  but 
must  not  be  employed  habitually ;  laxatives  that  can  be  used  more  freely  are 
carbonate  of  magnesium  in  one-  or  two-grain  doses  in  a  little  milk  or  aromatic 
water,  and  the  solution  of  the  citrate  of  magnesium  in  doses  of  one  to  four 
fluid  drachms. 

Older  children  must  be  trained  to  the  formation  of  the  habit  of  regular 
daily  evacuation  of  the  bowels  at  a  fixed  time.  Neglect  of  this  very  important 
rule  is  very  often  the  cause  of  constipation  persisting  through  adult  life,  with 
its  disagreeable  train  of  symptoms.  Attention  should  also  be  directed  to  the 
posture  assumed  in  the  act  of  defecation,  in  order  that  all  the  necessary  mus- 
cles may  be  brought  into  play.  It  is  important,  too,  at  this  age  to  encourage 
outdoor  exercise,  and  to  so  regulate  the  diet  that  the  child  will  receive  plenty 
of  water  and  an  abundance  of  laxative  food.  In  this  class  belong  fruit,  either 
in  its  natural  state  or  cooked,  oatmeal  or  cracked-wheat  porridge,  corn  and 
brown  bread,  green  vegetables,  molasses,  etc.  Farinaceous  foods  must  be 
restricted,  but  milk  may  be  taken  freely  if  the  digestion  be  good.  In  the 
proscribed  list  come  cheese,  uncooked  dried  fruits,  fruits  having  numbers  of 
small  seeds,  and  spices. 

In  the  administration  of  medicine  select  the  particular  one  that  agrees  best 
with  the  patient;  seek  the  appropriate  dose  to  secure  an  evaluation;  then 
gradually  reduce  the  dose  until  the  constipation  is  ended.  One  of  the  most 
useful  drugs  is  calomel,  given  alone  or  in  combination  with  powdered  rhubarb, 
half  a  grain  of  the  former  to  one  grain  of  the  latter.  This  may  be  repeated 
several  times  daily,  but  care  must  be  taken  not  to  administer  calomel  repeat- 
edly in  either  tuberculous  or  rachitic  children.  If  any  rectal  irritation  be 
present,  compound  licorice  powder  combined  with  sulphur  is  very  useful.  If 
flatus  be  present,  carbonate  of  magnesium  combined  with  asafoetida  will  afford 
relief.  The  fluid  extract  of  cascara  sagrada  in  one-  or  two-drop  doses  is  a  very 
good  remedy.  Dr.  Earle  of  Chicago  recommends  "  in  the  case  of  a  child  two 
years  of  age  to  clean  out  the  bowels  with  two  or  three  grains  of  calomel  com- 
bined with  a  little  compound  licorice  powder,  followed  for  a  few  days  with  car- 
bonate of  magnesium  3ij  in  f  Jj  of  water,  one  to  three  teaspoonfuls  dailv  until 
the  bowels  are  relaxed.  Then  give  non-astringent  iron  preparations,  nux 
vomica,  and  possibly  magnesium  sulphate  or  cascara,  until  the  cure  is  complete." 

It  has  also  been  suggested  that  small  doses  of  ipecacuanha,  either  alone  or 
combined  with  calomel,  are  very  useful. 

When  there  is  great  distention  of  the  bowels  it  will  be  of  advantage  to 
bandage  the  abdomen  in  order  to  assist  in  the  restoration  of  muscle-tone.  The 
colon  may  be  punctured  with  a  hypodermatic  needle  when  its  distention  is  so 
great  that  collapse  is  imminent  from  heart  displacement.  When  there  are  large 
collections  of  fiecal  matter  in  the  colon,  the  more  active  cathartics  must  be 
exhibited,  accompanied  by  irrigation  of  the  bowel  through  a  rectal  tube.  If 
the  faeces  are  very  hard,  it  is  advisable  to  add  to  the  fluid  injected  inspissated 
ox-gall  in  the  proportion  of  3ij  to  the  pint.     I  frequently  add  to  the  ox-gall 


CHRONIC   CONSTIPATIOX.  501 

the  following  mixture,  which  stimulates  the  bowel  to  relieve  itself  of  its  con- 
tents, and  also  helps  to  carrA*  off  flatus: 

I^.   01.  terebinthinie f.5J- 

Tr.  asafoetidse 

01.  ricini da  f^iv. — M. 

Sig.   Add  to  a  quart  of  warm  water,  and  use  for  irrigation. 

The  suds  of  ordinary  brown  Avashing  soap  may  also  be  added  to  this  mix- 
ture. If  the  rectum  be  impacted,  instrumental  and  manual  assistance  must 
be  given;  injections  of  small  quantities  of  yeast  have  been  also  used  with  suc- 
cess. Gradual  dilatation  of  the  sphincter  has  also  been  successfully  employed. 
If  constipation  be  accompanied  by  the  symptoms  of  indigestion,  the  diet  .should 
be  revised;  pepsin  Avith  muriatic  acid  and  cascara  or  taraxacum  should  be  pre- 
scribed. I  again  desire  to  call  attention  to  the  phosphate  of  sodium ;  in  older 
children  it  may  be  given  in  doses  of  from  five  to  eight  grains  dissolved  in  water. 

The  constipation  which  succeeds  a  diarrhoea  requires  the  use  of  tonics.  Of 
these,  strychnine  stands  first  in  efiicacy.  administered  either  alone  or  in  the 
favorite  combination  of  iron,  quinine,  and  strychnine.  AVhen  atony  of  the  mus- 
cular coat  occasions  the  trouble,  nux  vomica  combined  with  belladonna,  ergot. 
and  phosphorus  are  very  valuable  remedies. 

As  each  case  must  be  treated  on  its  own  merits,  many  of  the  cathartic 
remedies  which  have  not  been  alluded  to  by  name  will  undoubtedly  meet  spe- 
cial indications  in  special  cases.  Thus  when  there  is  an  interference  with  the 
hepatic  functions  the  folloAving  is  an  excellent  prescription : 

^.   Resinse  podophylli       gi'-j- 

Alcohol fjiss. 

Syr.  rubi  idai q.  s.  ad  f|iij. — M. 

Sig.  A  teaspoonful  to  a  dessertspoonful  every  morning,  according  to  the 
obstinacy  of  the  constipation. 

When  a  copious  evacuation  is  desirable  the  following  is  recommended: 

]^.   Tr.  nucis  vomicte lUxij. 

Tr.  belladonnae TTLxxiv. 


Inf.  sennae .     f 


Inf.  calumbae    .    .    . q.  s.  ad  f^iij. — M. 

Sig.   One  teaspoonful  for  a  dose. 

The  constipation  which  attends  the  various  diathetic  conditions  demands 
individual  attention,  but  by  no  means  to  the  exclusion  of  the  diathesis  itself. 
Cod-liver  oil  and  the  syrup  of  the  iodide  of  iron,  both  someAvhat  laxative  in 
nature,  are  especially  useful  in  these  cases.  A  very  good  formula  is  that  pre- 
scribed by  Dr.  J.  Lewis  Smith  : 

3^'.   Olei  morrhu8e fSij- 

Liquor,  calcis, 

Syr.  calcii  lactophosphatis    ....  aa  f^j. — M. 

Sig.  Give  from  one-quarter  to  one  teaspoonful  three  times  daily,  accord- 
ino;  to  age  of  child. 

For  anaemic  children  mineral  Avaters  containing  iron  are  beneficial.  Thus 
Friedrichshall   is   serviceable,  as  it  has  a  tonic  and  laxative  effect,  and   also 


502    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

favors  the  elimination  of  uric  acid.  In  such  cases  a  mixture  of  sulphate  of 
magnesium,  sulphate  of  iron,  and  tinctui-e  of  nux  vomica  is  also  serviceable. 

Galvanism  has  its  use  in  the  treatment  of  constipation.  The  negative  pole 
is  passed  well  up  into  the  rectum,  and  the  positive  along  the  course  of  the 
colon  over  the  abdomen,  for  the  negative  pole  excites  local  contraction,  and  the 
positive  pole  peristalsis.  Galvanism  is  to  be  preferred  to  faradism,  being 
more  efficacious. 

In  conclusion,  attention  must  be  directed  to  one  of  the  most  important 
measures  used  in  the  treatment  of  chronic  constipation — namely,  massage  of 
the  abdomen  and  its  contents.  The  technique  of  massage  in  children,  though 
it  differs  in  no  essential  particular  from  the  same  procedure  in  adults,  should 
be  modified  in  conformity  with  the  position  of  the  digestive  organs  at  the  various 
periods  of  the  child's  life.  As  the  main  cause  of  constipation  in  children,  exclu- 
sive of  the  weak  muscular  coat  of  the  bowel,  resides  in  the  descending  colon,  it  is 
rarely  necessary  to  practise  the  manipulations  on  the  right  side  of  the  abdomen.' 
The  application  of  massage  for  as  short  a  time  as  three  minutes  has  been  known 
to  produce  the  desired  effect,  and  the  sitting  should  not  last  more  than  ten  minutes. 
It  may  be  repeated  two  or  three  times  a  day.  The  method  of  application  is  as 
follows :  The  operation  is  preferable  before  nursing  or  feeding,  excepting  when 
the  child  is  very  fretful  or  when  the  abdominal  walls  become  very  tense  on 
handling.  In  such  cases  it  can  be  accomplished  during  tlic  act  of  feeding,  for 
when  the  walls  are  very  tense  nothing  can  be  effected.  The  hands  should  be 
clean,  warm,  and  dry.  The  resistance  and  rigidity  of  the  muscles  will  deter- 
mine the  amount  of  pressure  to  be  used.  The  production  of  pain  should  be 
avoided ;  hence  the  pressure  should  be  gradually  made,  and  until  the  child 
becomes  accustomed  to  it  the  manipulation  should  be  very  gentle.  The  finger- 
tips placed  upon  the  skin  of  the  abdomen  are  moved  about  with  the  skin  over 
the  intestines,  but  not  riihhed.  For  the  first  two  or  three  minutes  concentric 
circles  are  described  by  the  manipulation  in  the  region  of  the  umbilicus ;  then 
in  a  similar  manner  the  descending  colon  is  treated,  more  pressure  being  made 
in  the  downward  than  in  the  upward  movement.  More  manipulation  is  re- 
quired in  the  left  iliac  fossa  than  elsewhere,  for  obvious  reasons.  The  caecum 
and  ascending  colon  may  at  times  also  require  to  be  manipulated  in  the  same 
way.  In  older  children  sudden  tapping  of  the  abdominal  walls  with  the  finger- 
tips, Avhich  will  excite  an  instantaneous  contraction  of  the  abdominal  muscles,  has 
been  found  to  be  of  value.  The  results  obtained  by  massage  have  been  very 
gratifying,  and  it  should  always  be  added  to  whatever  other  treatment  may  be 
instituted  at  any  period  of  infancy  or  childhood. 


SIMPLE  ATROPHY 

By  LOUIS  STAER,  M.  D., 

PniliADELPHIA. 


Simple  Atrophy,  or  the  slow  wasting  commonly  termed  "marasmus," 
is  a  familiar  occurrence  in  hand-fed  babies,  and  one  of  the  most  fi-equent 
causes  of  death  in  early  infancy.  It  is  a  condition  in  which  there  is  extreme 
wasting  of  the  soft  tissues  of  the  body,  either  without  special  organic  lesions 
or  with  catarrhal  inflammation  of  the  mucous  membrane  of  the  gastro-intestinal 
canal. 

Etiology. — Wasting  usually  occurs  during  the  first  twelve  months  of  life, 
though  it  may  begin  in  the  second  year,  and  is  most  frequently  encountered 
among  children  of  the  poor.  It  arises  both  in  breast-fed  babies  and  in  those 
brought  up  by  hand,  being  in  either  case  due  to  insufficient  nourishment.  The 
child  wastes  because  he  is  starved. 

Food  can  be  insufficient  in  two  ways  :  first,  when  it  is  supplied  in  amounts 
too  limited  to  meet  the  demands  of  the  system  ;  and  second,  when  it  contains  a 
minimum  of  the  elements  essential  to  nutrition  or  presents  them  in  a  form 
ill  adapted  to  the  feeble  digestive  powers  of  infancy.  For  example,  nursing 
infants  waste  in  consequence  of  feeding  either  from  a  breast  that  yields  too  little 
good  milk,  or  from  one  that  secretes  abundantly  a  poor,  watery  fluid  entirely 
unfit  for  nourishment.  With  artificially-fed  children,  on  the  other  hand,  it 
rarely  happens  that  the  quantity  of  food  is  too  small ;  the  fault  lies,  rather,  in 
the  direction  of  quality.  Undiluted  cows'  milk,  milk  thickened  with  starchy 
materials,  farinaceous  foods,  and  even  table  food — meat,  vegetables,  and  bread — 
are  given  to  babies  a  few  weeks  or  months  old.  Now,  all  of  these  are  highly 
nutritious,  but  the  digestive  apparatus  is  not  sufficiently  developed  to  prepare 
them  for  absorption.  They  are  strong  foods,  adapted  to  nourish  and  strengthen 
much  older  children  and  adults,  but  as  the  infimt  cannot  appropriate  them,  he 
starves  no  less  surely,  if  more  slowly,  than  when  taking  no  food  at  all.  Such 
aliment  also,  while  remaining  undigested  in  the  stomach  and  intestines,  under- 
goes fermentation,  with  the  formation  of  irritant  products,  causing  vomiting 
or  diarrhoea — conditions  that  still  further  lower  the  vital  powers  and  hasten 
atrophy. 

It  is  often  possible  to  trace  the  disease  directly  to  want  of  cleanliness 
in  the  feeding  apparatus,  and  especially  to  the  use  of  a  form  of  bottle  that 
has  until  lately  been  very  popular  in  this  country,  as  it  is  still  in  England.  This 
bottle  has,  in  place  of  a  plain  gum  tip,  an  arrangement  of  glass  and  rubber 
tubing  of  small  calibre.  One  extremity  of  the  rubber  tubing,  which  is  eight 
or  nine  inches  long,  terminates  in  a  small  nipple-shaped  tip  and  bone  shield : 
the  other,  after  penetrating  an  ornamental  rubber  cork,  is  fitted  to  a  bit  of  glass 
tubing  long  enough  to  extend  quite  to  the  bottom  of  the  bottle.  By  this  plan 
the  trouble  of  holding  the  bottle  and  keeping  it  at  a  proper  angle  during  feed- 
ing is  avoided.  This  seeming  advantage,  though,  is  counterbalanced  both  by 
the  minor  drawback  that  the  child,  left  to  itself,  is  apt  to  continue  suction  long 

503 


504  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

after  the  bottle  is  exhausted,  thus  swallowing  a  quantity  of  air,  and  by  the 
greater  disadvantage  that  the  tubing  can  never  be  kept  clean. 

For  a  number  of  years  the  author  nuide  it  a  rule  to  ask  for  the  bottle  of 
every  hand-fed  infant  presented  for  treatment,  and  few  days  passed  without  his 
seeing  several  of  the  complicated  contrivances  referred  to.  In  almost  every 
instance,  notwithstanding  the  most  careful  and  frequent  cleansing,  a  sour 
odor  could  be  detected,  and  if  milk  were  present  it  contained  numerous  small 
curds ;  while  in  cases  of  carelessness  the  odor  was  intolerable,  and  the  interior 
of  the  tubing  was  encrusted  with  a  layer  of  altered  curd.  With  simple  bottles 
and  tips,  on  the  contrary,  alterations  in  the  character  of  the  milk  and  coating 
of  the  interior  of  the  tips  were  very  infrequent.  As  there  is  little  difficulty  in 
keeping  the  bottles  themselves  clean,  there  can  be  only  one  reason  for  this 
difference — namely,  in  the  simple  instrument  the  nipple  is  readily  removed  and 
as  easily  inverted  and  cleaned,  but  in  the  other  there  is  no  Avay  of  cleaning 
thoroughly  the  twelve  or  more  inches  of  fine  tubing.  The  latter  cannot  be 
inverted,  and  the  passage  of  a  stream  of  Avater  or  of  a  stiff  brush  oftly  imper- 
fectly removes  the  milk  clinging  to  the  interior.  This,  of  course,  soon  under- 
goes decomposition,  and  in  this  state  quickly  inaugurates  change  in  the  next 
supply  of  milk  placed  in  the  bottle.  It  is  evident  that  a  constant  supply  of 
food,  no  matter  how  good  originall}'',  thus  rendered  acid  and  partially  curdled, 
must,  like  an  excess  of  farinaceous  or  other  unsuitable  food,  produce  irritation 
of  the  alimentary  canal,  interfere  with  the  processes  of  nutrition,  and  lead  to  a 
state  in  which  the  features  of  wasting  and  disordered  digestion  are  com- 
bined. 

The  custom  of  preparing  in  the  morning,  without  sterilizing,  a  supply  of 
food  sufficient  for  the  whole  day  is  another  fruitful  cause  of  atrophy.  If  this  be 
done,  no  matter  how  carefully  the  mixture  be  proportioned  or  how  well  adapted 
to  the  age  and  digestion  of  the  child,  it  becomes  unfit  for  consumption  after 
standing  eight  or  ten  hours.  The  change  may  or  may  not  be  appreciable  to 
the  senses,  but  test-paper  will  always  show  acidity  and  the  microscope  demon- 
strate the  existence  of  actively-moving  bacteria.  Again,  food  upon  which  a  child 
has  thrived  for  three  or  four  months,  perhaps,  can  become  unsuitable,  and  conse- 
quently lead  to  wasting,  if  the  digestive  powers  be  suddenly  reduced  by  an  inter- 
current disease. 

Wasting,  while  it  is  less  serious  in  babies  suckled  at  the  breast,  frequently 
occurs  in  a  modified  form  under  these  circumstances.  There  are  several  addi- 
tional causal  factors.  Thus,  an  infant  may  be  given  to  a  wet-nurse  whose  own 
baby  is  much  older  than  her  foster-child.  In  this  case  the  milk  is  too  strong, 
for  it  is  a  Avell-known  fact  that  as  lactation  advances  human  milk  bcomes  pro- 
portionately richer  in  curd  and  cream,  and  the  nursling,  unable  to  digest  and 
assimilate  it,  ceases  to  thrive,  and  may  even,  in  consequence,  suffer  from  indi- 
gestion or  diarrhoea.  Human  milk  is  also  affected  by  dietetic  and  emotional 
influences,  and,  altering  with  the  state  of  the  general  health  of  the  mother, 
may  deteriorate  in  quality  or  otherwise  become  unfit  for  food.  Finally,  it  hap- 
pens at  times  that,  although  the  mother  may  be  healthy  and  have  an  abundant 
breast,  and  although  the  infimt  may  be  robust,  yet  it  does  not  thrive  on  the 
milk  supplied.  Here  the  fault  is  generally  an  over-richness  in  cream.  While 
noting  these  facts,  it  must  be  remembered  that  m  many  cases  of  wasting  in 
nursing  infants  the  fault  is  not  with  the  mother's  milk,  l)ut  in  the  digestive 
organs  of  the  child,  an  attack  of  catarrh  having  temporarily  impaired  the  pro- 
cess of  digestion.  Without  care  and  proper  management  the  derangement 
may  be  prolonged,  and  not  infrequently  leads  to  unnecessary  Aveaning. 

Morbid  Anatomy. — After  death  the  muscular  and  other  tissues  are  found 


iSIMPLE   ATROPHY.  505 

in  a  state  of  atrophy,  and  there  is  a  total  disappearance  of  normal  fat  from  the 
body.  Fatty  degeneration  of  the  kidneys,  lungs,  and  brain  may  be  discovered; 
the  stomach  is  sometirnes  ulcerated,  and  hsemorrhagic  effusions  into  the  cranium 
are  not  uncommon. 

Symptoms. — The  clinical  features  differ  materially  according  to  whether 
the  element  of  insufficiency  be  one  of  quantity  or  quality.  They  may,  there- 
fore, be  divided  into  two  classes — viz.  those  developed  by  food  that  is  suitable 
but  not  sufficient,  and  those  resulting  from  unsuitable  food. 

The  first  group  of  symptoms  is  most  frequently  encountered  in  children  who 
have  been  nursed  at  the  breasts  of  feeble  or  overworked  mothers,  in  Avhom  the 
milk  is  often  both  scanty  and  of  poor  quality.  There  is  a  gradual  loss  of 
plumpness,  the  muscles  grow  flaccid,  and  there  seems  to  be  an  arrest  of  growth. 
The  face  is  wliite,  the  lips  pale  and  thin,  the  skin  harsh  and  dry  or  too  moist, 
and  the  anterior  fontanelle  level  or  slightl}^  depressed.  The  temper  is  irritable 
and  sleep  restless  and  disturbed ;  or  the  child  is  abnormally  quiet,  dozing  con- 
stantly, and  sucking  his  fingers  until  they  become  raw.  When  nursed  the  child 
seizes  the  nipple  ravenously  ;  then,  if  there  be  little  milk,  he  quickly  drops  it 
to  cry  passionately,  as  if  disappointed  at  not  being  able  to  satisfy  his  hunger ; 
but  if  the  milk  be  abundant,  though  thin,  he  will  lie  a  long  time  quietly  at  the 
breast,  and  often  fall  asleep  with  the  nipple  in  his  mouth.  The  bowels  are 
inclined  to  constipation,  the  stools  being  scanty,  hard,  and  dry.  Physical  signs 
connected  with  the  chest  and  abdomen  are  negative,  and  no  indication  of  dis- 
ease of  any  special  organ  of  the  body  can  be  detected. 

In  the  second  class,  features  of  wasting  are  associated  Avith  those  of  irritation 
of  the  alimentary  canal,  and  the  symptoms  altogether  are  much  more  grave 
than  in  cases  of  the  preceding  group.  The  subjects  are  almost  invariably  hand- 
fed  infants.  Emaciation  progresses  with  a  rapidity  and  to  an  extent  depending 
upon  the  original  strength  of  the  child's  constitution,  the  age  at  which  artificial 
feeding  was  begun,  and  the  sort  of  food  employed.  It  is  often  so  extreme  that 
an  infant  several  months  old  Aveighs  less  and  appears  smaller  than  at  birth,  and 
this  even  after  a  large  quantity  of  food,  such  as  it  is,  has  been  consumed.  The 
combination  of  great  wasting  with  a  voracious  appetite  is  very  striking,  and  is 
only  apparently  contradictory,  since  hunger — the  demand  of  the  tissues  for 
reparative  material — cannot  be  appeased  by  food  Avhich,  from  its  bad  quality, 
is  incapable  of  digestion  or  proper  preparation  for  absorption  and  assimilation. 
Unsuitable  food,  too,  by  irritating  the  mucous  membrane  of  the  stomach,  creates 
a  fictitious  appetite. 

Sooner  or  later  the  face  becomes  pinched,  the  eyes  sunken ;  the  lips  are  pale, 
and  when  moved  display  a  deep  furrow  about  the  angles  of  the  mouth ;  the 
facial  expression  is  uneasy  or  languid,  and  the  anterior  fontanelle  is  deeply 
depressed.  The  skin,  generally,  is  dry,  harsh,  and  yellowish,  hangs  in  loose 
folds  over  the  bones,  and  may  be  mottled  by  an  eruption  of  strophulus  or  ui'ti- 
caria,  or  present  red  patches  of  intertrigo  in  the  neighborhood  of  the  genitalia 
and  over  the  buttocks  and  inner  surface  of  the  thighs.  The  extremities  are 
cold  and  the  hands  clay-like.  The  tongue  is  heavily  furred  or  red  and  dry,  and 
with  the  mucous  membrane  of  the  mouth  may  be  the  seat  of  aphthous  ulceration 
or  thrush  deposit.  As  already  stated,  the  appetite  is  often  ravenous,  and  the 
cries  of  hunger  are  violent,  oft  repeated,  and  only  temporarily  silenced  by  food ; 
thirst  is  increased  ;  colic  is  common  :  the  bowels  are  constipated,  and  the  stools, 
which  are  voided  with  difficulty  and  straining,  are  composed  of  a  few  light- 
colored,  cheesy  lumps  partly  covered  with  greenish  mucus. 

Attacks  of  acute  vomiting  and  diarrhoea  often  interrupt  the  regular  course 
of  the  disease.    At  such  times  there  is  moderate  fever  during  the  night,  though 


500  AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

ordinarily  the  temperature  is  subnormal.  Again,  chronic  vomiting  and  chronic 
diarrhoea  are  apt  to  arise  as  complications,  and  greatly  increase  the  danger  of 
a  fatal  termination. 

Sleep  is  restless  and  disturbed,  and  many  hours,  particularly  during  the 
night,  are  spent  in  fretful  cr^nng.  A  common  group  of  symptoms  connected 
with  the  nervous  system  is  "  inward  spasms."  When  these  occur  the  upper 
lip  becomes  livid,  somewhat  everted,  and  tremulous ;  the  eyeballs  rotate  or  there 
is  a  slight  squint,  and  the  fingers  and  toes  are  strongly  flexed.  They  fre- 
quently usher  in  true  convulsions. 

Sometimes  the  nervous  manifestations  are  much  more  complex.  Thus,  I 
have  seen  cases  where  there  was  retraction  of  the  head,  boring  of  the  head 
into  the  pillow,  an  approximation  to  the  "gun-hammer"  decubitus,  general 
hypergesthesia,  and  the  tache  cerebrale, — all  suggestive  of  tubercular  meningitis. 
Such  symptoms  disappear  under  an  appropriate  diet  with  proper  medicinal 
treatment,  and  are  to  be  referred  to  an  intensely  excitable  nervous  system — a 
condition  depending  upon  insufficient  nourishment,  and  differing  merely  in 
degree  from  that  leading  to  "inward  spasms." 

There  is,  of  course,  extreme  prostration,  the  cardiac  action  is  weak,  and 
the  respiration  shallow.  The  urine  is  citron-colored  or  very  dark  yellow,  has 
a  specific  gravity  of  1009  to  1012.5,  a  strong,  characteristic  odor,  and  is 
diminished  in  quantity.  It  is  always  cloudy  or  milky,  only  becoming  clear  on 
the  approach  of  recovery.  The  sediment  deposited  on  standing  contains 
variously-shaped  cylinders  ;  fatty  elements  Avith  tinted  nuclei ;  mucus;  colored 
uric  acid  ;  urates  in  a  crystallized  or  amorphous  condition  ;  pigment,  etc.  The 
reaction  is  sometimes  highly  acid.  The  proportion  of  urates  is  decidedly,  that 
of  uric  acid  notably,  and  of  coloring  matter  and  extractives  somewhat,  increased. 
Albumin  is  always  present  in  variable  quantity,  and  sugar  also  may  be  fre- 
quently detected. 

Death  may  be  preceded  by  convulsions  or  the  symptoms  of  spurious 
hydrocephalus,   or  may   result  from  prostration. 

Diagnosis. — Great  emaciation  may  result  from  inherited  syphilis  or  acute 
tuberculosis,  but  both  of  these  conditions  are  attended  by  characteristic  symp- 
toms, rendering  their  diagnosis  a  matter  of  little  difficulty.  In  inherited  syph- 
ilis the  child  snuffles  and  cries  hoarsely.  The  skin  is  dry,  wrinkled,  old-parch- 
ment-colored, and  mottled  with  coppery  or  rust-colored  spots.  Often  the  buttocks, 
perineum,  genitalia,  and  upper  portion  of  the  thighs  are  the  color  of  the  lean 
of  ham.  Mucous  patches  are  present  at  the  margin  of  the  anus  and  of  the 
lips.  The  corners  of  the  mouth  are  fissured,  the  nostrils  red  and  excoriated, 
and  the  bridge  of  the  nose  is  flattened.  Enlargement  of  the  spleen  can 
frequently  be  detected  on  abdominal  palpation. 

In  acute  tuberculosis  there  is  fever,  the  rectal  temperature  reaching  100°  to 
101°  F.  in  the  evening;  cough  with  irregularly  distributed  bronchial  rales,  and 
usually  slight  oedema  of  the  legs. 

When  symptoms  resembling  those  of  tubercular  meningitis  are  present,  it 
is  often  necessary  to  delay  a  definite  opinion.  In  simple  atrophy,  however, 
the  open  fontanelle  is  level  or  depressed ;  the  belly  is  never  scaphoid ;  the 
bowels,  though  frequently  constipated,  are  never  locked  ;  vomiting  is  apt 
to  be  associated  with  diarrhoea ;  the  respiration  and  pulse  are  regular  in 
rhythm  ;  the  temperature,  as  a  rule,  is  subnormal ;  there  is  no  hydrencephalic 
cry ;  and  the  antecedent  history  and  the  course  are  diff"erent  from  the  tuber- 
cular disease. 

Prognosis. — A  vast  number  of  cases  die  annually  in  our  large  cities,  yet 
the  results  of  appropriate   management   are  often    rapidly    and   surprisingly 


PLATE  Xin. 


CASE  OF  Si:.IPLE  ATEOPHl',  ffit.  three  months. 

\Veight  at  birth,  4  lbs  ■  weight  on  admission  to  Children's  Hospital,  33^  lbs.    Fed  on  a  mixture  of  cane-sugar  and  water. 

(Died  twelve  hours  after  admission  to  hospital.) 


SIMPLE  ATROPHY.  507 

successful.  Patients  should  never  be  given  up  unless  there  be  extreme  wasting 
and  prostration,  or  unless  the  symptoms  of  spurious  hydrocephalus  arise, 
convulsions  occur,   or  obstinate  chronic  vomiting  or  diarrhoea  be  developed. 

Treatment. — For  the  arrest  of  wasting  from  insufficient  nourishment,  the 
first  and  main  thing  to  be  attended  to  is  the  diet.  Without  entering  at  length 
into  this  subject,^  it  may  be  stated,  as  a  uniform  rule,  that  in  selecting  a  diet 
the  object  should  be  to  fix  upon  one  suited  to  the  age  and  digestive  powers 
of  the  child,  so  that  he  may  be  able  to  digest,  and,  therefore,  be  nourished  b}", 
all  the  food  consumed. 

Generally,  infants  under  twelve  months  who  have  to  be  either  partially  or 
entirely  "brought  up  by  hand"  do  well  upon  cows'  milk,  diluted  with  lime- 
water  or  with  barley-water.  Often  it  is  well  to  sterilize  the  milk,  or — a  method 
which  has  been  most  uniformly  successful  in  my  hands — to  add  to  the 
milk  mixture  peptogenic  milk  powder,  and  subject  to  a  temperature  of  155° 
F.  for  six  minutes.  The  food  should  be  administered  from  a  bottle  capable 
of  holding  half  a  pint,  made  of  colorless  glass,  so  that  the  least  particle  of  dirt 
can  be  seen,  and  provided  with  a  soft  India-rubber  tip.  Unless  sterilized  or 
Pasteurized,  the  whole  quantity  of  food  intended  to  be  given  in  a  day  should 
never  be  prepared  at  once,  but  each  portion  must  be  made  separately  at  the 
time  of  administration.  Thus,  a  bottle  of  the  sort  described,  absolutely  clean, 
may  be  filled  with  a  mixture  of  one  part  of  lime-water  to  two  or  three  of  sound 
milk,  or  with  one  part  of  barley-water  to  two  or  three  of  milk,  to  either  of 
which  may  be  added  from  one  to  two  tablespoonfuls  of  cream  and  a  tea- 
spoonful  of  pure  sugar  of  milk.  The  bottle  must  next  be  placed  in  hot  water 
until  the  contents  become  warm,  when  it  is  ready  for  the  child. 

The  degree  of  dilution  of  the  milk  and  the  proportion  of  cream  added  vary 
with  the  age  and  feebleness  of  digestion,  but  it  is  upon  the  latter  that  we  must 
chiefly  base  the  composition  of  the  food.  Lime-water  is  the  preferable  diluent 
when  there  is  frequent  vomiting  or  acid  eructation.  Both  it  and  barley-water 
are  of  service  in  preventing  the  formation  of  large,  compact  curds — an  object 
that  is  even  better  accomplished  by  peptogenic  milk  powder,  and  by  the 
process  of  partial  predigestion.  In  some  cases  it  may  be  necessary  to  discon- 
tinue milk  foods  entirely,  putting  the  child  temporarily  upon  weak  broths  or 
raw  beef  juice. 

After  digestion  has  been  brouo;ht  into  o;ood  condition,  the  food  may  be 
cautiously  increased  to  a  standard  suitable  for  a  healthy  child  of  the  same  age. 
At  eight  or  ten  months  from  two  to  four  fluidounces  of  thin  mutton  or  chicken 
broth,  free  from  grease,  may  be  allowed  each  day  in  addition  to  the  milk  ;  at 
twelve  months,  the  yolk  of  a  soft-boiled  egg,  rice  and  milk,  and  carefully 
mashed  potatoes  moistened  with  gravy  ;  and  at  the  end  of  the  second  year-, 
a  small  quantity  of  finely-minced  meat. 

Once  daily  the  patient  should  be  bathed  in  warm  water,  or  at  least  sponged 
over  with  warm  Avater,  and  every  morning  and  evening  a  teaspoonful  of  warm 
olive  oil  or  of  cod-liver  oil  should  be  rubbed  into  the  skin  over  the  abdomen 
and  chest.  At  the  same  time  the  belly  must  be  completely  covered  with  a 
soft  flannel  binder,  and  the  feet  and  surface  generally  kept  warm'  by  woollen 
clothing.  In  this  way  attacks  of  colic,  if  not  entirely  prevented,  are  rendered 
much  less  frequent  and  severe. 

If  there  be  intertrigo,  cleanliness  and  the  free  use  of  oxide-of-zinc  oint- 
ment usually  suffice  to  effect  a  cure. 

Of  medicines,  bicarbonate  of  sodium,  pepsin,  pancreatin,  nux  vomica,  and 
cod-liver  oil  are  perhaps  the  most  useful.      Cod-liver  oil  should  not  be  given 

'  For  the  details  of  diet  and  general  management,  see  Introduction. 


508  AMEjRICAN  text- bo  ok  OF  DISEASES  OF  CHILDREN. 

until  the  digestive  powers  have  been  brought  into  a  comparatively  normal  state 
by  proper  food,  antacids,  and  digestants  and  the  general  tone  increased  by 
tincture  of  nux  vomica.  The  oil  is  most  easily  borne  when  given  in  emulsion, 
and  may  be  advantageously  combined  with  lactophosphate  of  lime  or  with  the 
hypophosphites. 

Such  symptoms  as  constipation,  diarrhoea,  and  vomiting  demand,  of  course, 
appropriate  treatment. 


DISEASES  OF  THE  CAECUM  AND  APPENDIX. 

By  JOHN   ASHHURST,  Jr.,  M.  D., 

Philadelphia. 


Inflammatory  Affections  of  the  Gmctjm  and  Appendix. 

Under  the  names  of  typhlitis,  perityphlitis,  appendicitis,  csecitis,  perityph- 
litic  abscess,  etc.  are  included  by  systematic  writers  certain  cases  of  inflam- 
mation, usually  severe  and  sometimes  ending  in  suppuration  or  in  general 
peritonitis,  met  with  in  the  right  ilio-lumbar  region.  While  these  cases  are 
met  with  at  all  ages,  they  are  sufficiently  common  in  children  to  make  their 
consideration  proper  in  a  work  devoted  to  the  maladies  of  childhood,  and  they 
are  so  often  attended  with  danger  and  lead  to  such  serious  consequences  that 
their  importance  can  hardly  be  overestimated. 

The  terms  typhlitis  and  ccecitis  are  strictly  applicable  to  inflammation,  catar- 
rhal or  parenchymatous,  afi"ecting  the  caecum  (blind  gut)  or  caput  coli ;  ^^en- 
typhlitis  to  an  inflammation  of  the  areolar  or  connective  tissue  behind  the 
caecum,  where  this  portion  of  bowel  is  usually  uncovered  by  peritoneum ;  peri- 
typhlitic  abscess  to  a  collection  of  pus  occurring  in  the  same  region ;  and  the 
somewhat  barbarous  term  appendicitis  to  an  inflammation  of  the  pouch  or 
diverticulum  known  as  the  appendix  vermiformis.  Without  denying  that 
the  caput  coli  itself  may  be  primarily  the  seat  of  inflammation,  as  indeed 
may  any  portion  of  the  intestines,  constituting  the  grave  condition  enteritis, 
and  while  acknowledging  at  least  the  possibility  of  a  true  perityphlitis,  per- 
haps leading  to  extra-peritoneal  suppuration,  there  can,  I  think,  be  no  doubt 
that  in  the  large  majority  of  instances  the  appendix  vermiformis  is  the  part 
primarily  involved,  and  that  the  resulting  abscess,  when  pus  is  formed,  is 
intra-peritoneally  situated,  though  fortunately,  in  most  cases,  walled  oft"  by 
adhesions  which  prevent  the  general  infection  of  the  peritoneal  cavity. 

Morbid  Anatomy. — The  pathological  lesions  found  in  cases  of  inflamma- 
tion of  the  caecum  and  appendix  are  quite  variable.  In  the  majority  of  cases 
the  inflammation  does  not  advance  beyond  the  stage  of  lymph-formation,  and 
even  after  repeated  attacks  (for  the  disease  is  often  recurrent)  the  parts  Avill  be 
found  indurated  and  thickened,  and  matted  together  by  dense  adhesions ;  but 
there  will  be  no  abscess.  In  other  instances,  and  particularly  when  the  patient 
is  tuberculous,  pus  will  form  at  an  early  period,  usually  as  the  result  of  ulcer- 
ation and  perforation  of  the  intestinal  wall,  but  sometimes  without  perforation, 
simply  from  the  intensity  of  the  inflammation.  Foreign  bodies,  such  as  grape- 
seeds,  etc.,  are  occasionally  found  lodged  in  the  caecum  or  appendix,  or  loose  in 
the  surrounding  abscess ;  but  more  commonly  what  are  supposed  to  be  foreign 
bodies  are  really  concretions  of  earthy  phosphates  Avith  faecail  matter  and  inspis- 
sated mucus,  or  of  inspissated  mucus  alone.  The  caecum  from  its  shape  and 
position  is  apt  to  become  the  lodging-place  for  concretions  of  this  character, 
which  set  up  irritation  and  may  lead  to  ulceration  of  the  caecal  wall,  while  small 

509 


510    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

concretions  may  enter  the  appendix,  or,  as  is  more  commonly  tlie  case,  the  mouth 
of  the  appendix  becoming  occluded  by  catarrhal  inflammation  and  thickening, 
concretions  form  in  situ  by  inspissation  of  the  retained  secretion  of  the  part, 
which  in  the  normal  condition  is  poured  into  the  cjBcum,  and  forms  a  natural 
lubricant  for  the  faecal  mass  in  its  passage  through  the  large  intestine.  When 
pus  forms  in  these  cases,  it  may  make  its  way  into  an  adjoining  segment  of 
bowel ;  may  become  more  or  less  thorough^  encysted  and  form  a  fluctuating 
tumor  in  the  iliac  fossa ;  may  burrow  in  various  directions,  coming  to  the  sur- 
face in  the  lumbar  region  above  the  iliac  crest,  or,  passing  downward  in  the 
course  of  the  psoas  muscle,  below  Poupart's  ligament;  or,  finally,  may  infect 
the  general  cavity  of  the  peritoneum,  causing  diS'use  purulent  peritonitis,  which 
quickly  proves  fatal.  In  exceptional  cases  the  pus  has  been  known  to  perfor- 
ate the  diaphragm,  causing  pleurisy  and  empyema,  or  to  enter  the  hip-joint. 

Etiology. — The  causes  of  typhlitis  and  appendicitis  may  be  divided  into 
the  predisposing  and  the  exciting  causes.  Among  the  former  may  be  men- 
tioned sex.,  these  affections  being  much  more  common  in  the  male  than  in  the 
female,  in  the  proportion,  it  is  said,  of  six  to  one ;  age,  most  cases  occurring  in 
early  life;  the  presence  of  tubercle,  tuberculous  patients  being  not  only  more 
exposed  to  appendicitis  than  the  non-tuberculous,  but  the  disease  in  them  more 
([uickly  running  on  to  suppuration,  and  convalescence  after  an  operation, 
should  such  be  necessary,  being  eff"ected  more  slowly  and  with  more  interrup- 
tions ;  and  habitual  constipation,  the  retention  of  ftecal  matter  in  the  caecum, 
which  is  sometimes  distended  to  an  enormous  size,  maintaininf;  a  constant 
source  of  irritation,  and  exposing  the  intestinal  wall  to  the  dangers  of  ulcer- 
ation and  perforation.  The  exciting  causes  are  the  entrance  of  foreign  bodies 
into  the  appendix — seeds,  pins,  hairs,  etc. ;  the  ingestion  of  indigestible  food  : 
exposure  to  cold  or  wet ;  falls,  blows,  or  strains  of  the  abdominal  parietes  ;  and 
the  abuse  of  drastic  purgatives. 

Symptoms. — The  symptoms  of  typhlitis  and  appendicitis  are  variable  and 
often  deceptive.  Sometimes  beginning  with  a  chill,  the  early  symptoms  are  more 
often  those  of  enteritis  generally,  pain,  vomiting  and  constipation,  fever,  and 
tenderness  with  some  fulness  in  the  region  of  the  inflamed  part.  The  ^7om  is 
usually  greatest  in  the  right  iliac  fossa,  but  is  sometimes  referred  to  the  navel, 
and  may  even  be  most  marked  on  the  left  side  of  the  abdomen  ;  but  even  when 
the  pain  is  misplaced,  the  greatest  tenderness  will,  unless  general  peritonitis 
be  impending,  be  found  upon  the  right  side,  and  especially  at  a  point  distant 
an  inch  or  an  inch  and  a  half  (in  the  adult  two  inches)  from  the  anterior  supe- 
rior spinous  process  of  the  ilium,  and  in  a  line  drawn  from  that  point  to  the 
umbilicus.  This  tender  spot,  which  is  known  as  "  McBurney's  point,"  corre- 
sponds to  the  position  of  the  appendix,  and,  as  already  mentioned,  it  is  the 
appendix  which  is  primarily  involved  in  the  large  majority  of  cases.  At  a 
later  period,  when  pus  has  formed,  the  "soft  spot"  Avhich  precedes  pointino' 
of  the  abscess  may  sometimes  be  detected  in  precisely  the  same  locality.  Coin- 
cidently  with  the  development  of  tenderness  in  the  right  iliac  region,  gentle 
palpation  will  reveal  a  fulness,  followed  at  a  later  stage  bv  tenderness  and 
tumefaction,  in  the  position  of  the  cfecum ;  and  in  order  to  relieve  the  inflamed 
part  from  pressure  of  the  superjacent  tissues,  the  patient  will  usually  secure 
relaxation  of  the  abdominal  wall  by  lying  on  his  back,  slightly  turning  to  the 
right  side,  and  with  the  right  knee  drawn  up. 

The  vomiting  is  often  distressing,  attended  with  considerable  effort;  and 
aggravates  the  pain  by  succussion  of  the  inflamed  parts:  the  ejected  matters 
consist  at  first  of  the  contents  of  the  stomach,  and  afterward  of  the  intestinal 
juices  with  bile ;  ftecal  vomiting  does  not,  as  a  rule,  occur,  even  Avhen  general 


DISEASES    OF    THE    C^CUM  AND    APPENDIX.  511 

peritonitis  follows,  this  being  a  point  of  some  importance  in  the  diagnosis  of 
these  conditions  from  intussusception  and  other  forms  of  mechanical  obstruction 
of  the  bowel.  The  constipation  in  appendicitis  and  typhlitis  is  not  complete : 
there  may  be  an  occasional  discharge  of  flatus ;  evacuations  may  be  secured 
by  the  use  of  enemata,  and  the  administration  of  salines  may  cause  even  free 
catharsis  without  modifying  the  other  symptoms  of  the  disease.  The  fever  is 
not  very  intense,  the  temperature  varying  from  101°  to  102°  F.,  and  is  accom- 
panied Avith  a  quick  pulse,  furred  tongue,  and  intense  thirst :  when  suppura- 
tion occurs  the  fever  may  assume  a  hectic  type,  and  in  the  cases  which  ter- 
minate unfavorably  the  tongue  becomes  brown  and  dry,  sordes  accumulate 
about  the  lips  and  teeth,  and  the  patient  passes  into  a  decidedly  "typhoid" 
condition. 

When  suppuration  occurs  the  symptoms  undergo  some  modification.  The 
pain  and  tenderness  are  usually  increased ;  rigors  may  occur  at  irregular  inter- 
vals; the  tumefaction  in  the  right  iliac  region  becomes  somewhat  boggy,  the 
overlying  integument  being  perhaps  congested  and  slightly  oedematous ;  a  "soft 
spot"  may  be  observed;  and,  if  the  pus  be  not  evacuated,  fluctuation,  with 
ultimately  pointing,  as  in  abscesses  elsewhere.  There  are  sometimes  pain  in  the 
right  knee  and  ankle,  and  oedema  of  the  leg.  The  pus  in  these  cases  commonly 
has  a  strong  faecal  odor  from  pro.ximity  to  the  bowel,  even  though  no  perfora- 
tion be  discoverable. 

Diagnosis. — The  diagnosis  of  appendicitis  and  typhlitis  can  usually  be 
made  without  difiiculty  if  the  symptoms  be  carefully  noted,  the  affections  in 
regard  to  which  confusion  is  most  likely  to  occur  being  enteritis,  intestinal 
obstruction,  psoas  and  iliac  abscess,  and  hip  disease.  Enteritis — by  which  term 
is  meant  inflammation  involving  all  the  coats  of  a  segment  of  intestine — is  well 
described  by  Sir  Thomas  Watson  as  "peritonitis  with  something  more."  It 
may  occur  in  any  part  of  the  bowel,  not  being  limited  to  the  right  iliac  region, 
and  the  localizing  symptoms  of  appendicitis — McBurney's  point,  etc. — are 
therefore  wanting.  The  paralysis  of  the  gut  is  more  complete,  constipation 
consequently  being  more  absolute,  with  no  discharge  of  flatus,  and  the  vomit- 
ing, if  relief  be  not  afforded,  soon  assuming  a  faecal  character.  Typhlitis, 
using  the  term  accurately,  is  of  course  a  form  of  enteritis,  but  when  the  inflam- 
mation is  limited  to  the  caecum  the  symptoms  are  less  severe  than  when  a  larger 
portion  of  bowel  is  implicated.  Mechanical  obstruction  of  the  intestine  in 
children  is  usually  of  the  character  of  intussusception,  though  internal  strangu- 
lation by  bands  or  diverticula  is  occasionally  met  with.  In  the  latter  condition 
the  pain  would  be  felt  mainly  at  the  seat  of  obstruction  or  more  commonl}^  at 
the  umbilicus;  there  would  be  no  fever,  the  temperature  more  probably  being 
subnormal,  sometimes  even  after  the  development  of  peritonitis ;  there  would 
be  faecal  vomiting,  with  absolute  constipation  and  inability  to  pass  wind ;  gen- 
eral tympany,  from  paralysis  of  the  bowel  allowing  gaseous  distention ;  partial 
suppression  of  urine;  and  the  patient  would  pass  into  a  state  of  collapse,  sooner 
or  later  according  to  the  position  and  closeness  of  the  strangulation.  In  intus- 
susception there  might  be  fever  from  secondary  inflammation  of  the  aff"ected 
bowel;  there  would  be  a  tumor,  but  instead  of  occupying  the  right  iliac  fossa, 
it  would  be  found  in  a  median  position  or  upon  the  left  side ;  there  would,  in 
acute  cases,  be  a  discharge  of  blood  and  mucus  from  the  bowel ;  and  digital 
exploration  of  the  rectum  would,  in  children  at  least,  probably  detect  the  lower 
end  of  the  invagination.  Psoas  abscess  is  usually,  though  not  invariably, 
accompanied  by  evidences  of  preceding  disease  of  the  spinal  column,  is  not 
attended  by  pain  or  marked  tenderness,  and  presents  no  intestinal  complica- 
tions ;  iliac  abscess,  if  depending  upon  ovarian  or  periuterine  inflammation  and 


512    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

situated  on  the  right  side,  may  more  closely  simulate  appendicitis;  but  even  here 
the  distinction  may  be  made  by  observing  the  absence  of  bowel  symptoms.  In 
hip  disease  the  peculiar  and  characteristic  deformity  and  malposition  of  the  limb, 
varying  with  the  stage  of  the  disease,  Avill  suffice,  when  present,  to  clear  up  the 
diagnosis;  in  appendicitis,  though  extension  of  the  limb  may  cause  great  pain, 
it  is  not  accompanied  by  the  arching  of  the  lumbar  spine  observed  in  hip  disease, 
and  the  joint  may  be  moved,  without  causing  suffering,  in  other  directions.  In 
the  rare  cases  in  which  an  abscess,  originating  in  appendicitis,  opens  into  the 
hip-joint,  causing  secondary  disease  of  that  articulation,  the  symptoms  would  be 
confused,  both  maladies  then,  in  fact,  coexisting  in  the  same  subject;  but  under 
ordinary  circumstances  the  absence  of  intestinal  symptoms  in  the  one  case,  and 
the  absence  of  joint  symptoms  in  the  other,  ought  to  prevent  the  possibility 
of  error. 

With  regard  to  the  special  diagnostic  importance  of  "McBurney's  point," 
a  good  deal  of  difference  of  opinion  prevails  among  practitioners,  and  the  tend- 
ency at  the  present  time  is  to  consider  it  of  but  little  value.  For  my  own 
part,  I  am  disposed  to  place  considerable  reliance  upon  this  symptom,  and 
believe  that  the  detection  of  induration  and  tenderness,  or  at  a  later  period  of 
a  "soft  spot,"  in  this  particular  situation  is,  Avhile  perhaps  not  pathognomonic, 
at  least  strongly  significant  of  disease  originating  in  the  appendix. 

Tumor  of  the  kidney,  perinephric  abscess,  carcinoma  of  the  bowel,  and 
abscess  of  the  abdominal  ivall  have  been  mistaken  for  appendicitis,  but  careful 
examination  and  investigation  of  the  history  of  the  case  ought  to  prevent  an 
error  in  this  direction. 

The  diagnosis  of  perforation  of  the  cfficum  or  appendix  may  be  made  when 
symptoms  of  suppuration  occur,  or  when  the  spread  of  pain  and  tenderness  to 
the  left  side,  of  the  abdomen  indicates  the  threatened  implication  of  the  peri- 
toneum generally.  Fortunately,  before  or  immediately  after  the  occurrence  of 
perforation,  adhesions  usually  form  and  seal  off"  the  affected  part  from  the  rest 
of  the  peritoneal  cavity,  and  even  where  this  does  not  occur,  an  interval  of  some 
hours,  or  even  a  day  or  tAvo,  may  intervene  before  the  development  of  univer- 
sal peritonitis,  giving  an  opportunity  for  prompt  surgical  intervention  which 
may  save  life  even  in  this  emergency. 

Prognosis. — The  prognosis  in  appendicitis  and  typhlitis  is  in  the  large 
majority  of  cases  favorable.  Under  judicious  treatment  the  acute  symptoms 
will  subside  in  from  four  days  to  a  fortnight,  although  a  certain  amount  of 
induration  and  tenderness  may  persist  for  a  much  longer  period.  The  patient 
is  now  apt  to  become  intolerant  of  the  regimen  and  rest  Avhich  has  been  hitherto 
enforced,  and  resumes  his  ordinary  diet  and  manner  of  living,  Avith  the  result 
that  relapse  occurs;  and  this  sequence  of  events  may  be  repeated  indefinitely. 
The  reason  that  recurrence  of  appendicitis  is  so  often  met  with  is,  I  believe, 
that  the  patients  will  not  persist  in  treatment  until  completely  recovered.  If 
thoroughly  cured,  a  second  attack  is  not,  according  to  my  experience,  to  be  par- 
ticularly dreaded. 

When  perforation  occurs  the  prognosis  becomes  more  gloomy.  In  the  rare 
cases,  if  such  exist,  in  which  the  opening  is  in  the  c.^cum  behind  the  peri- 
toneum, a  burrowing  abscess  will  result,  and  convalescence  will,  under  the  most 
favorable  circumstances,  be  tedious.  If  the  perforation  be  intra-peritoneal, 
peritonitis,  local  or  general,  is  inevitable ;  in  the  former  case,  the  infected  area 
being  sepai'ated  b\^  adhesions  from  the  general  cavity,  recovery  after  operation 
may  be  hoped  for  ;  in  the  latter,  though  by  prompt  intervention  a  patient  may 
occasionally  be  snatched,  as  it  were,  from  the  very  jaws  of  death,  yet  the  large 
majority  will  perish  ;  diff'use  suppurative  peritonitis  is  almost  always  a  fatal 


DISEASES    OF    THE    CAECUM  AND    APPENDIX.  513 

affection.  In  tuberculous  patients  the  prognosis,  cceteris  paribus,  is  ahvays 
less  favorable  than  in  others. 

Treatment. — The  treatment  of  appendicitis  and  typhlitis  may  be  either 
prophylactic  or  curative.  As  preventive  measures,  care  should  be  taken  to  avoid 
constipation  by  regulation  of  the  diet,  by  encouraging  defecation  at  a  fixed 
hour  daily,  and,  if  necessary,  by  the  use  of  laxatives.  The  patient  should  be 
warmly  clad,  especially  around  the  abdomen,  should  keep  the  feet  dry,  and 
should  avoid  exposure  to  cold  and  wet  generally.  When  the  disease  actually 
occurs,  the  indications  for  remedial  treatment  are — (1)  to  keep  the  inflamed 
part  at  rest ;  (2)  to  relieve  the  congestion ;  (3)  to  prevent  pain ;  and  (4)  to 
maintain  the  patient's  nutrition  without  overtaxing  the  impaired  powers  of 
digestion.  If  suppuration  occur,  the  pus  must  be  promptly  evacuated  by 
incision  and  drainage.  The  first  indication  is  met  by  keeping  the  patient  in 
bed  and  by  avoiding  the  use  of  purgatives,  which  under  these  circumstances 
can  only  do  harm.  The  constipation  and  consequent  accumulation  of  fgecal 
matter  in  these  cases  are  owing  to  paralysis  of  the  bowel,  more  or  less  com- 
plete, due  to  its  inflamed  state ;  or,  in  other  Avords,  are  a  result,  not  a  cause,  of 
the  inflammation.  This  is  a  distinction  which  often  the  friends  of  the  patient, 
and  sometimes  even  the  physician,  seem  unable  to  comprehend ;  they  cannot 
understand  that  the  patient  is  not  ill  because  his  bowels  are  not  moved,  but 
that  his  bowels  are  not  moved  because  he  is  ill.  In  saying  this  I  am  not 
unmindful  of  the  fact  that  salines,  in  small  but  frequently  repeated  doses,  are 
often  used  in  these  cases,  and  that  the  patients  sometimes  do  well  under  this 
treatment ;  but  the  benefit  is  due  to  the  action  of  the  remedy  as  an  indirect 
means  of  eff"ecting 'depletion  and  drainage,  and  if  this  could  be  accomplished 
without  catharsis  it  would  be  so  much  the  better.  The  second  and  third  indi- 
cations are  met  by  the  application  of  leeches  (if  the  symptoms  are  very  urgent), 
and  by  the  use  of  warm  cataplasms  and  the  administration  of  opium.  The 
fourth  indication  is  met  by  careful  feeding  with  peptonized  milk  or  other  liquid 
nutriment,  or,  if  the  patient  vomit,  by  employing  nutritive  enemata.  The  course 
of  treatment  may  then  be  established  as  follows :  The  patient  being  strictly 
confined  to  bed,  a  few  leeches  are  applied  over  the  seat  of  greatest  pain,  draw- 
ing from  two  to  six  fluidounces  of  blood  according  to  his  age ;  if  for  any  reason 
leeching  be  thought  unadvisable,  a  small  blister  may  be  applied,  and  the  part 
afterward  covered  with  mercurial  and  belladonna  ointments,  equal  parts,  spread 
upon  lint,  and  over  this  in  turn  a  warm  flaxseed  or  elm  poultice.  Enough 
opium  should  be  given  to  relieve  pain,  either  by  the  mouth  in  the  form  of  the 
deodorized  tincture,  or  by  suppository  ;  or  morphia  may  be  given  hypodermat- 
ically  if  preferred.  Belladonna  may  properly  be  combined  with  the  opium,  and 
is  also  to  be  used  locally  with  the  mercurial  ointment,  as  already  described. 
When  the  pain  has  entirely  ceased,  but  not  before,  if  the  bowelg  do  not  move 
spontaneously  in  the  course  of  twenty-four  hours,  a  warm  enema  of  olive  oil 
and  soap-suds  may  be  administered  ;  if  this  fail,  and  if  there  be  no  tendency  to 
vomiting,  small  doses  of  the  Epsom  or  Rochelle  salt — from  half  a  drachm  to  a 
drachm — may  be  tentatively  given  every  hour  or  two  hours,  the  enema  being 
repeated  twice  daily ;  if  there  is  nausea  or  vomiting,  the  saline  should  be 
omitted,  and  calomel  in  minute  doses  (gr.  2^0"  1^2)?  "^^''*'^  bicarbonate  of  sodium 
(gr.  j-ij),  may  be  given  instead.  Administered  in  this  way,  and  the  patient 
being  still  kept  under  the  influence  of  opium,  I  doubt  if  these  medicines  cause 
any  increase  of  peristalsis,  and  the  good  which  they  undoubtedly  do  is,  as 
already  mentioned,  due  to  the  serous  flow  from  the  congested  and  inflamed 
bowel  to  which  they  give  rise. 

After  the  subsidence  of  all  acute  symptoms  the  salines  may  be  continued  in 
33 


514    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

reduced  doses,  so  as  to  cause  two  or  three  passages  from  the  intestines  daily, 
and  the  local  use  of  mercury  and  belladonna,  or  a  belladonna  plaster,  should  be 
continued  until  the  swelling  and  tenderness  have  disappeared,  when  the  remain- 
ing induration  may  be  treated  by  painting  the  part  with  tincture  of  iodine 
every  day  or  every  other  day,  according  to  the  effect  produced,  maintaining 
mild  but  persistent  counter-irritation  without  blistering.  During  the  early  stages 
the  right  lower  limb  may  be  flexed  over  a  pillow  to  relax  the  abdominal  wall, 
but  as  soon  as  possible  it  should  be  brought  flat,  and,  if  there  is  any  tendency 
to  permanent  contraction,  weight-extension  should  be  applied  to  keep  the  limb 
in  proper  position. 

In  the  large  majority  of  cases,  unless  the  patient  be  tuberculous,  prompt 
and  persistent  treatment  on  the  lines  above  indicated  will  suffice  to  eff"ect 
recovery.  After  convalescence  the  patient  should  live  by  rule,  avoiding  indi- 
gestible food,  and  observing  all  the  precautions  referred  to  in  speaking  of 
prophylaxis. 

If,  however,  instead  of  yielding  to  treatment,  the  symptoms  persist,  and  the 
evidences  of  deep-seated  suppuration — fluctuation,  superficial  oedema,  or  a  "  soft 
spot" — are  manifested,  no  time  should  be  lost  in  resorting  to  an  exploratory 
operation.  So  important  is  promptness  under  these  circumstances  that  it  has 
been  maintained  that  in  every  case  the  physician  should  associate  with  himself 
a  surgeon  to  watch  the  patient  from  the  beginning  of  the  attack,  so  that  there 
may  be  no  delay  when  the  critical  moment  arrives.  I  am  not  prepared  to  say 
that  this  is  always  necessary,  but  I  do  say  that  if  a  physician  undertakes  the 
management  of  a  case  of  appendicitis  alone,  he  should  possess  the  tactus 
eruditus  which  will  enable  him  to  recognize  suppuration  as  soon  as  it  occurs. 
I  have  more  than  once  been  called  to  patients  who  had  been  treated  many 
days,  if  not  weeks,  by  practitioners  who  had  not  detected  the  presence  of  pus, 
the  signs  of  which  were  yet,  to  the  surgical  sense,  quite  obvious 

Operations  for  Appendicitis. — It  was  formerly  recommended,  when 
suppuration  was  believed  to  have  occurred  in  cases  of  csecal  or  appendiceal 
inflammation,  to  verify  the  diagnosis  by  the  introduction  of  an  exploring 
needle  ;  but  the  feeling  of  modern  surgeons  is  against  the  use  of  this  instru- 
ment, as  being  very  apt,  on  the  one  hand,  to  miss  striking  the  purulent  col- 
lection, and,  on  the  other  hand,  if  it  should  reach  the  abscess,  apt  to  infect 
the  peritoneal  cavity  as  it  is  withdrawn  ;  and  a  careful  incision  of  moderate 
extent  is,  I  have  no  doubt,  safer  in  every  way  than  the  blind  thrust  of  a  needle- 
point, as  well  as  more  likely  to  discover  the  seat  of  suppuration.  Before 
making  the  incision  the  abdominal  wall  should  be  thoroughly  cleansed  and 
purified,  but  with  great  care  and  gentleness,  as  it  would  be  quite  possible 
for  a  vigorous  antiseptic  scrubbing  to  break  through  the  limiting  adhesions 
and  diff'use  the  contents  of  an  abscess  through  the  peritoneal  cavity.  Opera- 
tors diff"er  as  to  the  best  line  for  incision  :  when  it  was  believed  that  the  purulent 
collection  was  formed  outside  of  the  peritoneum,  the  rule,  as  laid  down  by 
Willard  Parker,  Hancock,  Buck,  and  Sands — who  may  be  regarded  as  the 
pioneers  in  this  branch  of  surgery — was  to  make  the  incision  above  Poupart's 
ligament,  as  in  tying  the  external  iliac  artery,  and  endeavor  to  reach  the 
abscess  by  cautiously  working  upward  and  pushing  the  serous  membrane  out 
of  the  way  ;  but  since  it  is  now  generally  recognized  that,  as  taught  by  Weir, 
the  abscess  is  actually  intra-peritoneal  in  origin,  the  marginal  incision  is  no 
longer  thought  important,  and  surgeons  aim  to  reach  and  evacuate  the  pus  by 
the  most  direct  route.  If  the  case  is  so  far  advanced  that  fluctuation  is 
manifest,  the  incision  should  be  made  where  this  is  most  perceptible;  but 
under  other  circumstances  the  best  position,  I  think,  is  in  the  general  direc- 


DISEASES   OF   THE    C^CUM  AND   APPENDIX.  515 

tion  of  the  right  linea  semilunaris,  taking  care  that  a  part  of  the  wound  shall 
be  through  the  so-called  "  McBurney's  point,"  which,  as  already  mentioned, 
corresponds  to  the  usual  situation  of  the  appendix.  Some  operators  prefer  to 
place  the  incision  more  laterally,  believing  that  they  thus  secure  better  drain- 
age, but,  upon  the  whole,  in  most  cases,  I  prefer  the  anterior  position. 

The  first  cut,  about  four  inches  in  length,  should  pass  through  the  skin  and 
superficial  fascia,  and  the  deeper  layers  are  then  cautiously  divided  upon  a 
director,  all  bleeding  being  checked  before  the  abdominal  cavity  is  opened. 
When  the  peritoneum  is  reached,  it  is  cautiously  raised  with  forceps  and  nicked 
by  the  edge,  not  the  point,  of  the  knife  held  sideways — as  in  the  operation  for 
strangulated  hernia — the  wound  being  then  carefully  enlarged  with  blunt- 
pointed  scissors  guided  and  guarded  by  the  finger  as  a  director.  As  soon  as 
the  cavity  is  opened  a  gush  of  pus  will  usually  serve  to  confirm  the  diagnosis, 
but  if  this  does  not  occur  the  surgeon  should  cautiously  explore  with  his  finger 
and  a  blunt  director  in  the  neighborhood  of  the  caecum  until  the  seat  of  sup- 
puration is  discovered.  After  evacuation  of  the  pus  the  cavity  is  carefully 
but  thoroughly  washed  out  with  hot  distilled  water,  and  the  surgeon  then 
searches  for  the  appendix,  which,  if  found,  should  be  removed.  Often  this 
can  be  done  without  difficulty,  the  organ,  enlarged  and  thickened,  being  readily 
separated  by  the  finger  from  its  adhesions  and  brought  out  at  the  wound ;  its 
neck  should  then  be  tied  with  two  strong  carbolized  silk  ligatures,  and  divided 
between  them.  If,  however,  the  appendix  cannot  readily  be  found,  it  is  better 
to  allow  it  to  remain  than  unduly  to  prolong  the  operation  by  hunting  for  it, 
nothing  being  more  deleterious  in  abdominal  surgery  than  prolonged  delay  and 
unnecessary  manipulation  of  the  viscera. 

After  a  final  washing  with  hot  distilled  water,  a  full-sized  drainage-tube, 
of  glass  or  rubber,  should  be  introduced,  carried  to  the  bottom  of  the  cavity, 
and  secured  with  a  stout  ligature  or  safety-pin.  Some  surgeons  merely  pack 
the  wound  with  iodoform  gauze,  instead  of  introducing  a  tube,  but  my  own 
preference  is  for  the  latter  practice.  As  to  the  choice  between  glass  and 
rubber,  my  rule  is,  when  the  abscess-cavity  is  completely  walled  off  from  the 
general  peritoneal  surface,  to  use  a  rubber  tube,  which  is  shortened  from  time 
to  time  as  the  wound  heals  ;  but  when  the  peritoneal  cavity  is  opened,  I  employ 
a  glass  tube,  armed  with  a  rubber-dam  and  containing  a  rope  of  absorbent 
cotton,  which  is  renewed  as  often  as  it  is  saturated  without  disturbing  the  dress- 
ing applied  to  the  rest  of  the  wound,  the  tube  being  at  the  same  time  sucked 
out  with  a  long-beaked  syringe  until  the  secretion  becomes  of  a  pale  straw 
color,  and  is  reduced  to  a  minimum,  when  the  tube  is  finally  removed.  A 
few  sutures  may  be  applied  to  the  extremities  of  the  wound,  but  it  should 
not  be  tightly  closed,  being  rather  allowed  to  heal  firmly  by  granulation  and 
cicatrization. 

There  is  little  or  no  danger  of  consecutive  hernia  in  this  situation,  and  if 
there  is  any  communication  with  the  bowel,  faecal  fistula  will  be  less  apt  to  fol- 
low in  an  open  wound  than  in  one  which  has  united  only  superficially.  Fsecal 
fistula,  however,  contrary  to  the  doctrine  formerly  held,  is  really  a  rare  com- 
plication after  the  operation  for  appendicitis,  and  is  not  to  be  dreaded  unless 
some  grave  constitutional  condition,  such  as  general  tuberculosis,  interfere  with 
the  healing  of  the  wound. 

All  surgeons  are  agreed  as  to  the  propriety  of  operative  intervention  in  cases 
of  acute  appendicitis  in  which  suppuration  is  believed  to  have  occurred,  but 
some  go  further,  and  enthusiastic  operators  advise  that  the  appendix  should  be 
removed  after  recovery  as  a  means  of  preventing  recurrence  of  the  disease.  I 
have  myself  operated  under  these  circumstances,  and  successfully,  but  I  think 


516    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

that  there  are  very  few  cases  in  which  such  a  course  is  justifiable.  The  time  to 
perform  an  operation  in  itself  dangerous — and  opening  the  peritoneal  cavity  is 
dangerous,  orvniecological  and  surirical  enthusiasts  to  the  contrary  notwith- 
standing — is  when  a  greater  and  imminent  danger  may  be  averted  by  so 
doing,  and  not  when  the  patient  is  well ;  and  when  Ave  consider  that  the 
very  extensive  statistics  of  the  London  Hospital  show  that  90  per  cent,  of 
all  cases  of  appendicitis  end  in  recovery  without  operation,  we  may  well  hesi- 
tate before  submitting  a  patient  to  a  mode  of  treatment  equally  needless  and 
heroic.  The  only  circumstances  which  seem  to  me  to  justify  an  operation  after 
convalescence  are  when  the  patient  has  had  repeated  attacks  at  decreasing 
intervals  and  of  increasing  severity,  and  when  he  is  going  to  be  so  placed 
that  skilled  surgical  assistance  will  not  be  available  in  the  event  of  further 
recurrence. 

Non-inflammatory  Affections. 

The  ciecum  has  occasionally  been  found  in  a  hernial  protrusion  {caecal 
hernia),  as  has  the  appendix,  the  latter  particularly  in  the  variety  of  rupture 
incorrectly  called  congenital,  in  Avhicli  the  bowel  escapes  into  the  patulous 
vaginal  process  of  peritoneum.  C^ecal  hernia  is  often  irreducible  through  the 
formation  of  adhesions  between  the  portion  of  gut  uncovered  by  peritoneum 
and  the  adjoining  structures.  The  appendix,  even  when  not  itself  diseased, 
sometimes  acquires  adhesions  to  other  parts,  and  may  then  cause  internal 
strangulation,  a  loop  of  bowel  being  caught  beneath  the  appendix  and  con- 
stricted as  if  by  a  fibrous  band.  Should  such  a  condition  be  discovered  during 
an  operation  for  intestinal  obstruction,  the  appendix  should  be  divided  between 
two  ligatures,  or,  which  would  be  better,  excised,  so  as  to  prevent  the  possi- 
bility of  a  recurrence.  Malignant  groivths  are  met  with  in  the  caecum,  though 
not  often  in  children,  and  may  be  treated  on  the  same  principles  which  guide 
the  surgeon  in  dealing  with  similar  affections  in  other  portions  of  the  bowel. 


INTUSSUSCEPTION. 

BY  JOHN  ASHHURST,  Jr.,  M.  D., 
Philadelphia. 


Intussusception,  or  invagination  of  the  bowel,  is  by  far  the  most  frequent 
cause  of  mechanical  obstruction  of  the  intestine  met  with  in  childhood,  though 
internal  strangulation  by  an  adherent  appendix  or  by  Meckel's  diverticulum, 
or  more  rarely  by  a  band  of  organized  lymph  left  from  a  previous  peritoni- 
tis, occasionally  occurs.  Invagination,  as  the  name  implies,  consists  in  an 
ensheathing  of  one  segment  of  bowel  within  another,  the  invaginated  part  being 
almost  always  from  a  higher  portion  (that  is,  farther  from  the  anus)  than  that 
into  which  it  is  received.  Thus,  the  jejunum  is  invaginated  into  the  ileum, 
that  into  the  caecum  and  colon,  etc.  The  much  rarer  condition,  that  in  which 
the  lower  segment  is  received  into  the  upper,  is  called  retrograde  intussuscep- 
tion. It  is  not  uncommon  for  this  affection  to  occur  among  the  multiple  invagi- 
nations which  arise  during  the  act  of  dying,  but  direct  intussusceptions  are 
those  which  are  met  with  during  life,  and  which  call  for  treatment.  Every 
complete  intussusception  involves  three  layers  of  bowel,  and  each  layer  consists 
of  all  the  intestinal  coats ;  the  outer  layer  is  the  sheath.,  or  receiving  layer, 
the  intussuscipiens ;  and  the  internal  or  entering  lager,  together  with  the 
middle  or  returning  layer,  constitutes  the  invaginated  part,  or  intussusceptum. 
The  ayex  of  the  intussusception  is  at  the  junction  of  the  inner  and  middle 
layer — the  lowest  point,  therefore,  of  the  intussusceptum ;  while  its  neck  is  at 
the  junction  of  the  middle  and  external  layers — the  uppermost  part  of  the  intus- 
suscipiens. Double  intussusceptions  are  occasionally  met  with,  five  layers  of 
gut  being  then  involved,  either  a  second  intussusceptum  having  been  forced 
into  the  first,  which  then  constitutes  its  sheath,  or  the  intussicipiens  with  its 
contained  intussusceptum  being  in  turn  invaginated  into  a  fresh  portion  of 
bowel,  which  then  forms  a  second  sheath.  Still  more  rarely  triple  intussuscep- 
tions, involving  seven  layers  of  bowel,  have  been  found. 

Locality. — In  rather  more  than  one-half  of  all  cases  of  intussusception  the 
invagination  occurs  about  the  junction  of  the  small  and  large  intestines: 
usually  the  caecum,  and  afterward  the  colon,  is  inverted,  the  ileum  pushing  before 
it  the  ileo-csecal  valve,  which  is  thus  found  at  the  apex  of  the  intussusceptum ; 
much  more  rarely  the  ileum  slips  through  the  valve,  which  then  constitutes  the 
neck  of  the  intussuscipiens,  and  the  intussusceptum  grows  by  successive  invagi- 
nation of  fresh  portions  of  small  intestine.  The  former  variety  is  known  as 
ileo-ccecal,  and  the  latter  as  ileo-colic  intussusception.  In  somewhat  less  than 
one-third  of  the  whole  number  of  cases  the  invagination  is  limited  to  the  small 
intestine  {ileal  or  jejunal  intussusception),  and  in  the  remainder,  or  about  one- 
sixth,  to  the  large  intestine  (colic  intussusception). 

Except  in  the  ileo-colic  variety,  in  which  the  neck  remains  fixed,  an  intus- 
susception increases  at  the  expense  of  its  sheath,  which  becomes  gradually 
inverted,  the  apex  of  the  intussusception  remaining  constant  while  its  neck  is 

5]7 


518    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

continually  changing ;  in  the  ileo-colic  variety  fresh  portions  of  ileum  keep 
passing  through  the  valve,  and  the  neck  therefore  remains  unchanged  while  the 
apex  varies.  As  the  entering  layer  carries  the  mesentery  with  it  into  the 
sheath,  a  certain  amount  of  traction  is  exerted  upon  one  side  of  the  intussus- 
ceptum,  and  as  a  result  the  intussusception  becomes  curved  or  even  sharply 
flexed  upon  itself,  and  at  the  same  time  the  apex  becomes  displaced  toward  the 
mesenteric  side  of  the  intussuscipiens,  both  of  these  conditions  tending  mechani- 
cally to  render  the  occlusion  of  the  gut  more  complete  than  it  would  be  other- 
wise. The  extent  of  boivel  involved  in  an  intussusception  varies  from  a  few 
inches  to  six  or  more  feet. 

Though  an  invagination  usually  begins  on  the  right  side  of  the  abdo- 
men, its  increase,  in  the  most  common  or  ileo-caecal  variety,  is  mainly  at  the 
expense  of  the  large  intestine ;,  and  therefore  by  the  time  it  has  acquired  suf- 
ficient size  to  be  recognized  by  palpation  the  tumor  will  be  chiefly  on  the  h-ft 
side,  and  eventually  the  ileo-cnecal  valve  with  the  apex  of  the  intussusceptum 
may  be  pi'otruded  from  the  anus :  even  when  this  does  not  occur,  the  apex,  in 
children  at  least,  can  very  commonly  be  detected  by  digital  exploration  of  the 
rectum. 

Morbid  Anatomy. — The  adjacent  serous  layers  in  an  intussusception 
soon  become  more  or  less  closely  united  by  adhesions,  which,  if  firm,  render 
the  invagination  irreducible.  These  adhesions  may  join  the  two  layers  of  the 
intussusceptum  to  each  other  over  a  considerable  space,  or  may  be  limited  to 
the  region  of  the  neck  ;  they  are  very  seldom  found  exclusively  at  the  apex. 
The  sheath  of  the  intussusception  may  become  ulcerated  from  pressure,  and 
even  perforation  may  occur ;  but  more  commonly,  beyond  a  certain  amount  of 
congestion  and  inflammation,  no  marked  changes  are  found  in  this  layer.  The 
intussusceptum,  on  the  other  hand,  is  usually  more  or  less  completely  strangu- 
lated, and  becomes  gangrenous,  when,  if  there  are  firm  adhesions  at  the  neck, 
the  dead  portion  may  be  separated  and  evacuated  as  a  whole  or  in  segments 
through  the  anus,  the  patient  eventually  recovering.  Under  other  circum- 
stances, the  adhesions  being  defective,  fiecal  extravasation  into  the  peritoneal 
cavity  may  occur,  the  death  of  the  patient  following ;  or  the  adhesions,  Avhile 
preventing  death  at  the  moment,  may  form  the  starting-point  of  a  stricture, 
which  in  turn,  at  a  later  period,  may  cause  fatal  obstruction. 

Post-mortem  inspection  in  a  case  of  intussusception  reveals  the  elongated 
tumor  caused  by  the  invagination,  usually  on  the  left  side  of  the  abdomen,  with 
an  apparent  absence  of  that  portion  of  bowel  which  is  invaginated.  The  outer 
laj'er  or  sheath  of  the  intussusception  is  usually  of  a  gray  color,  doughy  in 
feel,  and  sometimes  ulcerated  from  distention,  while  the  intussusceptum.  when 
exposed,  is  found  of  a  deep-red  color,  resembling  a  clot  of  blood,  or  black  and 
gangrenous.  The  intestine  above  the  seat  of  obstruction  is  commonly  much 
dilated,  and  filled  with  faecal  matter  and  gas,  while  that  below  is  collapsed  and 
shrunken,  and  is  either  empty  or  contains  a  small  quantity  of  blood  and  mucus. 
There  is  sometimes  general  peritonitis. 

Etiology. — Xothnagel  has  investigated  experimentally  the  causes  of  intus- 
susception, and  describes  a.  paralytic  and  a  spasmodic  varietv,  the  latter  being 
the  more  frequent.  Differing  from  the  ordinary  doctrine,  he  believes  that  the 
invagination  is  caused  by  the  normal  gut  being  draAvn  over  the  spasmodically 
contracted  part,  rather  than  by  that  being  mechanically  driven  into  its  sheath. 
Treves  also  adverts  to  the  influence  exercised  by  the  longitudinal  muscular 
fibres  of  the  bowel,  acting  from  the  contracted  part  as  from  a  fixed  point,  and 
thus  drawing  the  uncontracted  part  over  the  other.  Age  and  sex  are  usually 
spoken  of  as  predisposing  causes  of  invagination,  the  large  majority  of  cases 


INTUSS  USCEPTION.  519 

occurring  in  male  children ;  the  great  relative  lepgth  of  the  colon  in  infancy, 
together  with  the  width  of  the  mesocolon,  doubtless  favors  the  displacement  of 
the  gut,  and  in  some  degree  accounts  for  the  frequency  of  intussusception  in  the 
early  periods  of  life.  Impaired  general  health,  diarrhoea,  the  presence  in  the 
bowel  of  undigested  or  irritating  food,  polypoid  growths,  strictures  and  tumors 
of  the  intestine,  and  previously  existing  adhesions,  are  often  predisposing 
causes  of  more  or  less  importance.  The  exciting  cause  is  increased  and  irreg- 
ular peristaltic  movement,  no  matter  hoAv  produced. 

Symptoms. — The  chief  symptoms  of  intussusception  are  pain,  nausea  and 
vomiting,  tympanitic  distention  of  the  abdomen,  fever,  tenesmus,  with  discharge 
of  blood  and  mucus  by  the  rectum,  the  presence  of  a  tumor  (usually  on  the  left 
side),  and  a  corresponding  depression  or  flattening  on  the  right  side.  Abdom- 
inal pain  is  usually  the  first  symptom  manifested,  occurring  suddenly,  of  a  very 
intense  character,  referred  mainly  to  the  umbilicus,  the  child  Avrithing  and 
drawing  up  its  limbs  in  agony,  and  accompanied  by  vomiting  of  whatever  may 
be  in  the  stomach,  and  often  by  a  liquid  faecal  discharge,  evacuating  the  con- 
tents of  the  bowel  below  the  seat  of  obstruction.  The  pain  is  not  constant  at 
first,  but  occurs  at  irregular  intervals,  each  paroxysm  being  commonly  attended 
by  a  discharge  of  bloody  mucus  from  the  rectum,  but  as  the  case  goes  on  the 
pain  becomes  continuous,  though  even  then  marked  by  exacerbations.  The 
cause  of  the  pain  is  at  first  the  mechanical  squeezing  of  the  invaginated 
bowel  by  its  sheath ;  afterward  the  increased  peristalsis  of  the  intestine  above, 
endeavoring  to  force  its  contents  through  the  part  which  is  occluded ;  and 
finally,  the  extreme  distention  of  the  upper  bowel  and  the  inflamed  condition 
of  the  intussusception  itself  and  of  its  peritoneal  covering.  A  sudden  cessa- 
tion of  pain  in  the  last  stages  indicates  the  occurrence  of  gangrene,  which 
may  be  followed  by  discharge  of  the  sphacelated  portion  and  recovery,  but  is 
more  often  the  immediate  precursor  of  death.  Abdominal  tenderness^  local- 
ized at  the  seat  of  invagination,  is  developed  in  connection  with  the  pain  as 
soon  as  inflammation  of  the  affected  portion  of  bowel  has  set  in. 

The  vomiting  in  intussusception  is  a  very  prominent  symptom,  being  present, 
according  to  Dr.  Fitz's  statistics,  in  70  per  cent,  of  all  cases,  but  is,  I  think, 
less  distressing,  in  the  early  stages  at  least,  than  in  cases  of  internal  strangula- 
tion. When  secondary  enteritis  occurs  the  vomiting  increases,  but  even  then 
comparatively  seldom  assumes  a  faecal  character.  The  vomiting  diminishes 
again  with  the  approach  of  collapse. 

Tympanites  is  not  very  marked  in  intussusception,  being,  according  to  Dr. 
Fitz,  only  present  in  the  minority  of  cases.  Indeed,  there  is  often  a  marked 
depression  in  the  right  iliac  fossa  (signe  de  Dance)  from  the  displacement  of 
the  caecum  toward  the  left  side. 

Fever  is  not  present  at  the  beginning  of  an  intussusception,  but  is  observed 
in  connection  Avith  the  occurrence  of  secondary  enteritis,  the  thermometer  ris- 
ing to  102°  or  103°  F.  This  is  of  some  importance  in  aiding  the  diagnosis 
between  invagination  and  internal  strangulation,  the  temperature  in  the  latter 
condition  sometimes  remaining  subnormal  even  after  the  development  of  gene- 
ral peritonitis.  Partial  suppression  of  urine  often  accompanies  the  fever  in 
intussusception,  and  appears  to  depend  more  on  the  acuteness  than  on  the  local- 
ity of  the  disease. 

Unlike  other  forms  of  intestinal  obstruction,  invagination  is  not  necessarily 
accompanied  by  constipation^  though  in  the  acute  variety,  owing  to  the  lateral 
displacement  of  the  gut  from  traction  of  the  mesentery  and  to  secondary 
enteritis,  faecal  discharges  are  absent.  In  chronic  intussusception,  however, 
there  may  be  little  interference  with  defecation,  and  in  acute  cases  there  is  a 


520    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

constant  desire  to  go  to  ^ioo\,{tenesmus),  with  frequent  discbarges  of  blood  and 
mucus.     Tbis  symptom  Mr.  Pollock  considered  to  be  almost  pathognomonic. 

The  tumor  is  a  very  characteristic  symptom  of  intussusception,  and,  as 
already  mentioned,  is  usually  found  on  the  left  side.  In  tbis  it  differs  from 
the  tumor  of  faecal  impaction,  ■which  is  almost  always  found  on  the  right  side, 
and  which  may  often  be  made  to  pit  by  deep  pressure  over  its  surface.  The 
right  side  in  intussusception  is,  as  mentioned  above,  often  depressed  and  flat- 
tened (Dance's  sign),  and  the  tumor  is  painful  and  tender  to  the  touch.  It  can 
frequently  be  detected  by  introducing  the  finger  into  the  rectum,  and  sometimes 
comes  so  low  as  to  protrude  from  the  anus. 

Chronic  intussusceptions  are  sometimes  met  with,  and  have  been  particu- 
larly studied  by  Rafinesque,  who  finds  that  70  per  cent,  occur  in  the  region 
of  the  ileo-c?ecal  valve  (60  per  cent,  ileo-csecal,  10  per  cent,  ileo-colic),  and  that 
the  remainder  are  equally  divided  between  the  large  and  small  intestine.  The 
symptoms  of  chronic  invagination  are  much  less  distinctive  than  those  of  the 
acute  variety,  the  tumor  changing  its  shape  and  locality  from  time  to  time, 
faecal  evacuations  being  often  continued,  diarrhoea  sometimes  alternating  with 
constipation,  and  the  pain  and  vomiting  occurring  at  perhaps  long  intervals. 

Diagnosis. — Intussusception  has  been  confounded  with  simple  colic,  appen- 
dicitis, enteritis,  dysentery,  faecal  impaction,  and  other  forms  of  mechanical 
obstruction.  From  colic  it  may  be  distinguished  by  the  paroxj'smal  character 
of  the  pain,  the  vomiting,  and  the  tenesmus,  with  discharge  of  bloody  mucus. 
The  detection  of  a  tumor,  either  on  the  left  side  of  the  abdomen  or  by  rectal 
exploration,  would  further  demonstrate  the  nature  of  the  affection.  From 
appendicitis  and  consequent  suppurative  peritonitis,  the  diagnosis  can  be  made 
by  noting  the  symptoms  just  referred  to,  and  by  further  ob.serving  that  in 
those  affections  there  are  tympanites,  tenderness,  and  fulness  in  the  right 
iliac  fossa  (as  contrasted  with  the  depression  in  invagination),  and  an  earlier 
development  of  fever.  In  enteritis  there  is  also  fever  from  the  beginning, 
with  constipation,  but  without  bloody  discharges  and  without  any  well-defined 
tumor.  I  have  known  the  convexity  of  the  lumbar  vertebrae,  as  felt  by 
abdominal  palpation,  to  be  mistaken  for  the  tumor  of  intussusception,  but 
the  error  could  hardly  be  made  except  by  carelessness.  The  tenesmus,  pain, 
and  evacuation  of  blood  and  mucus  are  the  only  points  of  resemblance  between 
intussusception  and  dysentery,  while  the  mode  of  attack  and  course  of  the  sev- 
eral aflections  are  entirely  difl^'erent.  In  facal  impaction  there  is  a  tumor,  but 
usually  on  the  right  side,  and  it  can  be  indented  b}-  firm  pressure,  while  the 
peculiar  evacuations  of  invagination  are  wanting.  The  only  form  of  mechan- 
ical obstruction,  apart  from  intussusception,  which  is  likely  to  be  met  with  in 
children  is  internal  strangulation,  and  in  that  condition  the  profound  and  early 
collapse,  the  low  temperature,  and  the  stercoraceous  vomiting  will  clear  up  the 
diagnosis. 

Prog-nosis. — The  prognosis  in  cases  of  intussusception  is  always  grave  in 
the  extreme,  Leichtenstern's  statistics  showing  a  death-rate  (in  acute  cases)  of 
73  per  cent.,  and  Fitz's  smaller  figures  one  of  69  per  cent.  The  most  favorable 
termination  is  in  spontaneous  reduction  of  the  invagination,  Avhich  can,  as  a 
rule,  only  be  effected  during  the  first  few  days  of  the  attack,  before  the  forma- 
tion of  adhesions.  If  reduction  fails,  there  remains  a  chance  for  recovery  after 
sloughing  of  the  intussusception,  the  mortality  in  cases  in  which  this  "occurs 
being  only  41  per  cent,  while  in  those  in  which  sloughing  is  absent  the  death- 
rate  is  85  per  cent.  Even  when  sloughing  does  occur,  however,  and  the  patient 
recovers  from  the  immediate  risks  of  the  process,  he  is  by  no  means  free  from 
the  danger  of  ulterior  complications,  the  cicatricial  contraction  and  adhesions 


INTUSSUSCEPTION.  521 

which  follow  often,  as   already  mentioned,  laying  the   foundation  for  future 
obstruction  by  stricture  or  internal  strangulation. 

The  prognosis  of  chronic  intussusception  is  also  very  grave  :  while  the 
immediate  risks  to  life  are  less  than  in  the  acute  cases,  there  is  not  the  same 
hope  of  recovery  by  sloughing  and  evacuation  of  the  invaginated  part,  and, 
unless  relief  be  afforded  by  an  operation,  a  fatal  result  must  be  anticipated. 

Treatment. — The  indications  for  treatment  in  acute  intussusception  are  to 
put  the  bowel  completely  at  rest ;  if  the  case  is  seen  at  an  early  period,  to 
attempt  reduction  ;  and,  if  the  invagination  has  already  become  irreducible,  to 
sustain  the  patient's  strength  until  separation  of  the  strangulated  part  may 
occur,  when  recovery  may  be  hoped  for.  The  first  indication  is  met  by  the 
free  use  of  opium,  preferably  in  combination  with  belladonna.  These  remedies 
are  best  given  in  the  form  of  the  extract,  by  suppository,  and  of  the  former 
one-twelfth  of  a  grain,  and  of  the  latter  one-twenty-fourth,  may  be  adminis- 
tered to  a  child  of  two  years,  every  hour  or  two  hours  according  to  the 
urgency  of  the  symptoms.  Morphine  and  atropine  may  be  used  hypodermatically 
instead,  but  the  rectal  administration  is,  on  the  whole,  I  think,  to  be  preferred. 
Advantage  may  also  be  derived  from  the  employment  of  anodynes  locally,  and 
the  abdomen  may  be  covered  with  belladonna  and  mercurial  ointments  spread 
upon  lint  or  flannel  and  reinforced  by  a  warm  poultice.  In  the  attempt  to 
effect  reduction  the  physician  may  employ  large  injections  of  warm  water,  or, 
which  is,  I  think,  better,  warm  olive  oil ;  inflation  with  atmospheric  air  or 
various  gases  ;  and  manipulation  or  abdominal  taxis. 

The  injections  may  be  given  with  an  ordinary  hand-ball  syringe  or  with  a 
fountain  syringe  (gravity  injection),  the  patient  being  etherized  and  held  in  a 
semi-inverted  position,  with  the  hips  higher  than  the  shoulders,  and  the  trunk 
elevated  at  an  angle  of  about  45°.  The  height  to  which  the  reservoir  which 
supplies  the  fluid  should  be  raised  will  be  about  eight  feet  in  the  case  of  an 
infant,  and  not  more  than  twenty  feet  in  that  of  an  adult.  The  quantity  to 
be  injected  may  vary  from  one  to  six  quarts  according  to  the  age  of  the  patient. 
The  injections  are  best  administered  through  a  large  rectal  tube,  so  that  the 
force  of  the  current  may,  if  possible,  be  directed  immediately  upon  the  apex 
of  the  intussusception,  and  not  expended  upon  the  wall  of  the  bowel.  Care 
must  be  taken  not  to  allow  the  fluid  to  escape  alongside  of  the  tube,  by  pro- 
viding this,  as  suggested  by  Mr.  Lund,  with  an  India-rubber  collar,  Avhich  may 
be  firmly  pressed  against  the  anus,  or  by  wa'apping  it  with  cotton  or  lint,  which 
is  introduced  within  the  sphincter  to  accomplish  the  same  end. 

Inflation  with  atmospheric  air  may  be  practised  through  the  long  tube  or 
long-nozzled  bellows,  the  same  precautions  being  taken  against  escape  of  the 
air  aloncrside  of  the  tube  as  in  the  use  of  enemata.  Professor  Senn  recom- 
mends  the  employment  of  hydrogen  gas  as  preferable  to  atmospheric  air,  the 
gas  being  supplied  from  an  India-rubber  balloon  holding  four  gallons,  which  is 
slowly  but  steadily  compressed  by  the  operator.  Carbonic-acid  gas  is  preferred 
by  Libur,  Jate,  and  Ziemssen,  and  is  furnished  in  a  nascent  state  by  suc- 
cessively injecting  solutions  of  bicarbonate  of  sodium  and  tartaric  acid.  Abdom- 
inal taxis  Avas  introduced  as  a  mode  of  treatment  in  these  cases  by  Mr.  Jonathan 
Hutchinson,  and  consists  in  systematically  compressing  and  kneading  the 
belly  from  beloAv  upward,  the  patient  being  etherized  and  in  an  inverted  posi- 
tion. In  combination  with  the  use  of  enemata  it  has  occasionally  proved  an 
efficient  remedy,  but  its  employment  is  necessarily  attended  with  some  danger 
of  injury  to  the  bowel,  and  should  therefore,  it  seems  to  me,  be  resorted  to  with 
caution,  and  only  during  the  early  stages  of  the  case. 

Reduction  by  one  or  other  of  the  methods  mentioned  is  most  likely  to  be 


522    AJI±:BICA^^  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

accomplished  during  the  first  two  days  of  an  intussusception,  and  may  occa- 
sionally be  effected  as  late  as  the  fourtli  day,  but  after  that  period  should  not 
be  attempted,  the  physician's  efforts  being  then  directed  to  sustaining  the 
patient  through  the  processes  of  sloughing  and  evacuation  of  the  strangulated 
intussusception.  In  this  stage  the  use  of  opium  and  belladonna  should  be 
continued ;  little  or  no  food  should  be  given  by  the  mouth,  but  the  patient 
should  be  systematically  fed  by  means  of  nutritive  enemata.  To  relieve  thirst, 
■which  is  often  distressing,  water  may  also  be  given  by  enema,  and  the  patient 
mav  suck  small  pieces  of  ice.  If  the  abdomen  becomes  very  much  distended, 
the  stomach  may  be  carefully  washed  out  through  a  stomach-tube,  thus  allaying 
vomiting  and  evacuating  the  liquid  contents  of  the  upper  portion  of  the  small 
intestine ;  or  gas  and  fluid  may  be  withdrawn  by  puncturing  a  distended  seg- 
ment of  bowel  with  the  fine  tube  of  an  aspirator.  Puncture  of  the  howel, 
practised  in  this  way,  entails  a  certain  risk  of  faecal  extravasation,  but  is  fol- 
lowed by  less  shock  than  enterotomy,  which,  however,  may  be  preferred  when 
the  patient's  condition  does  not  forbid  it. 

Enterotomy — or,  as  it  is  sometimes  called,  Kelaton's  operation — consists 
in  making  an  incision,  usually  in  the  right  iliac  region,  and  opening  the  first 
distended  coil  of  intestine  which  presents  itself.  This  may  be  done  in  two 
ways :  if  it  is  not  desired  to  establish  a  f;\lse  anus,  a  knuckle  of  bowel  is  gently 
draAvn  out  through  the  wound,  and.  having  been  packed  around  with  sterilized 
gauze,  is  opened,  preferably  by  a  transverse  incision,  and  allowed  to  discharge 
itself  outside  of  the  abdominal  cavity ;  if  the  evacuation  is  not  sufficiently 
complete,  a  full-sized  drainage-tube  may  be  introduced  into  the  gut,  and  the 
surgeon  sits  by  the  patient,  keeping  the  bowel  under  observation,  if  necessary, 
for  several  hours,  until  the  fiiecal  flow  has  entirely  relieved  the  tension  ;  the 
tube  is  then  removed,  the  opening  in  the  intestine  closed  with  a  Lembert's 
suture,  the  bowel  replaced,  and  the  external  wound  closed  and  dressed  in  the 
ordinary  manner.  If  it  be  thought  better  to  establish  temporarily  a  false  anus, 
the  bowel  should  first  be  stitched  to  the  abdominal  parietes,  then  carefully 
opened,  and  the  edges  of  the  incision  again  stitched  to  the  external  wound  so 
as  to  prevent  any  possibility  of  fseces  escaping  into  the  cavity-  of  the  peri- 
toneum. If  the  case  does  well,  after  the  separation  and  evacuation  of  the 
gangrenous  intussusceptum  the  fiilse  anus  may  be  allowed  to  close,  as  it  usually 
will  without  difficulty  as  soon  as  the  natural  passage  is  restored.  If  the  open- 
ing degenerate  into  a  faecal  fistula,  a  plastic  operation  may  be  required  for  its 
relief. 

The  mode  of  treatment  above  described  is  that  which  I  would  recommend 
in  cases  of  acute  intussusception.  Laparotomy,  Avhicli  may  be  required  in 
cases  of  chronic  invagination,  does  not  seem  to  me  desirable  in  cases  of  the 
acute  variety,  and  is  shown  by  statistical  investigation  to  have  no  efiect  in 
diminishing  the  death-rate  of  the  disease.  Thus,  Avhile  Leichtenstern's  collec- 
tion of  557  terminated  cases,  taken  all  together,  gives  151  recoveries  and  406 
deaths  (73  per  cent.),  the  tables  published  in  the  fifth  edition  of  my  Surgery  give 
95  cases  treated  by  laparotomy,  with  26  recoveries  and  68  deaths  (1  undeter- 
mined), showing  an  almost  identical  percentage  of  mortality.  Fitz's  statistics 
present  the  operation  in  a  still  less  favorable  light,  51  cases  treated  without 
operation  having  giren  16  recoveries  and  35  deaths  (69  per  cent.),  while  36 
operated  on  gave  only  6  recoveries  and  30  deaths  (83  per  cent.).  The 
objections  to  the  operation  in  acute  cases  are  that  there  is.  as  has  been  seen,  a 
reasonable  chance  of  recovery  without  it,  and  that  the  eai-ly  age  at  which 
intussusception  usually  occurs  renders  operative  interference  peculiarly  danger- 
ous.    I  am  well  aware  that  a  few  brilliant  results  from  laparotomy  in  infants 


INTUSSUSCEPTION.  523 

have  been  recorded  by  Mr.  Hutchinson,  the  late  Dr.  Sands,  of  New  York,  and 
other  operators,  but  these  cases  should  be  regarded  as  surgical  curiosities,  show- 
ing what  infants  may  sometimes  safely  endure,  rather  than  as  furnishing  pre- 
cedents for  future  guidance.  In  chronic  intussusception  the  circumstances  are 
somewhat  different.  As  the  strangulation  of  the  intussusceptum  is  not  sufficiently 
complete  to  offer  a  chance  for  recovery  by  the  process  of  sloughing,  when  the 
surgeon  finds  that  reduction  cannot  be  effected  the  operation  may  be  properly 
resorted  to,  particulai'ly  as  in  these  cases  the  patients  have  usually  passed  the 
period  of  infancy.  When  the  bowel  protrudes  through  the  anus,  the  plan  sug- 
gested by  Howse,  and  successfully  employed  by  Mikulicz,  Willard,  Fuller,  and 
others,  may  be  tried,  the  protruding  portion  being  held  from  retracting  by 
strong  pins,  and  then  cut  off;  but  under  other  circumstances  laparotomy  is  the 
proper  measure. 

Laparotomy  for  intussusception  may  be  thus  performed  :  The  patient  having 
been  etherized  and  the  abdominal  wall  carefully  cleansed,  an  incision  is  made 
directly  over  the  tumor  if  one  can  be  recognized,  but  otherwise  in  the  median 
line.  The  wound  is  carefully  deepened  until  the  peritoneum  is  reached,  when 
this  is  opened  with  every  precaution  against  injury  to  the  bowels  or  other 
viscera.  If  the  intussusception  is  found,  the  invaginated  gut  is  brought  out 
through  the  incision,  the  rest  of  the  intestine  being  gently  pressed  back  with 
warm  towels  or  sponges,  since  the  exposure  and  chilling  of  large  portions  of 
bowel  always  produces  an  unfavorable  effect  on  the  patient.  Careful  attempts 
at  reduction  are  then  to  be  made  by  gently  compressing  and  pushing  upward 
the  invaginated  part  from  below,  this  being  at  once  safer  and  more  efficient 
than  efforts  to  withdraw  the  gut  by  traction  from  above.  If  the  intussuscep- 
tion is  not  immediately  found,  the  surgeon  introduces  his  hand,  through  the 
incision,  which  in  this  case  would  be  median,  and  explores  the  right  iliac  fossa,  as 
recommended  by  Mr.  Treves,  finding  the  caecum,  and  then  searching  upAvard  or 
downward  according  as  that  part  is  empty  or  distended  with  faeces.  In  examin- 
ing the  small  intestine  the  direction  in  which  the  search  should  proceed  may 
be  determined,  as  suggested  by  Mr.  Head,  by  observing  the  relations  of  the 
mesentery,  which  is  attached  to  the  posterior  wall  of  the  abdomen  from  the 
left  side  of  the  second  lumbar  vertebra,  obliquely  downward  to  the  right  sacro- 
iliac symphysis.  If  reduction  cannot  be  effected,  the  surgeon  may  proceed  to 
the  establishment  of  a  false  anus  immediately  above  the  seat  of  invagination, 
or,  if  the  state  of  the  patient  should  permit  more  prolonged  manipulation,  he 
may  excise  the  intussusception  bodily  {enter ectomy),  and  restore  the  continuity 
of  the  bowel  either  by  direct  suture  {circular  enterorraphy)  or  by  Prof.  Senn's 
method  of  lateral  anastomosis^  as  may  be  thought  best.  The  latter  procedure 
or  one  of  its  modifications — for  a  description  of  which  the  reader  is  referred  to 
special  works  on  surgery — is  ordinarily  preferable,  as  requiring  less  time  than 
the  end-to-end  suture.  The  subsequent  treatment  is  to  be  conducted  as  after 
laparotomy  for  other  causes,  as  has  been  described  in  the  article  on  Diseases  of 
the  Appendix. 


INTESTINAL  PARASITES. 

By  CHARLES  W.  TOWNSEND,  M.  D., 

Boston. 


The  older  writers  on  the  diseases  of  cliildreii  devote  a  good  deal  of  space 
to  the  subject  of  intestinal  worms,  particular!}^  to  the  symptoms  supposed  to  be 
caused  by  them,  and  to  their  treatment.  Text-books  of  to-day  dwell  more 
upon  the  natural  history  of  these  animals — an  extremely  interesting  subject — 
but  are  apt  to  pass  very  lightly  over  the  practical  considerations  of  symp- 
tomatology and  treatment.  Although  intestinal  worms,  like  the  teeth,  have 
with  propriety  been  dethroned  from  their  high  position  as  etiological  factors 
in  many  of  the  diseases  of  children,  Ave  must  not  be  carried  too  far  with  the 
swing  of  the  pendulum  and  disregard  entirely  the  parasite  as  a  causative  agent. 
Among  the  laity,  with  exceptions  among  the  upper  classes,  worms  still  hold  a 
very  important  position,  and  it  is  essential,  therefore,  that  we  should  look  at 
the  subject  fairly,  and  not  pass  it  off'  as  of  very  minor  importance. 

There  are  no  intestinal  parasites  peculiar  to  infancy  and  childhood,  although 
the  round-  and  pin-worms  are  so  much  more  common  in  children  than  in  adults 
that  they  are  often  spoken  of  as  peculiar  to  children. 

Omitting  several  varieties  that  are  rarely  encountered  and  are  of  no  practical 
importance,  the  species  of  worms  that  are  found  in  children  are  as  follows : 
Ascaris  lumbricoides,  round-worm ;  oxyuris  vermicularis,  pin-woi'm ;  two 
species  of  tape-Avorms,  txina.  mediocanellata,  beef  tape-worm,  and  taenia  solium, 
pork  tape-worm  ;  and  the  unimportant  trichocephalus  dispar.  All  of  these  are 
Nematode  worms,  Avith  the  exception  of  the  tsenise,  which  belong  to  the  group 
of  Cestodes. 

As  these  parasites  have  diff'erent  habits  and  habitats,  and  each  requires  a 
special  treatment,  it  will  be  necessary  to  consider  them  individually. 

I.  Ascaris  Lumbricoides  (Round-worm). 

The  male  round-worm  is  from  four  to  six  inches  in  length,  the  female  about 
ten  inches.  It  is  of  a  yellowish-Avhite  color,  more  or  less  tinged  with  red  in 
the  fresh  state ;  as  usually  shoAvn,  preserved  in  alcohol,  it  is  of  an  ivory  Avhite. 
The  Avorm  is  cylindrical  in  shape,  tapering  to  a  point  at  both  ends.  The  mouth 
is  situated  betAveen  three  lips  furnished  Avith  fine  teeth  at  the  anterior  extremity 
of  the  body.  The  anus  is  about  an  inch  from  the  posterior  extremity,  and  the 
vulva  in  the  female  is  anterior  to  the  middle.  The  sexes  are  easily  distinguished 
by  their  relative  size  and  by  the  fact  that  the  posterior  extremity  of  the  male 
is  curved,  that  of  the  female  being  straight  (Fig.  1,  a  and  b). 

From  earth-worms,  which  I  have  known  to  be  presented  by  patients  Avith 
the  intention  of  deceiving,  they  may  be  distinguished  by  their  color  and  by 
the  fact  that  earth-worms,  being  annelids,  have  plainly-marked  segments. 
Female  lumbricoids  Avhich  have  been  carelessly  handled  and  subjected  to  pres- 

624 


INTESTINAL    PARASITES,  525 

sure  often  show  the  ovaries  hanging  out  like  a  bunch  of  small  worms,  and  may 
deceive  the  superficial  observer. 

The  ova  of  the  round-worm  are  produced  by  the  females  in  great  quantities, 

Fig.  1. 


Round-worms   and   Pin-worms    (%   Natural   Size),     a,  Male    Round-worm :    b.  Female  Round-worm ; 

c,  Female  Pin-worm. 

and  pass  off  in  the  faeces,  Avhere  they  can  easily  be  found  with  the  microscope. 
They  are  oval  in  shape,  about  ^^  of  an  inch  long,  with  dark  granular  con- 
tents and  thick  transparent  coats,  which  are  often  stained  yelloAV  by  bile  (Fig. 

The  proper  habitat  of  the  adult  ascarides  is  the  small  intestine,  but  they 
are  of  a  wandering  disposition,  and  have  been  found  in  the  stomach,  oesopha- 
gus, and  mouth,  occasionally  getting  up  into  the  posterior  nares  and  coming 
out  anteriorly,  or  going  down  into  the  larynx  or  even  into  the  lungs.  They 
also  wander  down  into  the  rectum,  and  are  expelled  with  the  faeces  or  slip  out 
unattended.  They  have  even  escaped  into  the  peritoneal  cavity  through  per- 
forations made,  not  by  them,  as  was  once  supposed,  but  by  ulcerations.  They 
have  been  known  to  pass  into  the  pancreatic  and  biliary  ducts.  When  in  large 
numbers  the  worms  are  often  coiled  together  into  balls  in  the  intestines.  The 
ova  do  not  develop  until  they  have  passed  out  with  the  faeces,  and  have  again 
found   their   way  into  the  child's  gastro-intestinal   canal,  when  the  embryos 


ryZe    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


rapidly  come  to  maturity.  Outside  of  the  body  they  resist  destructive  agencies 
with  great  obstinacy,  and  it  is  said  may  retain  their  vitality  for  years. 

Method  of  Infection. — As  the  ova  are  produced  in  such  countless  num- 
bers— Davaine  having  found  some  three  thousand  eggs  in  a  bit  of  fgeces  as 
large  as  a  grain  of  wheat — and  as  they  are  so  resistant  to  outside  destructive 
agencies,  it  is  not  surprising  that  they  should  be  very  common  among  the  classes 
of  individuals  where  personal  cleanliness  is  not  cultivated.  As  children  are 
greater  barbarians  in  their  personal  habits  than  adults,  it  is  natural  that  ascari- 
des  should  be  much  more  often  found  among  them.  The  habit  children  have 
of  putting  their  fingers  as  well  as  toys  and  other  objects  into  their  mouths 
might  easily  lead  to  self-infection  with  ova  from  parasites  in  their  own  intestines, 
as  well  as  with  ova  from  elsewhere.  In  the  country,  infants  creeping  about  the 
floor  may  be  infected  by  the  dust  brought  in  on  the  shoes  from  manure-heaps. 

Among  the  upper  classes  ascarides  are  certainly  very  much  less  common, 
and  they  are  rarely  seen  in  the  adult.     Here,  where  habits  of  cleanliness  are 

Fig.  2. 


Comparative  size  of  eggs  of  Intestinal  Parasites:  o,  Taenia  Solium;  b,  Taenia  Mediocanellata ;  e,  Ascaris 
Lumbricoides ;  d,  Trichocephalus  Dispar ;  c,  Oxyuris  Vermieularis.    (After  Striimpell.) 

cultivated,  infection  would  be  more  likely  to  come  only  through  drinking-water 
or  food.  If  the  contents  of  privies  are  used  in  the  garden  for  manure,  the 
contained  ova  may  readily  find  their  way  into  water  used  for  drinking  or  be 
served  with  salads  or  other  uncooked  vegetables.  By  proper  filtration  of  the 
water  or  by  cooking  of  vegetables,  this  danger  can  be  escaped. 

Symptoms. — It  is  not  uncommon  to  find  numerous  intestinal  worms  in 
the  lower  animals  without  any  evidence  of  ill  effect,  and  it  is  frequently  the 
case  that  we  discover  lumbricoides,  in  greater  or  less  numbers,  in  the  dejec- 
tions of  children  Avho  are  well  in  every  way  and  have  presented  none  of  the 
classical  symptoms  of  worms.  It  is  certainly  the  case,  therefore,  that,  while 
the  round-worm  is  confined  to  its  proper  place — the  small  intestine — even  if 
it  be  in  great  numbers,  it  may  be,  and  generally  is,  entirely  harmless,  and 
has  no  appreciable  effect  on  the  condition  of  the  child,  producing  no  symptoms. 
The  amount  of  nourishment  it  extracts  for  itself  is  hardly  worth  considering 
unless  the  worms  exist  in  great  numbers. 

On  the  other  hand,  when  we  consider  the  high  state  of  nervous  tension  that 
exists  in  the  child,  and  the  ease  with  which  reflex  phenomena  are  produced, 
it  is  reasonable  to  suppose  that  the  presence  of  the  living  worms  in  the  intestine 
may  cause  certain  reflex  symptoms,  and  in  that  Avay  interfere  with  the  general 
health. 

The  common  symptoms  ascribed  to  round-worms  by  the  laity  are  general 
lassitude,  with  nervous  fidgeting,  picking  at  the  nose,  offensive  breath,  abdominal 
pain,  headaches,  feverish  attacks — called  "worm  fever" — and  lack  of  flesh, 
notwithstanding  a  fair,  or  at  times  ravenous,  appetite.  The  bowels  are  irregular, 
there   being  either  constipation  or  diarrhoea  with  mucous  discharges.     Tliere 


INTESTINAL    PARASITES.  527 

may  be  vomiting  and  disturbed  sleep  with  grinding  of  the  teeth.  This  is  the 
common  and  exact  picture  of  a  child  debilitated  by  improper  feeding  and  an 
insufficiency  of  fresh  air  and  exercise — a  child  that  is  cooped  up  with  many 
others  in  close  school-room  air,  and  whose  whole  life  is  poorly  managed  from  a 
hygienic  point  of  view.  That  such  children  sometimes  have  ascarides  is  not 
surprising  when  we  consider  the  ease  of  infection,  but  that  the  parasites  are  the 
cause  of  their  condition  is  certainly  not  the  case,  although  the  nervous  symp- 
toms may  undoubtedly  be  aggravated  by  them.  It  is  probable  that  these 
debilitated  children,  with  plenty  of  mucus  in  their  intestines,  are  more  desir- 
able habitats  for  the  round-worms,  so  that  the  parasites  thrive  in  this  class  and 
retain  their  foothold,  while  healthier  children  more  easily  get  rid  of  them. 

The  symptom,  picking  the  nose,  is  often  spoken  of  by  mothers  as  if  it  were 
pathognomonic  of  worms.  This  is  not  the  case ;  it  is  simply  a  nervous  trick 
common  to  debilitated  children,  as  is  often  proved  by  the  unproductive  admin- 
istration of  anthelmintics.  My  experience  is  that  in  the  majority  of  cases 
where  round-worms  are  found,  their  presence  is  unsuspected  and  their  dis- 
covery accidental.  Having  once  been  found,  it  is  common  enough  for  almost 
any  symptom  to  be  attributed  to  them  by  the  mother. 

Numerous  cases  have  been  reported,  however,  where  the  connection  between 
the  worms  and  severe  nervous  symptoms,  such  as  convulsions,  chorea,  aphonia, 
etc.,  seemed  to  be  very  intimate,  the  nervous  symptom  being  relieved  on  the 
evacuation  of  the  parasites. 

One  such  case  is  recorded  among  those  in  the  Boston  Children's  Hospital : 

Kate  M ,  four  years  old,  had  had  two  convulsions  before  she  came  under  observa- 
tion. She  was  in  good  general  condition,  and  no  reflex  cause  could  be  found  for  the  con- 
vulsions except  round- worms,  which  she  had  passed  from  time  to  time.  She  was  given 
santonin  :  a  quantity  of  worms  were  expelled,  and  she  x'emained  well  for  six  months,  when 
she  had  another  convulsion.  Worms  were  again  brought  away,  but  she  came  back  a 
month  later,  reporting  occasional  attacks  of  twitching  and  tremors,  but  no  real  convul- 
sions. Anthelmintic  treatment  again  expelled  round-worms,  and  she  was  lost  sight  of 
for  three  years,  during  which  there  was  no  history  of  worms  or  nervous  phenomena.  At 
the  end  of  this  time  she  again  applied  for  treatment  for  attacks  every  two  or  three  weeks 
of  flushing  and  pallor,  pain  in  the  belly  and  convulsions.  Santonin  tvas  again  given, 
bringing  away  worms  and  giving  relief  as  before. 

There  is  a  certain  mechanical  danger  from  ascarides,  owino-  to  their  habit 
of  wandering.  A  number  of  cases  have  been  recorded  of  these  worms  entering 
the  cystic  and  common  bile-ducts,  giving  rise,  in  the  latter  case,  to  jaundice. 
They  have  even  penetrated  to  the  hepatic  ducts  and  caused  abscesses  of  the 
liver.  They  have  also  been  found  in  perityphlitic,  hernial,  and  tubercular 
abscesses  connected  with  the  intestine,  having  wandered  into  these  abscesses 
after  their  formation,  and  possibly  in  some  cases  contributing  to  the  irritation 
and  suppuration  there.  That  they  may  cause  perforation  of  the  normal  intestine 
is  not  the  case,  but  Avhen  we  consider  their  stiffness  and  activity  during  life, 
and  their  sharply-pointed  extremities,  it  does  not  seem  unlikely  that  they  might 
break  through  an  ulceration  which  needed  only  the  last  straw,  so  to  speak,  but 
which  otherwise  might  have  healed. 

Another  danger  from  round-worms  arises  from  the  fact  that  they  sometimes 
ascend — with  or  without  the  aid  of  vomiting — into  the  fauces,  whence  they 
may  be  drawn  into  the  larynx  and  cause  suffocation  and  death.  If  the 
worm  be  drawn  into  the  trachea  or  a  bronchus  and  is  not  expelled,  death  is 
not  immediate,  but  ensues  in  thi-ee  or  four  days  from  gangrene  of  the  lung. 
The  fact  that  a  child  is  found  dead  with  a  lumbricoid  in  the  larynx  does 
not,  however,  necessarily  prove  that  this  was  the  cause  of  death,  for  these  worms 


528    A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

not  infrequently  wander  away  from  the  intestine  after  death  from  other  causes. 
In  the  majority  of  cases  when  the  worm  ascends  to  the  fauces  it  is  expelled 
through  the  mouth,  or  more  rarely,  through  the  nose. 

When  the  parasites  are  collected  in  great  numbers  in  the  intestine,  they 
may  mechanically  cause  congestion  of  the  mucous  membrane,  and  even  obstruc- 
tion of  the  bowel,  or  volvulus.  In  these  cases  the  Avorms  are  found  tightly 
twisted  together,  forming  an  obstructive  ball. 

Hillyer,  in  the  Lancet  (1892,  ii.,  p.  773),  relates  an  interesting  case  of  this 
sort,  where  there  were  at  the  same  time  extreme  nervous  symptoms : 

A  child,  five  and  a  half  years  old,  never  strong,  began  to  have  severe  abdominal 
pains,  for  which  castor  oil  was  given  with  the  result  of  causing  vomiting,  but  no  action 
of  the  bowels.  Three  round  worms  were  found  in  the  vomitus.  The  child  then  became 
unconscious,  the  eyes  wide  open,  the  prfpils  dilated,  the  skin  cold  and  clammy.  Death 
ensued  on  the  following  day.  At  the  autopsy  the  ileum  was  found  occluded  at  a  point 
fifteen  inches  above  the  ileo-ciieca]  valve  by  a  tightly-wound  ball  of  eight  round  worms. 
Forty-two  worms  in  all  were  found  in  the  intestine.  There  was  extreme  congestion  of 
the  intestine  above  the  obstruction  and  at  tliat  point.  Below  the  obstruction  the  bowel 
was  empty,  above  it  was  distended. 

Diagnosis. — This  can  never,  and  should  never,  be  made  Avithout  seeing 
the  worms  themselves  or  their  eggs.  Motliers  in  their  anxiety  often  mistake 
shreds  of  mucus  for  worms,  so  it  is  essential  that  the  physician  should  see  the 
suspected  parasites  in  every  case.  As  Avas  stated  above,  debilitated  children 
with  mucus  in  their  dejections  are  the  ones  that  present  symptoms  popularly 
thought  to  be  diagnostic  of  worms. 

The  ova  are  so  numerous  that  they  are  easily  found  in  the  sediment  of 
liquid  stools;  this  can  be  scraped  from  the  napkin  or  taken  up  Avith  a  pipette, 
or  the  residue  examined  after  filtration.  If  the  stools  are  not  naturally  liquid, 
they  can  be  stirred  up  Avith  Avater.  A  method  suggested  by  Epstein  is  simple 
and  effective, — viz.  the  introduction  of  a  Ndlaton  catheter  into  the  rectum. 
The  small  amount  of  foeces  that  Avill  cling  to  the  eye  of  the  catheter  is  in(n-e 
than  sufficient  for  microscopic  examination.  The  poAver  generally  used  for 
urinary  sediments — i.  e.  about  330  diameters — ansAvers  for  these  examinations. 
The  eggs,  Avhich  have  been  described  above,  are  easily  recognized  (Fig.  2,  c), 
and  readily  distinguished  from  the  smaller,  sharper,  oval  eggs  of  the  pin-Avorm 
and  the  round  eggs  of  the  tape-worm. 

Treatment. — Although  ascarides,  as  a  rule,  cause  no  discomfort  and  are  in 
no  wise  detrimental  to  the  host,  when  Ave  consider  the  various  accidents,  some 
of  them  fatal,  Avhich  may  be  caused  by  them,  as  Avell  as  the  obscure  nervous 
symptoms  which  occasionally  OAve  their  origin  to  this  source,  it  is  certainly 
wiser  to  treat  all  cases  as  soon  as  they  are  discovered,  and  to  get  rid  of  the 
worms'. 

Of  the  remedies  that  can  be  used  for  round-worms,  it  is  hardly  Avorth  Avhile 
to  mention  more  than  three.  These  are  santonin,  spigelia,  and  chenopodium. 
All  of  these  have  the  poAver  of  killing  or  benumbing  the  parasites,  but  require 
the  aid  of  cathartics  to  cause  their  expulsion. 

Santonin,  made  from  Levant  worm-seed,  is  probably  the  most  widely  used 
of  all  anthelmintics.  It  is  the  common  basis  of  proprietary  Avorm-lozenges. 
Care  should  be  used  in  its  administration,  as  it  is  extremely  poisonous  in  over- 
doses, several  fatal  cases  having  been  reported.  In  poisonous  doses  it  produces 
gastro-intestinal  irritation,  dizziness,  tremor,  yelloAv  vision,  dilated  pupils,  and 
loss  of  consciousness,  Avith,  at  times,  convulsions.  Santonin  is  an  almost  taste- 
less white  powder,  nearly  insoluble  in  water.  It  can  be  given  in  powder  mixed 
Avith  sugar,  or  made  up  into  lozenges.     The  dose  at  the  age  of  tAvo  years  is 


INTESTINAL   PARASITES.  529 

^  to  1^  grain;  at  six,  1  grain;  and  at  twelve  or  fifteen,  2  grains.  It  should 
be  given  morning  and  night,  or  in  some  cases  three  times  daily,  with  the 
addition  of  a  cathartic — calomel,  castor  oil,  or  cascara  cordial — every  second 
day  as  long  as  lumbricoids  continue  to  be  passed.  When  it  is  remembered 
that  very  grave  symptoms  have  been  caused  by  a  dose  of  4  grains  to  a  child 
four  years  old,  and  that  a  feeble  child  of  five  has  been  killed  by  2  grains  of 
santonin,  it  is  easily  seen  tl^at  care  must  be  used  in  its  administration,  and  that 
there  is  danger  in  its  indiscriminate  use. 

Spigelia,  or  pink-root,  one  of  our  native  plants,  is  also  an  efficient  and,  in 
proper  doses,  entirely  safe  drug.  The  freshly  prepared  fluid  extract  of  spigelia 
and  senna^  of  the  Pharmacopoeia  of  1870  combines  the  necessary  cathartic  with 
the  anthelmintic  in  a  manner  both  efficient  and  pleasant  to  the  taste.  The 
dose  is  half  a  teaspoonful  for  a  child  of  two  years,  a  teaspoonful  for  one  from 
four  to  ten  years  old.  It  should  be  given  two  or  three  times  daily,  depending 
on  its  effect  upon  the  bowels. 

Oil  of  chenopodium  is  the  third  remedy  for  ascarides,  and  is  said  to  be 
safer  and  less  irritating  than  the  others.  It  can  be  given  on  sugar  in  doses  of 
five  drops  to  a  child  of  three,  and  ten  drops  to  one  of  ten  years,  three  times 
daily.  A  cathartic  is  required,  as  with  the  other  anthelmintics,  and  should  be 
given  every  second  or  third  day. 

n.  OxYURis  Vermicularis  (Pin- worm,  Thread-worm,  Seat- worm). 

This  is  a  small  worm,  as  the  first  two  of  its  common  names^  would  imply. 
(Fig.  1  shows  the  comparative  size  of  pin-  and  round-worms.)  The  female 
is  from  a  quarter  to  half  an  inch  in  length ;  the  male,  only  about  a  third 
as  large,  measures  from  ^Jj  t<^  i  of  an  inch.  Its  color  is  nearly  white,  its 
shape  fusiform,  tapering  to  a  fine  point  in  the  female,  having  a  blunter  and 
generally  curved  tail  in  the  male.  The  mouth  is  situated  in  the  middle  of  the 
blunt  end,  and  is  surrounded  by  three  slightly  projecting  lips  (Figs.  3,  4). 
The  eggs  are  ovoid  in  shape,  more  pointed  at  one  end.  They  measure  0.053 
mm.  in  length  by  0.028  mm.  in  breadth,  are  considerably  smaller  than  the  eggs 
of  ascaris,  and  have  a  thinner  and  smoother  coating  (Fig.  2,  e). 

This  worm  inhabits  the  rectum  and  large  intestine  throughout  its  entire 
course,  as  well  as  the  lower  end  of  the  small  intestine.  The  eggs  are  passed 
out  with  the  faeces  in  great  numbers,  and,  when  swallowed,  the  embryo  is  set  free 
in  the  digestive  tract  and  descends  to  the  colon,  rapidly  developing  into  the 
adult  woi^m.  The  number  of  these  parasites  in  one  individual  may  be  so 
enormous  that  the  whole  mucous  surface  of  the  colon  and  rectum  becomes  coated 
with  them,  as  if  with  a  layer  of  pus.  In  the  caecum,  where  they  are  undis- 
turbed, the  sexes  are  about  equally  divided.  In  the  rectum  and  in  the  stools 
the  females  preponderate,  as,  owing  to  their  larger  size,  they  are  less  easily 
destroyed  than  the  smaller  more  fragile  males.  The  great  preponderance  of 
females  is  also  partly  apparent,  as  the  males,  from  their  minute  size,  are  often 
overlooked.  Pin-worms  are  frequently  seen  alive  outside  the  anus  in  the  folds 
of  skin,  sometimes  getting  into  the  groins,  and  in  little  girls  they  often  crawl 
into  the  vagina. 

Method  of  Infection. — Auto-infection  is  constantly  taking  place  in  chil- 
dren having  pin-worms.  The  irritation  caused  by  the  worm  leads  them  to 
scratch  about  the  anus  ;  numerous  eggs  become  lodged  under  the  finger-nails, 
and  are  later  taken  into  the  mouth  and  stomach.     It  is  very  common  to  find 

'  This  can  be  written  for  directly.  Its  formula  is  as  follows :  li .  Ext.  spigelise  fl.,  f  5x. ;  Ext. 
sennse  fl.,  f^vj.;  Olei  anisi,  Ti:\^xx. ;  Olei  cari,  n\^xx. 

34 


530    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 


Fig.  4. 


several  children  in  one  family  suffering  simultaneously.  Food  and  toys  that 
are  handled  by  these  children  become  carriers  of  the  infection.  Vegetables 
and  drinking-water  may  also  be  infected,  as  in  the  case  of  round-worms. 

Syraptoms. — The  oxyuris  gives  rise  to  a  very  evident  symptom  in  nearly 
all  cases — namely,  an  intense  itching  about  the  anus,  -which  leads  the  patient 
to  scratch  vigorously,  causing  bleeding  and 
in  .some  cases  setting  up  an  eczema.  The 
itching  occurs  most  severely  in  the  early 
part  of  the  night  while  the  patient  is  in 
bed.  It  is  thought  to  be  due  to  the  move- 
ments of  the  worms  in  the  rectum,  and 
is  entirely  relieved  by  their  removal  from 
this  point,  even  if  they  remain  in  quanti- 
ties higher  up.  In  fact,  it  is  probable 
that  the  parasites  while  in  the  small  intes- 
tine produce  no  appreciable  symptoms. 

As  a  result  of  the  itching  the  sleep  of 
the  child  is  disturbed,  and  various  slight 
nervous  symptoms  may  be  induced.    Grind- 
Oxyuris Vermicuia-  inc;  of  the  teeth,  crvinor  out  in  .sleep,  invol- 

ris:  a,  Male,  Nat-         '^  ^     -^   i  •  *       i     •  • 

urai  size ;  6,  The  untary  twitchmg,  and  msomnia  are  com- 
(after  Bened^n)^'  Q^on.  In  one  of  my  cases  pavor  nocturnus 
was  apparently  caused  by  the  reflex  irri- 
tation of  the  worms ;  and  in  a  very  sensitive  child  it  is 
probable  that  reflex  convulsions  or  chorea  might  ensue. 
As  a  result  of  the  disturbed  rest  and  of  the  more  or  less 
constant  irritation,  the  patient  is  often  debilitated,  peevish. 
and  nervous,  and.  like  all  nervous  children,  apt  to  acquire 
the  trick  of  picking  the  nose,  and  to  have  occasional  reflex 
feverish  attacks.  He  may.  however,  escape  without  a 
symptom. 

In  tAvo  of  the  pin-worm  cases  at  the  Boston  Children's 
Hospital  fainting  was  a  prominent  symptom.  One  of  these. 
a  girl  of  ten  years,  was  said  to  have  "  worm-fever '"  about 
once  a  month.  Kx  this  time  she  had  fainting  attacks  and 
passed  great  quantities  of  the  parasites. 

xA.s  a  reflex  cause  of  incontinence  of  urine  these  parasites 
hold  a  well-recognized  place.  In  eight  of  the  hospital  cases 
incontinence  existed.  In  girls  vulvo-vaginitis  is  sometimes 
caused  by  the  irritation  of  the  worms  that  have  found 
their  way  into  the  vagina ;  this,  in  turn,  is  also  a  cause  of  incontinence  of 
urine.  Nine  instances  are  recorded  among  48  cases  at  the  hospital.  As  34 
of  these  cases  were  in  girls,  this  makes  a  proportion  of  27  per  cent,  of  vulvo- 
vaginitis from  this  cause.  The  great  preponderance  of  females  in  this  list.  34 
to  14.  may  be  partly  explained  by  the  urgent  symptom  of  vulvo-vaginitis  call- 
ing them  to  the  hospital  for  treatment.  Curiously  enough,  the  same  prepon- 
derance of  girls  is  also  found  in  the  round-worm  cases — 11  girls  to  5  boys. 
Masturbation  in  either  sex  may  be  caused  by  the  irritation.  One  of  my 
cases  had  a  rectal  polypus,  probably  due  to  rectal  irritation.  Prolapse  of  the 
rectum  may  be  set  up  by  the  straining.  As  to  the  age  at  which  the.se  worms 
are  chiefly  found  in  children,  35  of  the  48  cases  at  the  hospital  occurred  in  chil- 
dren between  two  and  seven  years  old,  inclusive.  The  youngest  was  an  infant 
of  twentv-one  months. 


Oxyuris  Vermiculari? : 
a'  Female,  Natural 
size  :  b.  The  same  en- 
larged. (After  BeDC- 
den). 


INTESTINAL   P-ARASITES.  531 

As  bearing  on  the  frequency  of  worms  in  general,  and  of  each  species  in 
particular,  I  have  examined  the  out-patient  records  of  the  Boston  Children's 
Hospital,  and  find  that  out  of  5200  medical  patients  of  all  kinds,  there  were 
65  where  the  diagnosis  of  worms  was  made  on  the  evidence  of  the  parasites 
themselves.  My  general  impression  was  that  the  round-worms  Avere  more 
common  than  the  pin-worms  in  children,  and  this  is  so  stated  by  Councilman 
in  the  Cyclopcedia  of  the  Diseases  of  Children.  A  much  larger  number  of  the 
latter  were  seen  at  the  Children's  Hospital,  however,  owing  no  doubt  to  the 
more  urgent  symptoms  they  produce,  and  the  general  absence  of  symptoms  in 
round-worms.  Forty-eight  of  the  65  cases  had  pin-worms,  and  only  17  round- 
worms, 3  of  these  being  afflicted  with  both  varieties.  The  remaining  four  had 
tape-worms — in  1,  Taenia  solium  ;  in  1,  Taenia  mediocanellata  ;  and  in  2  the 
species  was  not  accurately  determined. 

Diagnosis, — As  in  all  cases  of  intestinal  parasites,  the  diagnosis  can  only 
be  made  with  certainty  by  the  discovery  of  the  worm  itself  or  the  ova.  The 
history  of  anal  pruritus  in  a  child  should  always  lead  one  to  suspect  the  pre.s- 
ence  of  pin-worms,  and  the  anus  and  its  neighborhood  should  be  carefully 
searched.  By  the  use  of  an  enema  large  numbers  of  the  worms  may  be 
brought  to  light.  By  examining  under  the  microscope  scrapings  from  beneath 
the  finger-nails,  the  folds  about  the  anus,  or  the  detritus  scooped  out  from 
inside  the  anus  with  a  grooved  director  or  catheter,  the  eggs  are  often  found  in 
large  quantities,  and  are  easily  recognized,  as  described  above.  In  all  cases  of 
incontinence  of  urine,  masturbation,  and  leucorrhoea  the  oxyuris  should  be 
thought  of  and  sought  for. 

As  in  the  case  of  lumbricoids,  intestinal  mucus,  which  in  greater  or  less 
quantity  is  mingled  with  fsBcal  discharges,  has  often  been  mistaken  by  the 
nurse  or  mother  for  pin-worms,  as  is  illustrated  by  the  following  case : 

Allen  M ,  three  and  one-half  years  old,  was  brought  to  my  clinic  at  the  Boston 

Children's  Hospital  with  the  history  of  having  passed  great  quantities  of  pin-worms  in 
the  last  few  days.  His  symyitoms,  which  the  mother  attributed  to  the  worms,  were 
vomiting,  slight  diarrhoea,  with  feverishness  and  general  debility.  He  had  a  similar 
attack  a  year  ago,  and  was  thought  to  have  passed  worms  then.  Examination  in  the 
folds  about  the  anus  failed  to  reveal  any  worms,  and  a  microscopical  examination  of 
detritus  from  under  the  finger-nails,  outside  the  anus  and  inside  the  anus  was  negative 
as  regards  the  finding  of  ova.  The  mother  brought  next  time  some  of  the  faeces  which 
she  believed  to  be  swarming  with  the  worms.  The  faecal  mass  when  placed  in  water 
showed  plenty  of  stringy  mucus,  which,  gathered  in  thread-like  clusters,  certainly  simu- 
lated very  closely  actual  pin-worms.  There  was  in  this  case  undoubted  irritation  of 
the  intestine,  giving  rise  to  various  symptoms  suggestive  of  worms,  and  to  an  extra 
secretion  of  mucus.    The  irritation,  however,  was  due  to  an  improper  diet,  not  to  worms. 

Treatment. — As  long  as  any  worms  remain  in  the  bowel  there  is  a  con- 
stant source  of  infection.  Treatment  must  therefore  result  in  the  complete 
expulsion  of  the  parasites,  or  we  shall  have,  what  is  often  unfortunately  the 
case,  a  relapse  or  return  of  the  trouble.  Besides  this,  measures  must  be  taken 
to  prevent  reinfection  from  the  old  sources  after  cure.  If  the  worm  confined 
itself  to  the  rectum,  as  is  erroneously  believed  by  some,  treatment  from'  below 
with  injections  would  be  simple  and  effectual.  This  treatment,  although  giving 
relief  for  a  time,  is  of  course  entirely  inadequate,  as  many  of  the  worms  are 
out  of  reach  in  the  caecum  or  even  in  the  lower  part  of  the  small  intestine. 
The  proper  method,  therefore,  is  to  make  the  attack  both  from  above  and 
below.  By  the  mouth  may  be  given  either  santonin,  spigelia,  or  chenopodium, 
with  a  cathartic,  in  the  manner  already  described  in  the  treatment  of  ascarides. 
Cathartics  which  produce  free  watery  discharges  are  found  to  be  particularly 
efficient  in  the  treatment,  even  without  a  previously  administered  vermicide. 


532     A3IEBICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

Epsom  salts,  Seidlitz  powder,  or  Hunyadi  water  are  therefore  to  be  recom- 
mended, but  are  all  unfortunately  distasteful  to  children.  The  syrup  of 
raspberry  disguises  very  well  the  taste  of  Epsom  salts  in  a  25  per  cent, 
solution,  thus : 

I^.   Magnesii  sulphatis .^iv. 

Syrupi  rubi  idgei foij- — M. 

Sig.  A  tablespoonful  containing  one  drachm  of  the  salts. 

The  vermicide  and  cathartic  may  be  given  by  the  mouth  two  or  three  days  in 
the  week. 

Once  a  day  the  rectum  should  be  washed  out  with  a  copious  enema  of  cool 
soapy  Avater.  By  using  a  soft-rubber  catheter  attached  to  the  nozzle  of  the 
syringe  the  enema  can  be  introduced  higher  up,  and  will  be  more  effectual. 
Plenty  of  water  should  be  used,  so  as  to  distend  the  folds  of  the  rectum  and 
colon  in  which  the  worms  are  lodged.  Cold  water  alone  is  effectual  in  washino; 
out  and  killing  the  worms,  but  the  addition  of  castile  soap  makes  it  less  irri- 
tating to  the  bowel  and  more  fatal  to  the  worm  ;  and  this  addition  is  all  that 
is  necessary  if  the  injections  be  given  thoroughly.  Other  substances  are  often 
used  in  solution  in  the  enema  for  their  destructive  effects  on  the  worm.  These 
are  common  salt,  (juinine,  quassia,  alum,  tannin,  etc.,  but  it  may  be  doubted 
whether  these  solutions  are  any  more  effectual  than  properly  given  injections 
of  soap  and  Avater.  Where  there  is  relaxation  and  protrusion  of  the  rectum  an 
astringent  injection  is  of  use,  as,  for  example,  one  drachm  of  sulphate  of  iron 
to  one  pint  of  infusion  of  quassia;  or  a  solution  of  tannin  can  be  given,  in  the 
proportion  of  a  heaping  teaspoonful  to  a  pint  of  water.  All  irritating  injec- 
tions should  be  avoided,  and  dangerous  ones,  like  solutions  of  corrosive  sub- 
limate, had  better  not  be  used. 

As  the  worm  or  its  ova  may  live  in  the  folds  about  the  anus,  these  parts 
should  be  carefully  scrubbed  with  soap  and  water  and  anointed  w'ith  an  anti- 
septic ointment.  Boric-acid  ointment,  as  in  the  following  prescription,  besides 
destroying  worms,  is  of  use  in  allaying  the  irritation  or  eczema  caused  by  their 
presence : 

^.  Acidi  borici 3J. 

Olei  rosse gtt.  iij. 

Vaseline sj. — M. 

Even  after  a  complete  cure,  obtained  by  the  expulsion  of  all  the  worms, 
reinfection  is  likely  to  take  place  unless  certain  precautions  are  taken.  The 
bed-clothing,  the  blankets,  as  well  as  the  linen,  may  contain  the  eg'gs  of  the 
oxyuris ;  the  toys  undoubtedly  have  some  lodged  in  their  crevices ;  and  the 
carpet  or  floor  may  be  more  or  less  infected,  for  it  must  be  remembered  that  a 
small  bit  of  fgecal  matter  spilt  from  a  vessel  or  napkin  may  contain  thousands 
of  eggs.  The  room  and  its  contents  should  therefore  be  almost  as  thoroughly 
cleaned  as  in  the  case  of  one  of  the  exanthemata.  The  bed-clothing  should  be 
boiled,  the  toys  destroyed,  the  carpet  and  rugs  thoroughly  beaten,  and  the  floor 
and  furniture  scrubbed  with  soap  and  water.  The  neglect  of  this  undoubtedly 
accounts  for  the  frequent  failures  to  cure  this  troublesome  affection. 

m.  T^acNiA   (Tape-worm). 

The  common  tape-Avorm  is  from  twenty  to  fifty  feet  in  length,  of  a  white 
color,   and  composed  of  numerous  flattened  segments,  each  of  which,  except 


INTESTINAL    PARASITES. 


533 


those  near  the  so-called  head,  is  a  complete  hermaphrodite.  Nourishment  is 
absorbed  through  the  body-walls  from  the  contents  of  the  intestinal  canal,  in 
which  the  whole  worm  lies  immersed.  The  '"head"  is  a  modified  segment 
about  the  size  of  the  head  of  a  pin,  and  it  is  by  this  organ  with  its  suckers  or 
hooks  that  the  worm  retains  its  hold  on  the  intestine.  The  segments  near  the 
head  are  not  much  broader  than  a  piece  of  thread,  but  they  rapidly  increase  in 
size  and  become  from  one-quarter  to  one-half  an  inch  broad  at  the  other  ex- 
tremity of  the  worm. 

Varieties. — The  two  species  commonly  found  in  this  country  are  the  beef 
tape-w^orm,   Taenia  mediocanellata,   and  the  pork   tape-worm,    Tcenia  solium. 


Fig.  5. 


Fig.  6. 


Taenia  Mediocanellata.    Head  and  Mature 
ment,  Enlarged  (Heller). 


Seg- 


Two  other  species  may  be  mentioned,  as  they 
are  sometimes  encountered :  Tcenia  nana  and 
Tcenia  cucumerina.  Another  species,  belong- 
ing to  a  different  genus,  Bothrioeejjhalus  latus, 
is  found  only  in  certain  parts  of  the  continent 
of  Europe. 

The  beef  and  pork  tape- worms  (Figs.  5  and 
6)  are  easily  distinguished  by  their  heads,  and 
less  readily  by  the  sexually  mature  segments. 
The  pork  tape-worm  has  a  circle  of  hard  chiti- 
nous  hooks  on  the  head,  with  four  sucking 
disks,  and  the  head  itself  is  somewhat  pointed. 
The  head  of  the  beef  tape-w^orm  is  not  pointed, 
and  is  provided  with  four  suckers  only,  being 
devoid  of  the  circle  of  hooks.  This  species  may 
also  be  distinguished  by  the  sexually  mature 
segments  or  proglottides  which  are  passed  from 
the  anus.  In  the  pork  tape-worm  the  lateral 
branches  of  the  uterus  (Fig.  6,  b),  are  only 
eight  to  twelve  in  number,  and  quite  thick, 
while  in  the  beef  tape-worm  the  side  branches  are  finer  and  are  much  more 
numerous,  being  twenty  or  thirty  in  number  (Fig.  5,  b).  These  can  be  seen 
by  flattening  out  the  segments  between  two  microscopic  slides  and  holding  them 
up  to  the  light.     The  addition  of  glycerin  makes  them  more  transparent. 


Tsenia  Solium.    Head  and  Mature 
Segment,  Enlarged.    (Beneden.) 


534    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Taenia  nana  has  of  late  years  been  found  to  be  very  numerous  in  Italy, 
particularly  in  Sicily.  It  has  been  found  in  Egypt,  and  also  in  England. 
With  so  many  Italians  of  the  poorer  class  constantly  coming  to  this  country, 
its  occurrence  here  is  to  be  expected.  It  especially  attacks  children,  and  may 
occur  in  great  numbers  in  one  individual.  It  is  very  small,  being  only  ten  to 
fifteen  mm.  in  length.  The  head  is  armed  with  four  suckers  and  a  rostellum 
with  hooks,  which  can  be  protruded  or  entirely  withdrawn.  Severe  nervous 
symptoms  are  sometimes  caused  by  this  worm. 

Tamia  cucumerina  is  another  rare  form  of  tape- worm  which  especially 
infects  children,   being  acquired  by  them  from  dogs. 

Life  History. — The  ova  are  produced  in  each  segment  in  great  numbers, 
and  those  of  the  two  common  varieties  of  taenia  are  easily  distinguished  from  the 
eggs  of  the  round  and  thread-worms  by  their  smaller  size  and  spherical  instead 
of  oval  shape.  The  eggs  of  T.  mediocanellata  are  slightly  larger  than  those 
of  T.  solium,  which  are  about  y^  of  an  inch  in  diameter  (Fig.  2,  a  and  h). 

The  tape-worm  lives  in  the  small  intestine,  firmly  attached  to  the  mucous 
membrane  by  the  suckers  and  liooks  on  its  head.  While  the  head  is  attached 
to  the  upper  part  of  the  jejunum,  the  other  extremity,  in  the  common  species,  may 
reach  nearly  or  quite  to  the  ileo-csecal  valve.  The  pork  tape-worm  is  generally 
found  singly,  while  two  or  more  beef  tape-worms  may  occur  in  the  same  indi- 
vidual. The  worm  grows  by  a  process  of  breeding  or  segmentation  from  the 
segments  close  to  the  head.  As  these  become  farther  and  fiirther  removed  from 
the  head  by  this  process,  they  become  larger  and  sexually  mature.  The  first 
sexually  mature  segment  of  T.  solium  is  about  the  four  hundred  and  fiftieth 
from  the  head.  Some  of  the  ova  are  extruded  from  the  lower  mature  seg- 
ments, and  pass  off"  with  the  fgeces,  but  most  of  them  escape  from  the  anus  still 
contained  in  the  ripe  segments,  which  break  off"  entire.  These  segments,  be- 
sides passing  out  in  the  fsecal  mass,  may  slip  out  of  the  anus  into  the  under- 
clothing; and  this  happens  so  frequently  that  attention  is  usually  called  to  the 
presence  of  the  worm  in  this  way. 

For  the  development  of  the  eggs  another  host  is  utilized,  this  host  being  the 

hog  in  the  case  of  T.  solium,  and  cattle  in  the  case  of  T.  mediocanellata.     In  the 

case  of  the  hog,  with  its  fondness  for  grubbing  around  in  heaps  of  off'al  and 

manure,  infection  easily  takes  place.     Cattle  may  be  infected  in  a  similar  way 

Fig.  7.  while  cropping  grass  that  has  been  fertilized  with  human 

feces.     In  the  animal's  stomach  the  thick  outer  coatings  of 

the  ova  are  dissolved,  the  embryos  are  set  free,  and  proceed 

at  once  to  pierce  the  stomach-walls,  and,  cai'ried  along  in  the 

blood-current,  bury  themselves  in  the  muscles,  the  liver  or 

other  viscera.    Here  they  develop  into  cysticercus  cysts,  which 

in  the  pork  tape-worm  are  a  little  larger  than  a  pea,  in  the 

beef  tape-worm  somewhat  smaller.     Within  these  cysts  the 

larval  taenia  or  scolex  grows,  the  head  being  formed  with  a 

short  neck  and  a  flask-shaped  body  (Fig.  7).     These  cysts 

remain  quiescent  for  from  three  to  six  years,  after  which 

they  die  and  become  calcified.     If,  however,  the  flesh  con- 

(!5SS!7"ai    taining  living  cysts  is  taken  into  the  human  stomach,  the 
tape-worm.  larval  scolcx   sprouts   into  the   mature  tape-worm   and   the 

cycle  of  changes  is  complete. 

It  occasionally  happens  that  the  eggs  of  tape-worms  are  swallowed  by  men, 
and  cysticerci  may  develop  in  various  parts  of  the  body,  especially  in  the  sub- 
cutaneous and  intermuscular  connective  tissue,  or  in  the  brain  or  eye. 

Method  of  Infection. — The  consumption  of  raw  or  imperfectly  cooked 


INTESTINAL   PARASITES.  535 

meat,  in  which  the  temperature  has  not  been  raised  to  a  sufficient  point  to  kill 
the  cysticerci,  is  the  source  of  infection  for  tjenia.  Infants  and  children  are 
liable  to  become  infected  with  the  beef  tape-worm  from  the  use  of  raw  meat, 
sometimes  recommended  in  intestinal  troubles.  When  the  beef  is  very  finely 
minced  or  when  the  juice  only  is  used,  the  beef  being  thoroughly  pressed 
and  strained,  this  danger  is  removed.  The  consumption  of  raw  sausages  is 
a  more  common  cause  of  the  pork  tape-worm  among  continental  nations 
than  in  this  country;  here  the  beef  tape-worm  is  probably  more  commonly 
met  with. 

Children,  from  their  uncleanly  habits  and  their  custom  of  sucking  the 
fingers,  are  more  exposed  to  the  danger  of  swallowing  the  ova  and  developing 
cysticerci. 

Symptoms. — The  symptoms  caused  by  tape-worms  in  the  intestine  are  as 
obscure  as  those  of  round-worms,  and,  as  with  these  parasites,  are  often  lacking. 
A  child,  as  well  as  an  adult,  may  harbor  a  tape-worm  for  years,  the  only  indica- 
tion of  this  being  the  passage  of  segments  from  time  to  time  per  anum.  Un- 
comfortable sensations  in  the  abdomen  and  pain  in  the  region  of  the  navel,  Avith 
the  various  nervous  symptoms  given  under  the  head  of  Lumbricoids,  such  as 
picking  at  the  nose,  disturbed  sleep,  fitful  and  at  times  ravenous  appetite,  have 
been  observed  in  these  cases.  There  may  be  nausea  and  salivation,  and 
vomiting  is  at  times  present.  The  bowels  are  often  irregular.  The  movements 
of  the  worm  in  the  intestine  are  sometimes  described,  but  it  is  doubtful  whether 
this  is  anything  more  than  a  psychical  phenomenon.  Failure  to  take  on  flesh 
notwithstanding  a  ravenous  appetite  is  to  the  laity  a  characteristic  symptom  of 
tape-worm,  but  its  significance  is  of  very  doubtful  value,  for  it  is  a  symptom 
often  present  without  the  worm,  and  is  indicative  of  faulty  digestion  and  imper- 
fect assimilation.  As  with  the  other  intestinal  worms,  chorea  and  convulsions 
have  been  attributed  to  tgeni^B. 

The  following  case  came  under  my  care  at  the  Children's  Hospital  in  July, 
1890: 

Angelina  M ,  four  and  a  half  years  old,  has  had  a  tape-worm  for  two  years.    The 

mother  has  found  segments  frequently  in  her  under-clothing  and  in  the  stools.  She  has 
been  under  treatment  by  various  doctors  from  time  to  time,  but  without  permanent  relief, 
as  the  whole  worm  has  never  been  expelled.  The  child  was  accustomed  to  eat  a  great 
deal  of  very  rare  beef  She  complains  of  constantly  feeling  tired,  is  peevish  and  fretful, 
frequently  picking  the  nose,  and  is  restless  at  night.  Her  head  perspires  a  great  deal, 
her  appetite  is  at  times  ravenous,  and  she  complains  of  pain  about  the  navel.  The 
bowels  are  regular. 

Under  treatment — which  I  shall  give  below — she  expelled  a  beef  tape-worm  twenty- 
four  feet  long,  with  the  head  entire.  It  is  extremely  interesting  to  note  that  a  year  later, 
in  May,  1891,  the  patient  returned,  complaining  of  exactly  the  same  symptoms,  which 
had  never  been  recovered  from,  but  she  never  passed  any  more  segments  of  worm. 

Diagnosis. — There  is  no  difficulty  in  making  the  diagnosis  of  tape-worm, 
for  the  mature  segments  slip  from  the  anus  at  intervals  of  every  few  days 
or  are  passed  in  the  stools.  Their  white  color  and  peculiar  shape  at  once 
attract  attention,  so  that  it  is  not  necessary  to  make  microscopic  examinations 
of  the  fteces  or  to  resort  first  to  anthelmintic  treatment.  The  distinction 
between  the  two  common  species  of  taenia  is  made  in  the  manner  detailed  in 
the  description  of  the  worms.  The  fact  that  patients  are  apt  to  mistake 
shreds  of  mucus  for  worms,  requires  the  physician  to  assure  himself  of  the 
correctness  of  the  identification  before  beginning  treatment. 

Treatment. — Having  made  sure  that  a  worm  is  present,  appropriate  treat- 
ment should  be  at  once  instituted  unless  contraindicated  by  some  acute  illness ; 


536    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

for,  although  the  worm  in  the  intestine  may  produce  no  symptoms,  there  is 
always  danger  of  cysticerci  developing  somewhere  in  the  body  from  the  acci- 
dental ingestion  of  the  ova. 

Half-hearted  measures  are  sure  to  be  failures,  consuming  time,  irritating  the 
child,  and  wasting  its  strength.  To  be  successful  the  entire  worm,  including 
the  head,  should  be  obtained,  although  it  often  happens  that  if  the  worm  be 
broken  oif  close  to  the  head  and  expelled,  there  is  no  return  of  the  trouble.  This 
can  probably  be  explained  by  the  fact  that  the  head  is  in  reality  expelled,  but, 
l)eing  so  small,  is  not  found  in  the  fsecal  debris.  This  is  particularly  apt  to  be 
the  case  if  the  mother  or  nurse  attempt  to  find  the  head.  It  is  much  better 
for  the  physician  himself  to  make  the  search.  This  should  be  done  by  adding 
Avater  to  the  stool  and  shaking  up  the  faecal  mass  or  stirring  it  gently  with  a 
stick,  being  careful  not  to  break  up  the  worm ;  by  decanting  the  water  from 
time  to  time  and  adding  fresh,  a  clear  mixture  will  be  obtained  in  which  it  is 
easier  to  find  the  parasite. 

Treatment  consists,  first,  in  the  preparatory  dietetic  management ;  secondly, 
in  the  administration  of  some  drug  which  experience  has  shown  will  kill  or 
benumb  the  worm ;  and  lastly,  in  the  use  of  a  cathartic  to  remove  the  ofiend- 
ing  body. 

The  preparatory  treatment  is  partial  starvation,  in  order  to  weaken  the 
worm.  For  this  purpose  small  amounts  of  such  food  as  can  be  digested  in  the 
stomach  are  to  be  preferred,  and  the  colon  should  be  unloaded,  so  as  to  make 
the  exit  for  the  worm  easy.  As  children  cannot  stand  much  starving,  the  pre- 
paratory period  should  be  shorter  than  in  adults,  and  it  loses  some  of  its  irk- 
someness  by  including  the  night.  After  a  light  dinner  the  child  should  be 
given  a  bowl  of  beef-tea  with  a  half  slice  of  white  bread  for  supper :  an 
enema  must  be  given  in  the  evening  and  the  child  put  to  bed  early.  The  break- 
tast  must  consist  of  beef-tea  alone.  An  hour  later,  say  at  9  a.  m.,  the  anthel- 
mintic can  be  given,  to  be  followed  in  one  hour  by  the  cathartic.  The  stools 
should  be  carefully  preserved  and  examined  as  explained  above.  It  sometimes 
happens  that  the  worm  is  partially  expelled  by  a  movement  from  the  bowels, 
and  is  left  hanging  out  of  the  anus.  In  this  case  great  care  should  be  used 
not  to  break  it  off,  a  large  injection  being  given  to  dilate  the  rectum  and  allow 
the  removal  of  the  Avorm  by  gentle  traction.  Dilatation  of  the  anus  by  a  small 
rectal  or  nasal  speculum  will  take  oif  the  pressure  of  the  sphincter  and  aid  in 
extraction. 

It  only  remains  to  consider  the  various  tsenicides  recommended.  The  list 
is  a  large  one,  but  I  will  mention  only  the  important  ones.  These  are — pom- 
egranate, the  bark  of  the  root  and  its  alkaloid  pelletierine ;  filix  mas,  the  root 
of  the  male  fern  ;  kousso  ;  pumpkin-seed  ;  turpentine  ;  and  cocoa-nut. 

The  first,  pomegranate,  is  one  of  the  most  efficient.  It  can  be  given  in  a 
decoction,  which,  however,  makes  a  disagreeable  draught,  and  one  apt  to  defeat 
its  own  purpose  by  causing  vomiting.  A  much  neater  Avay,  and  one  that  I 
have  always  employed,  is  to  use  the  alkaloid  pelletierine.  The  tannate  of  this 
alkaloid  is  made  into  an  elegant  but  very  expensive  preparation  by  Tanret  of 
Paris,  and  is  put  up  in  small  bottles  containing  one  adult  dose.  This  can  be 
obtained  in  all  our  large  cities,  and  its  efficiency  makes  up  for  its  high  price. 
As  pomegranate  in  full  doses  causes  nausea,  giddiness,  faintness,  and  indistinct- 
ness of  vision,  it  is  best  for  the  child  to  lie  doAvn  after  the  dose  is  given.  In 
the  case  of  tape-worm  in  the  child  of  four  and  a  half  years,  related  above,  the 
preparation  of  the  tannate  of  pelletierine  was  given,  one-third  of  the  bottle,  which 
contained  five  teaspoonfuls.  being  administered  at  a  dose.  The  child  com- 
plained of  slight  dizziness  and  headache.     An  hour  after  the  taenicide  a  full 


INTESTINAL    PARASITES. 


537 


dose  of  castor  oil  was  given,    and   four  hours  later  the   worm  was  expelled 
entire. 

The  oil  of  male  fern,  oleoresina  aspidii,  is  ths  next  most  efficient  remedy  for 
tape-worm,  a  teaspoonful  being  given  to  a  child  of  five  years,  shaken  up  with 
some  agreeable  menstruum,  as  in  the  following  recipe : 

^.   Oleoresinae  aspidii .     3j. 

Tinct.  quillaise f^ss, 

Spts.  aurantii  dulcis foj- 

Syr.  aurantii q.s.  adfgvij. — M. 

Kousso  appears  to  be  used  more  by  European  than  American  physicians 
and  is  said  to  be  efficient  and  free  from  danger.  The  freshly-prepared  infusion 
is  best  used  (infusum  brayerse,  U.  S.  Ph.),  but  is  very  objectionable  to  children 
from  its  disagreeable  taste,  and  is  liable  to  produce  vomiting. 

Pumpkin-seed  is  a  perfectly  safe  and  simple  remedy,  but  in  my  experience 
is  never  efficient,  a  small  part  of  the  worm  being  left  behind  to  reproduce  the 
trouble.  The  outer  shell  of  the  seeds  should  be  removed,  and  the  inside  rubbed 
up  with  syrup  or  honey  into  an  agreeable  mass.  One  or  two  ounces  of  this  can 
be  eaten,  followed,  as  in  all  cases,  by  a  purgative. 

Another  agreeable  remedy  is  the  meat  of  the  cocoa-nut.  From  large  quan- 
tities of  this  there  have  been  favorable  reports  lately,  but  as  cocoa-nut  is  rather 
indigestible  it  might  have  an  untoward  effect  on  the  child. 

With  pelletierine  or  male  fern,  preferably  the  former,  properly  given  with 
all  the  details  of  treatment  attended  to,  success  should  always  finally  crown  our 
efforts,  and  it  seems  to  me  better  not  to  waste  time  with  any  other  remedies. 


Fig.  8. 


IV. — Tbichocephalus  dispar  (Whip- worm). 

This  is  a  small  worm,  thickened  at  one  end,  but  tapering  out  like  a  whip- 
lash at  the  other.  It  is  four  or  five  centimetres  long,  and  lives  in  the  caecum 
where  it  is  often  found  in  large  numbers  (Fig. 
8).  The  eggs  (Fig.  2,  d)  are  about  the  size  of 
the  ova  of  the  pin-worm,  from  which  they  are 
easily  distinguished  by  the  irregular  rounded 
shape.  At  each  extremity  is  a  break  in  the 
egg-walls.  Of  16  children  examined  for  this 
purpose,  I  found  the  eggs  of  this  worm  in  the 
faeces  of  one.  The  worm  gives  rise  to  no  symp- 
toms, as  far  as  known.  Trichocephalus  Dispar  (Heller). 


DISEASES  OF  THE  LIVER. 

By    JOHN   H.    MUSSER,   M.   D., 

Philadelphia. 


Diseases  of  the  Liver  are  not  of  frequent  occurrence  in  childhood. 
The  factors  essential  for  the  development  of  hepatic  disorder  require  the 
element  of  time  to  aid  them.  This  is  one  reason  gall-stones,  for  instance,  do 
not  occur  in  early  life.  Moreover,  the  customary  food  and  drink  of  early 
childhood  do  not  influence  hepatic  function  and  nutrition  deleteriously,  and 
therefore  functional  derangements,  hepatic  congestion,  and  sclerosis  are  rela- 
tively infrequent.  Other  etiological  factors  of  liver  disease  in  adult  life  are 
not  operative  in  childhood.  The  liver  is  more  frequently  the  seat  of  secondary 
disease  than  possibly  any  other  organ.  The  primary  diseases  usually  occur  in 
adult  life,  and  hence  the  secondary  effects  are  only  observed  at  that  period. 
For  instance,  cancer  of  the  liver  and  abscess  following  amoebic  dysentery  are 
not  of  frequent  occurrence  in  childhood. 

While  the  above  applies  chiefly  to  organic  disease  of  the  liver,  the  writer 
fully  believes  that  functional  disorder  in  late  childhood  and  early  adolescence 
is  of  more  frequent  occurrence  than  we  are  led  to  believe  from  the  text-books. 
If  the  broad  view  of  Murchison  be  true,  that  lithremia  and  allied  disorders  with 
their  long  train  of  functional  derangements  in  the  gastro-intestinal  tract,  the 
nervous  system,  and  the  circulatory  apparatus,  or  their  results,  terminate 
in  organic  disorder  of  liver,  kidney,  arteries  or  nerve-structure,  we  must 
believe  that  the  beginnings  are  found  in  the  errors  of  diet,  the  improper 
clothing,  the  misguided  exercise,  the  vicious  methods  of  education,  and  abnor- 
mal excitements  of  the  nervous  system  which  occur  in  childhood.  It  is  true 
the  physiological  labors  of  the  liver  are  so  closely  related  to,  or  rather  so 
markedly  an  adjunct  to,  the  physiological  labors  of  other  organs  of  the  prim?e 
viae  that  it  is  almost  impossible  to  fix  upon  the  disturbing  factor  when  disorder 
is  observed.  Hence  a  clinical  distinction  between  malnutrition  and  malassimi- 
lation  cannot  be  made.  Functional  disorders,  therefore,  will  not  be  discussed 
in  this  chapter,  and  for  the  above  reasons  are  usually  excluded  in  works  on 
diseases  of  children. 

Diseases  of  the  gall-ducts,  save  catarrhal  inflammation,  are  due  either  to 
gall-stones  (not  prgsent  in  childhood)  and  their  consequences  or  to  diseases 
outside  of  the  duct  that  do  not  arise  in  early  life.  Hence  affections  of  these 
passages  need  not  be  considered. 

General  Btiology. — The  causes  of  liver  disease  in  childhood  do  not  differ 
from  those  in  adult  life,  though  they  are  not  as  frequently  operative,  or  the 
results  of  their  operation  are  not  seen.  Icterus  neonatorum  and  congenital 
obliteration  of  the  ducts  are  the  diseases  of  the  liver  peculiar  to  childhood, 
and  therefore  have  a  distinct  etiology.  Other  affections  of  the  liver  are  com- 
mon to  both  periods.     Errors  of  diet,  excess  in  rich  food  or  in  stimulants, 

538 


DISEASES    OF   THE  LIVER.  539 

cause  congestion  of  the  liver  in  children  as  in  adults.  Seasonal  changes  are 
factors,  although  it  seems  that  high  temperature  does  not  often  tend  to  cause 
acute  congestion  of  the  liver  in  children ;  at  least,  writers  on  tropical  diseases 
do  not  specifically  refer  to  the  occurrence  of  acute  congestion  in  early  life. 
Malaria  causes  congestion  of  the  liver  at  any  age ;  checking  of  discharges  or 
chronic  constipation  are  not  marked  factors  in  childhood ;  but  the  congestions 
that  arise  in  the  course  of  infectious  diseases  are  more  commonly  found  at  this 
time.  Scarlet  fever,  measles,  and,  notably,  relapsing  and  yellow  fever,  are 
attended  by  congestion  of  the  liver.  In  passive  congestion  we  find  the  same 
influences  at  work  in  the  child  and  the  adult.  The  effects  of  obstruction  of 
heart  and  lungs  are  similar. 

As  in  congestion,  so  in  fatty  liver,  the  causes  are  not  peculiar.  In  chil- 
dren abnormally  obese  or  the  subjects  of  phthisis  or  profound  anaemia,  the 
disease  is  liable  to  occur,  just  as  in  adult  life.  The  same  is  true  of  amyloid 
disease;  prolonged  suppuration  alone  or  in  tuberculous  bone  disease  or  in 
tuberculosis  of  the  lungs  leads  to  its  frequent  occurrence  in  children.  Syphilis 
is  a  common  associate  and  rachitis  is  occasionally  observed  with  amyloid  liver. 
Osier  states  that  amyloid  disease  is  found  in  prolonged  convalescence. 

Syphilitic  inflammation  of  the  liver  in  children  is  almost  always  con- 
genital. In  hydatid  disease  of  the  viscus  we  see  a  common  cause  at  both 
periods  of  life,  and  as  hydatids  grow  slowly,  it  is  possible  infection  takes  place 
in  childhood,  but  symptoms  do  not  arise  until  later  in  life. 

In  suppurative  hepatitis  the  etiological  factor  diff'ers  at  different  ages.  In 
this  aff'ection  in  children  we  do  not  find  the  baneful  causative  effects  of  high 
temperature,  nor  does  it  appear  to  follow  amoebic  dysentery  as  frequently  as  in 
adults.  It  is  possible  this  form  of  dysentery  is  not  common  in  children.  The 
writer  had  occasion  to  analyze  all  the  recorded  cases  of  abscess  of  the  liver 
up  to  1890,  and  found  that  portal  pygemia  and  traumatism  were  more  frequent 
causes  than  tropical  dysentery  (respectively  10  and  8  in  34  cases),  and  that 
round  worms  in  the  ducts  were  only  slightly  less  common. 

In  cirrhosis  of  the  liver,  again,  the  causes  are  not  dissimilar,  although  the 
infectious  diseases  play  a  more  important  part  in  childhood,  while  alcoholism 
is  an  infrequent  causal  agency.  Klein  points  out  the  frequency  of  scarlatina, 
and  Laure  and  Honorat,  and  Siredey,  measles,  as  factors  in  its  production. 
Tuberculosis  is  another  cause.  It  is  remarkable  to  find  the  aff'ection  occurring 
with  general  arterio-capillai'y  fibrosis.  Howard  believed  "that  rich,  high-seasoned 
food  is  likely  to  produce  cirrhosis  in  childhood,  and  that  we  have  reason  to 
believe  ptomaines  are  causal  agencies. 

But  little  attention  need  be  paid  to  the  morbid  anatomy  and  pathology 
of  diseases  of  the  liver  in  childhood.  The  morbid  processes  do  not  differ  from 
similar  processes  in  adults,  and,  as  the  scope  of  this  article  is  limited,  the  dis- 
cussion of  morbid  anatomy  and  pathological  histology  will  be  omitted. 

General  Symptomatolog-y. — The  subjective  and  objective  symptoms  of 
hepatic  disease  in  childhood  usually  present  the  same  striking  picture  of  mor- 
bid change  as  in  adult  life.  Apart  from  the  symptoms  that  attend  failing 
health,  the  subjective  sensations  of  hepatic  disorder  are  few.  If  we  consider 
functional  derangements  of  the  liver  to  be  the  primary  cause  of  lithsemia,  then 
indeed  the  above  remark  is  not  correct ;  but,  as  previously  noted,  such  rela- 
tionship will  not  be  considered. 

Pain  is  a  subjective  symptom  found  only  in  one  or  two  of  the  disorders 
which  are  to  be  discussed  in  this  article.  It  occurs  in  suppurative  hepatitis, 
in  syphilitic  inflammation  of  the  liver  when  the  capsule  is  involved,  and 
in  a  slight  degree  in  congestion.     It  may  be  localized  to  a  small  area,  or 


540  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  "whole  organ  may  be  the  seat  of  pain.  It  is  constant,  increased  by 
pressure  or  movement.  It  may  extend  to  the  right  shoulder.  The  patient 
may  be  compelled  to  lie  on  the  affected  side  with  the  legs  drawn  up.  The 
paroxysmal  pain  that  characterizes  hepatic  colic,  and  is  the  most  frequent  pain 
of  hepatic  disease  in  adults,  does  not  occur.  Pain  in  the  region  of  the  liver 
in  childhood  must  be  distinguished  from  pleurodynia  and  pleurisy.  In  pleuro- 
dynia there  is  immobility,  respiration  and  other  movements  are  painful,  the 
area  is  tender  on  superficial  examination  by  palpation,  and  other  portions 
of  the  body  may  be  affected  with  rheumatism,  or  there  is  a  distinct  history 
of  exposure.  In  pleurisy  the  pain  is  markedly  increased  by  breathing,  is 
associated  with  a  pleural  friction,  and  is  sharp  and  lancinating,  attended 
by  cough  and  increased  by  it.  Pressure  at  a  localized  area  increases  it.  It  is 
often  difficult,  indeed  impossible,  to  distinguish  right-sided  pleurisy  from  a 
perihepatitis.  In  both  friction  occurs ;  in  the  former,  fluid  may  soon  be 
detected  in  the  pleural  cavity,  or  the  development  of  pneumonia  may  aid  to 
distinguish  the  two.  It  may  be  said  that  the  pain  that  attends  liver  disease  is 
increased  by  pressure  at  any  part  of  the  liver,  particularly  upward  along  the 
lower  edge  of  the  viscus,  or  in  the  epigastrium. 

Pain  in  simple  abscess  of  the  liver  is  localized ;  the  locality  corresponding 
to  the  seat  of  injury  when  that  is  the  cause  of  the  abscess.  In  pylephlebitis 
the  pain  is  more  diffused.  In  abscess  there  is  localized  tenderness  ;  in  peri- 
hepatitis the  parts  are  exquisitely  tender  on  palpation.  Weight  and  fulness 
and  uneasy  sensations  are  described  by  the  patient  when  there  is  enlarge- 
ment of  the  liver.     They  are  not  of  diagnostic  value. 

The  subjective  symptoms  referable  to  gastro-intestinal  derangement  are 
many,  but  are  not  characteristic.  Loss  of  appetite,  a  bitter  taste,  nausea, 
dyspeptic  symptoms,  particularly  flatulency,  with  irregular  or  costive  bowels, 
occur.  The  objective  symptoms — noted  by  the  usual  methods  of  physical 
examination — are  jaundice,  ascites,  enlargement  of  the  spleen  and  of  the 
abdominal   veins,   luiemorrhoids,  and  fever  and   sweats. 

Physical  Examination. — The  liver  in  infancy  and  childhood  is  larger  in 
proportion  to  the  weight  of  the  body  than  in  adult  life.  It  therefore  presents 
a  relatively  greater  surface  for  examination.  The  left  lobe  is  particularly 
accessible  to  physical  examination.  The  upper  border  of  the  liver  extends  to 
the  fifth,  sixth,  and  seventh  ribs  in  the  mid-clavicular,  axillary,  and  scapular 
lines  respectively.  The  lower  border  extends  two  inches  below  the  margin 
of  the  ribs.  In  the  median  line  the  left  lobe  extends  to  within  an  inch  of 
the  umbilicus. 

Inspection. — The  decubitus  of  the  patient  is  not  peculiar  in  hepatic  affec- 
tions except  when  acute  inflammation  is  present.  The  recumbent  posture  is 
assumed  and  the  legs  drawn  up.  The  patient  may  lie  on  the  right  side.  If 
pain  be  present,  it  is  increased  by  keeping  on  the  left  side.  The  abdomen  is 
usually  distended  by  flatus,  or  in  certain  affections  by  ascites.  If  the  liver  be 
enlarged,  the  right  lower  third  of  the  thorax  is  distended,  as  well  as  the  con- 
tiguous portion  of  the  abdomen.  If  there  is  much  enlargement  or  if  acute  pain 
is  present,  the  movement  of  the  right  lower  half  of  the  thorax  is  limited. 
The  epigastrium  is  distended.  The  swelling  of  the  hepatic  area  may  corre- 
spond to  the  entire  organ  or  may  be  localized.  In  abscess  and  hydatid  disease 
tumors  may  be  detected  in  the  left  lobe  of  the  liver,  along  the  lower  border 
of  the  right  lobe,  or  as  swelling  with  projection  of  the  ribs  at  points  corre- 
sponding to  the  convex  surface  of  the  liver.  Hence  the  epigastrium,  the  right 
hypochondrium,  and  right  lumbar  region,  and  the  mid-clavicular,  mid-axillary, 
and  scapular  lines  along  the  upper  border,  are  the  favorite  seats  of  election 


DISEASES    OF    THE   LIVEB.  541 

of  tumors.  In  abscess  the  superimposed  skin  may  be  reddened.  The  appear- 
ance of  the  veins  over  the  surface  must  be  noted. 

Palpation. — By  palpation  the  position  of  the  lower  border  of  the  liver  and 
the  character  of  its  surface  are  determined.  The  former  is  easily  ascertained 
if  the  abdomen  is  not  too  much  distended  and  if  the  child  can  be  kept  quiet 
during  the  examination.  The  normally  large  left  lobe  must  not  be  mistaken 
for  a  tumor.  The  liver  moves  with  respiration,  and  this  fact  must  be  ascer- 
tained in  order  to  exclude  the  presence  of  tumors  in  the  abdomen  due  to  other 
causes.  Faeces  in  the  transverse  colon  must  be  excluded  by  the  administration 
of  purgatives.  The  surface  of  the  liver,  as  well  as  its  edge,  may  be  soft,  as 
in  fatty  liver,  or  indurated,  as  in  amyloid  disease.  In  both  the  edge  is  smooth  ; 
in  cirrhosis  it  may  be  sharp,  but  is  invariably  hard.  Bosses  may  be  detected 
due  to  cancer,  hydatid  disease,  or  abscess.  In  hydatid  disease  they  are  soft 
and  may  fluctuate;  in  abscess  they  are  hard  at  first,  then  become  soft  and 
fluctuating.  A  friction  vibration  is  sometimes  detected  by  the  palpating  hand 
in  cases  of  perihepatitis,  and  the  peculiar  fremitus  may  be  elicited  in  hydatid 
disease.     (Edema  of  the  surface  is  observed  occasionally  in  abscess. 

Percussion. — By  this  means  the  size  of  the  liver,  whether  diminished  or 
enlarged,  can  be  accurately  determined,  and  the  degree  of  enlargement  ascer- 
tained. Marked  deviations  from  the  normal  boundaries  of  percussion,  as  indi- 
cated above,  serve  to  distinguish  the  changes.  It  must  not  be  forgotten  that 
to  define  the  upper  border  deep  percussion  must  be  employed,  and,  to  define 
the  lower  border,  light  percussion.  The  colon  must  be  emptied  of  faeces,  and 
the  character  of  the  evacuations  noted.  Affections  of  the  pleura,  particularly 
effusions,  must  be  excluded.  When  a  pleural  effusion  is  present  there  is  a  uni- 
form bulging  of  the  side,  the  respiratory  movement  of  the  liver  is  restricted, 
and  a  depression  is  sometimes  seen  between  the  effusion  and  the  liver  if  that 
organ  be  pushed  down.  By  percussion  it  is  found  that  the  dulness  of  eff"usion 
is  movable,  and  that  its  upper  limit  is  S-shaped  or  horizontal.  The  rational 
symptoms  of  pleurisy  aid  to  distinguish  it.  When  the  liver  is  enlarged  the 
ribs  are  everted. 

In  determining  the  outline  of  the  liver  by  percussion  it  is  well  to  ascertain 
if  it  be  regular  or  not.  AVhen  the  liver  is  enlarged  in  its  entirety  the  normal 
shape  is  not  departed  from.  If  the  enlargement  is  due  to  hydatid  disease  or 
abscess,  the  outline  is  irregular.  The  area  of  dulness  may  extend  out  from  the 
normal  liver  in  positions  indicated  by  palpation.  Sometimes  the  enlargement, 
though  uniform,  occurs  in  one  direction  only ;  thus  in  abscess  or  hydatid  dis- 
ease of  the  convexity  the  increase  in  dulness  is  upward  and  to  the  right ;  in 
hydatid  disease  of  the  centre,  downward.  Both  aff'ections  may  be  limited  to 
the  left  lobe,  and  then  an  increase  in  size  of  the  corresponding  area  is  noted. 

Diagnosis. — By  means  of  physical  examination,  with  a  study  of  rational 
symptoms,  simulated  enlargement  of  the  liver  is  excluded.  Apparent  increase 
in  the  size  of  the  liver,  as  determined  by  palpation  and  percussion,  may 
depend  upon  congenital  change  in  the  shape  of  the  liver  or  upon  displace- 
ment of  this  organ  by  the  deformities  of  the  chest,  due  to  rickets  or  to  caries 
of  the  vertebra.  Congenital  change  in  shape  is  recognized  by  the  fact  that 
it  is  noted  soon  after  birth,  and  that,  while  it  is  persistent,  symptoms  of  hepatic 
disease  are  absent. 

Apparent  enlargement  of  the  liver  upward — dulness  extending  to  the 
fourth  rib  in  front — may  be  due  to  tumors  in  the  abdomen  or  to  ascites  ;  or  the 
normal  liver  dulness  may  be  continuous  with  the  dulness  due  to  sarcoma  of  the 
kidney,  to  tuberculous  disease  of  the  omentum,  to  an  ovarian  tumor,  or  to 
encysted  or  free  fluid  in  the  peritoneal  cavity. 


542    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

If  fluid  be  present,  the  dulness  may  change  if  the  patient  turns  on  the  left 
side  ;  the  lower  border  can  then  be  defined.  If  the  fluid  be  encysted,  diagno- 
sis is  more  difficult.  A  history  of  previous  peritonitis  or  a  history  of  tuberculo- 
sis, with  associated  development  of  the  disease  in  other  organs,  with  fever  and 
emaciation,  is  suggestive  of  tuberculosis,  which  is  usually  the  cause  of  encysted 
fluid  as  well  as  omental  disease.  A  tumor  of  the  right  kidney  may  be  dis- 
tinguished from  an  enlarged  liver  if  the  tumor  be  rounded,  if  the  fingers  can  slip 
between  the  tumor  and  the  liver,  if  a  tympanitic  note,  indicating  the  presence 
of  the  intestine,  be  found  to  run  across  the  surface  of  the  kidney,  if  the  tumor 
do  not  move  Avith  respiration,  and  finally  by  urinalysis. 

The  physical  examination  is  not  complete  unless  the  characteristics  of  the 
organs  adjacent  to  the  liver  are  observed.  Without  such  examination  no 
diagnosis  can  be  made  nor  rational  treatment  conducted. 

Operative  exploration  of  the  liver,  accomplished  by  means  of  the  aspirator 
or  hypodermic  syringe,  properly  sterilized,  is  useful  to  confirm  the  diagnosis 
of  hydatid  disease  or  of  abscess  of  the  liver.  By  this  means  three  kinds  of 
liquid  may  be  withdrawn — serum,  pus,  or  hydatid  fluid.  The  former,  serum, 
does  not  occur  in  the  liver ;  either  the  pleura  or  the  space  underneath  the  dia- 
phragm yields  it ;  but  its  presence  does  not  exclude  hepatic  disease,  for  serous 
inflammation  may  complicate  the  liver  affection.  Cases  are  recorded  in  which, 
after  emptying  the  pleura  of  serum,  deeper  exploration  through  the  diaphragm 
yielded  pus.  The  association  of  pleurisy  or  empyema  and  subdiaphragmatic 
abscess  with  hepatic  disease  must  not  be  forgotten. 

By  the  aspirator  clear  laudable  pus  may  be  withdrawn.  It  often  contains 
crystals  of  leucin  and  tyrosin,  and,  it  is  said,  the  characteristic  liver  cells.  If 
such  cells  can  be  recognized,  it  is  proof  positive  that  the  pus  was  originally  in 
the  liver.  The  pus  may  be  so  mixed  with  blood  as  to  appear  reddish-brown,  like 
anchovy  sauce.  In  this  case,  on  microscopical  examination,  the  amoeba 
dysenterica  is  sometimes  found  in  the  purulent  fluid.  The  abscess  is  then 
secondary  to  dysentery. 

Hydatid  fluid  is  clear,  alkaline,  of  low  specific  gravity,  contains  sugar, 
a  trace  of  albumin,  and  a  large  amount  of  chloride  of  sodium.  Succinic  acid 
has  also  been  detected.  On  microscopic  examination  booklets,  echinococcus 
membrane,  sometimes  scolices,  and  often  hrematoidin  crystals  are  found.  It  is 
to  be  remembered  that  hydatid  cysts  may  suppurate;  pus  will  then  be  secured 
by  aspiration,  in  which  the  remains  of  the  echinococcus  cyst  are  present. 

In  diseases  of  the  liver  in  childhood  an  accurate  diagnosis  can  be  made 
only  by  a  consideration  of  the  personal  history  of  the  patient,  of  the  previous 
diseases  from  which  he  suffered,  of  the  evolution  of  the  disease  the  nature  of 
which  is  to  be  solved,  the  subjective  symptoms  and  physical  signs  of  the  ail- 
ment, and  the  condition  of  all  the  organs  and  structures  of  the  body.  A  sys- 
tematic pursuit  for  all  the  facts,  as  embraced  above,  is  necessary  in  the  study 
of  disease  of  any  portion  of  the  body ;  but  the  liver,  more  than  other 
organs,  is  subjected  to  onslaughts  of  morbid  action  that  primarily  develop 
elsewhere  ;  hence  previous  ailments  must  be  investigated  and  the  integrity  of  all 
the  tissues  carefully  ascertained.  For  the  diff"erential  diagnosis  of  the  various 
affections  this  is  essential.  Of  the  hepatic  affections  discussed  in  this  work, 
congenital  disease  of  the  gall-ducts,  some  forms  of  congestion,  and  hydatid 
disease  are  the  only  ones  that  are  not  secondary  to  aff"ections  of  other  organs. 

A  diagnosis  is  fiicilitated  not  only  by  inquiring  into  the  integrity  of  the 
various  organs  of  the  body,  but  also  by  securing  definite  information  regard- 
ing the  occupation,  habits,  residence,  and  all  other  conditions  of  life  of  the 
patient.     Illustrations   could  be  advanced   in   any   disease,  but  it  suffices  to 


DISEASES   OF   THE   LIVER.  543 

point  out  the  value  of  the  knowledge  of  alcoholism  in  cirrhosis,  of  exposure 
to  phosphorus  in  yellow  atrophy,  of  residence  among  dogs  in  hydatid  disease. 

Jaundice. 

Etiology. — As  seen  most  frequently  in  childhood,  jaundice  is  due  to 
obstruction  of  the  bile-ducts — the  hepatogenous  form — resulting  from  pressure 
upon  the  ducts,  or  obstruction  within  them. 

Pi'essure  upon  the  Ducts. — Organic  disease  of  structures  adjacent  to  the 
ducts  which  might  press  upon  them  is  very  rare  in  childhood. 

Ohst7'uctio7i  within  the  Ducts. — Affections  of  the  mucous  membrane  are 
abnormal  processes  very  liable  to  occur  in  infancy.  When  the  lining  mem- 
brane of  the  ducts,  and  particularly  the  portion  of  the  common  duct  known 
as  the  pars  intestinalis,  is  the  seat  of  catarrh,  the  membi'ane  swells  and  causes 
obliteration  of  the  lumen.  Jaundice  therefore  occurs.  Congenital  obliteration 
of  the  ducts  is  also  found  to  be  a  cause  of  jaundice.  Gall-stones  do  not  occur 
in  childhood,  and  the  wandering  of  worms  into  the  duct  is  rare.  It  is  seen, 
therefore,  that  the  obstructive  or  hepatogenous  form  of  jaundice  is  due  in  the 
larger  proportion  of  cases  to  catarrh  of  the  ducts  and  sometimes  to  obstruction 
of  them  by  round-worms. 

The  causes  of  hcematogenous  or  non-ohstructive  jaundice  are  also  few  in 
number.  Yellow  fever,  malaria,  epidemic  jaundice,  and  pyaemia  may  be  pos- 
sible causal  factors ;  poisoning  by  phosphorus,  the  use  of  ether  or  chloroform, 
mercurial  poisoning,  and  snake-bite  are  rare  possibilities.  No  cases  of  acute 
yellow  atrophy  in  childhood  have  been  reported. 

Jaundice  is  a  symptom,  not  a  disease.  It  is  recognized  by  symptoms  and 
general  physical  signs. 

Symptoms. — Icterus,  or  the  yellow  hue  of  skin  in  jaundice,  is  usually  first 
noticed  by  the  nui'se  or  mother.  The  color  varies  from  lemon-yellow  to  olive- 
green  or  a  bronzed  hue.  In  obliteration  of  the  ducts  it  is  most  intense.  It 
develops  gradually,  usually  on  the  face  first.  In  the  obstructive  form  it  is 
general.  The  conjunctivae  are  deeply  colored ;  the  mucous  membranes  are  tinted ; 
the  secretions  are  bile-tinged ;  the  sweat  stains  the  linen  yellow.  The  urine  is 
loaded  with  bile-pigment.  It  is  brownish-yellow  or  has  a  greenish  tinge. 
When  shaken  in  a  test-tube  a  yellow  froth  rises  to  the  surface.  By  the  nitrous 
acid  test  the  play  of  colors  characteristic  of  reaction  with  bile-pigment  is  seen. 
While  the  tissues  and  secretions  are  bile-tinged,  the  faeces  are  deprived  of 
the  pigment.  They  are  pale  or  slate-gray  in  color,  very  offensive  and  pasty. 
The  temperature  is  frequently  subnormal.  Prostration  occurs,  and  angemia 
arises.  The  influence  of  the  bile  on  the  nerve-centres  or  their  peripheral 
terminations  is  seen  in  the  character  of  the  pulse,  the  occurrence  of  itching, 
and  the  grave  cerebral  phenomena  to  which  the  term  cholestersemia  has  been 
applied.  The  pulse-rate  is  much  diminished ;  it  often  falls  to  two-thirds  or 
one-half  of  the  customary  frequency.  Itching  is  a  most  distressing  symptom 
and  is  caused  by  the  bile-pigment  irritating  the  peripheral  cutaneous  nerve- 
filaments.  Often  the  body,  particularly  the  trunk,  is  covered  with  scratch- 
marks.     The  skin  is  liable  to  eruptions,  as  erythema  and  boils. 

Ordinary  cases  of  jaundice  frequently  show  some  irritability  of  temper  and 
mental  depression.  This  may  be  followed  by  drowsiness  and  by  stupor  ending 
in  coma.  In  children  convulsions  are  frequently  seen.  In  malignant  cases  the 
typhoid  state  usually  closes  the  scene ;  the  pulse  becomes  rapid,  fever  occurs, 
the  tongue  is  dry  and  brown,  sordes  collect  on  the  teeth,  and  there  is  sub- 
sultus  tendinum  with  low  delirium,  and  sooner  or  later  convulsions  and  coma. 


544  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Here  too  hjemorrhages  occur,  the  leakage  being  subcutaneous  or  into  the 
mucous  membranes,  and  appearing  as  nose-bleed,  h^matemesis,  or  melsena. 

.Epidemic  jaundice  occurs  at  times  in  children.  Denton  reports  a  small 
epidemic  among  children  of  the  same  school.  The  symptoms  were  sudden 
vomiting,  headache,  vague  gastric  pains,  with  prostration,  and  in  three  or  four 
days  intense  jaundice.  Duration,  ten  to  twelve  days.  Hennig,  after  a  study 
of  three  house-epidemics  of  infectious  icterus,  concludes  that  it  is  a  general 
acute,  specific,  infectious,  miasmatic,  non-contagious  disease.  It  may  be  spo- 
radic, epidemic  or  endemic,  and  appears  to  have  a  relation  to  typhoid  fever 
and  to  typhus.  The  infectious  agent  arises  outside  of  the  human  body.  The 
disease  runs  a  favorable  course  and  never  relapses. 

Raven  believes  ordinary  catarrhal  jaundice  may  be  infectious,  and  reports 
an  instance  in  which  one  child  of  a  family  became  icteric  from  exposure,  and 
that  four  others  of  the  house  developed  the  aifection,  apparently  by  contagion. 

Diagnosis. — The  diagnosis  of  jaundice  is  not  difficult.  The  greenish- 
yellow  hue  of  chlorosis,  with  the  pearly  conjunctiv.e,  would  suggest  an  exam- 
ination of  the  blood,  the  result  of  which  would  distinguish  chlorosis  and 
jaundice.  Similar  examination  would  enable  an  exact  diagnosis  of  pernicious 
(idiopathic)  aujemia  to  be  made  in  cases  resembling  jaundice  in  the  straw- 
colored  skin  and  the  conjunctivae  made  yellow  by  the  deposition  of  fat.  The 
rarity  of  Addison's  disease  in  cliildhood  is  such  as  to  preclude  the  possibility 
of  an  error  in  diagnosis.  The  same  may  be  said  of  malignant  disease  of  the 
abdominal  viscera.  Malaria,  however,  occurs  at  any  age ;  but  the  rational 
symptoms,  the  plasmodia  and  pigment  in  the  blood,  and  the  condition  of  the 
spleen  aid  in  the  diagnosis  of  the  paludal  disorder. 

Varieties  of  Jaundice. — Jaundice  in  the  New^-Born. — In  the  new- 
born infant  jaundice  occurs  in  mild  form  during  the  first  week  of  life  on 
account  of  ligation  of  the  cord  and  consequent  alteration  of  blood-pressure  in 
the  liver,  and  in  malignant  form  in  (1)  congenital  obliteration  of  the  biliary 
passages,  and  (2)  pylephlebitis  secondary  to  inflammation  of  the  umbilical 
vein. 

Simple  jaundice  in  infants  rarely  produces  grave  symptoms.  The  skin, 
the  conjunctiva,  and  the  mucous  membranes  show  a  yellow  discoloration,  vary- 
ing in  degree  in  diiferent  cases.  The  urine  is  loaded  with  bile-pigment.  The 
child  sleeps  more  than  in  health,  and  may  not  arouse  when  feeding  should 
take  place.  The  bowel  movements  may  be  pasty  and  white.  Such  jaundice 
begins  twelve  or  twenty-four  hours  after  birth.  It  lasts  two  days  to  a  fort- 
night. The  infant  usually  remains  well  nourished.  It  is  due  to  low  tension 
in  the  blood-vessels  of  the  portal  circulation  (after  ligature  of  the  cord),  which 
causes  rapid  absorption  to  take  place  from  the  bile-capillaries  in  which  the 
tension  is  higher.     Quincke  thinks  it  is  due  to  patency  of  the  ductus  venosus. 

Icterus  neonatorum  is  to  be  distinguished  from  the  pseudo-jaundice  that  oc- 
curs after  birth  due  to  a  destruction  of  red  corpuscles  in  excess  of  the  powers 
of  the  liver  to  discharge  them  from  the  body  in  the  bile.  In  this  condition 
the  conjunctiva  is  not  injected,  the  stocls  are  not  clay-colored,  and  the 
urine  does  not  contain  much  pigment.  The  discoloration  fades  like  a  bruise 
from  yellowish  red  to  flesh  color.  It  is  said  late  ligature  of  the  cord  allows 
a  portion  (one-half)  of  the  blood  in  the  placenta  to  flow  into  the  infant's 
body,  and  therefore  this  distends  the  foetal  vessels  by  so  much.  This  fact  is 
of  importance  if,  as  Parks  states,  distended  blood-vessels  exhibit  more  intense 
jaundice. 

The  treatment  of  the  mild  jaundice  of  infants  is  very  simple.  The  bowels 
should  be  opened  by  a  mild  laxative,  such  as  calomel  or  gray  powder  in  minute 


DISEASES    OF   THE  LIVER.  545 

doses,  or  a  few  grains  of  calcined  magnesia.  The  kidneys  should  be  kept 
active  by  nitre  or  citrate  of  potassium  "vvell  diluted.  The  child  should  be 
aroused  to  be  fed,  and  the  effects  of  the  jaundice  on  the  nerve-centres  should 
be  carefully  watched.  Ammonia  in  the  form  of  the  muriate  or  the  aromatic 
spirits  should  be  given,  as  in  the  following  prescription : 

i^.  Ammon.  chloridi .    .  gr.  j. 

Syr.  acacise f  Iss. — M. 

Sig.     A  coffee-spoonful  every  two  hours. 
Or, 

!^.   Spt.  ammon.  aromat fsj. 

Syrupi fSvij. — M. 

Sig.     One-half  teaspoonful  every  two  hours. 

Spirits  in  the  form  of  whiskey  in  hot  water  may  be  given  if  there  be 
depression.  Hot  water,  sweetened,  can  be  given  with  advantage  in  copious 
drafts,  particularly  when  fasting,  for  its  effect  on  the  liver  and  kidneys. 

There  does  not  seem  to  be  any  reason  against  the  use  of  gentle  massage 
and  faradism ;  both  are  vaunted  in  catarrhal  jaundice  in  later  life.  Exter- 
nally mild  sinapisms,  with  light  friction,  must  be  employed  if  the  circulation 
fails ;  and  the  extremities  must  be  kept  warm. 

Jaundice  due  to  Congenital  Obliteration  of  the  Bile-passages. — Four  forms 
of  obliteration  have  been  noted :  First,  that  in  which  no  passage  exists 
between  the  liver  and  duodenum  ;  second,  in  which  there  is  one  permeable 
canal,  but  no  exit  from  the  gall-bladder ;  third,  in  which  both  cystic  and 
hepatic  ducts  are  obliterated ;  and,  fourth,  in  which  obliteration  has  taken 
place  below  the  junction  of  the  cystic  and  hepatic  ducts. 

Congenital  malformation,  Avith  narrowing  of  the  lumen  of  the  parts  on 
account  of  defective  development,  may  exist  to  such  degree  that  it  leads  to 
sluggish  discharge  of  bile,  which  causes  irritation  of  the  ducts.  A  catarrhal 
process  is  set  up,  and  leads  to  complete  obliteration.  The  process  is  slow,  but 
the  obliteration  is  finished  in  some  cases  during  intra-uterine  life ;  in  others 
not  until  a  few  months  after  birth.  In  a  few  cases  the  inflammation  of  the 
ducts  and  the  surrounding  parts  has  led  to  localized  peritonitis.  In  all  cases, 
"biliary"  cirrhosis  of  the  liver  has  developed  secondarily. 

The  condition  is  rare.  Dr.  John  Thomson  was  able  to  collect  64  cases. 
We  are  indebted  to  his  monograph  for  the  following  facts  :  The  parents  of 
the  children  affected  with  obliteration  of  the  bile-ducts  are  usually  healthy. 
Syphilis  in  the  parents  is  not  an  important  factor.  In  several  instances  more 
than  one  child  of  the  same  family  was  affected,  and  in  a  large  number  of 
instances  nearly  all  the  children  of  families  in  which  one  case  occurred  had 
infantile  jaundice  or  were  subject  to  digestive  disturbances.  The  character  of 
the  labor  did  not  seem  to  influence  the  occurrence  of  the  disease.  At  birth 
the  affected  child  presented  no  abnormal  appearance,  except  jaundice.  In 
2  out  of  60  cases  the  lesions  of  congenital  syphilis  were  seen.  Boys  were 
affected  more  frequently  than  girls. 

Jaundice  is  the  most  pronounced  symptom.  It  is  most  frequently  present 
at  birth,  but  may  not  develop  until  one,  two,  or  six  days  after,  and  may  be 
delayed  beyond  a  fortnight.  It  soon  becomes  of  a  greenish  hue,  and  it 
progressively  deepens  until  the  final  termination.  The  urine  contains  bile 
coloring  matter.  The  meconium  may  be  normal  or  colorless.  When  it  is 
normal  the  obliteration  has  taken  place  late  in  uterine  life  or  not  until  after 
birth.     The  motions  are  whitish-gray  at  first  or  become  so  immediately  after 

35 


;j46    A3IEBICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREX. 

the  meconium  is  passed.  At  times  green  matter  is  voided  with  the  stools. 
It  may  be  due  to  mercury  which  had  been  administered  or  to  micro-organisms 
in  the  faeces. 

Next  to  jaundice,  the  occurrence  of  spontaneous  haemorrhages  is  the  most 
frequent  and  characteristic  symptom.  They  occur  subcutaneously,  from  the 
umbilicus,  the  bowels,  the  stomach,  the  nose,  and  other  portions  of  the  body. 
The  occurrence  of  hemorrhage  is  of  very  bad  prognostic  omen,  death  usually 
occurring  a  short  time  afterward.  Usually  in  jaundice  the  blood-corpuscles 
are  so  reduced  as  to  create  the  hjemorrhagic  tendency,  but  Thomson  believes 
haemorrhages  occur  because  of  some  change  in  the  blood-vessels  produced  by 
an  excess  of  ptomaines  in  the  blood,  the  function  of  the  liver  by  which  these 
poisonous  materials  are  destroyed  being  in  abeyance. 

With  or  without  haemorrhage,  convulsions  frequently  take  place.  These 
phenomena  are  of  frequent  occurrence  in  other  forms  of  jaundice,  and  are  not 
peculiar  to  the  affection  under  consideration. 

Progressive  and  easily  recognized  enlargement  of  the  liver  and  spleen 
takes  place,  with  the  development  of  the  grave  phenomena  indicated.  Emacia- 
tion and  exhaustion  rapidly  progress,  and  death  ensues  from  slight  intercurrent 
disease,  from  coma  or  from  exhaustion. 

The  diagnosis  is  not  difficult ;  the  prognosis  of  a  fatal  termination  is  posi- 
tive. The  duration  is  from  one  week  to  four  months.  Two  cases  recorded  by 
Thomson  lived  to  the  eighth  month.     Treatment  is  without  curative  results. 

Jaundice  due  to  Inflammation  of  Umbilical  Vein. — Icterus  may  occur  in 
infants  because  of  inflammation  of  the  umbilical  vein,  with  secondary  pyle- 
phlebitis. The  stump  of  the  cord  is  swollen  and  may  exude  pus,  or  the 
navel  is  ulcerated  and  inflamed.  Hi^morrhage  is  likely  to  arise.  The  skin 
is  discolored  around  the  navel,  and  the  parts  are  tender.  The  liver  is  enlarged, 
and  may  be  tender  over  the  surface.  In  rare  cases  a  localized  or  general 
peritonitis  occurs.  The  attack  may  be  ushered  in  with  a  convulsion,  which 
is  apt  to  recur.  The  infant  is  restless  and  cries  very  much.  The  desire  to 
nurse  is  lost.  Vomiting  occurs,  and  often  diarrhoea  soon  sets  in.  Foci  of 
infection  arise  in  other  structures — the  joints,  the  brain,  the  lungs.  The 
joints  become  painful  on  movement  and  are  swollen  and  red. 

After  the  convulsion,  or  perhaps  without  it,  fever  sets  in  with  the  customary 
phenomena.  The  temperature  is  high  and  may  be  intermitting ;  the  pulse  is 
very  rapid,  the  respiration  increased;  cough  may  be  present:  jaundice  is  not 
very  intense.  As  the  temperature  rises  the  liability  to  convulsions  increases, 
and  death  follows  the  convulsions,  occurs  in  coma,  or  may  take  place  from 
exhaustion.  After  death  a  septic  pleurisy,  pericarditis,  peritonitis,  or  menin- 
gitis may  be  found,  or  similar  inflammation  of  the  kidneys  observed. 

The  fever,  the  local  signs  and  symptoms,  and  the  jaundice  render  the 
diagnosis  easy.  In  a  few  cases  the  local  signs  are  not  noted,  under  which 
circumstances  the  difficulties  are  greater.  The  prognosis  is  most  grave.  The 
treatment  is  simply  symptomatic.  Prevention  of  this  fatal  illness  of  the  new- 
born must  be  sought  in  strict  antiseptic  dressings  of  the  cord.  Often  a  cord 
bleeds  after  the  first  ligature.  The  second  tvino;  is  most  dangerous  unless 
done  with  proper  precautions.  The  writer  had  a  case  of  this  character  in 
which  infection  took  place  from  and  at  the  hands  of  a  dirty  nurse.  Before 
ligating  the  cord  dirty  rags  were  applied  to  attempt  to  control  the  haemorrhage. 

Jaundice  in  WinvkeVs  Disease. — Jaundice  is  seen  in  that  fatal  affection 
of  the  new-born  known  as  Winckel's  disease,  or  acute  lijemuglobinuria. 
Cyanosis  and  haemorrhage  occur  with  the  hemoglobinuria,  but  the  liver  and 
spleen  do  not  enlarge. 


DISEASES   OF   THE  LIVER.  547 

Jaundice  in  Later  Infancy  and  Childhood. — Icterus  occurs  at  any 
period  of  childliood  and  in  both  sexes.  It  is  usually  of  the  so-called  catarrhal 
form.  Errors  of  diet,  improper  food,  excesses,  irregular  meals,  improper  cloth- 
ing, exposure  and  chilling  of  the  extremities,  leading  first  to  gastro-intestinal 
catarrh,  are  common  causes. 

The  onset  is  gradual,  being  preceded  by  the  symptoms  of  acute  or  subacute 
catarrh  of  the  stomach  and  duodenum.  There  is  some  tenderness  in  the  epi- 
gastrium and  the  right  hypochondriac  region,  the  liver  is  enlarged  and  may 
extend  an  inch  or  two  below  the  normal  line,  and  the  characteristic  signs 
and  symptoms  of  jaundice  are  present.  The  hue  does  not  change  to  the  green 
or  bronzed  yellow  of  malignant  jaundice.  Haemorrhages  do  not  often  occur. 
A  moderate  degree  of  fever  is  observed  for  a  short  time.  The  course  may 
extend  over  three  or  four  months. 

The  diagnosis  is  not  generally  difiicult.  A  history  of  long-continued 
improper  feeding  or  of  a  sudden  attack  of  vomiting,  etc.  from  improper  food 
or  from  cold,  is  usually  elicited.  The  gradual  development  of  the  jaundice, 
with  relatively  slight  constitutional  symptoms,  with  moderate  fever  only,  aids 
in  the  recognition  of  the  character  of  the  affection.  The  causal  presence  of 
worms  or  hydatid  cysts  in  the  ducts  cannot  be  distinguished  during  life. 

The  prognosis  is  good. 

Treatment. — If  fever  be  present,  rest  in  bed  must  be  enjoined.  The 
extremities  must  be  kept  warm.  Mild  counter-irritation  over  the  epigastrium, 
by  means  of  sinapism  or  frictions  with  stimulating  liniments,  may  be  em- 
ployed ;  massage  is  also  beneficial.  Gerhard  advises  compression  of  the  gall- 
bladder or  gentle  manipulation  in  that  region.  Faradism  has  also  been 
advised.  The  diet  must  be  bland  and  free  from  saccharine  or  amylaceous 
articles.  Milk  diluted  with  an  alkaline  or  carbonated  Avater  or  with  lime- 
water  and  taken  hot,  koumyss  if  vomiting  be  present,  junket,  and  animal 
broths,  such  as  beef-tea,  mutton-broth,  and  chicken-tea,  may  be  administered. 
After  the  acute  symptoms  have  subsided  semi-solids  may  be  used.  Prepara- 
tions of  milk  and  eggs,  beef-jellies,  oyster-broth,  and  clam-broth  are  appe- 
tizing. Light  fish  may  be  selected  as  convalescence  proceeds,  and  sweet- 
breads, broiled  beefsteak,  and  the  white  meat  of  chicken. 

If  there  be  much  gastric  disturbance,  sedatives  must  be  used.  Calomel 
in  small  doses,  calomel  and  bismuth,  effervescing  alkaline  waters,  carbonic- 
acid  water,  citrate  of  potassium  in  ofiicinal  solution  favorably  made,  are  of 
service.  If  there  be  pain,  minute  doses  of  magnesia  -may  be  added  to  the 
mercurial  powder,  or  paregoric  may  be  given  with  the  citrate  of  potassium  : 

!^.   Liq.  potassii  citratis f^ij- 

Tr.  opii  camph f^j. 

Sig.     One-half  to  one  teaspoonful  every  two  or  three  hours. 

Hydrochlorate  of  cocaine  in  solution  sometimes  allays  the  vomiting.  If 
there  be  constipation,  an  enema  sufficient  thoroughly  to  evacuate  the  bowels 
frequently  relieves  the  vomiting.  Afterward,  if  necessity  requires,  the  bowels 
should  be  opened  by  a  mercurial,  as  calomel  or  gray  powder,  in  small,  fre- 
quently-repeated doses,  or  by  the  citrate  of  magnesium,  or  a  saline  purgative, 
as  Hunyadi,  Friedrichshall,  Bedford,  or  Saratoga  water. 

When  the  acute  symptoms  are  ameliorated,  it  remains  to  treat  the  catarrhal 
inflammation  of  the  duodenum  and  ducts  and  the  symptoms  due  to  the  jaundice. 

In  the  treatment  of  catarrh  the  diet,  as  indicated  above,  must  be  persisted 
in  ;  small  doses  of  bismuth  may  be  continued.     Nitrate  of  silver  in  small  dose, 


548    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

with  opium  if  pain  be  present,  is  a  valuable  sedative  "which  modifies  the 
catarrhal  process.  In  young  children  it  may  be  given  in  solution  and  should 
be  administered  on  an  empty  stomach  : 

I^.  Argent,  nitrat gr.  ss. 

Mucilag.  acaciae f.sij- — M. 

Sig.   Teaspoonful  three  times  daily  to  a  child  under  two  years. 

Oxide  of  zinc,  in  doses  of  one-twelfth  of  a  grain  every  three  hours,  is  also 
useful. 

Small  doses  of  ipecacuanha  are  often,  after  acute  symptoms  have  subsided, 
of  service.  One-fourth  to  one  grain  of  the  powder  three  times  daily  is  praised 
highly  by  many. 

Phosphate  of  sodium  is  a  most  valuable  drug  in  catarrhal  jaundice.  Ten 
grains  three  times  a  day  in  milk  for  an  infant  or  half-drachm  to  one  drachm 
for  a  child  of  ten,  in  hot  water,  and  taken  fasting,  proves  of  inestimable 
benefit.     It  may  be  used  with  other  remedies. 

Chloride  of  ammonium  is  much  used,  particularly  in  India ;  one  to  five 
grains  of  the  drug  every  three  hours  is  frequently  followed  by  surprising 
results.  It  may  be  administered  in  syrup  of  licorice  or  in  syrup  of  orange. 
It  does  appear  to  dissolve  toughened  mucus,  to  allay  congestion,  and  to  pro- 
mote secretion  from  the  glands  in  the  tubes. 

Pilocarpine  in  doses  of  one-sixteenth  of  a  grain  has  been  recommended. 
It  seems  to  have  been  of  great  benefit  to  adults. 

After  the  tongue  cleans,  or,  as  is  often  the  case,  its  epithelium  is  restored 
and  the  papillse  assume  a  normal  aspect,  the  sedative  remedies  may  be  dis- 
continued and  a  weak  bitter  or  an  acidulated  bitter  may  be  given : 

R.  Acid,  hydrochlorici  dil • .    .    .    TTLxxxij. 

Infus.  serpentariae f-Sij- — M. 

Sig.   Teaspoonful  in  water  before  meals. 

For  more  chronic  cases  dilute  nitric  acid  internally  and  the  local  pack 
of  nitric  acid  are  often  serviceable. 

If  the  jaundice  be  of  malarial  or  gouty  origin,  quinine  in  the  former,  or 
colchicine  in  the  latter,  has  been  often  prescribed. 

Finally,  to  treat  the  catarrhal  process,  the  method  of  Krull  is  strongly 
insisted  upon  :  Two  to  four  pints  of  water  are  injected  into  the  colon  two  or 
three  times  daily.  The  temperature  is  raised  at  each  enema.  The  first  enema 
is  given  with  the  water  at  a  temperature  of  o9°  F.  It  is  made  two  or  three 
degrees  warmer  until  enemata  at  temperature  of  72°  are  given.  Krull  and 
others  testify  warmly  to  its  beneficial  effects  in  children.  The  writer  has  seen 
most  surprising  results  in  adults,  and,  as  no  harm  can  result  from  its  use, 
would  not  hesitate  to  use  it  in  children. 

Of  the  symptoms  of  jaundice  requiring  especial  attention,  itching  may  be 
mentioned.  Sponging  with  sedative  lotions  is  of  service.  Ten  drops  of  car- 
bolic acid  to  a  pint  of  water,  a  solution  of  the  bichloride  of  mercury,  1  to  3000, 
hot  solutions  of  alkalies,  as  bicarbonate  of  sodium  or  boi'ax,  a  drachm  of  each 
to  the  pint,  may  be  employed. 

Pilocarpine  is  recommended  by  Goodhart.  He  preferred  to  give  it  hypo- 
dermatically  ;  2t  ^^  T?  ^^  ^  grain  should  be  given  to  children  over  four  years 
old.  Since  it  was  advised  by  Goodhart  a  number  of  physicians  have  com- 
mended  its   use.     Internal   diaphoretics  of  domestic   origin  at  times   are  of 


DISEASES   OF   THE   LIVER.  549 

service.     An  infusion  of  sage  or  hot  drinks,  -with  a  stimulant,  excite  perspira- 
tion and  relieve  the  itching. 

Intestinal  dyspepsia  with  flatulency  and  painful  digestion  require  some 
medication.  The  diet  should  in  a  measure  prevent  the  development  of  these 
symptoms ;  nevertheless,  they  occur.  Preparations  of  pancreatin  given  an 
hour  after  meals,  with  an  alkali,  "will  aid  much  in  digestion.  If  they  are  not 
of  service,  such  drugs  as  correct  fermentation  in  the  intestines  must  be  adminis- 
tered. Of  these,  salol,  naphthalin,  and  thymol  are  of  great  service,  while 
creasote,  carbolic  acid,  and  charcoal  may  be  given  with  advantage.  Salol  may 
be  administered  in  powder  or  compressed  pill.  Naphthalin  and  beta-naphthol 
should  be  given  in  gelatin-coated  pill  or  capsule.  The  coating  does  not  dis- 
solve until  the  drug  reaches  the  intestine,  and  hence  is  of  great  advantage. 
Creasote  or  cai'bolic  acid  may  also  be  given  in  pill  or  in  emulsion  with  syrup 
of  acacia.  A  prescription  like  the  following  generally  overcomes  the  disagree- 
able symptoms : 

^.  Creasoti gi'-  4- 

Carbonis  lig gr.  j, 

Pancreatin gi"-  j- 

Bismuthi  subnitrat gr.  iij. — M. 

Ft.  chart.  No.  i. 
Sig-.  Take  after  meals. 

^.  Acidi  carbolici gtt.  iv. 

Sodii  bicarb 3j. 

Spiritus  chloroformi f^ij. 

Pulv.  aeaci?e 

Sacchari  albi aa  gr.  xx. 

Aquge q.  s.  ad  fsiij. — M. 

Sig.   A  teaspoonful  after  meals  or  every  three  hours. 

In  selecting  creasote  the  drug  made  from  the  beechwood  must  be  used, 
and  willow  charcoal  is  preferable  to  the  animal  form. 

The  cerebral  symptoms  of  jaundice  can  only  be  overcome  by  hastening 
the  elimination  of  bile  and  at  the  same  time  supporting  the  patient.  Stimu- 
lants must  be  used ;  preparations  of  ammonia,  alcohol,  and  caffeine  are  to  be 
selected.  The  preparations  of  ammonia  are  probably  the  best.  Of  course 
the  patient  must  be  nourished,  and,  if  necessary,  caff"eine  and  cocaine  may  be 
resorted  to.  Both  are  advantageous  stimulants,  because  they  cause  increased 
secretion  from  the  kidneys,  which  are  chiefly  concerned  in  eliminating  the  bile. 
The  poison  without  doubt  sets  up  nephritis.  It  is  necessary  to  guard  against 
this  complication  if  possible.  Creating  diaphoresis  by  jaborandi  or  the  hot 
vapor-bath  brings  about  this  result.  The  kidneys  may  be  relieved  also  by  local 
applications,  and  particularly  by  the  use  of  dry  cups.  In  the  case  of  more 
or  less  persistent  jaundice  these  organs  should  be  relieved  qui-te  frequently 
in  the  manner  just  suggested.  The  alkaline  waters  that  maj^  be  selected  for 
their  beneficial  effects  upon  the  liver  should  also  have  diuretic  properties.  If 
they  are  not  sufficient,  the  citrate  of  potassium  or  cream  of  tartar  lemonade 
may  be  given. 

The  slow  pulse,  the  subnormal  temperature,  and  the  prostration  that  ensues 
in  jaundice  are  to  be  treated  in  accordance  with  the  general  principles  of  the 
management  of  these  conditions.  If  haemorrhages  occur,  turpentine  or  erigeron 
may  be  administered  internally.     Sulphuric  acid  and  the  acetate  of  lead  are 


550    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

also  valuable  astringents.  The  blood  is  always  reduced  in  jaundice,  the  red 
corpuscles  diminished  in  number.  It  is  possible  the  systematic  inhalation  of 
oxygen  may  prevent  this  diminution,  or  at  least  combat  symptoms  depending 
upon  it.     It  certainly  is  worthy  of  trial. 

Congestion  of  the  Liver. 

Both  the  active  and  pasHive  forms  are  seen.  Active  congestion  is  acute, 
and  is  induced  by  an  exaggeration  of  all  circumstances  which  increase  the 
physiological  congestion  that  takes  place  under  the  stimulus  of  food.  Over- 
eating, the  eating  of  rich  food,  the  abuse  of  stimulants,  are  liable  to  cause  an 
acute  attack  of  hepatic  congestion.  Excess  of  heat  may  superinduce  an 
attack  in  hot  climates. 

The  symptoms  are  much  like  those  of  catarrhal  jaundice,  with  the  physical 
signs  of  enlargement  of  the  liver.  The  jaundice  is  not  intense.  The  face 
becomes  sallow  and  cachectic  if  jaundice  be  absent.  The  patient  loses  in 
health  and  strength.  Some  pain  is  complained  of  in  the  hepatic  region, 
which  is  tender  on  palpation.  The  liver  is  enlarged  uniformly  in  all  direc- 
tions, often  extending  two  inches  beyond  the  normal  boundaries ;  the  edge 
can  be  felt  and  is  smooth  and  rounded  ;  the  surfaces  also  are  smooth.  In  a 
few  cases  the  gall-bladder  is  enlarged,  and  can  be  detected  in  the  right  hypo- 
chondriac region  to  the  left  of  the  midclavicular  line  in  a  line  drawn  from  the 
acromion  process  of  the  right  shoulder  to  the  umbilicus. 

With  the  removal  of  the  cause  the  symptoms  disappear,  and  by  the  end 
of  a  month  the  functions  of  the  gastro-intestinal  tract  are  restored  and  the  liver 
is  reduced  in  size.  In  some  cases  enlargement  of  the  organ  and  the  peculiar 
complexion  of  the  patient  continue  for  a  longer  period. 

Passive  Congestion. — The  passive  form  of  congestion  is  associated  with 
disease  of  the  heart  and  lungs  and  chronic  malarial  poisoning.  The  pro- 
nounced symptoms  are  due  to  the  disturbance  of  these  organs ;  along  with 
congestion  in  other  organs  the  liver  becomes  engorged  with  blood,  and  hence 
gradually  enlarges.  The  shape  of  the  enlargement  is  similar  to  that  in  active 
congestion.  The  edge  of  the  liver  is  likely  to  be  sharper  and  more  indurated. 
No  nodules  can  be  detected  on  the  surface.  In  the  right  midclavicular  line  the 
lower  border  may  extend  to  the  level  of  the  umbilicus,  and  in  the  median  line 
the  left  lobe  may  extend  three-fourths  the  distance.  Frequently  the  upper 
border  cannot  be  so  readily  made  out,  because  of  the  occurrence  of  eifusion 
into  the  right  pleura.  The  rational  symptoms  ai'e  those  of  mild  gastro-intes- 
tinal catarrh.  The  tongue  is  furred ;  there  are  nausea,  loss  of  appetite, 
and  intestinal  dyspepsia ;  vomiting  and  constipation  may  occur,  or  there  may 
be  diarrhoea.  A  slight  form  of  jaundice  is  developed.  Albuminuria  is 
observed,  and  the  urine  presents  the  appearance  of  congestion  of  the  kid- 
neys. On  account  of  the  interest  centred  in  the  condition  of  the  heart  and 
lungs  passive  congestion  of  the  liver  is  frequently  overlooked. 

Diagnosis. — The  diagnosis  of  active  and  passive  congestion  of  the  liver 
is  made  without  difficulty.  The  presence  of  a  cause  for  the  congestion,  together 
with  the  mode  of  onset,  are  pronounced  factors  in  the  diagnosis. 

Prognosis. — In  the  acute  forms  the  prognosis  is  generally  favorable.  In 
chronic  congestion  the  prognosis  is  modified  by  the  knowledge  of  the  cause 
of  the  congestion. 

Treatment. — The  removal  of  the  cause  is  essential  to  the  successful  man- 
agement of  active  congestion  of  the  liver.  Correction  of  errors  in  diet,  in  habits 
of  life,  or  in  occupation  often  suffices  to  relieve  the  aifection.     The  gastro- 


DISEASES    OF    THE  LIVER.  551 

intestinal  symptoms  are  treated  as  in  catarrhal  jaundice.  More  stress  must 
be  laid  on  the  use  of  purgatives  for  depletion.  The  alkaline  Avaters  and  the 
mercurials  are  of  benefit.  Phosphate  of  sodium  is  useful :  it  may  be  given 
in  hot  solution  on  an  empty  stomach  either  at  night  or  on  rising  in  the 
morning.  The  hygienic  and  dietetic  management  employed  in  catarrhal  jaun- 
dice is  of  use  in  active  congestion  of  the  liver.  In  hot  climates,  if  such  con- 
gestion occur,  two  drugs  are  used  and  lauded.  The  chloride  of  ammonium 
in  3-  to  5-grain  doses,  every  two  or  three  hours,  relieves  the  discomfort  and 
appears  to  remove  the  engorgement  of  the  organ.  Ipecacuanha  is  used  for  a 
similar  purpose.  The  drug  must  be  given  in  large  doses,  administered  twice 
in  the  twenty-four  hours ;  5  grains  to  children  under  five  years  of  age  is 
admissible.  In  order  that  vomiting  should  not  be  caused  by  the  drug,  the 
administration  should  be  preceded  by  a  few  drops  of  the  deodorized  tincture 
of  opium  and  a  sinapism  applied  to  the  epigastrium.  T^venty  minutes  after 
the  application  the  drug  may  be  given.  After  the  more  acute  symptoms  have 
subsided  bitter  tonics  should  be  prescribed.  If,  however,  there  is  pronounced 
gastric  catarrh,  small  doses  of  calomel  or  bismuth  or  nitrate  of  silver,  as 
advised  in  catarrhal  jaundice,  may  be  a<lministered.  One  of  the  mineral  acids, 
especially  dilute  nitric  acid,  in  small  doses,  is  given  after  the  subsidence  of 
the  acute  symptoms,  particularly  if  the  liver  does  not  diminish  in  size. 

Passive  congestion  of  the  liver  is  treated  by  alleviating  the  symptoms  due 
to  the  engorgement,  and  by  the  employment  of  measures  and  remedies  to  relieve 
the  primary  cause  of  the  disease. 

Fatty  Liver. 

Enlargement  of  the  liver  due  to  fattv  infiltration  or  defeneration  occurs  in 
the  course  of  other  diseases  or  on  account  of  improper  habits  of  the  patient. 
In  children  it  is  always  an  intercurrent  aifection.  Tuberculosis  and  wasting 
diseases  generally  are  associated  with  fatty  infiltration.  The  wasting  that 
attends  gastro-intestinal  catarrh  is  associated  with  fatty  liver.  This  is  par- 
ticularly the  case  if  the  catarrh  results  from  the  excessive  use  of  sugar  and 
starchy  food.  The  enlargement  is  due  to  an  accumulation  of  fat  in  the  liver, 
and  not  to  degeneration  of  the  structures.  It  is  said  that  children  who  are 
closely  confined  and  have  become  anaemic  are  liable  to  this  disease. 

Syraptoms. — The  subjective  symptoms  are  negative.  Enlargement  of 
the  liver,  which  is  uniform  in  all  directions,  is  observed.  The  organ  is  of 
doughy  consistency  and  the  edge  is  rounded.  The  surface  is  smooth  and  pain- 
less on  palpation.  Jaundice,  ascites,  and  other  symptoms  due  to  hepatic  dis- 
order do  not  occur. 

Treatment. — The  treatment  depends  upon  the  cause.  If  enlargement  from 
fat  accumulation  is  found  in  children  who  tend  to  be  obese,  and  who  have 
been  indiscreet,  strict  hygienic  and  dietetic  management  must  be  invoked. 
The  carbohydrates  must  be  excluded  from  the  diet ;  out-door  exercise  must  be 
carefully  planned,  and  if  it  cannot  be  indulged  in,  massage  and  Swedish  move- 
ments must  be  directed.     Sea-air  has  been  advised  in  cases  of  this  character. 

AmyliOed  Disease  of  the  Liver. 

In  this  form  of  liver  disease  the  organ  is  enlarged  and  but  few  hepatic 
symptoms  of  a  subjective  character  are  observed.  The  affection  is  associated 
with  amyloid  disease  in  the  spleen,  kidneys  and  intestines.  The  degenera- 
tion occurs  in  the  course  of  phthisis,  chronic  bone  disease,  prolonged  suppura- 
tion, and  rickets.     It  may  occur  at  any  age  throughout  childhood. 


5o2    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Symptoms. — Anemia  is  a  prominent  general  symptoro,  and  the  pallor  of 
the  face  is  striking.  The  liver  is  enlarged  in  all  directions  ;  undue  prominence 
of  the  abdomen  in  the  course  of  any  of  the  above-named  affections  should 
lead  to  an  examination  of  this  viscus.  In  addition  to  the  enlargement  of  the 
liver,  the  spleen  is  also  found  to  be  enlarged.  The  liver  sometimes  attains 
a  very  large  size ;  it  may  be  twice  or  three  times  the  normal  weight.  The 
surface  is  smooth,  the  edges  hard  and  rounded.  xSo  pain  attends  palpation. 
The  external  veins  may  be  distended  ;  but  jaundice  does  not  occur,  and  ascites 
only  results  from  diseases  in  other  parts  of  the  body,  generally  from  the  con- 
dition of  the  kidneys.  Diarrhoea  is  usual,  and  hosmorrhage  from  the  bowels 
may  also  take  place. 

Diagnosis. — The  nature  of  enlarged  liver  occurring  in  the  course  of  the 
diseases  previously  indicated  can  usually  be  determined  without  much  dif- 
ficulty. The  diagnosis  is  rendered  more  positive  by  the  detection  of  similar 
disease  in  the  spleen  and  by  the  occurrence  of  albuminuria  and  polyuria 
due  to  amyloid  disease  of  the  kidney.  The  recognition  of  amyloid  disease 
should  be  attempted  in  all  cases  in  which  operative  measures  for  the  relief 
of  bone  disease  or  suppuration  is  contemplated.  Any  grave  operation  will  be 
contraindicated  by  the  presence  of  this  complication. 

Treatment. — Notwithstanding  the  frequent  suggestion  by  prominent 
authorities  of  the  use  of  alkalies  and  the  preparations  of  iodine  in  the  treat- 
ment of  this  affection,  there  does  not  seem  to  be  any  drug  which  modifies  or 
changes  the  course  of  the  disease.  The  removal  of  the  cause,  if  possible,  is 
the  most  rational  method  of  treatment.  The  few  symptoms  that  are  caused 
by  the  functional  derangement  or  enlargement  of  the  liver  are  to  be  treated. 
It  must  not  be  forgotten  that  in  some  cases  it  is  almost  impossible  to  say  how- 
much  amyloid  disease  is  present  or  to  what  extent  the  enlargement  of  the 
major  organs  within  the  abdomen  is  due  to  congestion.  The  symptoms  and 
etiology  may  point  with  certainty  to  the  presence  of  amyloid  disease.  If  in 
such  cases  the  heart  be  weak  or  there  be  organic  disease,  venous  congestions 
of  the  viscera  may  also  take  place ;  and  apparently  hopeless  amyloid  disease 
may  be  cured  by  recognition  of  this  pathological  fact,  and  hence  by  resorting 
to  removal  of  the  cause  by  the  administration  of  digitalis,  strophanthus,  and 
other  heart-tonics. 

Syphilitic  Inflammation  of  the  Liver. 

The  morbid  process  above  indicated  due  to  the  special  specific  poison  is 
seen  in  the  congenital  forms  of  the  disease  in  childhood.  Two  forms  of  inflam- 
mation occur — one  in  which  the  disease  is  limited  or  in  large  part  confined  to 
the  capsule ;  the  second,  in  which  the  connective  tissue  of  Glisson's  capsule 
is  the  seat  of  inflammation. 

Symptoms. — The  symptoms  are  generally  seen  in  children  who  have  the 
characteristic  appearance  of  face,  trunk,  and  extremities  of  congenital  syphilis, 
elsewhere  described  in  this  book.  The  skin  eruptions,  coryza  and  other 
mucous  inflammations,  anaemia,  emaciation,  and  malnutrition,  and,  later  in 
life,  the  appearance  of  the  teeth,  complexion,  and  shape  of  head,  render  the 
recognition  of  congenital  syphilis  comparatively  easy.  In  perihepatitis  there 
is  much  pain  over  the  liver,  breathing  is  diflRcult.  and  there  is  fever.  The 
temperature  rises  to  100°  or  101°,  the  pulse  is  frequent,  the  countenance 
distressed.  Relief  to  the  pain  takes  place  when  the  patient  assumes  the 
upright  position  and  ci'ouches  forward,  or  when  he  lies  on  his  back  with 
the  legs  drawn  up.      The  marked  tenderness  interferes  with  palpation    and 


DISEASES    OF   THE   LIVER.  553 

percussion.  When  the  pain  subsides  the  organ  is  found  enlarged  and  the 
edges  hard.  After  a  week  or  ten  days  the  more  severe  symptoms  abate  and 
convalescence  is  rapid  unless  the  patient  be  broken  down  by  previous  bad 
health.  Recurrence  takes  place  on  exposure  or  fatigue  or  without  apparent 
cause. 

In  another  group  of  cases  the  shrinking  of  new-made  connective  tissue 
begins,  and  soon  the  organ  is  grasped  in  the  toils  of  fibroid  overgrowth,  con- 
traction takes  place,  and  all  the  symptoms  of  portal  obstruction  arise. 

Jaundice  may  be  the  only  manifestation  of  infantile  hepatic  syphilis.  It  is 
in  all  probability  due  to  perihepatitis,  with  compression  of  the  gall-duct,  or  to 
enlarged  glands,  Avhich  likewise  compress  it,  or,  most  frequently,  to  adhesive 
inflammation  of  the  portal  vein. 

Syphilis  may  be  the  cause  of  cirrhosis  of  the  liver.  The  symptoms  are 
twofold — one  due  to  the  congenital  taint  Avith  possible  associated  lesions  in 
other  structures  ;  the  other,  to  portal  obstruction.  The  latter  symptoms  do  not 
differ  from  those  of  portal  obstruction  in  cirrhosis  of  the  liver  of  alcoholic 
origin. 

Diagnosis. — The  diagnosis  of  syphilitic  disease  of  the  liver  is  determined 
largely  by  the  association  of  the  lesions  and  well-known  appearances  of  congen- 
ital syphilis,  with  symptoms  indicating  inflammation  and  functional  disorder  of 
the  liver.  Often  the  symptoms,  and  particularly  the  objective  ones,  are  not 
obvious.  The  apparent  alteration  in  size  of  the  liver  is  not  demonstrable ; 
there  is  little  if  any  pain,  and  features  of  portal  obstruction  are  not  observed. 
Jaundice  may  be  the  only  symptom  present.  It  is  Avell  to  bear  in  mind  that 
persistent  jaundice  in  childhood  without  apparent  cause,  certainly  if  the  gastro- 
intestinal tract  be  free  from  catarrh,  may  be  of  syphilitic  origin.  The  thera- 
l^eutic  test  often  aids  in  making  a  diagnosis. 

Treatment. — The  treatment  is  largely  that  of  the  cause,  the  remedies 
applied  for  the  relief  of  congenital  syphilis  being  indicated.  In  addition 
to  the  constitutional  treatment  the  pain,  jaundice,  ascites,  and  other  symptoms 
are  to  be  relieved  by  methods  previously  indicated  in  this  paper. 

Suppurative  Hepatitis.  ' 

Two  varieties  are  seen.  In  one  the  abscess  is  single,  and  in  the  other 
multiple ;  in  the  former  the  suppuration  in  nearly  all  the  cases  is  secondary 
to  trauma ;  in  the  latter  suppurative  pylephlebitis  has  occurred  on  account  of 
suppuration  in  the  portal  area. 

Symptoms. — The  symptoms  in  the  two  forms  differ  entirely.  In  traumatic 
abscess,  after  the  injury  there  is  much  pain  in  the  hepatic  region  and  symp- 
toms of  perihepatitis.  The  parts  about  the  seat  of  injury  are  swollen,  and 
the  external  surface  may  show  the  signs  of  a  blow.  After  the  injury  the  pain 
may  diminish  and  the  child  be  apparently  well,  when  a  recurrence  of  the  local 
symptoms  will  arise ;  or  the  effects  of  the  injury  may  not  subside  in  the  usual 
time.  Pain  in  the  region  of  the  liver  will  be  complained  of,  and  on  examina- 
tion the  organ  is  found  to  be  enlarged.  The  enlargement  is  not  uniform.  It 
may  be  upward  only,  or,  as  is  most  frequently  the  case,  be  indicated  by  exten- 
sion of  the  lower  border  of  dulness  downward.  On  palpation  the  hepatic 
region  is  painful ;  oedema  over  the  most  painful  part  or  over  the  hepatic  area 
or  the  area  of  enlargement  may  be  observed.  If  the  abscess  be  developing  in 
the  right  or  left  lobe,  an  undue  prominence  may  be  seen  in  the  right  hypo- 
chondriac or  in  the  epigastric  regions  respectively.  It  will  be  noted  to  move 
with  respiration  and  to  be  continuous  with  liver  dulness  on  percussion. 


554    A 31  E RICA N  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

AYitli  the  development  of  the  local  signs  of  enlargement  and  inflammation  gen- 
eral symptoms  arise.  The  fever,  which  may  have  been  due  to  trauma,  does  not 
disappear,  and  indeed  becomes  more  pronounced.  It  assumes  a  remittent  or  even 
distinctly  intermittent  type,  and  may  be  preceded  by  daily  rigors  and  followed  by 
exhaustive  sweats ;  prostration  ensues,  and  there  may  be  a  loss  of  flesh.  The 
tongue  is  furred,  appetite  lost,  vomiting  may  occur,  and  diarrhoea  is  frequently 
present.  If  the  inflammation  be  seated  on  the  convex  surface  of  the  liver, 
breathing  is  interfered  Avith  and  cough  may  be  present ;  both  respiratory  acts 
will  in  all  probability  be  attended  with  pain.  The  pain  is  then  noted  in  the 
sixth  or  seventh  interspace  in  front  or  the  seventh  or  eighth  interspace  behind. 
It  may  extend  to  the  right  shoulder,  and  in  some  cases  pain  in  this  position  alone 
is  complained  of. 

As  previously  intimated,  sometimes  the  symptoms  of  suppuration,  with 
local  signs  of  inflammation,  do  not  develop  until  a  long  time  has  elapsed  after 
the  injury.  The  genei'al  symptoms  may  arise  befoi*e  local  signs  of  inflamma- 
tion are  evident.  Between  the  injury  and  the  development  of  the  symptoms 
the  child  is  not  in  good  health.  Loss  of  appetite,  languor,  inability  to  exert 
himself  as  was  his  former  habit,  with  loss  of  flesh  and  strength,  are  very  likely 
to  be  present. 

Multiple  abscess  of  the  liver  is  usually  preceded  by  a  history  of  suppura- 
tion, and  therefore  a  point  of  infection  somcAvhere  in  the  portal  area.  An 
appendicitis  is  one  of  the  most  frequent  affections  which  precede  this  form  of 
suppuration.  It  is  thYis  seen  that  active  abdominal  symptoms  may  be  present 
prior  to  the  development  of  symptoms  indicating  involvement  of  the  liver. 
If  in  the  course  of  such  symptom's  jaundice  arises  and  the  liver  becomes 
enlarged  and  painful,  we  may  well  suspect  that  the  inflammation  has  spread 
to  the  portal  vein.  The  type  of  the  fever  may  also  change.  It  becomes  dis- 
tinctly intermittent,  and  daily  chills  attend  it.  The  onset  of  jaundice  is 
characterized  not  only  by  the  discoloration  of  the  skin,  but  by  the  develop- 
ment of  symptoms  of  the  typhoid  state.  Delirium  of  a  low  muttering  character 
soon  occurs,  deepening  into  stupor.  The  tongue  becomes  dry  and  brown, 
sordes  collect  about  the  teeth  and  lips,  and  subsultus  is  seen.  In  some 
inst|.nces  convulsions  occur ;  in  others  death  takes  place  from  exhaustion. 
Diarrhoea,  if  not  previously  present,  is  sure  to  arise.  The'  stools  are  offensive 
and  watery,  and  contain  light-colored  fecal  matter.  The  urine  contains  bile- 
pigment,  soon  becomes  scanty  and  high-colored,  and  is  found  to  contain  albu- 
min and  to  have  blood,  epithelial,  and  granular  casts.  The  nephritis  may 
become  so  marked  as  to  be  a  serious,  indeed  fatal,  complication. 

The  patient  usually  lies  on  the  right  side,  and  when  he  assumes  the  opposite 
position  complains  of  a  heavy,  dragging  sensation.  The  skin  is  sallow,  the 
complexion  muddy.  The  facies  is  quite  characteristic.  Waring  describes  the 
appearance  as  follows :  Countenance  expressive  of  anxiety,  shi'unk,  collapsed, 
pale,  livid,  or  parchment-like. 

Diagnosis. — If  the  symptoms  of  suppuration  just  indicated  arise  after 
trauma  or  the  occurrence  of  suppuration  of  the  portal  area,  diagnosis  is  not 
difficult.  The  cases  of  suppuration  secondary  to  worms  in  the  hepatic  duct, 
or  to  suppurative  inflammation  of  the  ducts,  extremely  rare  in  childhood,  ai'e 
recognized  with  difficulty.  The  absence  of  a  focus  of  suppuration  in  any  other 
portion  of  the  body  Avhen  hectic  symptoms  are  present  should  determine  the 
necessity  of  careful  examination  of  the  liver.  Enlargement,  either  general  or 
local,  may  be  made  out  by  careful  percussion.  The  exploratory  needle  may 
render  positive  a  suspicion  of  hepatic  suppuration,  but  the  negative  results  of 
puncture  do  not   exclude   abscess.     Friction-sound  at  the  base  of  the   right 


DISEASES    OF    THE   LIVER.  555 

lung,  with  diminished  expansion  of  that  side,  may  call  attention  to  possible 
hepatic  suppuration. 

Reference  has  not  been  made  to  abscess  of  the  liver  occurring  in  the 
course  of  dysentery.  The  writer  has  not  been  able  to  find  any  recorded  cases 
of  this  association  in  childhood,  though  there  is  no  special  reason  why  it 
should  not  occur.  In  cases  of  dysentery  it  is  important  to  interrogate  as  to 
the  condition  of  the  liver,  and,  on  the  other  hand,  in  acute  liver  affections  the 
presence  or  absence  of  dysentery  is  to  be  ascertained.  Amoebae  in  the  stools, 
in  pus  from  an  abscess,  or  in  expectoration  would  confirm  the  diagnosis  of  this 
form  of  abscess  of  the  liver. 

Prognosis. — In  multiple  abscess  of  the  liver  the  prognosis  is  very  grave, 
such  cases  terminating  fatally.  In  single  abscess,  if  the  pus  can  be  reached 
by  aspiration  or  by  the  knife,  the  prognosis  is  much  more  favorable.  If  the 
abscess  be  beneath  the  diaphragm  in  the  upper  portion  of  the  right  lobe,  the 
issue  is  much  more  doubtful  than  when  superficial. 

Treatment. — The  management  of  a  case  falls  entirely  into  the  hands  of 
the  surgeon.  In  multiple  abscess  of  the  liver  no  measures  are  of  avail.  In 
single  abscess  or  where  the  number  is  limited  to  three,  free  incision  must  be 
made  and  may  result  favorably.  If  the  abscess  be  situated  along  the  margin 
of  the  ribs  or  in  the  epigastric  region,  the  operation  is  simple  and  reparation 
takes  place  rapidly.  The  writer  has  seen  two  such  cases  recently  in  the  Phila- 
delphia Hospital.  An  abscess  of  the  convexity  of  the  right  lobe  must  be 
reached  through  the  pleural  cavity.  Excision  of  the  ribs  is  necessary,  and 
isolation  of  the  pleural  cavity  quite  essential.  After  pus  is  secured  and  the 
cavity  drained  and  irrigated,  a  drainage-tube  must  be  inserted  and  the  case 
treated  by  the  usual  surgical  methods.  Recently  the  writer  reported  a  case 
under  his  care  in  which  Dr.  Willard  performed  the  operation  above  indicated 
most  successfully. 

Hydatid  Disease. 

This  is  a  comparatively  rare  afiection  in  this  country.  It  seems,  however, 
to  be  on  the  increase ;  within  the  last  two  years  the  writer  has  seen  six  cases, 
and  knows  it  to  have  been  more  common  in  the  experience  of  others.  In 
children  it  is  even  more  rare  than  in  adults.  With  the  exception  of  a  child 
under  twelve  at  the  University  clinic,  no  cases  have  come  under  the  writer's 
observation.  In  the  literature  of  the  disease  few  if  any  cases  are  reported 
under  two  years  of  age.  The  liver  is  one  of  the  organs  most  frequently 
affected.  In  childhood  it  appears  to  be  the  organ  selected  in  70  per  cent, 
of  the  cases.  In  the  recent  exhaustive  work  of  Graham  a  few  cases  only  are 
recorded.  He  states  that  within  a  period  of  one  year  he  observed  hydatids 
in  ten  children,  their  ages  varying  from  five  to  eight  years.  The  youngest 
case  that  he  refers  to  is  one  operated  on  by  Thomas,  a  boy  aged  two  years  and 
one  month.  This  disproves  the  statement  of  Leuckart,  who  at  the  time  of  his 
publication  believed  the  youngest  cases  recorded  to  have  been  four  and  six 
years  of  age  respectively. 

There  is,  therefore,  no  immunity  for  children  if  their  associations  are  such 
as  to  cause  infection.  The  infection  may  occur  very  early  in  life,  but  the  slow 
growth  of  the  cyst  makes  it  possible  that  they  are  not  recognized  for  years. 
Moreover,  in  childhood,  as  Graham  remarks,  "  the  organs  in  which  the  cysts 
are  situated  are  less  likely  to  be  so  completely  affected  as  is  the  case  in  the 
adult  subject  where  the  pressure  changes  are  more  permanent." 

Space  will  not  permit  a  discussion  of  the  mode  of  development  or  infection 
of  the  human  species.     The  growth  in  the  child  and  the  manner  of  its  infec- 


556    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tion  do  not  differ  from  the  same  in  adults  (for  description  of  which  recent  text- 
books on  pathology  contain  sufficient  information). 

Symptoms. — The  cyst  in  the  liver  may  develop  and  reach  a  large  size 
■without  recognition.  Attention  is  first  called  to  its  presence  by  the  occurrence 
of  mechanical  symptoms ;  the  abdomen  enlarges  or  there  are  enlargement  and 
swelling  of  the  liver  region.  On  examination,  if  the  liver  be  the  seat  of  the 
disease,  it  is  found  to  be  enlarged.  The  enlargement  may  be  uniform  ;  usually, 
however,  it  takes  place  in  a  particular  direction.  If  the  growth  springs  from 
the  convex  surface  of  the  liver,  the  area  of  dulness  extends  higher  in  the 
axillary  region  and  behind  in  the  scapular  line.  If  it  begins  in  the  right  lobe, 
and  the  lower  portion  thereof  particularly,  the  extent  of  dulness  is  increased 
downward  toward  the  umbilicus.  Sometimes  the  tumor  is  confined  to  the  left 
lobe  of  the  liver,  and  hence  is  recognized  in  the  epigastric  region.  The  prom- 
inence in  the  epigastric  region  or  below  the  ribs  in  the  mammary  line  is 
smooth  and  tense  on  palpation  ;  sometimes  fluctuation  can  be  detected.  In  a 
moderate  proportion  of  cases  the  so-called  hydatid  fremitus  is  elicited,  if  the 
left  hand  be  placed  over  the  tumor  and  another  portion  tapped  quickly  and 
forcibly  with  the  right. 

The  tumor  is  painless,  and  there  is  no  tenderness  on  pressure.  The  patient 
suffers  from  distention.  There  is  interference  with  respiration,  so  that  fre- 
quently he  is  compelled  to  sit  up  in  bed  in  order  to  alleviate  the  dyspnoea. 
The  general  health  is  usually  unaffected. 

In  some  cases  the  cyst  is  in  such  relation  to  the  hepatic  duct  as  to  cause 
compression  jaundice.  The  jaundice  usually  develops  gradually.  In  rare  cases 
the  cyst  breaks  into  the  hepatic  duct ;  some  pain  follows  this  accident,  and  on 
account  of  the  obstruction  by  the  cystic  contents  jaundice  develops.  If  the 
patient  comes  under  observation  after  rupture  of  the  cyst  has  taken  place,  the 
diagnosis  is  rendered  more  obscure.  The  enlarged  cyst  has  been  dispersed, 
and  therefore  most  of  the  signs  of  tumor  disappear. 

Suppuration  of  the  cyst  sometimes  takes  place,  and  in  addition  to  the 
symptoms  due  to  hepatic  pressure  those  of  pyaemia  arise, — rigors,  periodical 
elevations  of  temperature,  sweats,  and  great  prostration.  Jaundice  occurs 
either  because  of  the  pyaemia,  or,  if  it  be  intense,  because  of  obstruction  of 
the  ducts  and  probably  suppurative  cholangitis. 

The  outcome  of  cases  of  hydatid  disease  varies.  The  liability  to  rupture 
is  the  same  at  all  periods  of  life ;  perforation  may  take  place  into  the  stomach, 
the  colon,  the  pleura  and  bronchi,  or  in  some  cases  externally.  It  has  been 
said  that  in  a  few  cases  where  this  accident  has  occurred  recovei*y  has  taken 
place.  The  perforation  may  also  take  place  into  the  pericardium  or  the  vena 
cava ;  Avhen  this  accident  occurs  death  takes  place  suddenly. 

Diagnosis. — A  diagnosis  is  not  usually  difficult.  Irregular  enlargement 
of  the  liver,  the  surface  of  which  is  smooth  and  painless,  or  the  presence  of  a 
tumor  of  the  same  character  connected  with  the  liver,  probably  fluctuating,  in 
an  individual  otherwise  in  good  health,  usually  indicates  the  presence  of  this 
disease.  If  the  cysts  are  multiple,  and  the  surface  of  the  tumor,  therefore, 
irregular,  the  diagnosis  is  more  difficult.  The  health  is  usually  retained,  and  the 
benign  nature  of  the  enlargement  thus  inferred.  Syphilitic  disease  of  the  liver 
and  carcinoma  must  be  excluded  in  adults.  The  rarity  of  the  latter  affection 
in  childhood  and  the  absence  of  a  primary  focus  of  malignant  disease,  with 
retention  of  health  and  strength,  exclude  cancer.  In  syphilis  the  enlargement  of 
the  liver  may  be  irregular  and  a  distinct  boss  recognizable.  This  usually 
occurs  in  tertiary  syphilis,  a  form  not  seen  in  childhood.  In  congenital  syphilis 
involving  the  liver  large  prominences  are  not  seen.     Nevertheless,  in  both 


DISEASES    OF   THE   LIVER.  557 

instances  it  is  well  to  resort  to  exploratory  puncture,  and,  if  syphilis  be  sus- 
pected, to  the  treatment  as  a  test  in  diagnosis.  If  suppuration  takes  place  in 
the  cyst,  it  cannot  be  distinguished  from  abscess  unless  it  be  known  before  the 
accident  that  there  was  a  painless  enlargement  of  the  liver  Avithout  fever.  In 
adults  dilatation  of  the  gall-bladder  has  been  mistaken  for  hydatid.  This  con- 
dition does  not  occur  in  childhood,  and  hence  need  not  be  considered.  Hydro- 
nephrosis has  also  been  mistaken  for  hydatid  disease.  The  condition  is  not 
common  in  children,  but  can  be  distinguished  by  the  results  of  exploratory 
puncture.  When  the  cyst  extends  upward,  it  is  often  difficult  to  distinguish 
it  from  a  pleural  effusion.  The  same  physical  signs  in  the  lower  part  of  the 
right  chest  may  be  present  as  in  effusion.  Frehrichs  believed  that  the  direc- 
tion of  the  upper  line  of  dulness  is  significant  in  hydatid  disease  of  the 
liver.  It  does  not  take  the  S  curve,  as  in  effusions,  but  reaches  the  highest 
point  at  the  angle  of  the  scapula.  Sometimes  empyema  complicates  a  hydatid 
cyst,  as  in  cases  reported  by  Murchison.  The  cases  that  are  most  difficult  of 
diagnosis  are  those  which  have  ruptured  into  the  lungs  before  coming  under 
observation.     The  appearance  of  booklets  in  the  sputum  is  characteristic. 

Reference  has  been  made  in  the  beginning  of  this  article  to  results  of 
exploratory  puncture  in  cases  of  suspected  hydatid  disease.  The  fluid  with- 
drawn has  special  properties  which  render  the  recognition  of  the  disease  abso- 
lute. 

Prognosis. — From  results  of  observation  at  the  post-mortem  table  we  see 
that  a  number  of  cases  of  hydatid  disease  of  the  liver  undergo  spontaneous 
cure.  These  cases,  of  course,  are  not  recognized  during  life.  If  the  disease 
is  recognized  and  the  tumor  is  accessible,  the  prognosis  is  very  good.  The 
results  of  treatment  are  generally  quite  favorable. 

Treatment. — Internal  medication  is  of  no  avail  and  need  not  be  discussed. 
Surgical  procedures  are  necessary.  Electrolysis  has  been  used,  but  since  the 
advent  of  antiseptic  surgery  has  fallen  into  disuse.  Medicated  injections  are 
not  in  high  favor.  Iodine,  carbolic  acid,  solution  of  bichloride  of  mercury, 
and  permanganate  of  potassium  have  been  used,  but  the  treatment  is  open  to 
objections.  Indeed,  at  the  present  time  all  methods  except  free  incision  are 
discarded  as  more  or  less  dangerous.  The  uncertainty  that  attends  the  intro- 
duction of  the  trocar  and  the  possibility  of  infection  render  such  methods 
more  or  less  hazardous,  while  the  difficulty  of  completely  emptying  the  cyst 
renders  it  liable  to  recur  after  the  fluid  is  withdrawn.  Recamier's  method  of 
opening  into  the  cyst  by  caustics  or  the  thermo-cautery  has  been  employed. 
The  method  is  tedious  and  painful,  and  not  without  danger. 

The  treatment  by  direct  incision  and  evacuation  of  the  contents  of  the 
cyst  has  been  rendered  possible  by  the  developments  of  abdominal  surgery. 
Incision  should  be  made  over  the  most  prominent  part  of  the  tumor  in  the 
manner  of  performance  of  a  laparotomy.  After  the  cyst  is  exposed  it  should 
be  attached  to  the  edges  of  the  abdominal  incision  ;  it  is  then  opened  by  the 
knife  and  its  contents  evacuated.  The  daughter-cysts  may  be  evacuated  by 
forceps.  Too  much  force  must  not  be  used.  In  order  to  secure  complete 
evacuation  irrigation  of  the  cyst-cavity  must  be  employed.  A  drainage-tube 
is  then  inserted  and  the  patient  dressed  as  in  an  abdominal  operation.  If  the 
cyst  grows  from  the  upper  surface  of  the  liver,  it  must  be  evacuated  by  pass- 
ing through  the  diaphragm.  One  or  two  ribs  should  be  resected,  the  pleura 
stitched  to  the  diaphragm,  and  evacuation  then  brought  about  by  the  previous 
method. 

In  oases  that  have  been  operated  upon  a  form  of  urticaria  known  as  the 
hydatid  rash  is  sometimes  seen.      It  is  said  that  the  fluid  of  a  hydatid  cyst 


558    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

will  not  cause  peritonitis.     Any  portions  of  the  cyst-wall  that  are  left  behind 
or  any  of  the  daughter-cysts  will  cause  suppuration. 

Cirrhosis  of  the  Liver. 

Through  the  writings  of  Palmer  Howard,  of  Edwards,  of  Hatfield,  and 
others  we  have  learned  that  in  its  etiology,  clinical  course,  and  mode  of  termina- 
tion cirrhosis  of  the  liver  in  childhood  "does  not  differ  from  that  in  adult  life. 

Etiology. — Alcoholism  is  a  very  constant  factor  in  its  causation.  The 
habit  is  usually  fostered  because  of  the  delicate  state  of  the  child  in  early 
infancy,  coupled  with  the  belief  of  ignorant  parents  that  rum  contributes  to 
its  development.  It  is  true  some  children  from  their  swaddling-clothes  have 
an  appetite  for  liquor,  an<l  when  not  discouraged  are  likely  to  develop  all  the 
lesions  of  alcoholism.  Syphilis,  as  already  mentioned,  is  another  prominent 
cause.  In  Howard's  cases  an  adhesive  pylephlebitis  took  place  primarily, 
followed  by  secondary  cirrhosis.  In  some  of  the  recorded  cases  chronic  heart 
disease  was  the  causal  factor.  The  infectious  fevers,  as  scarlatina  and  measles, 
play  an  important  part.  Tuberculosis  is  attended  by  a  form  of  cirrhosis  both 
when  the  liver  is  involved  in  the  tuberculous  disease  and  independently  of  it. 
Howard  and  others  believe  that  ptomaines  and  products  of  imperfect  digestion 
may  be  productive  of  this  affection.  In  rickets  there  is  often  found  enlarge- 
ment of  the  liver  which  is  due  to  an  overgrowth  of  connective  tissue. 

Hypertrophic  or  biliary  cirrhosis  is  rarely  seen  in  childhood.  It  is  due  to 
chronic  obstruction  of  the  biliary  passages,  and  hence  is  present  in  congenital 
obliteration  of  the  ducts. 

From  the  recorded  cases  collected  by  the  above-mentioned  authors,  cirrhosis 
of  the  liver  has  been  found  to  occur  more  frequently  in  males  than  in  females 
in  the  proportion  of  two  to  one.  The  largest  number  of  cases  occur  between 
the  ninth  and  thirteenth  years.  It  is  found,  however,  at  birth,  and  may  occur 
at  any  period  subsequently. 

Symptoms. — In  the  early  stages  of  the  disease  capillary  congestion  is 
noted  in  the  face.  This  may  increase.  As  the  disease  advances  the  face 
becomes  drawn,  the  parts  free  from  stigmata  are  pale,  or  a  sallow,  mu<ldy  com- 
plexion is  seen.  The  symptoms  due  to  obstruction  are  usually  most  prominent. 
Gastro-intestinal  catarrh  is  observed.  Morning  nausea  and  retching  with 
discharge  of  mucus  take  place,  the  appetite  is  poor,  the  bowels  irregular, 
alternating  attacks  of  diarrhoea  and  constipation  take  place,  and  the  bowel 
movements  usually  contain  considerable  mucus.  H:\?morrhages  from  the  lower 
end  of  the  oesophagus,  the  stomach,  or  the  intestinal  tract  may  occur,  and  are 
very  characteristic  S3miptoms  of  cirrhosis.  In  gastric  haemorrhage  the  vomiting 
has  no  relation  to  food,  and  is  not  associated  with  symptoms  of  gastric  ulcer. 
In  the  later  stages  of  the  disease  haemorrhages  occur  from  the  nose  or  the 
mouth,  and  purpuric  spots  develop.  They  are  due  to  the  state  of  the  blood. 
Hemorrhoids  are  frequently  present. 

Jaundice  occurs  in  about  the  same  degree  of  frequency  as  in  the  cases  of 
adults.  It  is  usually  slight,  and  may  disappear  and  recur  two  or  three  times 
in  the  course  of  the  disease.  Slight  fever  is  seen  in  many  cases.  The  temper- 
ature rises  to  101°  and  102°  in  the  evening.  It  may  be  present  for  a  long 
period  of  time,  an<l  as  the  end  approaches  disappear  entirely. 

The  urine  is  high-colored,  of  high  specific  gravity,  and  contains  an  excess 
of  ui'ates  and  uric  acid.  Frequently  nephritis  develops  in  the  course  of  the 
aff"ection.  Albumin  is  then  found,  and  the  urine  contains  hyaline  and  granular 
casts.     The  specific  gravity  always  remains  high,  and  there  is  an  excess  of 


DISEASES    OF   THE  LIVER.  559 

lithates.  From  time  to  time  sugar  may  be  detected,  but  a  persistent  glycosuria 
is  not  likely  to  arise. 

On  physical  examination,  when  the  disease  is  somewhat  advanced,  further 
evidences  of  portal  obstruction  and  attempts  at  compensatory  circulation  are 
seen.  The  venules  along  the  base  of  the  thorax,  extending  across  the  chest 
in  an  arc,  following  the  attachment  of  the  diaphragm,  are  very  distinct.  The 
external  veins,  particularly  the  epigastric  and  mammary,  are  particularly  dis- 
tinct. If  compensation  does  not  take  place,  ascites  develops,  and  after  its 
development  the  feet  may  swell.  The  spleen  is  frequently  enlarged,  but  its 
size  often  cannot  be  determined  when  ascites  is  present.  The  liver  is  found 
to  be  enlarged  if  the  case  is  seen  in  the  early  stage,  and  it  may  be  slightly 
tender  on  palpation.  Subsequently  it  diminishes  in  size,  or  the  small  size  is 
at  once  noted.  The  diminution  of  the  left  lobe  is  particularly  noticeable.  With 
the  walls  relaxed  the  edge  and  surface  can  sometimes  be  felt  rough  and  gran- 
ular. Some  cases  are  not  attended  by  atrophy.  Thus  there  may  be  much  fat 
in  the  liver,  and,  notwithstanding  the  connective-tissue  overgrowth,  the  organ 
remains  enlarged.  Fatty  atrophy  of  the  liver  is  the  name  applied  to  this 
form.  In  "  biliary  cirrhosis"  the  liver  is  enlarged  and  smooth.  Jaundice  is 
permanent,  and  the  other  symptoms  of  cirrhosis  are  present. 

On  account  of  the  organic  disease  of  the  liver  auto-intoxication  takes  place 
with  ptomaines  or  products  of  imperfect  digestion.  Low  delirium,  deepening 
into  stupor,  with  the  ocurrence  of  frequent  convulsions,  or  noisy  delirium  fol- 
lowed by  convulsions,  show  the  eifect  of  the  toxine  on  the  nervous  system. 
Jaundice  is  not  necessarily  present  when  these  symptoms  develop. 

Diagnosis. — The  disease  may  be  far  advanced,  and  not  recognized  because 
of  the  absence  of  symptoms  or  signs.  A  boy  aged  fifteen  years  died  in  the 
Presbyterian  Hospital  of  typhoid  fever.  He  had  been  under  the  observation 
of  the  writer  for  nine  years.  Acute  rheumatic  fever  with  endopericarditis  was 
the  reason  of  the  first  consultation  ;  valvular  disease  continued.  The  patient 
had  been  in  poor  health,  and  the  parents  were  wont  to  give  him  spirits.  This 
had  been  continued  more  or  less  until  the  fatal  illness  occurred.  At  the 
autopsy  cirrhosis  of  the  liver  in  an  advanced  degree  was  discovered. 

The  appearance  of  the  face,  the  symptoms  of  portal  obstruction,  and  the 
physical  signs  of  atrophied  liver  are  points  on  which  the  diagnosis  is  based. 

The  occurrence  of  subacute  gastritis  with  morning  vomiting,  of  hsemat- 
emesis,  and  of  mal^na,  without  the  physical  signs  of  a  small  liver,  are  never- 
theless most  suggestive,  particularly  if  the  patient  be  poorly  nourished,  with 
a  drawn,  pallid  countenance,  and  especially  congestion  of  the  cheeks — venous 
stigmata.  If  ascites,  enlargement  of  the  spleen,  and  jaundice  supervene,  the 
diagnosis  is  absolute. 

Treatment. — We  can  never  tell  whether  the  enlarged  liver  of  the  early 
stage  of  cirrhosis  is  one  in  which  congestion  predominates,  or,  on  the  other 
hand,  one  in  which  the  overgrowth  of  connective  tissue  is  in  excess.  If  the 
former,  we  know  that  there  are  measures  which  markedly  influence  the  engorge- 
ment. If  the  latter,  it  is  possible  a  further  increase  may  be  averted  by  proper 
hygienic  and  prophylactic  measures.  It  is  our  duty,  notwithstanding  the 
uncertainty,  to  relieve  engorgement.  External  depletion  by  cups  and  leeches, 
purgatives  in  quantity  to  ensure  three  to  six  liquid  stools  a  day,  Rochelle  salts, 
citrate  of  magnesium,  and  saline  waters,  are  to  be  used.  The  waters  of  such 
springs  as  Saratoga  and  Bedford  in  this  country,  and  Carlsbad  in  Germany, 
are  beneficial.  Counter-irritation  in  mild  degree  is  likewise  of  value.  If 
leeches  or  cups  are  inadvisable,  stimulating  liniments  may  be  employed.  The 
diet  is  to  be  carefully  selected.     A  milk  diet  is  for  a  time  the  most  satisfactory. 


r 


560   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHIIDEEX. 

Stimulants  and  rich,  stimulating  articles  of  food,  fats,  sugars,  and  starches  are 
to  be  avoided.  Waters  are  to  be  used  abundantly  :  they  may  be  taken  hot 
in  large  bulk  (a  glassful)  when  the  patient  is  fasting  to  tlush  the  liver. 

Phosphate  of  sodium  may  be  advantageously  added  to  waters  to  produce 
a  depurative  effect.  At  first  small  doses  of  calomel  or  mercury  with  chalk 
should  be  given  for  a  few  days.  A  furred  tongue,  nausea,  constipation,  Avith 
pasty  stools,  indicate  its  use.  From  time  to  time  it  should  be  repeated. 
Iodide  of  potassium  has  been  said  to  relieve  the  engorged  liver  in  the  early 
stage  of  cirrhosis,  but  the  chloride  of  ammonium  is  a  better  drug,  in  doses  of 
five  to  ten  grains  in  syrup  of  licorice  or  in  emulsion,  given  every  four  hours. 

The  treatment  of  the  second  stage  is  entirely  symptomatic.  Gastro- 
intestinal catarrh,  haemorrhages,  ascites,  jaundice  with  its  resulting  phenomena, 
and  finally  the  distressing  symptoms  of  the  cirrhotic  cachexia,  require  in 
turn,  or  too  fre([uently  at  the  same  time,  careful  therapeutic  and  dietetic 
management. 

Whatsoever  the  symptoms  may  be,  the  diet  plays  a  most  important  part. 
The  class  of  food  referred  to  aboVe  is  to  be  selected ;  from  time  to  time  a 
strict  course  of  milk  diet  may  be  instituted.  Again,  with  the  ascites  most 
prominent,  a  dry  diet  should  be  advised.  The  condition  of  the  stomach  and 
bowels  very  largely  determines  the  character  of  diet.  If  there  be  much 
intestinal  dyspep'sia,  albuminoid  food  should  be  administered  Meats  chopped 
fine  and  made  into  a  pulp  can  be  given  for  a  long  period  of  time.  In  order 
to  create  free  discharge  of  the  products  of  digestion,  large  quantities  of  water 
should  be  taken  once  or  twice  a  day.  The  disadvantage  of  a  continuous  meat 
diet  arises  in  the  possible  development  of  scurvy.  This  may  be  counteracted 
by  the  use  of  lemon-juice  once  or  twice  in  twenty-four  hours.  The  gastro- 
intestinal catarrh  is  treated  by  the  same  class  of  remedies  as  are  indicated  and 
have  already  been  detailed  in  the  management  of  catarrhal  jaundice. 

Haemorrhage  from  the  stomach  is  to  be  treated  by  rest,  the  use  of  cracked 
ice,  the  external  application  of  the  ice-bag,  the  administration  of  food  by  the 
rectum,  and  the  use  of  astringents.  An  opiate  should  always  be  given  to  quiet 
the  agitated  patient.  Morphine  hypodermatically  or  dry  on  the  tongue  may  be 
selected,  or  the  deodorized  tincture  of  opium  combined  with  the  chosen  astringents 
used.  Gallic  acid  is  one  of  the  preferable  astringents  :  aromatic  sulphuric  acid 
may  also  be  employed.     Both  should  be  given  well  diluted  in  iced  water : 

^.  Tr.  opii  deodorat 

Acid,  sulphuric,  aromat cia  f§j. — M. 

Sig.  Eight  to  ten  drops  every  two,  three,  or  four  hours,  well  diluted. 

The  acetate  of  lead  alone  or  with  bismuth  is  a  valuable  astringent. 
Hamamelis  may  be  given  in  the  form  of  the  fluid  extract  well  diluted;  twenty 
drops  is  a  sufficient  dose,  and  may  be  given  evei'y  one  or  two  hours  to  a  child  of 
ten.  Astringent  preparations  of  iron  usually  are  advised — the  sulphate,  the 
chloride,  and  the  pernitrate.  They  should  be  given  in  small  doses  frequently 
repeated.  If  nausea  and  vomiting  are  not  present,  ergot  might  be  used ;  the 
writer,  however,  has  never  had  any  benefit  from  its  use ;  indeed,  gallic  acid 
and  the  aromatic  sulphuric  acid  have  been  sufficient  to  control  the  bleeding. 
Intestinal  hfemorrhage  may  be  treated  by  astringents  by  the  mouth  or  by 
enemata.  If  bleeding  be  from  the  rectum  or  the  lower  portion  of  the  colon, 
weak  solutions  of  alum  or  of  salts  of  iron  by  enema  are  of  special  value. 
The  solution  should  be  cold  if  the  bleeding  is  from  hemorrhoids.  One-half 
drachm  of  MonseVs  solution  to  three  ounces  of  water  are  the  proper  j)ropor- 


DISEASES    OF    THE   LIVER.  561 

tions  for  enemata  of  this  character.  Ice  may  be  used  in  the  rectum,  as  well 
as  ice-water.  By  the  mouth  the  astringents  advised  for  gastric  haemorrhage 
can  be  used.  It  is  best  to  administer  them  in  such  form  that  they  will  be 
dissolved  in  the  intestine ;  a  one-grain  pill  of  Monsel's  salt  may  be  given 
every  half  hour  or  hour.  The  pill  should  be  hard.  Acetate  of  lead  in  pill 
may  also  be  given.  In  this  class  of  cases  aromatic  sulphuric  acid  has  been 
sufficient  in  the  writer's  experience.  Turpentine  has  been  advised  by  com- 
petent authorities,  and  may  be  given  in  capsule  in  doses  of  two  or  three 
drops  every  two  hours.  The  oil  of  erigeron  is  also  considered  to  be  a  valu- 
able styptic. 

If  the  ascites  be  not  too  great  or  of  too  long  standing,  it  may  be  removed 
by  dry  diet  and  diuretics.  Alkaline  diuretics  are  particularly  of  service. 
Cream-of-tartar  lemonade  and  infusion  of  scoparius  are  excellent  diuretics. 
Saline  waters  which  act  on  the  kidneys  and  the  bowels  are  of  great  service. 
Gentle  catharsis  may  be  maintained  without  fear  of  exhaustion  if  salines  be 
used.  On  account  of  the  tendency  to  intestinal  catarrh,  irritating  cathartics 
should  not  be  employed.  At  times  the  effusion  seems  to  come  to  a  standstill ; 
the  bowels  have  been  sluggish,  and  the  internal  viscera  apparently  loaded  Avith 
stagnated  blood  from  passive  congestion.  A  brisk  cathartic  often  relieves 
engorgement  and  starts  up  absorption  of  the  exuded  fluid.  In  children  the 
compound  jalap  powder  is  the  best  of  the  class.  It  should  be  given  in  doses 
of  twenty  grains ;  the  amount  may  be  increased  if  necessary.  If  the  simple 
diuretics  and  cathartics  are  of  no  avail,  four  measures  are  to  be  considered  and 
may  be  tried : 

1st.  The  use  of  calomel  with  diuretics,  as  in  the  well-known  pill  of  calomel, 
digitalis,  and  squills.  It  may  be  given  in  accordance  with  the  following 
formula : 

^.  Hydrarg.  chlorid.  mit gr.  ■^. 

Pulv.  digitalis g^-  4- 

Pulv.  scillie gr.  l. — M. 

Ft.  pil.  No.  i. 

Sig.  To  be  taken  every  three  hours. 

After  this  combination  is  administered  for  ten  days  it  should  be  withdrawn 
and  squills  and  digitalis  given  alone.  It  then  may  be  resorted  to  again,  the 
frequency  of  its  use  depending  upon  the  effect  of  calomel  on  the  bowels. 

2d.  Caffeine  is  a  valuable  diuretic,  particularly  if  stimulating  effects  are 
desirable.  Dose  1  to  3  grains  to  a  child  under  ten.  The  hydrochlorate  of 
cocaine  is  another  drug  of  the  same  class,  and  seems  to  have  been  of  service. 

3d.  Copaiba.  This  is  a  most  valuable  drug  in  ascites.  Its  diuretic  effect 
is  decisive  and  usually  permanent ;  it  is  to  be  given  in  capsule ;  three  minims 
is  sufficient  for  a  child,  to  be  taken  every  four  hours. 

4th.  Paracentesis.  Paracentesis  should  be  employed  early  and  frequently, 
if  after  a  short  trial  the  remedies  above  indicated  do  not  lessen  the  amount 
of  effusion.  No  hesitancy  should  arise  on  account  of  danger,  as  no  accidents  or 
complications  are  likely  to  occur.  A  number  of  cases  have  been  reported  in 
which  frequent  tapping  has  cured  the  ascites,  and  thereby  arrested  for  a  time 
at  least  the  progress  of  the  hepatic  disease. 

The  treatment  of  jaundice  need  not  require  further  consideration,  for  it 
has  been  discussed  fully  in  a  previous  portion  of  this  article.  The  symptoms 
of  the  cirrhotic  cachexia  which  ensue  in  the  latter  stages  of  this  malady  are 
alleviated  by  careful  nursing,  attention  in  detail  to  diet,  and  the  administra- 

36 


562    A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tion  of  remedies  which  secure  full  functional  activity  of  the  various  oi'gans 
of  the  economy.  This  particularly  applies  to  the  circulation.  Cardiac  tonics 
are  indicated.  Stimulants  should  not  be  withheld,  and  now  are  of  service  to 
counteract  prostration,  aid  digestion,  and  increase  the  strength  of  the  heart 
and  circulation.  All  measures  that  can  be  invoked  to  relieve  exhaustion, 
improve  anaemia,  and  aid  nutrition  should  be  resorted  to.  The  administration 
of  concentrated  food — animal  broths,  meat  extracts,  etc. ;  the  inhalation  of 
oxygen ;  the  use  of  stimulating  baths  and  lotions ;  measures  to  prevent  the 
development  of  bed-sores, — each  or  all  may  be  used  as  indications  demand. 
Proper  clothing,  in  order  that  the  extremities  and  abdomen  may  be  kept 
warm,  must  be  insisted  upon.  At  this  stage  multiple  haemorrhages  and  pur- 
pura are  liable  to  ensue.  The  internal  administration  of  astringents,  but  more 
particularly  of  turpentine,  or  the  oil  of  erigeron,  appears  to  check  their  devel- 
opment. 


PERITONITIS;  TUMORS  OF  THE  PERITONEUM 
AND  OMENTUM;  AND  ASCITES. 

By  J.   HEXRY  FRUITNIGHT,  A.  M.,  M.  D., 

New  Yoke. 


I.  Acute  Peritonitis. 

This  affection  is  an  acute  inflammation  of  the  serous  membrane  lining  the 
abdominal  cavitj  and  covering  the  abdominal  viscera.  It  is  characterized  by 
a  tendency  to  effusion,  by  adhesions  through  coagulable  lymph,  and  by  the 
deposition  of  purulent  or  sero-purulent  fluid.  Such  an  inflammation  may  be 
confined  to  a  portion  of  the  membrane,  when  it  is  said  to  be  circumscribed  or 
local,  or  it  may  involve  the  whole  surface  of  the  peritoneum,  and  thus  become 
general.  At  the  onset  only  will  it  be  circumscribed  or  limited,  for,  unless 
checked,  it  quickly  manifests  a  disposition  to  extend  over  the  whole  of  the 
inner  surface  of  the  peritoneal  sac. 

Etiology. — Peritonitis  may  occur  during  intra-uterine  life,  in  the  new- 
born, and  during  infancy  and  childhood.  In  early  life  idiopathic  peritonitis  is 
not  a  very  frequent  disease,  since  at  this  period  the  peritoneum  is  not  so  sus- 
ceptible to  inflammation  as  the  serous  membranes  of  the  thoracic  and  cranial 
cavities.  "When  it  occurs  during  intra-uterine  life,  it  is  always  traceable  to 
syphilis  in  the  parents.  It  may  cause  the  death  of  the  foetus  in  utero,  or  the 
child  may  be  born  suffering  from  the  disease  or  its  consequences.  So  far  as 
is  known,  no  symptoms  in  the  mother  serve  to  indicate  the  existence  of  peri- 
tonitis in  the  foetus.  If  it  be  not  fatal  before  birth,  the  resulting  adhesions  are 
very  apt  to  interfere  with  the  development  of  the  intestines  or  to  cause  a  con- 
striction of  a  portion  of  the  bowel. 

In  the  new-born,  acute  peritonitis  is  most  frequently  the  result  of  septic 
or  py?emic  processes.  It  is  usually  caused  by  an  unhealthy  inflammation  of 
the  umbilicus  or  by  the  absorption  of  septic  matter  at  that  point.  (See 
Diseases  of  the  New-born.) 

In  infancy  and  childhood  an  attack  may  be  traced  to  exposure  to  wet  and 
cold.  Thus,  wetting  and  chilling  of  the  feet,  damp  beds,  chilly  winds,  sudden 
alterations  of  temperature,  rapid  cooling  of  the  heated  body,  and  excessive 
fatigue  may  be  enumerated  under  this  head  as  causes  of  acute  peritonitis,  just 
as  they  may  act  in  the  production  of  inflammation  in  other  structures.  Very 
often  traumatism  may  serve  as  the  exciting  cause,  and  here  may  be  enumerated 
contusions,  direct  blows  upon  the  abdomen,  and  the  wounds  of  cutting  or  blunt 
instruments  produced  accidentally  or  surgically,  as  in  paracentesis  abdominis. 
Again,  various  mechanical  causes  (which  are  in  reality  traumatic  in  their 
nature)  may  operate  in  its  production,  such  as  intestinal  invagination,  stran- 
gulated hernia,  displacements  of  some  of  the  internal  organs,  or  laceration  or 
unusual  stretching  of  the  peritoneal  membrane.     In  like  manner,  peritonitis 

56.3 


564    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

may  be  caused  by  the  extrusion  of  foreign  matters  into  the  serous  cavity,  as 
in  ruptured  hepatic  or  splenic  abscess,  rupture  or  perforation  of  the  stomach, 
bile-ducts,  spleen,  uterus,  urinary  bladder,  ureters,  or  some  part  of  the  intes- 
tines. It  may  follow  or  accompany  acute  disease  of  some  organ  by  contiguity 
of  structure ;  and  here  may  be  mentioned  gastritis,  splenitis,  hepatitis,  dysen- 
tery, ulcerations  in  typhoid  fever,  and  ulcerations  of  the  vermiform  appendix, 
appendicitis,  and  the  like.  Numerous  instances  have  been  encountered  where 
an  empyema  perforating  the  diaphragm  has  set  up  acute  peritonitis ;  and  this 
result  has  been  observed  even  in  the  absence  of  perforation,  the  lymphatics 
acting  as  the  channel  of  communication.  In  girls  purulent  vulvo-vaginitis  has 
frequently  caused  acute  peritonitis  by  an  extension  of  the  inflammation  through 
the  uterus  and  Fallopian  tubes.  At  times  also  it  may  result  from  pressure 
and  ulcerative  absorption  caused  by  tumors  and  malignant  growths.  The 
sudden  retrocession  of  a  cutaneous  eruption  has  sometimes  been  closely  fol- 
lowed by  an  attack  of  peritonitis,  and  it  is  on  record  that  lumbricoid  worms 
have  penetrated  the  bowel  and  tfius  acted  as  an  exciting  cause. 

Finally,  it  may  occur  as  a  complication  of,  or  a  sequel  to,  rheumatism, 
erysipelas,  pernicious  intermittent  fever,  and  the  various  exanthemata. 

It  has  been  quite  well  established  that  in  the  development  of  peritonitis 
micro-organisms,  rendered  operative  by  any  of  the  before-mentioned  local 
disturbances,  must  be  regarded  as  the  essential  causes.  When,  experimentally, 
non-pathogenic  microbes,  even  when  combined  with  small  amounts  of  chemical 
irritants,  are  injected  into  the  peritoneal  sac,  purulent  peritonitis  is  not  pro- 
duced, but  only  a  serous  inflammation.  On  the  other  hand,  when  pathogenic 
micro-organisms  are  introduced  even  in  very  small  quantities,  severe  fibrino- 
purulent  peritonitis  ensues.  The  micro-organisms  which  produce  peritonitis 
are  those  found  in  pus,  the  staphylococcus,  and  the  streptococcus.  Before 
they  can  increase  in  number  a  preceding  or  accompanying  change  in  the  peri- 
tonuem  is  necessary.  If  the  absorptive  powers  of  the  peritoneum  be  greatly 
changed,  the  microbes  will  eflfect  a  putrefaction  of  the  intraperitoneal  fluids, 
and  as  a  consequence  will  produce  a  general  putrid  infection  of  the  whole 
system. 

Pathological  Anatomy. — The  transparent  and  shining  appearance  of  the 
membrane  is  lost.  This  is  accompanied  by  a  diminution  of  the  lubricating 
secretion,  rendering  the  serous  membrane  less  moist.  The  subperitoneal  ves- 
sels become  turgid  with  blood,  are  visible  through  the  thin  membrane  as  an 
interlacing  network,  and  when  they  are  greatly  distended  the  peritoneum  pre- 
sents a  velvety  appearance.  At  times  the  blood  exudes  through  the  coats  of 
the  vessels,  when  puncta  or  plaques  of  sanguineous  effusion  are  seen.  Later, 
if  the  disease  progresses,  the  serous  secretion  is  increased  in  quantity  and  altered 
in  character,  being  composed  of  liquid  serum  and  a  more  solid  or  glutinous 
material  known  as  coagulable  lymph.  It  may  happen,  however,  that  the  eff"u- 
sion  is  entirely  composed  of  serum ;  or,  on  the  other  hand,  serum  may  be  alto- 
gether absent.  In  metastatic  peritonitis  or  in  attacks  of  asthenic  character  the 
eff'usion  may  be  puriform  or  distinctly  purulent,  while  in  sthenic  cases  the  deposit 
of  lymph  may  vary  from  a  very  thin  layer  to  a  thickness  of  several  lines,  and  it 
is  usually  of  a  yellowish  color.  When  abundant,  it  may  be  found  in  layers, 
smooth  or  corrugated,  or  it  may  exist  as  bands  of  adhesion  uniting  the  vis- 
cera with  each  other  or  with  the  parietal  peritoneum.  At  first  villous  in  appear- 
ance, it  afterward  becomes  smooth  and  denser,  and  finally  assumes  a  structure 
similar  to  true  peritoneal  membrane.  When  once  foinned.  plastic  lymph  acts  as 
an  irritant  to  the  serous  surfaces  with  which  it  may  come  in  contact — a  fact 
which  serves  to  explain  how  inflammation  is  so  apt  to  be  diffused  over  the  entire 


PERITONITIS.  565 

peritoneal  surface.  When  health  is  restored  these  bands  of  adhesion  may 
partly  or  entirely  disappear.  If  they  continue  they  may  cause  little  inconve- 
nience, though  it  may  happen  that,  by  their  topographical  relations,  they 
may  interfere  with  the  functions  of  the  organs  to  which  they  adhere.  In  chil- 
dren the  effusion  is  most  commonly  purulent ;  it  may  be  merely  puriform, 
decidedly  purulent,  or  simply  sanious.  Ulceration  may  occur  through  the 
abdominal  walls  or  through  the  diaphragm  into  the  lung  or  bronchi,  or  again 
through  the  digestive  tract,  the  bladder,  the  vagina,  or  through  the  psoas  muscle, 
permitting  pus  to  escape  from  the  peritoneal  cavity  by  one  of  these  various 
channels. 

When  peritonitis  exists  as  a  sequel  to  scarlet  fever,  measles,  rheumatism, 
or  other  fever,  the  serous  fluid  is  in  excess,  whilst  the  plastic  lymph  is  incon- 
siderable in  amount  or  nearly  absent.  The  results  of  an  attack,  while  at  times 
causative  of  further  disease,  may  in  other  cases  be  protective  against  more 
serious  accidents:  adhesions  may  supervene  which  will  seriously  interfere  with 
the  functions  of  the  organs  or  parts  which  are  bound  down  or  united  by  these 
bands ;  on  the  other  hand,  as  in  some  cases  of  perforation,  this  same  inclina- 
tion to  plastic  exudation  may  be  conservative  of  life,  the  deposit  being  a  means 
by  which  nature  seeks  to  effect  reparation. 

Symptoms. — The  earliest  and  most  pronounced  symptom  of  peritonitis  is 
pain.  At  first  the  area  of  pain  may  be  limited  ;  afterward  it  Avill  extend  over 
the  whole  abdomen.  The  pain  is  accompanied  by  high  fever  and  decided  con- 
stitutional disturbances,  such  as  rigors  and  general  malaise.  Pressure  over  the 
abdomen  and  augmented  action  of  the  abdominal  muscles,  as  in  deep  inspira- 
tions, coughing,  sneezing,  expectoration,  and  the  like,  will  aggravate  the  pain. 
The  lightest  weight  cannot  be  borne  upon  the  abdomen  ;  hence  the  little  patient 
assumes  a  position  which  will  relax  the  abdominal  walls  as  much  as  possible, 
and  lies  quietly  on  his  back  with  his  knees  bent  and  thighs  flexed.  The  belly 
is  hot,  rounded,  and  tense,  almost  invariably  swollen  and  tympanitic  from 
accumulation  of  flatus  due  to  paralysis  of  the  muscular  coat  of  the  intestines. 
Sometimes  flatus  may  be  readily  passed  per  anum,  at  others  not ;  and  in  this  case 
symptoms  of  intestinal  obstruction  are  simulated.  The  bowels  are  usually  con- 
stipated, though  diarrhoea  is  occasionally  met  with.  Vomiting  is  nearly  always 
present  from  beginning  to  end,  and  is  aggravated  whenever  food  is  taken, 
until  the  presence  of  bile  and  faecal  matter  in  the  ejecta  may  be  almost  sug- 
gestive of  some  mechanical  bowel  obstruction. 

The  skin  is  hot  and  dry ;  the  temperature,  as  a  rule,  is  elevated,  ranging 
from  101°  to  105°  F.,  but  it  becomes  subnormal  if  the  attack  terminates  in 
collapse.  Inflammation  of  the  peritoneum,  however,  may  coexist  with  a  nor- 
mal or  subnormal  temperature,  and  this  very  frequently  happens  in  the  puru- 
lent cases.  The  pulse  is  small,  feeble,  rapid,  and  wiry.  The  respirations  are 
accelerated,  shoi"t,  incomplete,  and  jerky,  and  are  costal  in  type,  the  abdominal 
wall  remaining  motionless.  The  tongue  is  coated  and  the  breath  is  foul.  The 
face  is  expressive  of  great  sufi"ering  and  anxiety,  and  when  the  attack  is  very 
severe,  the  alse  of  the  nose  are  drawn  upward,  the  nostrils  are  dilated,  and  the 
lips  are  parted,  so  as  to  expose  the  teeth,  producing  the  expression  known  as 
risus  sardonicus.  The  urine  is  scanty  and  high-colored,  and  often  contains 
albumin. 

When  the  attack  is  to  terminate  in  recovery  all  these  symptoms  gradually 
diminish  in  intensity,  whilst  the  countenance,  which  has  been  so  truthful  an 
exponent  of  the  patient's  condition,  once  more  becomes  placid  and  natural.  If 
the  attack  is  to  eventuate  in  death,  the  pulse  becomes  quicker  and  more  thready, 
the  general  surface  cold  and  clammy,  the  extremities  chilled,  and  the  breathing 


566     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

shallower  and  more  rapid,  until  life  goes  out  from  failure  of  the  general  vital 
forces.  In  a  few  cases  incoherency  of  speech  or  active  delirium  is  present 
toward  the  end,  but  most  generally  the  mind  remains  clear  and  logical  to  the 
last.  The  fatal  issue  of  an  attack  may  take  place  in  two  or  three  days,  though 
frequently  the  patient  may  live  until  the  sixth,  seventh,  or  eighth  day. 

Diagnosis. — Peritonitis  in  its  severer  forms  is  readily  recognized,  but  when 
subacute  or  circumscribed,  or  when  it  is  secondary  or  exists  as  a  complication, 
it  is  not  so  easy  of  diagnosis.  In  young  children  it  is  especially  difficult  to 
determine  its  presence  because  of  the  uncertainty  of  exact  localization  of  pain. 
In  erratic  cases  also  pain  may  be  absent,  and  thus  we  will  be  hampered  in  diag- 
nosis. The  diseases  simulating  acute  peritonitis  are  gastritis,  enteritis,  colic, 
rheumatism,  neuralgia,  renal  calculus,  and  lead-poisoning.  The  diagnosis  must 
depend  upon  the  severity  of  the  symptoms,  special  attention  having  been  paid 
to  the  history  of  the  case.  If  there  be  persistent  vomiting  of  all  fluids  and 
solids,  with  the  presence  of  sharp  paroxysmal  pain,  accompanied  by  tenderness 
on  pressure  upon  the  abdomen,  Avith  cessation  of  the  abdominal  respiratory 
movements,  a  frequent,  Aviry  pulse,  and  fever,  the  diagnosis  of  acute  peritonitis 
may  be  made  with  reasonable  certainty. 

Prognosis. — In  the  generalized  form  prognosis  is  always  grave.  It  has 
been  said  that  there  is  no  more  fatal  disease,  recovery  taking  place  in  rare 
cases  only.  The  more  pronounced  the  symptoms  are,  the  more  doubtful  will 
be  the  prospect  of  recovery;  and  if  the  patient  shall  have  passed  into  tl.e 
stage  of  collapse,  a  fatal  termination  is  usually  to  be  expected.  An  acute 
peritonitis  which  is  metastatic  in  origin  or  which  is  due  to  perforation  is  gen- 
erally fatal.  Diarrhoea  is  of  evil  portent,  and  constant  vomiting  with  complete 
obstruction  of  the  bowels  is  a  very  grave  symptom. 

Although  the  general  prospects  of  recovery  are  so  slight,  yet  patients 
apparently  moribund  have  been  known  to  get  well.  The  attack  may  last  but 
a  few  days,  or  even  only  from  thirty-six  to  forty rcight  hours,  and  very  rarely 
indeed  longer  than  a  week. 

Treatment. — The  cause  of  the  attack  will  determine  the  treatment  to  be 
followed  in  a  given  case.  Unfortunately,  however,  the  physician  will  not 
always  be  in  a  position  to  know  accurately  what  this  may  be  or  what  exact 
anatomical  lesions  may  exist.  The  patient  must  be  confined  absolutely  to  bed. 
All  food  and  drink  must  be  stopped,  only  cracked  ice  or  iced  water  to  moisten 
the  mouth  being  permitted.  This  interdiction  of  all  ingesta  must  be  impera- 
tive, in  order  to  avoid  the  harassing  and  painful  vomiting.  Nutrition  can  be 
maintained  until  the  cessation  of  vomiting  by  the  use  of  enemata  or  supposi- 
tories containing  appropriate  substances,  as  broth,  milk,  egg-albumin,  stimu- 
lants ;  later,  when  the  vomiting  shall  have  been  overcome,  the  food  should  be 
limited  to  twelve  or  fifteen  ounces  (best  predigested)  per  diem.  Ice  pills  may 
be  given  to  control  the  vomiting,  also  iced  champagne  in  small  doses  fre- 
quently repeated,  as  well  to  soothe  the  feeble  stomach  as  for  its  stimulating 
effects.  Locally,  various  remedies  have  been  employed.  Soft  flannel  cloths 
saturated  in  a  solution  of  tincture  of  iodine  in  castor  oil  and  applied  over  the 
belly  have  been  highly  recommended.  Local  bloodletting  by  the  application 
of  from  four  to  twelve  leeches  to  the  surface  of  the  abdomen  is  often  very 
valuable  in  the  initial  stage.  The  inunction  of  mercurial  ointment  to  the  abdo- 
men was  formerly  much  in  vogue.  Stupes,  made  by  steeping  flannels  in  a  pint 
of  hot  water  containing  ten  to  twenty  drops  of  spirits  of  turpentine  and  sprinkled 
with  laudanum,  are  often  of  great  service.  Light  flaxseed-meal  poultices, 
dashed  with  oil  of  turpentine  or  laudanum  and  laid  upon  the  abdomen,  have 
in  my  hands  been  of  great  value.     Care  should  be  taken  that  the  poultices  be 


PEJRIT0NIT18.  567 

not  too  hot,  lest  the  integument  be  burned.  By  some  physicians  cold  appli- 
cations, such  as  the  ice-bag  or  cold-water  coil,  are  preferred,  but  children 
almost  always  resist  their  use. 

As  to  the  methods  of  internal  treatment — whether  by  saline  purgatives  or 
by  opium — a  difference  of  opinion  still  exists  among  physicians  of  equal  skill 
and  eminence.  It  will  be  safe  to  abide  by  the  following  conclusion :  When  an 
attack  of  acute  peritonitis  is  recognized  almost  at  the  moment  of  its  inception, 
salines  by  their  rapid  and  complete  depletion  may  abort  an  attack.  The  peri- 
toneum will  be  drained  of  the  products  of  inflammation,  the  formation  of  bands 
and  adhesions  will  be  prevented  in  consequence  of  the  increased  peristaltic 
action  of  the  bowels,  whilst,  clinically,  pain  will  be  relieved  as  quickly  as  by 
the  administration  of  opium.  On  the  other  hand,  if  the  case  is  not  seen  by 
the  physician  until  some  hours  after  the  commencement  of  the  attack,  and 
especially  if  grave  doubts  exist  as  to  the  cause  of  the  disease,  opium  and  external 
methods  of  depletion  must  be  used.  It  need  scarcely  be  said  that  in  perforative 
peritonitis  the  purgative  treatment  must  not  be  thought  of  at  all. 

In  case  it  has  been  decided  to  administer  a  purgative,  either  a  seidlitz  pow- 
der or  some  other  mild  saline  or  calomel  is  to  be  preferred  for  children.  When 
opium  is  to  be  given — which  should  always  be  the  case  when  there  is  intense 
pain,  tenderness,  constant  vomiting,  and  a  distended  and  paralyzed  condition 
of  the  bowels — it  should  be  given  in  quantity  sufficient  to  relieve  pain,  to  reduce 
the  frequency  of  the  pulse  and  respiration  (the  latter  to  about  twelve  movements 
per  minute),  and  to  make  the  little  patient  slightly  drowsy.  Two  to  five 
minims  of  the  deodorized  tincture  of  opium,  or  one  to  four  grains  of  Dover's 
powder,  may  be  given  every  four  hours,  according  to  indications,  at  the  age  of 
six  years.  The  effects  of  th,e  opium  must,  of  course,  be  narrowly  watched,  for, 
as  is  well  known,  children  are  very  susceptible  to  its  action.  In  older  children 
morphine  may  be  given  either  per  orem  or  by  hypodermatic  injection  in  doses  of 
from  one-twelfth  to  one-sixth  of  a  grain.  The  tincture  of  belladonna  is  frequently 
combined  with  the  opium.  Excessive  tympany  can  be  relieved  by  the  use  of 
laxative  enemata  in  which  spirits  of  turpentine  or  tincture  of  asafoetida  has 
been  suspended ;  or,  in  case  of  their  failure,  the  long  rectal  tube  may  be  used. 
Free  stimulation  must  be  resorted  to  early,  and  such  alcoholics  as  brandy,  whis- 
key, and  champagne  are  to  be  preferred.  To  these  may  be  added,  to  assist  in 
keeping  active  a  flagging  circulation,  such  cardiac  stimulants  as  sparteine, 
strophanthus,  and  digitalis  ;  these,  if  vomited,  must  be  given  by  the  rectum  or 
under  the  skin.  Later,  when  the  attack  promises  to  terminate  favorably,  every 
effort  must  be  made  to  build  up  the  system  and  to  increase  nutrition  by 
the  exhibition  of  tonics  and  easily-assimilated,  nourishing  food. 

As  soon  as  the  diagnosis  of  acute  peritonitis  has  been  made,  the  question 
of  opening  and  draining  the  peritoneal  cavity  will  present  itself.  Here,  again, 
differences  of  opinion  are  encountered.  Some  advocate  an  early  and  immediate 
operation,  whilst  others  claim  that,  as  cases  recover  without  operation,  it  is 
better  not  to  risk  the  added  dangers  of  surgical  interference.  It  may  be  con- 
sidered proper  to  operate  in  the  following  forms  of  peritonitis :  First,  in  the 
fulminating  forms  of  the  disease,  which  are  characterized  by  a  rapid  advance 
of  the  symptoms,  excessive  vomiting  and  tympanites,  feeble  pulse,  and  great 
restlessness.  Secondly,  in  cases  in  which  collapse  seems  imminent  in  spite  of 
treatment,  and  which  present  a  decreasing  temperature  and  a  rapid  pulse  con- 
stantly growing  feebler.  Thirdly,  in  cases  in  which  pus  is  present  in  the 
abdominal  cavity,  or  in  which  a  tumor  is  located  in,  or  adjacent  to,  the  abdomen. 
Fourthly,  in  cases  in  which  the  peritonitis  is  the  result  of  perforation  or  ulcer- 
ation of  any  of  the  abdominal  viscera.     And  fifthly,  when  the  peritonitis  is 


568    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

due  to  intestinal  obstruction.  In  older  children  the  chances  of  success  are 
greater  than  in  the  younger  ones.  A  certain  number  of  cases  will  be  met  with 
in  which  the  diagnosis  will  be  questionable.  It  will,  at  times,  be  doubtful 
whether  the  exudation  be  purulent  or  composed  only  of  lymph,  and  whether 
the  inflammation  has  been  general  from  the  first,  or  has  spread  from  the  caecum 
•or  other  localized  inflammatory  area.  In  such  cases  it  is  held  to  be  justifiable 
to  perform  an  exploratory  operation,  which  may,  under  some  circumstances,  be 
the  means  of  saving  the  patient's  life.  To  discuss  the  method  of  operation  and 
the  questions  of  drainage  and  irrigation  is  not  embraced  in  the  scope  of  this 
article,  and  for  such  details  the  reader  is  referred  to  the  works  on  operative 
surgery. 

n.  Chronic  Peritonitis. 

As  a  chronic  aff"ection  peritonitis,  with  the  exception  of  the  tubercular  variety, 
is  rare.  As  early  as  1838,  Wolff  published  a  study  upon  chronic  peritonitis, 
and  stated  it  to  be  an  extremely  common  affection  in  children  ;  but  as  all  of  his 
one  hundred  cases  were  reported  cured,  it  seems  likely  that  a  large  proportion 
■were  incorrectly  diagnosticated.  Since  then  until  quite  lately  the  subject  has 
received  but  little  consideration  at  the  hands  of  medical  writers,  and  the  opinion 
has  gained  ground  that  all  chronic  peritonitis,  almost  without  exception,  is  tuber- 
cular (West).  This  view,  however,  has  been  considerably  modified  by  the  more 
recent  studies  of  Baginsky,  Vierordt,  Henoch,  and  others,  and  it  is  now 
accepted  that  the  peritoneum,  just  as  well  as  the  pleura,  may  be  the  seat  of  a 
simple  chronic  inflammation  with  serous  exudation. 

Chronic  peritonitis  may  sometimes  be  the  sequel  of  an  acute  attack  of  the 
disease,  but  it  is  more  frequently  an  independent  aff"ection. 

Etiology. — jNIost  of  the  patients  are  females — a  fact  that  suggests  a  possible 
connection  in  some  cases  between  the  peritoneal  inflammation  and  a  vulvo- 
vaginitis, which  is  by  no  means  uncommon  in  little  girls.  Rarely  a  history  of 
traumatism  may  be  elicited,  as  in  a  case  reported  by  Henoch,  confirmed  by 
post-mortem  after  a  course  of  six  weeks.  In  another  group  of  cases  a  preced- 
ing exanthem  may  be  the  apparent  etiological  factor,  as  seemed  to  be  likely  in 
two  cases — one  observed  by  Fiedler,  and  the  other  by  Henoch — both  occurring 
after  measles.  The  complete  cure,  after  several  tappings,  in  Henoch's  case 
leaves  little  doubt  of  its  true  character. 

Symptoms. — The  symptoms  of  non-tubercular  chronic  peritonitis  are 
rather  obscure.  The  abdominal  pain  is  apt  to  be  slight,  whilst  the  con- 
stitutional symptoms  are  variable.  Usually  the  health  fails  gradually  ;  the 
appetite  becomes  capricious ;  there  is  alternate  diarrhoea  and  constipation,  the 
former  of  Avhich  may  or  may  not  be  accompanied  by  pain  ;  sleep  is  disturbed, 
and  the  skin  is  hot  and  dry  at  night.  Subsequently,  pain  or  a  sensation  of 
tightness  in  the  abdomen  is  complained  of,  and  after  a  time  effusion  of  fluid 
takes  place,  fluctuation  may  be  discovered  on  examination,  and  the  cutaneous 
veins  are  turgid  and  well  defined.  The  pain  now  becomes  more  marked  ;  it  is 
usually  not  localized,  but  shifts  about  from  one  spot  to  another  ;  generally  there 
is  tenderness  on  pressure  over  the  abdomen  ;  still,  the  appetite  may  be  fairly 
good,  the  tongue  tolerably  clean,  and  the  bowels  not  particularly  irregular. 
As  the  effusion  accumulates  dyspnoea  appears  :  the  pulse  is  accelerated ;  even- 
ing and  morning  exacerbations  of  temperature  are  observed  ;  the  child 
rapidly  loses  strength,  becomes  much  emaciated  from  profuse  diarrhoea,  and 
eventually  dies  of  exhaustion.  Yet  cases  presenting  all  the  symptoms  of  chronic 
peritonitis  have  been  known  to  recover,  the  effused  fluid  and  other  products  of 
inflammation  being  gradually  removed  by  absorption. 


PERITONITIS.  569 

Diag-nosis. — When  ascites  is  the  only  symptom,  it  will  be  necessary  to  dif- 
ferentiate between  an  eifusion  due  to  simple  chronic  peritonitis  and  one  caused  by 
obstruction  to  the  portal  circulation.  The  latter  condition  is  comparatively  rare 
in  childhood,  whether  it  be  due  to  cirrhosis  of  the  liver  or  adherent  pericardium 
and  mediastinitis  ;  and  the  chances  are  immensely  in  favor  of  the  presence  of  a 
chronic  peritonitis.  The  ascites  due  to  cardiac  disease  can  be  eliminated  by 
careful  examination  of  the  heart.  Since,  in  the  beginning  of  the  disease,  the 
symptoms  simulate  those  of  chronic  intestinal  catarrh,  one  must  be  careful  to 
distinguish  between  this  aifection  and  chronic  peritonitis. 

The  differential  diagnosis  between  chronic  and  tubercular  peritonitis  will 
very  often  be  impossible.  The  point  of  greatest  value,  however,  i*s  the  general 
state  of  the  patient :  in  the  simple  form  the  general  nutrition  and  well-being 
of  the  child  suffer  but  little  as  long  as  digestion  is  not  greatly  disturbed  nor  the 
effusion  overwhelming  ;  while  in  the  tubercular  variety  the  early  emaciation  is 
striking.  Search  for  bacilli  in  the  effusion,  even  in  tubercular  cases,  is  often 
disappointing,  and  hence  a  negative  finding  does  not  exclude  the  more  serious 
disease. 

Prognosis. — This  must  be  guarded,  for,  while  most  cases  are  decidedly 
unpromising,  a  certain  proportion  recover.  The  history  and  progress  of  a  given 
case  must  give  us  the  cue. 

Treatment. — As  the  disease  usually  begins  Avith  an  intestinal  catarrh,  our 
treatment  must  be  directed  toward  that  condition.  The  child  must  be  placed 
under  the  best  hygienic  surroundings.  Plenty  of  sunlight  and,  when  possible, 
country  air  or  a  sojourn  at  the  seashore,  are  to  be  insisted  upon.  The  clothing 
should  be  carefully  regulated  to  meet  the  exigencies  of  the  case,  the  weather, 
and  other  external  conditions ;  and  a  flannel  bandage  must  be  constantly  worn 
about  the  abdomen.  The  patient  should  be  kept  at  rest,  and  it  is  a  good  plan, 
in  the  warm  weather,  to  wheel  his  couch  into  the  open  air  as  often  as  possible. 

The  diet  should  be  bland,  but  nutritious.  Moderate  quantities  of  under- 
done chops  or  steak,  fish,  fowl,  and  eggs  are  all  allowable ;  so  also  are  milk  and 
cream  if  they  do  not  disagree,  but  starchy  foods  are  better  avoided. 

Abdominal  pain  may  be  relieved  by  hot  opium  fomentations  or  inunctions 
of  belladonna  ointment;  when  these  fail  or  in  protracted  cases,  blisters  or 
stimulating  liniments,  tincture  of  iodine,  compound  iodine  ointment,  and  iodide 
of  potassium  ointment  are  useful  applications.  Frequently  in  these  cases  the 
application  to  the  abdomen  of  a  mild  mercurial  preparation,  such  as  an  oint- 
ment of  the  yellow  oxide  of  mercury,  about  twenty  grains  to  the  ounce,  will 
do  good  service. 

In  the  way  of  medicines  the  mineral  acids  and  preparations  of  pepsin  are 
useful  as  aids  to  gastric  digestion  ;  and  to  combat  the  intestinal  catarrh,  bis- 
muth, sulpho-carbolate  of  zinc,  the  bitter  vegetable  tonics,  and  alkalies  should 
be  administered. 

The  internal  use  of  iodine  is  also  beneficial.  This  may  be  administered  in 
the  form  of  iodide  of  potassium  in  guarded  doses,  which  must  be  discontinued 
on  the  first  indication  of  disordered  digestion  ;  but  a  preferable  form  is  the  syrup 
of  the  iodide  of  iron,  in  doses  of  from  five  to  thirty  drops,  according  to  the 
age  and  tolerance  of  the  patient,  several  times  daily.  I  usually  order  it  to  be 
given  in  cod-liver  oil,  which  is  convenient  and  efficacious. 

If  the  ascitic  effusion  shows  no  tendency  to  disappear  by  absorption,  tapping 
by  means  of  a  very  small  trocar  and  canula  should  be  resorted  to,  the  fluid 
being  allowed  to  drain  away  very  slowly.  It  has  been  advised  that  during  the 
first  few  weeks  the  fluid  be  drawn  off  once  in  twenty-four  hours,  the  amount 
varying  in  quantity  from  one  to  two  pints ;  then  every  two,  every  three  days, 


570    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and,  finally,  once  a  week.  Gradual  improvement,  it  is  said,  usually  takes  place 
under  this  treatment.  When  the  disease  has  defied  every  method  of  treatment, 
especially  if  the  fluid  returns  quickly  after  repeated  tappings,  permanent  drain- 
age of  the  peritoneal  cavity  has  been  recommended.  If  pus  be  present,  incision 
and  drainage  should  be  practised.  Recently  coeliotomy  and  washing  out  of  the 
peritoneal  cavity  have  been  advocated  by  some  surgeons  as  a  routine  treatment. 
In  some  instances  it  may  even  be  justifiable  to  perform  an  exploratory  opera- 
tion. However,  in  those  chronic  cases  in  which  the  symptoms  are  not  urgent 
and  the  child  is  not  failing,  it  will  be  the  part  of  Avisdom  and  prudence  not  to 
interfere  surgically,  but  to  wait  on  nature's  efforts,  supplemented  by  medical 
measures,  to  effect  a  restoration  to  health. 

m.  Tumors  of  the  Peritoneum  and  Omentum. 

Tumors  of  the  peritoneum  and  omentum,  though  rare  in  children,  are  occa- 
sionally met  with. 

Carcinoma  of  the  peritoneum  has  been  encountered  in  early  childhood  and 
even  in  foetal  life.  It  may  be  primary,  and  then  is  often  congenital,  but  it  is 
much  more  commonly  secondary.  Scirrhus  is  the  usual  variety,  and  generally 
occurs  in  diffused  nodules.  The  primary  form  is  difiicult  to  detect;  the  second- 
ary, much  less  so,  because  its  presence  will  be  suspected  when  symptoms  refer- 
able to  the  peritoneal  cavity  occur  in  the  course  of  cancerous  invasion  of  some 
other  portion  of  the  body. 

Sarcoma  of  the  peritoneum  has  also  been  met  with  in  childhood,  but  it  is 
of  very  rare  occurrence.  This  variety  of  neoplasm  may  grow  to  such  an 
extent  as  to  involve  the  omentum,  mesentery,  and  other  parts  in  addition  to 
the  peritoneum ;  in  fact,  both  carcinomatous  and  sarcomatous  growths  are  apt 
to  involve  both  peritoneum  and  omentum. 

Lipomata  may  also  grow  from  the  peritoneum.  They  are  encapsulated, 
and  have  no  connection  with  any  other  organ. 

Serous  cystic  tumors  of  the  peritoneum  also  occur.  These  cysts  are  com- 
posed of  pseudo-membrane,  which  during  their  evolution  and  organization  in- 
cludes a  portion  of  the  fluid  exudation  and  receives  an  internal  serous  invest- 
ment; they  are  attached  to  the  peritoneum  either  by  means  of  a  thin  neck  or 
by  a  broad  base.  Cystic  tumors  of  the  peritoneum  are  difficult  to  detect,  and 
must  be  differentiated  from  cysts  of  the  omentum,  from  cysts  of  the  various 
abdominal  viscera,  and  from  ascites. 

Tumors  of  the  omoitum  are  quite  rare  in  early  life.  Omental  cancer  is 
usually  of  the  colloid  variety,  and  it  may  grow  to  an  enormous  size.  Carci- 
noma, however,  is  seldom  limited  to  the  omentum,  the  peritoneum  being  usually 
involved  simultaneously.  Again,  when  scirrhus  invades  the  peritoneum  the 
omentum  usually  suffers  from  the  same  disease.  Cysts  and  hydatid  tumors  of 
the  omentum  are  met  with  in  children,  the  former  not  infrequently.  The  cysts 
are  usually  dermoid  in  nature,  though  simple  serous  cysts  are  encountered. 
Both  varieties,  but  especially  the  dermoid,  may  supjmrate. 

Symptoms  of  all  varieties  of  tumors,  whether  involving  the  omentum 
or  the  peritoneum,  or  both,  are  rather  vague,  particularly  in  their  incipiency. 
Later,  when  they  have  grown  larger,  the  so-called  pressure-symptoms  develop 
and  aid  us  in  making  a  diagnosis.  Even  then  it  is  very  difiicult  to  make  a 
correct  differential  diagnosis,  the  pressure-symptoms  chiefly  aiding  in  locating 
the  site  of  the  tumor,  without  throwing  light  upon  its  character. 

Cancer  of  the  peritoneum  and  omentum  produces  the  signs  of  a  diffuse, 
more  or  less  acute  peritonitis  with  effusion,  the  so-called  cancerous  peritonitis. 


PERITONEAL    TUMORS  AND   ASCITES.  571 

In  the  earlier  stages  of  the  disease  the  patient  will  complain  of  paroxysmal 
pain,  which  later  will  be  more  persistent.  Lipomata  are  attended  by  no  spe- 
cial symptoms  beyond  the  growth  of  a  painless  tumor.  Growths  confined  to 
the  omentum  are  movable  and  occasion  no  functional  disturbance  of  the  intes- 
tines. In  cystic  tumors,  either  of  the  omentum  or  peritoneum,  the  abdomen  is 
apt  to  be  enlarged;  if  the  tumor  be  superficial,  it  will  be  movable  on  palpa- 
tion and  give  signs  of  fluctuation,  which  must  be  distinguished  from  the  fluctu- 
ation of  ascites.  If  the  patient  live  long  enough  and  the  growth  attain  the 
proper  size,  true  ascites  will  supervene.  Pain,  of  course,  will  be  most  promi- 
nent in  the  cases  of  cancerous  tumors.  In  time,  whatever  may  be  the  nature 
of  the  tumor,  but  particularly  in  the  cases  of  carcinoma,  the  general  system 
suffers,  nutrition  is  impaired,  the  patient  is  easily  fatigued,  his  appetite  fails, 
and,  if  the  growth  cannot  be  removed,  a  cachectic  condition  develops  which  at 
last  terminates  in  death. 

Prognosis  is  most  favorable  in  cystic  tumors,  less  so  in  lipomatous  and 
hydatid  growths,  and  fatal  in  the  carcinomatous. 

Treatment  of  cancerous  tumors  consists  mainly  of  palliation  of  symp- 
toms. Anodynes  and  opiates  to  control  the  pain  are  indicated,  and,  if  the 
ascites  become  burdensome,  paracentesis  is  to  be  performed.  Attention  to  the 
general  condition  of  the  patient,  sustaining  his  strength  with  good  food  and 
tonics,  together  with  the  observance  of  well-established  hygienic  principles, 
will  embrace  all  that  can  be  done  for  these  unfortunate  sufferers.  Operative 
measures  are  not  to  be  advised  in  these  cases. 

Operation,  coeliotomy,  has  been  more  successful  in  cases  of  sarcoma,  lipoma, 
hydatid  growths,  and  particularly  in  cystic  tumors.  Cystic  tumors  may  be  ex- 
cised or  they  may  be  aspirated  and  drained.  As  drained  cysts  are  apt  to  refill, 
the  radical  operation,  excision,  is  to  be  preferred,  and  it  must  always  be  resorted 
to  when  suppuration  takes  place. 

The  proper  treatment  for  pressure-symptoms  will  be  suggested  by  their 
characters  in  individual  cases. 

rV.  Ascites. 

Ascites  is  an  accumulation  of  fluid — usually  serous — within  the  peritoneal 
cavity ;  occasionally  chylous  ascites  occurs,  but  in  children  this  variety  is 
extremely  rare'  Essentially  considered,  ascites  is  not  a  disease.  It  is  a  symp- 
tom of  either  general  dropsy  or  some  local  disease  of  the  abdominal  viscera, 
and  consists  of  a  transudation  of  liquid  into  the  peritoneal  cavity  in  conse- 
quence of  disturbed  circulation  in  the  liver  or  of  pressure  exerted  upon  some 
portion  of  the  portal  circulatory  system. 

Btiolog-y. — The  most  common  cause  of  ascites  in  children  is  cirrhosis  of 
the  liver,  which,  in  turn,  is  most  frequently  due  to  syphilis.  It  may  also  arise 
from  a  simple  osmosis  of  the  watery  constituents  of  the  blood,  in  which  case 
it  is  but  a  local  expression  of  a  general  hydrsemia  superinduced  by  some 
cachexia,  and  it  is  then  often  associated  with  hydrothorax  or  general  anasarca. 
Again,  it  may  result  mechanically  from  an  obstruction  to  the  venous  circulation 
caused  by  cardiac,  pulmonary,  or  peritoneal  disease.  Neoplasms  of  the  abdo- 
minal cavity,  whether  malignant  or  benign,  and  particularly  lymphatic  tumors 
situated  in  the  hilum  of  the  liver,  will  also  cause  it  by  mechanical  interference 
with  the  circulation  in  the  viscera. 

Bright's  disease  and  acute  nephritis  ;  organic  heart  disease ;  atelectasis  pul- 
monum  and  emphysema;  enlargement  of  the  spleen  and  profound  anaemia 
caused  by  malarial  poisoning;  the  pressure  of  lardaceous  lymph-glands  upon 


572    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  portal  vein  and  inferior  cava;  and  occasionally  chronic  tubercular  perito- 
nitis, which  interferes  with  the  circulation  in  the  peritoneum, — are  other  etio- 
logical factors.  Interstitial  nephritis  is  not  so  apt  to  cause  an  ascites  as  a 
general  anasarca.  Benign  tumors  in  the  abdominal  cavity  are  exceptionally 
accompanied  by  ascites,  malignant  tumors  constantly. 

Patholog-y. — The  pathology  of  ascites  is  comprehended  in  the  lesions 
involved  in  the  primary  affection.  The  changes  in  the  peritoneum  itself  are  slight 
and  inconstant.  Sometimes  this  membrane  has  simply  a  reddened  appearance, 
but  not  infrequently  it  is  pale  and  devoid  of  any  signs  of  inflammation. 

Symptoms. — The  constitutional  disturbance  attending  the  formation  of  an 
abdominal  effusion  usually  passes  unnoticed,  but  it  may  be  ushered  in  with  chil- 
liness, nausea,  headache,  vomiting,  colicky  pain,  or  a  brief,  intermitting  diar- 
rhoea. Pain  is  absent  unless  the  effusion  is  caused  by  peritonitis.  When 
effusion  has  reached  a  certain  point,  the  tenseness  of  the  abdominal  walls  is  apt 
to  cause  indigestion  and  irregularity  of  the  bowels ;  the  skin  becomes  dry  and 
has  an  ashen  or  clayey  look  ;  and  the  navel  protrudes  and  may  be  encircled  by 
a  plexus  of  dilated  veins,  termed  "  caput  Medusae."  In  very  large  effusions  the 
skin  of  the  abdomen  becomes  stretched  and  glistening,  and  at  times  fine  white 
striae,  similar  to  those  which  are  observed  upon  the  abdomen  of  a  pregnant 
woman,  make  their  appearance.  The  character  of  the  pulse  depends  upon  the 
primary  disease  ;  still,  it  is  generally  feeble  and  easily  compressed.  Provided 
no  inflammatory  disease  coexists,  the  temperature  is  normal.  The  urine  is 
variable  in  quantity,  though  usually  diminished ;  then  it  is  high  in  color,  and 
may  contain  albumin  and  fibrinous  casts.  As  a  result  of  mechanical  interfer- 
ence with  the  return  circulation  from  the  lower  extremities  ascites  is  very  fre- 
quently attended  by  oedema  of  the  feet  and  ankles.  Large  effusions,  crowding 
against  the  liver,  spleen,  and  kidneys,  and  forcing  the  diaphragm  up  to  the 
second  and  third  ribs,  cause  anaemia  of  these  organs  and  collapse  of  the  base  of 
the  lungs,  with  consequent  general  anasarca. 

Finally,  painful  and  difficult  micturition  or  incontinence  of  urine,  together 
with  difficulty  in  evacuating  the  bowels,  will  ensue.  The  constant  crowding 
upward  of  the  diaphragm  and  liver  causes  dyspnoea,  hydrothorax  supervenes, 
and  at  last  the  child,  unable  longer  to  assume  a  horizontal  positi;on,  dies  either 
from  asthenia  or  asphyxia. 

Physical  Examination. — Palpation  and  percussion  reveal  fluctuation 
indicative  of  the  presence  of  fluid,  which  varies  in  position  according  to  the 
posture  assumed  by  the  patient.  Thus,  whilst  standing,  the  abdomen  is  largest 
in  its  lowest  part ;  when  prone  it  spreads  laterally,  and  if  the  patient  be  turned 
on  either  side  it  falls  toward  the  more  dependent.  In  any  of  these  positions 
percussion  practised  over  the  uppermost  part  of  the  abdomen,  to  which  the  gas- 
containing  intestines  always  float  if  entirely  free  to  move,  gives  a  clear  tympan- 
itic note,  and  by  successively  altering  the  patient's  posture  the  tympany  readily 
moves  from  point  to  point,  while  the  dulness  due  to  the  fluid  also  changes  its 
place.     Wave-like  fluctuation  is  another  valuable  sign. 

Diagnosis. — The  diagnosis  of  ascites  is  comparatively  easy,  yet  it  must 
not  be  forgotten  that  •  in  children  other  conditions  are  often  encountered 
which  produce  an  enlargement  of  the  abdomen.  Naturally,  the  smaller  the 
effusion  the  more  difficult  is  it  to  make  a  diagnosis.  When  the  abdomen  is 
distended  by  a  sufficiently  large  amount  of  fluid,  wave-like  fluctuation  and 
movable  dulness  can  readily  be  obtained,  and  leave  no  doubt  of  the  diagnosis. 
Small  effusions,  although  always  obscure,  are  most  readily  detected  when  the 
patient  sits  or  lies  on  one  side. 

In  addition  to  detecting  the  presence  of  ascites,  it  is  necessary  to  determine 


PERITONEAL    TUMORS  AND   ASCITES.  573 

the  nature  of  the  antecedent  disease,  as  upon  this  prognosis  depends.  When 
the  tluid  is  large  in  amount  and  movable,  atrophic  cirrhosis  of  the  liver  may  be 
suspected.  _  If  the  eifusion  be  small  and  immovable  and  loculated,  the  cause  is 
most  probably  tubercular  peritonitis.  This  disease  is  characterized  by  the 
presence  of  disseminated  nodules,  and  its  symptoms  are  tenderness  upon  pres- 
sure, pain,  and  fever,  possibly  conjoined  with  indications  of  tubercular  disease 
in  some  other  organ. 

Prognosis. — Though  not  always  a  hopeless  condition,  the  prognosis  is  not 
very  encouraging.  Provided  the  primary  cause  upon  which  the  ascites  depends 
be  removable,  as  in  malaria  or  alcoholism,  and  the  liver  is  not  completely 
invaded  by  the  disease,  we  may  hope,  by  removal  of  that  cause  and  by  proper 
treatment  and  hygiene,  to  effect  a  cure  of  the  abdominal  dropsy. 

Treatment. — In  the  milder  degrees  of  ascites  treatment  coiisists  in  the 
administration  of  diuretics,  diaphoretics,  and  hydragogue  cathartics.  Acetate 
of  potassium,  combined  with  digitalis  and  compound  spirit  of  juniper,  acts  fav- 
orably.    A  very  efficient  combination  is  the  following  : 

^.  Magnesii  sulphat 

Potassii  bitartrat da  iss. 

Aqu^  cinnamomi       f  oiii- — ^I- 

Sig.   A  tablespoonful  every  three  or  four  hours,  according  to  its  effect  upon 
the  bowels. 

When  great  general  anasarca  coexists  with  the  ascites,  threatening  inter- 
ference with  respiration  and  circulation,  in  addition  to  the  free  purgation  hot 
vapor  baths  are  to  be  recommended.  These  may  be  applied  in  the  following 
manner:  The  patient,  completely  divested  of  clothing,  is  laid  upon  a  blanket, 
and  immediately  several  bricks,  which  have  been  in  the  mean  time  thoroughly 
heated  by  immersion  in  pails  of  hot  water,  and  then  enveloped  in  flannel 
cloths,  are  placed  at  the  shoulders  and  feet.  Care  must  be  taken  that  they  be 
neither  too  hot  nor  put  too  near  the  body,  lest  the  skin  be  scorched.  Another 
blanket  is  then  thrown  over  the  patient.  The  upper  corners  of  the  superim- 
posed blanket  are  brought  over  and  tucked  under  the  opposite  shoulders,  while 
the  other  end  of  the  upper  blanket,  with  the  lower  end  of  the  underlying  one, 
are  lapped  together  under  the  heels  of  the  patient,  and  the  head  alone  is  left 
to  protrude  from  this  improvised  sack.  This  hot  pack  is  maintained  for  at 
least  twenty  minutes,  producing  profuse  diaphoresis  and  usually  greatly  amelio- 
rating the  symptoms.  The  patient  and  his  friends  are  apt  to  complain  loudly 
of  this  heroic  treatment,  but  I  can  recollect  several  instances  where  by  its  use 
the  child  was  saved  from  imminent  death :  and  often  it  will  accomplish  the  end 
sought  when  all  other  measures  have  failed. 

A  strict  milk  diet  is  to  be  enjoined  as  a  rule.  When,  however,  hydrgemia 
is  prominent,  iron,  tonics,  nutritious  food,  and  good  air,  with  a  proper  obser- 
vance of  all  recognized  hygienic  rules,  are  indicated.  In  ascites  depending 
upon  atrophic  hepatic  cirrhosis  squills,  digitalis,  calomel,  and  iodide  of  potas- 
sium will  be  of  service.  In  this  variety,  however,  the  ordinary  diuretics  usually 
have  but  little  effect.     Here  Basham's  iron  mixture  is  highly  spoken  of — viz. : 

^.   Tinct.  ferri  chlorid. 

Acid,  acetic,  dil.     .    .    , da  fzj. 

Liq.  ammonii  acetat,    = f^vi. 

Aqua? =    =    .    o    o    c  q.  s.  ad  f^vj. — M. 

Sig.  Tablespoonful  three  times  daily  for  a  child  of  six  years. 


574    AlfEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

If,  despite  this  treatment,  the  fluid  continues  to  accumulate,  paracentesis 
abdominis  must  be  practised.  This  operation  shoukl  not  be  performed  too 
soon,  nor  should  we  delay  it  to  the  last  moment.  The  proper  time  is  when 
remedies  fail  after  a  fair  trial  and  when,  in  spite  of  treatment,  the  patient's 
general  health  daily  deteriorates.  Ordinarily  this  operation  is  simple  and  free 
from  danger.  Either  an  aspirator  or  fine  trocar  and  canula  may  be  used,  but 
I  prefer  the  latter.  This  tapping  can  be  repeated  as  often  as  the  exigencies  of 
each  particular  case  may  require.  If  fluid  reaccumulates  within  three  or  four 
days,  a  retapping  should  be  postponed  as  long  as  possible ;  if,  however,  a  num- 
ber of  weeks  elapse  before  the  peritoneal  cavity  is  refilled,  the  operation  may 
be  correspondingly  deferred  to  that  time. 

Permanent  drainage  by  means  of  a  rubber  tube  under  proper  antiseptic 
precautions  has  been  highly  commended  by  Dr.  A.  Caill^,  whenever,  after  one 
or  two  tappings,  the  ascitic  fluid  rapidly  reaccumulates.  When  all  other  meas- 
ures of  treatment  are  futile,  this  method  of  permanent  drainage  should  be 
utilized. 

While  the  operation  of  paracentesis  is  very  trifling,  every  antiseptic  pre- 
caution should  be  employed.  In  order  to  produce  local  anaesthesia  a  hypoder- 
matic injection  of  three  to  five  minims  of  a  2  to  4  per  cent,  solution  of  cocaine 
may  be  made  at  the  proposed  point  of  operation,  or  the  same  result  may  be 
obtained  by  the  rhigolene  spray  or  the  application  of  ice  and  salt.  The  linea 
alba,  below  the  umbilicus,  is  the  usual  point  of  election  except  for  loculated 
effusions.  In  the  latter  case,  as  distended  veins  ramify  extensively  over  the 
abdominal  wall,  caution  must  be  used  not  to  wound  any  of  them  with  the 
trocar.  As  the  fluid  escapes  pressure  is  kept  up  by  means  of  a  many-tailed 
bandage :  this  lessens  the  risk  of  syncope  and  secures  a  thorough  evacuation 
of  the  fluid.  If  the  puncture  has  been  made  at  the  side  of  the  abdomen,  the 
patient  must  lie  on  the  opposite  side  for  some  little  time,  so  that  the  wound 
may  cicatrize  properly.  This  will  obviate  the  occurrence  of  a  fistula,  a  sequel 
which  will  prove  a  source  of  great  annoyance  to  the  patient,  inasmuch  as  leak- 
age soils  the  clothing  and  provokes  cutaneous  inflammation. 


CONGENITAL  INTESTINAL  MALFORMATIONS 


DISEASES  OF  THE  ANUS  AND  RECTUM. 

By  henry  R.  WHARTON,  M.  D., 

Philadelphia. 


I.  Congenital  Malformations  of  the  Intestines, 

Congenital  malformations  of  the  small  intestine  are  met  with  much  less 
frequently  than  those  of  the  rectum  and  anus ;  in  the  Vienna  Foundling  Hos- 
pital only  9  anomalies  of  this  nature  were  found  among  150,000  infants. 
The  malformation  may  consist  of  a  stenosis  or  atresia  of  the  gut ;  or  the 
bowel  may  terminate  in  a  cul-de-sac  at  the  point  of  obstruction,  and  beyond 
this  point  again  begin  in  a  cul-de-sac,  the  remaining  portion  of  the  intestine 
being  well  developed ;  or  the  bowel  may  have  a  diverticulum  given  off  which 
attaches  it  to  the  abdominal  walls,  and  this  may  contain  a  fistula  opening 
upon  some  portion  of  the  body ;  or,  finally,  the  defect  may  consist  in  an 
abnormal  shortness  of  the  intestinal  canal.  Holmes  mentions  two  cases  of 
congenital  occlusion  of  the  small  intestine  in  which  the  diagnosis  was  satisfac- 
torily established,  and  Dr.  W.  Craig  reports  a  case  of  congenital  malformation 
of  the  small  intestine  in  a  child  who  lived  seventy-two  hours,  and  in  whom  the 
autopsy  showed  an  obstruction  of  the  small  intestine  at  the  upper  fifth  of  the 
ileum.  The  intestine  in  this  case  was  distended  above  the  point  of  obstruc- 
tion, and  upon  opening  the  bowel  it  was  found  that  it  ended  in  a  cul-de-sac ; 
further  examination  of  the  gut  beyond  the  point  of  obstruction  showed  that 
the  intestine  began  in  a  cul-de-sac,  and  the  intervening  space  between  these 
two  pouches  was  occupied  by  a  band  of  fibrous  tissue.  The  most  frequent 
position  of  congenital  occlusion  of  the  small  intestine  is  the  duodenum  near  the 
point  at  which  the  biliary  duct  and  pancreatic  duct  open,  or  at  the  point  where 
the  duodenum  becomes  jejunum  under  the  transverse  mesocolon.  Malforma- 
tions of  the  ileum  are  most  common  near  the  ileo-cffical  valve,  or  a  short 
distance  above  it,  where  the  ductus  omphalo-mesentericus  is  given  off.  Among 
the  congenital  malformations  of  the  small  intestine  may  be  mentioned  that 
condition  known  as  Meckel's  diverticulum,  which  consists  in  a  cylindrical  or 
flask -shaped  appendage  attached  to  the  ileum  a  metre  or  more  above  the  ileo- 
csecal  valve,  and  is  a  remnant  of  the  omphalo-mesenteric  duct.  Another  form 
of  this  defect  consists  in  the  presence  at  the  umbilicus  of  a  reddish  tumor 
covered  with  mucous  membrane,  which  has  been  described  as  a  warty  tumor 
of  the  umbilicus,  congenital  mucous  polypus  of  the  umbilicus,  and  as  adenoma 
of  the  umbilicus. 

Congenital  malformations  of  the  large  intestine  are  also  of  infrequent 
occurrence,  but  may  involve  the  colon,  the  sigmoid  flexure,  or  the  rectum. 
The  malformations  of  the  large  intestine  may  consist  of  an  occlusion  of  the 

575 


576    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDBEN. 

gut  at  any  portion  of  its  length  ;  or  the  gut  may  exist  in  a  rudimentary  condi- 
tion. The  latter  defect  is  most  apt  to  be  associated  with  Meckel's  diverticulum, 
with  a  faecal  fistula  between  the  ileum  and  the  fissure  above  the  umbilicus,  or 
with  a  faecal  fistula  between  the  small  intestine  and  some  portion  of  the  abdominal 
walls.  Atkin  reports  the  case  of  a  child  who  died  two  days  after  birth,  and  in 
whom,  upon  autopsy,  the  rectum  and  colon  were  found  to  be  in  a  rudimentary 
state,  smaller  than  an  ordinary  quill ;  in  this  case  the  parts  had  remained  in 
the  condition  in  which  they  exist  in  the  early  embryo. 

The  various  congenital  malformations  of  the  small  and  large  intestine  are 
probably  largely  to  be  attributed  to  accidents  in  development  due  to  a  com- 
plicated" disposition  of  the  intestinal  tract  of  the  embryo  ;  and  it  is  also  likely 
that  foetal  peritonitis  plays  an  important  part  in  the  production  of  these 
deformities.  Theremin  is  of  the  opinion  that  many  of  these  anomalies  are 
due  to  changes  in  the  peritoneum  which  have  taken  place  early  in  foetal  life. 

Symptoms. — The  symptoms  arising  from  congenital  malformations  of  the 
large  or  small  intestine  are  simply  those  of  intestinal  obstruction  in  a  more  or 
less  marked  degree,  which  depends  upon  the  completeness  of  the  occlusion  ;  and 
all  observers  are  agreed  as  to  the  absence  of  any  definite  symptoms  accurately 
localizing  the  seat  of  the  lesion.  The  vomiting  of  whitish  mucus,  with  ob- 
struction of  the  bowels,  in  the  case  of  a  new-born  infant,  points  to  an  occlu- 
sion high  up  in  the  small  intestine,  and  if  the  obstruction  exists  in  the 
jejunum  or  ileum,  this  may  be  replaced  by  the  vomiting  of  meconium.  In 
such  a  case  the  symptoms  would  in  no  wise  differ  from  those  consequent  upon 
the  presence  of  an  occlusion  situated  in  the  region  of  the  rectum  or  anus.  If 
a  faecal  fistula  is  present,  the  symptoms  of  obstruction  Avill  not  be  so  marked, 
and  the  position  of  the  fistula  may  serve  as  a  guide  to  the  situation  of  an  intes- 
tinal malformation. 

Diagnosis. — As  before  stated,  the  localization  of  the  lesion  is  often  most 
difiicult.  In  a  newly-born  child  who  presents  swelling  of  the  belly  with 
vomiting  and  obstruction  of  the  bowels,  the  anus  and  rectum  should  first  be 
examined  to  exclude  the  possibility  of  malformation  of  these  parts ;  a  soft 
catheter  should  be  passed  into  the  rectum,  and  if,  upon  injecting  water, 
meconium  is  brought  away,  it  can  be  inferred  that  the  obstruction  exists  at  a 
higher  point  of  the  intestinal  canal. 

Prognosis. — The  prognosis  is  always  unfavorable :  complete  occlusions  of 
the  duodenum  or  of  the  high  portion  of  the  jejunum  must  necessarily  prove 
fatal  in  a  short  time  ;  but  when  the  obstruction  is  incomplete  or  occupies 
a  position  low  down  in  the  small  intestine,  or  if  associated  with  a  faecal  fistula, 
the  patient  may  survive  for  some  time,  even  for  years.  Complete  occlusions  are 
usually  fatal  within  a  few  days  unless  relieved  by  operative  treatment. 

Treatment. — In  cases  of  complete  obstruction  operative  treatment  must 
be  resorted  to  promptly.  Up  to  the  present  time  the  results  obtained  have 
not  been  encouraging ;  but  with  the  improved  technique  of  abdominal  opera- 
tions more  favorable  results  may  be  looked  for  in  these  cases.  As  before 
stated,  the  diagnosis  of  the  seat  of  the  lesion  is  often  impossible ;  but  as  in 
cases  of  complete  occlusion  the  result  is  necessarily  speedily  fatal,  it  seems  wise 
to  attempt  an  exploratory  operation  Avith  the  hope  of  affording  relief  or  bring- 
ing about  a  cure.  A  median  laparotomy,  unless  there  is  some  definite  symp- 
tom present  which  points  to  the  exact  seat  of  the  obstruction,  should  be  the 
operation  selected.  If  upon  opening  the  abdomen  the  occlusion  is  found  situ- 
ated in  the  duodenum  or  high  up  in  the  jejunum,  the  case  must  be  abandoned 
as  hopeless,  unless  it  be  found  possible  to  excise  the  occluded  portion  of  the 
bowel  and  bring  the  ends  together  by  sutures  (circular  enterorraphy),  or  to  make 


MALFORMATIONS    OF    THE   RECTUM  AND    ANUS,        577 

an  attempt  to  establish  the  continuity  by  the  procedure  known  as  lateral  intes- 
tinal anastomosis.  If  the  occlusion  is  due  to  a  membranous  septum,  this  may 
be  exposed  -  by  incising  the  gut,  and  after  it  has  been  perforated  or  cut  away 
the  intestinal  wound  should  be  united  by  Lembert's  sutures  and  the  abdominal 
incision  closed  in  the  usual  manner.  If  the  occlusion  exists  low  down  in  the 
small  intestine  or  in  the  large  intestine,  circular  enterorraphy  or  lateral  anas- 
tomosis may  be  employed,  or  an  artificial  anus  may  be  made  by  bringing 
the  gut  to  the  abdominal  wound,  securing  it  there,  and  opening  it.  This  latter 
procedure  would  seem  to  be  the  wiser  one,  as  it  requires  much  less  time  to 
accomplish  it,  and  if  the  patient  survives,  after  he  has  attained  some  age  an 
attempt  may  be  made  to  establish  the  continuity  of  the  intestinal  canal  by 
lateral  anastomosis.  If  a  fsecal  fistula  is  present  and  there  are  no  marked 
symptoms  of  intestinal  obstruction,  no  operative  treatment  should  be  insti- 
tuted ;  but  if  the  patient  exhibits  symptoms  of  intestinal  obstruction,  the  fis- 
tula should  be  dilated  or  incised,  and,  if  relief  be  obtained,  further  operative 
treatment  should  be  postponed  until  a  later  period. 

n.  Congenital  Malformations  of  the  Rectum  and  Anus. 

Congenital  malformations  of  the  rectum  or  anus  occur,  according  to  various 
observers,  in  the  proportion  of  1  case  in  10,000  births. 

Pathology. — These  malformations  result  from  arrested  development  of  the 
parts  in  early  foetal  life.  At  its  earliest  commencement  the  alimentary  canal 
consists  of  a  simple  sac  or  bag  developed  from  the  innermost  layer  of  the  blas- 
toderm, partly  within  and  partly  Avithout  the  body  ;  and  as  development  pro- 
ceeds this  communication  between  the  two  portions  of  the  sac  is  shut  off,  and 
the  portion  within  the  abdomen  consists  of  a  simple  tube,  the  mesente^^on, 
which  terminates  at  the  anterior  extremity  of  the  embryo  in  a  blind  pouch, 
while  at  the  posterior  extremity  a  similar  pouch  is  formed.  The  cul-de-sac  at 
the  anterior  extremity  of  the  embryo  comes  in  contact  and  communicates  Avith 
an  invagination  of  the  epiblast,  which  is  called  the  stomodceum,  while  a  similar 
depression  of  the  epiblast  at  the  posterior  extremity  of  the  embryo,  named  the 
proctodceum,  forms  the  anal  orifice  and  communicates  with  the  mesenteron. 
The  majority  of  malformations  of  the  rectum  and  anus  are  due  to  an  interrup- 
tion in  the  latter  stages  of  the  process  just  described,  or,  in  other  words,  to  an 
arrested  or  irregular  development  of  the  proctodaeum  or  mesenteron.  The 
termination  of  the  rectum  in  the  genito-urinary  tract  is  due,  in  addition  to  the 
arrested  development  just  mentioned,  to  a  similar  arrested  development  in  the 
perineal  septum,  which  separates  the  rectum  from  the  genito-urinary  tract,  both, 
in  the  early  life  of  the  embryo,  having  a  common  orifice.  The  failure  of  devel- 
opment of  the  perineal  septum  explains  the  frequency  of  cases  of  imperforate 
rectum  and  anus  in  which  there  is  a  communication  between  the  intestinal  tube 
and  the  genito-urinary  tract. 

The  best  classification  of  the  malformations  of  the  rectum  and  anus  is  that 
adopted  by  Bodenhamer,  and  is  as  folloAvs  :  1.  Congenital  narrowing  of  the 
rectum  or  anus  without  complete  occlusion  ;  2.  Complete  occlusion  of  the  anus 
by  a  membranous  diaphragm  or  well-formed  skin ;  3.  The  anus  is  absent,  and 
the  rectum  ends  in  a  blind  pouch  at  a  point  more  or  less  distant  from  the  peri- 
neum ;  4.  The  anus  is  normal  in  appearance,  but  ends  in  a  cul-de-sac,  and  the 
rectum  ends  in  a  blind  pouch  at  a  variable  distance  above  this  point ;  5.  The 
anus  is  absent,  and  the  rectum  ends  by  a  fistula  at  any  point  of  the  perineum 
or  sacral  region ;  6.  The  anus  is  absent,  and  the  rectum  ends  in  the  vagina, 
the  bladder,  or  the  urethra;   7.  The  anus  and  rectum  are  normal,  but  the 

37 


578     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Fig.  1. 


Congenital  Xarrowin?  of  the 
Rectum  and  Anus. 


Fig.  2. 


ureter,  vagina,  or  urethra  opens  into  the  rectal  cavity  ;  8.  The  rectum  is  totally 
absent. 

1.  CoxGEXiTAL  Narrowing  of  the  Rectum  or  Anus,  without  Com- 
plete Occlusion. — This  variety  of  malformation  is  probably  more  common 

than  is  generally  supposed,  as  it  escapes  notice  if 
the  narrowing  is  not  sufficient  to  produce  marked 
symptoms  of  obstruction  ;  and  probably  in  many 
cases  of  this  nature,  in  which  the  stenosis  is  not 
extreme,  the  efforts  of  the  child  in  passing  the 
faeces  bring  about  the  necessary  amount  of  dila- 
tation. As  the  stenosis  may  not  be  sufficient  to 
prevent  the  escape  of  the  semifluid  fieces  of  infant 
life,  the  condition  may  not  be  detected  for  some 
time,  and  it  is  only  as  the  child  becomes  older  and 
the  faces  become  more  consistent  that  accumula- 
tion takes  place  in  the  rectum  and  attention  is 
directed  to  the  malformation  (Fig.  1). 

Treatment. — The  treatment  of  this  variety  of 
congenital  stenosis  is  best  conducted  by  gradual  dilatation,  which  may  be  carried 
out  by  the  daily  introduction  into  the  bowel  of  graduated  bougies,  or  by  the 
introduction  of  the  oiled  index  finger  of  the  mother  or  the  nurse,  which  is  by 
far  the  best  of  all  bougies  for  this  purpose. 

2.  Complete  Occlusion  of  the  Anus  by  Membranous  Diaphragm  or  by 
Well-formed  Skin. — In  this  form  of  malformation  closure  of  the  anus  may 
be  caused  by  a  diaphragm  of  mucous  membrane  or  skin, 
which  appears  to  be  due  to  the  adhesion  or  skinning  over 
of  the  surface  of  the  anus,  the  rest  of  the  proctodteum 
being  normally  formed  (Fig.  2). 

Treatment. — The  treatment  consists  in  making  a  cru- 
cial incision  at  the  position  of  the  anus,  opening  the  rectal 
pouch,  and  evacuating  the  fc^eces  and  trimming  off  the  edges 
of  the  mucous  membrane  and  skin.     The  wound  .should  be 

dusted   with    iodoform    and    dressed 

with  a  pad  of  antiseptic  gauze,  and 

the  subsequent  management    of  the 

case    consists    in    keeping    the    anus 

well  dilated  for  some  time  to  prevent 

cicatricial  contraction. 

3.  The    Anus    is   Absent,   and 

the  Rectum  ends  in  a  blind  pouch  at  a  point  more 

or  less  distant  from  the  Perineum. — In  this  variety  of 

malformation  the  rectal  pouch  may  terminate  near  the  skin. 

or  it  may  end  high  up  in  the  pelvis  and  the  space  between 

it  and  the  perineum   be   filled  with  cellular  tissue,  or  in 

other  cases  a  distinct  fibrous  cord  can  be  traced  from  the 
The  Anus  is  absent,  and  termination  of  the  rectum  to  the  skin  (Fig.  3). 
Blind  Pouch  (after  Ball).         Treatment. — In  the  treatment  of  this  malformation — 

and,  in  tact,  of  all  forms  of  imperforate  rectum  in  which 
complete  occlusion  exists — the  duty  of  the  surgeon  is  veiy  clear ;  he  should, 
as  soon  as  possible,  attempt  to  reach  the  rectal  pouch  by  a  perineal  incision. 
The  earlier  this  is  attempted  the  better,  for  delay  in  operating  certainly  con- 
duces largely  to  a  fatal  result.  I  cannot  subscribe  to  the  opinion  of  those  who 
advise  delay  until  the  rectum  is  distended  with  faces  and  gas,  which  may  make 


Complete  Occlusion  of 
the  Anus  by  Membran- 
ous Diaphragm  or  Skin 
(after  Ball). 


3IALF0BMATI0NS    OF    THE   RECTUM  AND    ANUS.        579 

the  position  of  the  rectal  pouch  more  apparent,  but  which  is  not  unattended 
with  the  risk  of  rupture  of  the  intestine  and  exhaustion  of  the  patient ;  and 
it  has  also  been  shown  that  by  delay  the  meconium  becomes  reduced  in  bulk 
through  the  absorption  of  the  fluids.  It  should  be  remembered  that  the  rectum 
in  infants  descends  in  the  hollow  of  the  sacrum  and  is  close  to  the  bone,  and 
except  at  its  upper  portion  is  uncovered  by  peritoneum  posteriorly  ;  in  front 
its  peritoneal  investment  descends  to  a  much  lower  level,  and  its  close  relation 
in  this  aspect  to  the  genito-urinary  tract  is  an  additional  reason  for  the  selection 
of  the  posterior  region  for  exploratory  operation.  Various  operative  measures 
have  been  recommended  and  resorted  to  in  cases  of  imperforate  rectum. 

Puncture  with  a  Trocar  Canula. — The  introduction  through  the  perineum 
of  a  trocar  and  canula  was  formerly  advised,  and  by  its  use  I  have  seen  the 
rectum  reached  and  meconium  evacuated ;  but  subsequently  it  is  usually  found 
necessary  to  enlarge  the  wound  made  by  the  instrument  to  secure  free  exit  of 
f?ecal  matter,  so  that  the  procedure  possesses  no  advantage  over  the  perineal 
incision,  and  has  the  disadvantage  that  the  rectal  pouch  may  be  entirely  missed 
by  the  trocar  and  important  structures  injured  by  its  blind  introduction. 

Perineal  Operation. — This  is  considered  the  best  operation  to  undertake  in 
these  cases,  since,  if  successful,  it  leaves  the  patient  with  an  anus,  in  the 
normal  position,  and  often  with  fair  control  of  the  bowels,  for  the  anal  sphincter 
is  frequently  well  developed  in  spite  of  the  malformation  of  the  rectum.  In  per- 
forming this  operation  the  child  should  be  placed  in  the  lithotomy  position,  and 
the  incision  should  be  made  in  the  median  line  of  the  perineum  from  the  root  of 
the  scrotum  to  the  coccyx.  The  tissues  should  be  divided  slowly,  any  bleeding 
vessels  being  secured  as  they  are  met  with.  The  surgeon  should  explore  the 
Avound  with  the  finger  during  the  operation,  to  discover,  if  possible,  the  bulg- 
ing of  the  rectal  pouch,  and  should  be  careful  to  make  the  deepest  incisions 
posteriorly.  In  a  female  infant  the  finger  introduced  into  the  vagina  during 
the  operation  may  give  the  surgeon  some  information  as  to  the  position  of  the 
rectum  ;  or  if  the  mass  of  fibrous  tissue  in  which  the  rectum  sometimes  ter- 
minates is  seen  or  felt,  it  may  serve  as  a  guide  to  the  position  of  the  rectal 
pouch.  Nearness  of  the  tuberosities  of  the  ischium  is  a  sign  of  absence  of  the 
rectum ;  and  if  it  is  found  that  the  vagina  or  bladder  fills  up  the  concavity  of 
the  sacrum,  it  is  an  indication  of  a  high  termination  of  the  rectal  pouch.  The 
incisions  may  be  carried  with  safety  to  the  depth  of  an  inch  and  a  half  or  two 
inches,  and  when  the  rectal  pouch  is  reached  it  should  be  incised.  After 
the  meconium  has  escaped  the  wound  in  the  rectum  should  be  sufiiciently 
enlarged,  and,  if  possible,  its  edges  should  be  brought  doAvn  and  sutured 
to  the  skin  of  the  perineal  wound,  care  being  taken  in  passing  the  sutures 
and  in  introducing  a  drainage-tube  to  leave  no  pocket  around  the  bowel 
for  the  accumulation  of  discharges.  The  suturing  of  the  edges  of  the  bowel 
to  the  skin  is  a  most  important  procedure,  and  one  which  diminishes  largely  the 
amount  of  contraction  in  the  newly-formed  anus,;  it  may,  however,  be  found 
impossible  to  bring  down  the  edges  of  the  rectal  wound  to  the  skin  in  cases 
where  the  rectum  terminates  high  up  in  the  pelvis.  In  such  cases  a  large 
flexible  catheter  or  a  metallic  tube  may  be  introduced  and  held  in  place  by 
tapes  ;  but  it  is  difiicult  to  keep  it  in  position,  as  it  is  apt  to  be  displaced  by 
the  straining  efibrts  of  the  child.  Verneuil  has  suggested  excision  of  the 
coccyx  in  the  early  part  of  the  operation,  which  facilitates  the  search  for  the 
gut,  and  in  case  it  is  found  this  procedure  enables  the  surgeon  more  readily  to 
attach  the  edges  of  the  rectal  pouch  to  the  skin.  The  dressing  of  the  wound 
should  consist  in  dusting  the  parts  with  iodoform  and  applying  a  pad  of  anti- 
septic cotton,  to  be  held  in  position  by  means  of  a  T  bandage. 


580     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

When  the  surgeon  has  carried  his  dissection  up  into  the  pelvis  as  far  as  he 
considers  it  is  safe,  an  inch  and  a  half  or  two  inches,  and  has  failed  to  reach  the 
rectal  pouch,  he  should  then  consider  the  advisability  of  abandoning  the  attempt 
to  reach  the  gut  through  the  perineum,  and  should  endeavor  to  open  the  intes- 
tine either  in  the  left  groin  (Littre's  operation),  or  in  the  left  loin  behind  the  peri- 
toneum (Amussat's  operation),  or  in  the  right  groin  (Huguier's  operation).  Of 
these  operations,  that  in  the  left  groin  is  to  be  recommended,  as  it  opens  the 
bowel  near  its  natural  termination.  If  the  surgeon  decides  upon  this  operation, 
he  should  make  an  incision  from  one  and  a  half  to  two  inches  in  length,  half  an 
inch  above  and  parallel  with  Poupart's  ligament,  beginning  at  a  point  opposite 
the  junction  of  the  middle  with  the  outer  third  of  this  structure.  Or  an  incision 
suggested  by  Ball,  following  the  line  of  the  linea  semilunaris,  stopping  just 
short  of  Poupart's  ligament,  may  be  substituted  for  the  former  incision.  The 
skin  and  muscular  layers  being  cut  through,  the  tascia  transversalis  and  peri- 
toneum may  be  pinched  up  together,  and  a  small  opening  made  in  them,  through 
which  a  director  should  be  passed,  and  the  two  can  then  be  divided  with  one 
incision.  It  is  sometimes  difficult  to  determine  whether  the  bowel  presenting 
in  the  wound  is  the  small  or  large  intestine  ;  this  can  be  ascertained  by  gently 
drawing  out  a  coil  :  if  it  be  the  small  intestine,  it  can  be  drawn  out  with  ease, 
and  the  mesentery  will  show  that  it  is  not  the  portion  of  the  bowel  sought 
for,  and  it  should  be  replaced.  On  the  other  hand,  the  large  intestine  cannot 
be  so  readily  drawn  out,  and  its  mesocolon,  if  it  have  one,  would  be  found 
attached  to  the  left  side.  The  bowel  should  next  be  secured  to  the  edges 
of  the  wound  by  several  sutures  of  fine  silk  or  catgut,  which  should  be  intro- 
duced by  passing  a  curved  needle  through  the  skin  and  parietal  peritoneum 
near  the  eclge  of  the  wound,  and  then  transfixing  a  portion  of  the  bowel  :  after 
which  the  needle  should  be  made  to  transfix  the  peritoneum  and  skin  again, 
being  brought  out  a  short  distance  from  the  point  of  insertion  ;  the  stitches 
should  then  be  secured.  Sutures  should  be  applied  in  this  manner  on  each  side 
and  at  the  extremities  of  the  incision,  after  which  the  gut  should  be  incised  to 
a  sufficient  extent  ami  the  meconium  allowed  to  escape.  After  the  escape  of 
the  latter  the  wound  should  l)e  carefully  cleansed,  and  the  edges  of  the  gut 
incision  may  be  attached  to  the  skin  by  a  few  silk  sutures.  The  surgeon  may 
introduce  the  finger  or  a  flexible  rubber  catheter  into  the  opening  in  the  gut  to 
ascertain,  if  possible,  the  point  of  termination  of  the  rectal  pouch  :  and  if  it  is 
found  to  be  near  the  upper  portion  of  the  perineal  incision,  he  may  deepen  the 
latter  on  a  guide  introduced  through  the  artificial  anus.  It  has,  however,  been 
found  better  to  rest  satisfied  with  the  relief  afforded  by  colotomy,  and  to  post- 
pone for  a  time  the  attempt  to  fi)rm  an  anus  in  the  perineal  region,  for  the 
majority  of  cases  in  which  this  has  been  attempted  have  been  followed  by  a 
fatal  result.  Attempts  to  accomplish  this  result  some  months  after  the  per- 
formance of  colotomy  have  been  more  satisfactory,  as  is  seen  in  cases  reported 
by  Byrd  and  Kronlein.  When  the  patient  has  attained  some  age,  and  an 
examination  through  the  artificial  anus  in  the  left  groin  shows  that  the  rectal 
pouch  terminates  well  down  in  the  pelvis,  a  director  or  rubber  catheter  may  be 
introduced  thr(Hxgh  the  colotomy  wound  and  made  to  enter  the  pouch,  and 
project  at  the  anus,  if  it  be  present,  or  at  some  point  of  the  perineum.  This 
may  then  be  cut  down  upon  as  a  guide,  and  the  gut  may  be  opened  and  sutured 
to  the  skin  if  the  edges  can  be  draAvn  down  to  that  point. 

If  the  surgeon  should  prefer  to  make  an  attempt  to  open  the  bowel  in  the 
left  lumbar  region,  the  best  guide  to  the  position  of  the  colon  is  a  line  half  an 
inch  posterior  to  a  point  midway  between  the  two  superior  spinous  processes  of 
the  ilium  ;  if  he  fails  to  find  the  large  intestine,  and  distended  small  intestine 


MALFOBMATIOXS    OF   THE   RECTUM  AND    ANUS. 


581 


Fig.  4. 


shows  itself  in  the  Tvound,  it  is  better  to  open  this  and  stitch  it  to  the  wound, 
rather  than  to  abandon  the  case  and  aHow  the  patient  to  perish  by  intestinal 
obstruction. 

The  results  obtained  by  the  various  operations  for  the  relief  of  the  symp- 
toms due  to  imperforate  rectum  show  that,  in  point  of  safety  and  as  a  matter  of 
comfort  to  the  patient,  the  perineal  operation  is  to  be  preferred.  Cripps  has 
collected  lOO  cases  of  the  various  operations  for  the  relief  of  imperforate  rec- 
tum ;  his  table,  although  exhibiting  a  high  rate  of  mortality,  50  per  cent., 
shows  that  the  largest  number  of  recoveries  followed  the  perineal  operation, 
and  the  next  in  number  were  those  cases  in  which  the  colon  was  opened  in  the 
iliac  region.  The  expediency  of  an  operation  for  the  establishment  of  an  arti- 
ficial anus,  either  in  the  perineum  or  in  the  groin,  in  young  children  with 
imperforate  rectum,  is  evidenced  by  a  number  of  well-attested  cases  in  which 
the  patient  lived  for  years  afterward  in  comfort. 

4.  The  i\.xus  is  Normal  in  Appearance,  but  Ends  ix  a  Cul-de-sac, 
AND  THE  Rectum  Ends  ix  a  Blixd  Pouch  at  a  very  little  Distance 
ABOVE  THIS  PoiXT. — In  this  form  the  anus  and  rectum  may  be  separated  by 
a  membranous  partition  of  greater  or  less  thickness,  or  a 
portion  of  the  bowel  may  be  impervious,  or  there  may  be 
multiple  obstructions,  or  the  anal  portion  may  communi- 
cate with  the  vagina  in  the  female  and  the  rectum  end 
in  a  cul-de-sac  (Fig.  4).  The  variety  of  malformation  in 
Avhich  the  anus  is  normal,  but  is  separated  from  the  rectum 
by  a  membranous  partition  of  greater  or  less  thickness,  is 
not  uncommon.  It  is  apt  to  escape  notice  for  some  time, 
as  the  anus  is  normal  in  appearance,  and  it  is  only  when 
the  nurse  or  mother  notices  that  the  child  passes  no  faeces 
and  the  belly  becomes  swollen,  or  vomiting  begins,  that  the 
nature  of  the  trouble  is  suspected.  The  introduction  of  the 
finger  or  probe  into  the  anus  will  soon  reveal  the  nature  of 
the  trouble.  An  attempt  should  at  once  be  made  to  reach 
the  rectal  pouch  by  an  incision  through  the  anus  backward 
toward  the  coccyx,  and  if  the  gut  be  found  it  should  be 
brought  down  and  sutured  to  the  edges  of  the  anal  wound.  This  procedure  is 
much  safer  than  puncture  through  the  anus,  which  the  surgeon  might  feel 
tempted  to  employ  if  the  partition  between  the  two  cavities  did  not  seem  very- 
thick.  If  it  be  found  impossible,  after  a  careful  dissection  in  the  perineal 
region,  to  find  the  rectal  pouch,  the  surgeon  should 
abandon  this  operation,  and  attempt  to  reach  the  gut  by 
an  incision  in  the  left  iliac  region. 

5.  The  Axus  is  Absext,  and  the  Eectum  Ends 
BY  A  Fistula  at  any  point  of  the  Perixeum  or 
Sacral  Regiox. — The  rectum  may  open  at  some  portion 
of  the  perineum  or  sacral  region,  or  it  may  terminate  in 
a  narrow  channel  under  the  raphd  of  the  perineum  and 
open  at  the  prepuce  or  at  the  symphysis  pubis,  or  may 
end  in  several  fistulte  at  different  points  (Fig.  5).  Such 
patients  may  have  satisfactory  evacuations  through  the 
fistulge,  and  may  live  for  months  or  years  without  suffer- 
ing much  inconvenience  from  the  deformity. 

Treatment. — If  a  child  so  suffering  shows  evidence 
of  discomfort  by  reason  of  the  fseces  not  passing  sufficiently  freely  through  the 
fistula,  this  should  first  be  dilated  or  increased  in  size  bv  incision,  and  if  relief 


Anus  ends  in  a  Cnl-de-sac, 
the  Rectum  ends  in  a 
Blind  Pouch  (after  Mol- 
Uere). 


Fig.  5. 


Anus  is  absent  ;  Rectum 
ends  by  a  ii>iuia  at  the 
prepuce  (after  Ball). 


582     A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

fi'om  the  symptoms  be  obtained,  no  further  operation  should  be  attempted  as 
long  as  the  child  remains  in  comfort.  When  the  patient  has  attained  an  age 
when  a  more  radical  operation  can  be  undertaken,  the  fistula  may  be  explored 
with  a  probe  or  director,  and  the  position  of  the  rectal  pouch  ascertained  if 
possible  ;  if  it  be  in  a  favorable  position,  a  perineal  opening  should  be  made 
to  reach  the  rectum,  and  Avhen  it  has  been  found  the  bowel  should  be  opened 
and  its  edges  brought  down  and  sutured  to  the  edges  of  the  perineal  wound. 
The  fistulous  tract  should  be  laid  open  or  touched  with  the  actual  cautery, 
and  allowed  to  heal  by  granulation. 

6.  The  Anus  is  Absent,  and  the  Rectum  Ends  in  the  Vagina,  Blad- 
der, OR  Urethra. — These  malformations,  according  to  the  point  of  termina- 
tion of  the  rectum,  are  classified  as  atresia  ani  vaginalis,  atresia,  ani  vesicalis, 
and  atresia  ani  urethralis.  Leichtenstern's  statistics  show  that  40  per  cent,  of 
rectal  malformations  are  of  this  nature.  This  tendency  of  the  rectum  to  ter- 
minate in  the  genito-urinary  tract  is  remarkable  when  we  consider  the  definite 
separation  which  exists  between  the  rectum  and  the  genito-urinary  tract  in  the 
adult :  it  is  attributed  by  Ball  to  the  method  of  development  of  the  proctod<ieum, 
or  a  tendency  to  reversion  to  the  cloacal  type  of  birds  and  lower  animals. 

Atresia  Ani  Vaginalis. — In  this  form  the  rectum  terminates  in  the  posterior 
walls  of  the  vagina,  either  by  a  small  or  large  aperture.  The  opening  may  be 
situated  immediately  within  the  fourchette,  or  may  be  located  high  up  in  the 
canal  (Fig.  6).  If  the  rectal  opening  is  sufficiently  large,  the  patient  does  not 
exhibit  any  symptoms  of  intestinal  obstruction,  and  the  nature  of  the  deformity 
is  only  ascertained  upon  inspection  of  the  parts,  when  it 
^^"  is  found  that  the  anus  is  absent,  and  that  fsecal  matter 

escapes  from  the  vulva. 

Treatment. — If  the  patient  suffers  no  inconvenience, 
operative  treatment  may  be  postponed  until  she  has  attained 
some  age,  when  the  greater  development  of  the  parts  will 
conduce  to  a  favorable  result.  Operations  for  the  relief  of 
this  variety  are  the  most  satisfactory  in  their  results  of  all 
those  that  have  been  devised  for  the  cure  of  congenital 
malformations  of  the  rectum.  When  an  operation  is  de- 
cided upon,  the  one  which  is  followed  by  the  best  results 
.         •      K     f       r.        is  performed  in  the  followino-  manner :   A  director  is  passed 

Anus    IS   absent  ;     Rec-       iii  -i  •*•  i-ii 

turn  ends  in  the  vagina,    throuffh  the  vagmal  openino;  into  the  rectum  and  is  pushed 

(After  Ball.)  i.      j  i     ■  ^  ■    ^  i.    ■  ^     ^  ■      j. 

backward,  its  point  being  made  to  project  as  near  as  pos- 
sible to  the  normal  position  of  the  anus;  this  is  cut  down  upon  from  the  per- 
ineum and  the  rectum  is  exposed  and  incised.  The  rectal  wound  being  then 
sufficiently  enlarged,  the  gut  is  dissected  loose  and  its  edges  are  brought  down 
and  secured  to  the  skin  by  sutures.  By  this  dissection  of  the  rectum  and  bring- 
ing down  of  its  edges,  the  opening  into  the  vagina,  if  it  be  a  low  one,  is  oblit- 
erated. If  a  high  opening  into  the  vagina  remain  after  the  anus  has  been 
established  in  its  normal  position,  an  operation  may  be  undertaken  later  to 
close  this  recto-vaginal  fistula.  An  ingenious  operation,  devised  by  Rizzoli, 
for  the  relief  of  this  malformation  is  performed  as  follows :  An  incision  is  car- 
ried from  the  lower  margin  of  the  vaginal  anus  backward  through  the  perineum 
towai-d  the  coccyx,  care  being  taken  not  to  open  the  intestine;  the  termination 
of  the  rectum  with  its  vaginal  orifice  is  now  carefully  dissected  out,  and  the 
abnormal  anus  is  transplanted  to  its  natural  situation  and  secured  in  that  posi- 
tion by  a  few  sutures,  after  which  the  perineal  and  vaginal  wounds  are  brought 
together  by  deep  sutures. 

Atresia  Ani  Vesicalis. — In  this  variety  the  rectum  communicates  with  the 


MALFORMATIONS    OF    THE   BEGTUM  AND    ANUS. 


583 


Fig.  7. 


Anus  absent;  the  Rec- 
tum ends  in  the  Blad- 
der.   (After  BaU.) 


Fig.  8. 


bladder,  either  by  a  narrow  orifice  near  the  base  of  the  organ  or  by  an  open- 
ing near  its  fundus  (Fig.  7).  The  absence  of  the  anus 
and  the  escape  of  faecal  matter  intimately  mixed  with  urine 
at  the  time  of  urination  would  point  to  the  nature  of  this 
very  serious  malformation. 

Treatment. — In  the  treatment  a  staff  may  be  intro- 
duced through  the  urethra  into  the  bladder,  and  an  incis- 
ion made  through  the  perineum  into  the  neck  of  the 
bladder,  as  in  lithotomy,  and  continued  into  the  rectum. 
As  the  result  of  this  operation  the  immediate  symptoms 
of  obstruction  may  be  relieved,  but  the  patient  is  left  with 
a  urinary  and  faecal  fistula.  Ball  suggests  a  laparo-colot- 
omy,  and,  when  the  colon  has  been  found,  its  complete 
division,  with  closure  of  the  lower  portion  and  the  bring- 
ing out  of  the  upper  portion  at  the  wound,  and  securing 
it  in  that  position  to  establish  an  artificial  anus.  This 
operation,  although  attended  with  greater  immediate  risk,  has  the  advantage  of 
leaving  the  patient  with  control  over  his  urinary  excretion. 
Atresia  Am  Urethralis. — In  this  form  the  rectum  com- 
municates with  some  portion  of  the  urethra,  allowing  the 
escape  of  a  small  amount  of  faecal  matter,  which  passes 
more  or  less  in  the  intervals  between  urination.  The 
urethral  opening  is  usually  so  small  that  faeces  cannot 
escape  in  sufficient  quantity,  and  the  symptoms  of  intes- 
tinal obstruction  are  soon  developed  (Fig.  8). 

Treatment. — The  treatment  consists  in  attempting  to 
find  the  rectum  by  means  of  perineal  incision,  opening  it, 
and  bringing  down  the  edges  of  the  gut  and  suturing  them 
to  the  skin. 

7.  The  Anus  and  Rectum  are  Normal,  but  the 
Ureters,  Vagina,  and  Uterus  Open  into  the  Rectal 
Cavity. — As  this  is  a  malformation  in  which  occlusion  of 
the  bowel  does  not  exist  and  life  is  not  endangered  by  its 
presence,  no  imtnediate  operation  is  called  for.  Where  the  ureters  open  into 
the  rectum,  no  operative  interference  could  be  of  any  avail,  but  in  that  form  in 
which  the  vagina  or  uterus  opens  into  the  rectum,  and  the  child  has  attained 
some  age,  an  operation  to  close  the  fistula  and  replace  the  organs  may  be 
attempted. 

8.  The  Rectum  is  totally  Absent. — This  differs  from  the  third  variety 
of  malformation  only  in  the  amount  of  rectum  which  is  wanting,  and  its  exist- 
ence may  be  suspected  in  those  cases  in  which  an  exploration  of  the  pelvis  by 
perineal  incision  fails  to  reveal  the  presence  of  the  rectal  pouch.  This  con- 
dition is  to  be  treated  by  laparo-colotomy,  in  the  left  inguinal  region,  and  the 
formation  of  an  artificial  anus. 

9.  The  Large  Intestine  is  totally  Absent. — This  condition  is  often 
associated  with  a  faecal  fistula  at  the  umbilicus  or  some  other  portion  of  the 
body,  and  its  treatment  consists  in  securing  a  free  exit  of  faeces  from  this  fistula 
by  dilatation  or  careful  incision,  or  by  the  formation  of  an  artificial  anus  if  no 
fistula  be  present. 


The  Anus  is  absent ;  the 
Rectum  ends  in  the 
Urethra.    (After  Ball.) 


584     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ni.  Diseases  of  the  Anus. 
Pruritus  Ani. 

This  affection  is  occasional!}^  seen  in  childhood,  and  is  characterized  by  a 
painful  itching  in  the  region  of  the  anus,  which  causes  the  child  constantly  to 
scratch  the  part,  so  that  the  skin  in  the  vicinity  becomes  thickened,  eczema- 
tous,  and  moist  from  exudation  as  a  result  of  the  constant  irritation.  Pruritus 
ani  may  result  from  various  causes — from  the  presence  of  oxyuris  vermic- 
ularis  in  the  rectum,  from  eczema  of  the  anus,  from  pediculi  or  scabies,  or 
from  the  presence  of  a  vegetable  parasite,  as  is  the  case  in  eczema  margina- 
tum. In  other  cases  in  which  the  itching  is  not  attributable  to  any  of  the 
above-named  causes  it  can  often  be  traced  to  improper  diet  or  chronic 
constipation. 

Treatment. — Where  the  condition  can  be  traced  to  the  presence  of  eczema, 
the  parts  should  be  frequently  bathed  with  hot  water  and  washed  carefully 
Avith  green  soap,  and  one  of  the  following  lotions  may  be  used : 

^.  Acidi  carbolici TTLxx. 

Liquor,  calcis f.l^'j- — M. 

Or, 

I^.  Acidi  carbolici f^ss. 

Glycerini f^j. 

Aquae q.  s.  adfgvj. — M. 

Or  the  following  ointment  may  be  applied : 

I^.   Ung.  picis  liquidse ,5J. 

Ung.  zinci  oxidi Siij. 

Ung.  aqu^e  rosse 3iv. — M. 

When  the  itching  can  be  traced  to  the  presence  of  parasites,  either  animal 
or  vegetable,  the  use  of  some  of  the  antiparasitic  lotions  or  ointments  appro- 
priate for  the  individual  case  Avill  rapidly  effect  a  cure.  W^here  the  condition 
is  dependent  upon  errors  in  diet,  a  change  of  diet  will  often  be  followed  by 
satisfactory  results.  Where  the  trouble  arises  from  chronic  constipation,  a 
change  of  diet  should  be  made  and  laxatives  should  be  administered,  or  ene- 
mata  or  suppositories  of  glycerin  should  be  employed. 

Syphilitic  Affections  of  the  Anus. 

Mucous  patches  and  moist  papules  occur  with  comparative  frequency  in 
the  region  of  the  anus  as  the  result  of  congenital  syphilis.  Allingliam  speaks 
of  numerous  cracks  or  fissures  of  the  mucous  membrane  of  the  anus  in  chil- 
dren suffering  from  hereditary  syphilis.  Condylomata  may  appear  upon  these 
syphilitic  lesions:  they  are  acuminated  and  spring  from  previously  existing 
papules  or  mucous  patches,  and  are  accompanied  by  discharges  of  a  charac- 
teristic fetid  odor.  These  growths  are  to  be  distinguished  from  the  simple 
forms  of  vegetation  which  frequently  occur  in  this  region,  and  are  not  depend- 
ent upon  the  presence  of  inherited  syphilis. 

Treatment. — The  treatment  should  be  both  constitutional  and  local.  The 
constitutional  effects  of  mercury  can  best  be  obtained  in  young  children  by 
the  use  of  a  binder  spread  with  mercurial  ointment  applied  around  the  abdo- 
men.    The  local  treatment  of  the  anal  lesions  consists  in  the  application  of  the 


DISEASES   OF   THE  ANUS.  585 

solid  stick  of  nitrate  of  silver,  or,  better,  the  acid  nitrate  of  mercury,  or  in  dust- 
ing them  with  a  powder  consisting  of  equal  parts  of  calomel  and  oxide  of  zinc. 

Vegetations  or  Warts  of  the  Axus. 

Vegetations  of  the  anus  are  not  infrequent  in  childhood,  and  the  growths 
may  attain  great  size.  They  are  similar  in  .structure  to  warts  situated  in  other 
parts  of  the  body,  and  are  papillary  overgrowths  covered  with  squamous 
epithelium.  From  their  situation  they  are  apt  to  be  kept  in  a  moist  condition, 
and  as  a  result  there  is  often  present  a  certain  amount  of  offensive  discharge. 

Treatment. — If  the  parts  can  be  kept  perfectly  dry,  a  cure  will  usually 
rapidly  result :  with  this  end  in  view,  when  the  growths  are  not  large,  dusting 
with  lycopodium  or  powdered  oxide  of  zinc  will  often  be  followed  by  their 
disappearance.  If  the  growths  are  large,  they  may  be  touched  with  the  solid 
stick  of  nitrate  of  silver  or  a  saturated  solution  of  chromic  acid ;  or  they  may 
be  destroyed  by  the  application  of  the  actual  cautery,  or  trimmed  away  with 
scissors.  The  objection  to  the  latter  mode  of  removing  them  is  the  profuse 
haemorrhage  which  may  result,  but  this  can  generally  be  controlled  by  the 
application  of  a  firm  compress  to  the  bleeding  surface. 

Fistula  ix  Axo. 

Fistula  in  ano  is  an  affection  in  which  there  is  a  communication  between 
the  mucous  surface  of  the  rectum  or  anus  and  the  skin  in  its  immediate  neigh- 
borhood. A  complete  rectal  fistula  is  one  in  which  there  is  a  sinus  leading 
from  the  rectum  to  some  point  of  the  skin  in  the  region  of  the  anus ;  an 
incomplete  fistula  or  an  internal  rectal  sinus  is  one  in  which  there  is  a  sinus 
passing  from  the  rectum  into  the  perirectal  cellular  tissue ;  another  form  of 
incomplete  fistula  is  known  as  the  external  rectal  sinus,  and  is  one  in  which 
there  is  an  opening  on  the  skin  passing  into  the  cellular  tissue  around  the 
rectum,  but  not  perforating  the  wall  of  the  gut.  Fistula  in  ano  is  certainly  a 
rare  affection  in  infants  and  children.  Allingham  mentions  the  fact  of  its 
occurrence  in  children  of  a  very  tender  age.  I  have  myself  seen  a  few 
cases  in  children,  and  recall  a  case  of  complete  fistula  in  a  child*  a  few  months 
of  age.  The  afi"ection  may  result  from  perforating  ulceration  of  the  mucous 
membrane  of  the  rectum,  or  from  an  ischio-rectal  abscess  opening  into  the 
rectum  or  through  the  skin  in  the  vicinity  of  the  anus,  and  also  fi'om  wounds 
involving  the  rectum  or  anus. 

Diagnosis. — This  affection  is  usually  not  difficult  to  diagnose  if  the  finger 
be  introduced  into  the  rectum  and  a  probe  passed  into  the  external  opening, 
when,  by  a  little  careful  manipulation,  the  probe  may  be  made  to  enter  the 
bowel  if  the  fistula  be  a  complete  one.  In  the  incomplete  form  of  fistula 
known  as  internal  rectal  sinus,  careful  palpation  of  the  tissues  surrounding 
the  anus  will  often  reveal  an  indurated  mass  of  tissue  which  indicates  the  posi- 
tion of  the  internal  fistula,  and  the  finger  introduced  into  the  rectum  may  also 
feel  the  orifice  of  the  internal  opening ;  while  the  discharge  of  pus  with  the 
stool  points  to  the  existence  of  this  affection.  In  the  form  of  incomplete 
fistula  known  as  external  rectal  sinus,  if  the  finger  be  introduced  into  the 
rectum  and  a  probe  passed  into  the  external  opening,  it  can  be  felt  at  some 
point  to  come  near  the  wall  of  the  bowel.  In  children  it  should  be  remem- 
bered that,  in  certain  cases  of  disease  of  the  bones  of  the  spine,  of  the  sacrum, 
or  of  the  pelvis,  the  purulent  matter  passing  through  the  connective  tissue 
about  the  rectum  may  find  its  way  to  the  surface  and  perforate  the  skin  in  the 
neighborhood  of  the  anus  ;  or  it  may  open  into  the  rectum  and  escape  by  the 


586     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

anus.     A  careful  examination  of  the  patient,  however,  will  reveal  the  origin 
of  the  pus  and  show  that  it  is  not  a  case  of  ordinary  fistula  in  ano. 

Treatment. — The  treatment  of  this  affection  consists  in  the  free  division  of 
all  the  tissues  betAveen  the  internal  and  external  opening  of  the  fistula,  and  is 
accomplished  as  follows  :  A  director  having  been  passed  into  the  external  open- 
ing of  the  fistula,  the  finger  is  introduced  into  the  rectum,  and  when  the 
point  of  the  director  is  felt  it  is  passed  through  the  internal  opening  and 
brought  out  at  the  anus ;  the  superimposed  tissues  are  then  divided  with 
a  bistoury.  The  track  of  the  fistula  should  next  be  carefully  explored  to 
discover  the  presence  of  any  branching  sinuses  running  off  from  it,  and  if 
these  be  found  they  should  be  freely  laid  open.  The  wound  resulting  should 
next  be  touched  Avith  the  solid  stick  of  nitrate  of  silver,  or  curetted,  irri- 
gated with  a  solution  of  bichloride  of  mercury,  and  packed  with  strips  of 
iodoform  gauze ;  this  dressing  should  be  changed  at  intervals  of  a  few  days, 
and  the  Avound  is  to  be  allowed  to  heal  by  granulation.  In  cases  of  incomplete 
external  fistula  the  director  should  be  introduced  into  the  external  opening, 
and  where  its  point  comes  in  contact  with  the  gut,  guided  by  the  finger  in 
the  rectum,  it  should  be  made  to  perforate,  and  its  point  brought  out  at  the 
anus.  The  superimposed  tissues  are  then  divided,  as  in  the  operation  for 
complete  fistula.  In  the  variety  of  incomplete  fistula  known  as  internal  rectal 
sinus,  the  position  of  the  fistula  being  located  as  before  described,  an  incision 
should  be  made  through  the  skin  at  this  point,  and  a  director  introduced  and 
made  to  enter  the  rectum,  its  end  being  brought  out  of  the  anus.  The  sub- 
sequent treatment  of  the  case  differs  in  no  wise  from  that  of  the  complete  fistula. 
Another  method  of  treatment  in  incomplete  fistula  of  either  variety  is  to  lay 
the  sinus  freely  open  down  to  the  bowel  without  dividing  the  sphincter,  and  to 
pack  the  wound  with  iodoform  gauze :  in  this  Avay  a  cure  may  often  be 
brought  about.  In  any  case  of  fistula  in  which  the  internal  communication  is 
very  high  up  in  the  rectum,  and  its  division  by  the  knife  is  considered  unsafe 
by  reason  of  the  hgemorrhage  Avhich  may  result,  an  elastic  ligature  may  be 
introduced  through  the  external  opening  by  means  of  an  eyed  probe  and  brought 
out  at  the  anus,  after  Avhich  the  ligature  is  tied  and  allowed  to  cut  its  way  out, 
and  the  Avound  resulting  is  treated  like  that  following  division  of  the  tissues  by 
the  knife. 

Fissure  of  the  Anus. 

Fissure  of  the  anus  is  an  affection  in  which  there  exists  at  some  portion  of  the 
mucous  membrane  of  the  anus  a  small  linear  ulcer,  which  causes  great  pain  at 
stool  or  after  the  bowels  have  been  moved.  This  affection  is  considered  infre- 
quent in  childhood,  but  I  am  of  the  opinion  that  its  presence  is  not  so  unusual  as 
is  generally  supposed,  and  feel  sure  that  a  careful  inspection  of  the  anal  region 
in  children  who  complain  of  pain  at  or  after  stool  Avill  often  show  its  presence. 
Allingham  and  Curling  mention  cases  which  they  have  met  with  in  quite  young 
patients,  and  I  have  myself  seen  cases  of  this  affection  in  children.  Kjellberg 
of  Stockholm  among  9098  children  found  128  cases  of  fissure  of  the  anus.  The 
majority  of  these  children  were  less  than  one  year  of  age,  and  in  73  cases  the 
patients  Avere  less  than  four  months  old.  Jacobi  thinks  fissure  of  the  anus  a 
much  more  common  affection  in  children  than  is  generally  supposed,  and 
believes  that  many  of  the  fretful  children  Avho  sleep  badly  and  cry  constantly, 
and  often  present  symptoms  similar  to  those  of  vesical  calculus,  sufi"er  from 
fissure  of  the  anus. 

Diagnosis. — Fissure  of  the  anus  should  be  suspected  in  cases  where  pain 
is  experienced  during  or  after  stool  and  where  the  stool  contains  a  fcAv  drops  of 


disi:ases  of  the  rectum.  587 

blood.  In  such  cases  a  careful  inspection  of  the  part  will  usually  reveal  the 
presence  of  a  fissure.  The  rectum  should  at  the  same  time  be  examined  with 
the  finger  for  the  presence  of  polypus,  which  frequently  coexists  with  fissure  of 
the  anus. 

Treatment. — The  treatment  of  this  affection  in  children  can  generally  be 
successfully  accomplished  by  an  application  of  a  20-grain  solution  of  nitrate 
of  silver  to  the  ulcer,  or  by  lightly  touching  the  surface  with  the  solid  stick  of 
nitrate  of  silver,  and  afterward  keeping  the  parts  well  covered  with  an  ointment 
composed  of  thirty  grains  of  iodoform  or  aristol  to  the  ounce  of  vaseline,  the 
bowels  being  kept  in  a  soluble  condition.  In  cases  which  are  found  intractable 
division  or  stretching  of  the  sphincter  may  be  resorted  to. 

Stricture  of  the  Axus. 

This  affection  may  be  congenital  or  may  result  from  an  operation  in  the 
vicinity  of  the  anus.  The  treatment  of  stricture  of  the  anus  consists  largely 
in  gradual  dilatation  of  the  contracted  orifice,  either  instrumental  or  digital ; 
if  this  fails  to  relieve  the  condition,  a  careful  incision  of  the  contracted  parts 
should  be  practised,  and  subsequent  dilatation  should  be  employed  for  some 
time. 

Marginal  Abscess. 

This  affection  con.sists  in  circumscribed  suppuration  starting  in  the  mucous 
follicles  of  the  anus,  or  from  a  fissure  of  the  anal  margin,  and  is  a  much  more 
common  and  less  serious  affection  in  childhood  than  ischio-rectal  abscess. 
Although  painful,  it  is  not  apt  to  result  in  the  formation  of  a  fistula  in  ano. 

The  treatment  consists  in  making  a  free  opening  with  a  bistoury,  and  to 
accomplish  this  the  tip  of  the  finger  should  be  passed  into  the  rectum  to  steady 
the  abscess-cavity  and  make  it  more  prominent  before  it  is  incised  ;  the  wound 
should  then  be  dressed  with  iodoform  gauze  or  with  lint  saturated  with  car- 
bolized  oil,  and  usually  heals  promptly. 

Diphtheria  of  the  Axus. 

This  affection  is  occasionally  seen  in  children  suffering  from  diphtheria  of 
the  pharynx,  and  usually  develops  late  in  the  disease  and  in  cases  in  which  the 
system  has  been  profoundly  impressed.  The  deposit  of  diphtheritic  membrane 
may  involve  the  anus  and  extend  on  to  the  buttocks,  and  to  the  mucous  mem- 
brane of  the  vulva  in  female  children. 

The  prognosis  is  extremely  unfavorable,  and  the  cases  which  have  come 
under  my  personal  observation  have  all  terminated  fatally  in  spite  of  treat- 
ment. 

The  treatment  consists  in  the  employment  of  such  constitutional  remedies 
as  are  appropriate  for  diphtheria,  and  the  local  application  to  the  affected  sur- 
face of  a  solution  of  bichloride  of  mercury,  1  :  2000  or  1 :  4000,  followed  by 
the  use  of  an  ointment  of  iodoform. 


IV.  Diseases  of  the  Rectum. 

Proctitis. 

Inflammation  of  the  rectum,  or  proctitis,  is  an  affection  frequently  seen  in 
childhood.  It  may  result  from  injury  to  the  mucous  membrane  by  the  fasces  or 
by  materials  contained  in  the  faeces,  or  it  may  follow  from  traumatism  received 


588    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

from  without.  It  is  recognized  in  two  forms — acute  catarrhal  and  chronic 
catarrhal  proctitis. 

Acute  Catarrhal  Proctitis. — In  this  affection  the  inflammatory  symptoms 
are  limited  to  the  rectum,  and  the  disease  is  characterized  by  great  tenes- 
mus and  the  frequent  passing  of  bloody  mucus,  at  first  mixed  with  faeces. 
In  addition  to  these  symptoms  there  are  usually  present  oedema  of  the  mucous 
membrane  of  the  anus  and  of  the  lower  portion  of  the  rectum,  and  vesical 
irritation  ;  and  as  a  result  of  this  condition  and  the  constant  straining  there 
is  often'  observed  a  partial  prolapsus  of  the  rectum.  Many  of  the  symptoms 
presented  are  those  of  acute  dysentery,  but  the  abdominal  pain  and  the  consti- 
tutional features  of  the  latter  affection  are  generally  wanting. 

Treatment. — The  patient  should  be  kept  in  a  recumbent  posture,  and 
small  doses  of  castor  oil  or  one  of  the  saline  cathartics,  either  sulphate  of 
sodium  or  of  magnesium,  or  one  of  the  natural  mineral  waters,  should  be 
administered  to  secure  free  evacuation  of  the  bowels.  The  diet  should 
be  restricted  to  milk,  animal  broth,  and  eggs.  If,  after  the  bowels  have 
moved,  tenesmus  continues,  an  enema  consisting  of  a  few  drops  of  tincture 
of  opium  and  starch-Avater  should  be  injected  into  the  rectum  ;  or  a  rectal  sup- 
pository containing  powdered  opium  grain  |,  extract  of  belladonna  grain  ^, 
iodoform  grain  1,  should  be  administered,  and  if  the  patient  shows  signs 
of  exhaustion  stimulants  should  be  employed.  The  disease  is  usually  of  short 
duration,  and  under  treatment  the  symptoms  generally  subside  in  a  few  days. 

Chronic  Catarrhal  Proctitis. — This  disease  usually  results  from  the  acute 
affection,  and  is  characterized  by  the  absence  of  pain  and  tenesmus,  although 
in  some  cases  in  which  ulceration  of  the  mucous  membrane  of  the  rectum  exists 
there  may  be  discharged  a  small  quantity  of  blood  and  muco-purulent  matter. 

Treatment. — The  diet  should  be  regulated  as  in  acute  proctitis,  and  if  the 
evacuations  are  not  sufficiently  free  the  bowels  should  be  moved  by  the  adminis- 
tration of  a  saline  cathartic.  The  local  treatment  should  consist  in  the  use  of 
enemata  of  nitrate  of  silver,  ^  to  1  grain  to  an  ounce  of  water,  which  should  be 
gradually  increased  in  strength  until  they  begin  to  cause  pain  ;  suppositories  of 
iodoform  and  extract  of  belladonna  may  also  be  employed  with  advantage. 

Periproctitis. 

Periproctitis  is  an  inflammatory  condition  involving  the  connective  tissue 
surrounding  the  rectum.  It  may  result  from  septic  causes  or  direct  injury, 
or  may  arise  from  the  introduction  of  foreign  matter  through  ulceration  or  per- 
foration of  the  rectum.  Abscess  or  gangrene  of  the  cellular  tissue  may  resul;t, 
with  subsequent  involvement  of  the  skin ;  erysipelas  also  may  attack  this 
region,  giving  rise  to  erysipelatous  periproctitis. 

Treatment. — In  this  affection,  as  soon  as  the  swelling  and  induration  can 
be  detected,  free  incision  should  be  made  through  the  skin  and  into  the  cellu- 
lar tissue  outside  of  the  margin  of  the  anus,  and  the  wounds  thus  produced 
irrigated  with  a  solution  of  bichloride  of  mercury,  1  :  1000  or  1  :  4000,  or 
touched  with  a  solution  of  chloride  of  zinc,  15  grains  to  the  ounce.  The  sur- 
faces then  should  be  dusted  Avith  iodoform,  and  covered  with  a  bichloride-gauze 
and  cotton  dressing.  If  the  parts  are  found  to  be  gangrenous,  a  charcoal 
or  an  antiseptic  poultice  should  be  applied,  and  the  patient  should  be  given 
alcohol  and  tonics  with  a  liberal  diet. 

ISCHIO-RECTAL    AbSCESS. 

Ischio-rectal  abscess  consists  of  a  purulent  collection  in  the  loose  cellular 
tissue  surrounding  the  rectum.     It  is  a  most  painful  and  serious  affection,  and 


DISEASES    OF    THE  RECTUM.  589 

is  the  most  frequent  cause  of  fistula  in  ano.  It  may  arise  from  injuries  of  the 
rectum,  either  from  within  or  from  without,  from  phlebitis  or  j^eriphlebitis  of 
the  hsemorrhoidal  veins,  or  from  the  escape  of  faecal  matter  into  the  cellular 
tissue  through  ulcers  perforating  the  rectum.  The  most  characteristic  symp- 
tom of  ischio-rectal  abscess  is  a  sense  of  fulness  in  the  lower  portion  of  the 
rectum,  with  throbbing  pain,  which  is  increased  at  the  time  of  stool.  Where 
this  affection  is  suspected  a  careful  examination  of  the  rectum  with  the  finger 
will  often  disclose  a  bulging  of  the  rectal  wall  at  some  point,  and  this  is  often 
accompanied  bv  swelling  and  oedema  of  the  skin  near  the  anus ;  the  presence 
of  fluctuation  in  this  region  will  often  be  revealed  upon  palpation. 

Treatment. — This  form  of  abscess  demands  prompt  and  free  opening,  and 
by  this  treatment  alone  is  the  pain  relieved  and  the  risk  of  the  formation  of  a 
fistula  in  ano  avoided.  In  opening  these  abscesses  I  usually  follovr  the  practice 
of  Allingham,  who  recommends  that  the  patient  should  be  etherized  and  placed 
in  the  lithotomy  position.  An  incision  should  be  made  at  a  little  distance  from 
the  anus  parallel  with  the  sphincter,  the  abscess-cavity  laid  freely  open,  and  the 
finger  introduced  into  the  wound  to  break  down  any  secondary  cavities  or  loculi. 
If  it  is  found  that  there  has  been  much  undermining  of  the  tissues,  incisions 
should  be  made  at  right  angles  to  lay  all  cavities  freely  open.  The  abscess- 
cavity  should  then  be  irrigated  with  a  solution  of  bichloride  of  mercury,  1  :  2000 
or  1 :  4000,  or  with  a  1 :  40  solution  of  carbolic  acid ;  and  the  wound  should 
next  be  carefully  packed  Avith  lint  saturated  with  carbolized  oil,  1:  30,  or,  as 
I  prefer,  with  iodoform  gauze.  An  external  dressing  of  iodoform  or  bichloride 
gauze  and  a  pad  of  bichloride  cotton  is  then  applied  to  the  wound  and  held  in 
position  by  a  T  bandage.  This  dressing  need  not  be  disturbed,  unless  it  become 
loose  or  soiled,  for  several  days,  when  the  cavity  should  be  irrigated  and  a 
few  strips  of  gauze  laid  lightly  in  it.  The  wound  should  be  allowed  to  heal 
by  granulation.  If  the  bowels  do  not  move  in  one  or  two  days,  a  gentle  lax- 
ative may  be  administered.  By  this  method  of  treatment  the  cavity  of  the 
abscess  rapidly  heals,  and  a  cure  results  without  the  formation  of  a  fistula  in 
ano. 

Ulceration  of  the  Rectum. 

Ulceration  of  the  rectum  is  not  a  common  affection  in  childhood,  but  it 
sometimes  results  from  chronic  dysentery  or  chronic  catarrhal  proctitis. 

The  treatment  consists  in  the  local  use  of  injections  of  nitrate  of  silver,  grain 
:^  to  1  to  the  ounce  of  water,  and  in  the  use  of  suppositories  of  iodoform.  A 
restricted  diet  should  also  be  enjoined,  and  the  bowels  should  be  regulated. 

Stricture  of  the  Rectum. 

This  affection  may  result  from  the  presence  of  new  growths,  from  the  con- 
traction following  wounds  of  this  organ,  the  result  either  of  accident  or  opera- 
tion, and  also  from  congenital  malformations  of  the  rectum ;  inherited  syphilis 
is  mentioned  as  occasionallv  causino;  con£enital  stricture  of  the  rectum. 

The  treatment  consists  in  gradual  dilatation  of  the  rectum,  either  instru- 
mental or  digital ;  if  the  condition  be  due  to  the  presence  of  growths,  their 
removal  should  be  accomplished  if  possible ;  and  if  due  to  inherited  syphilis, 
antisyphilitic  treatment  is  indicated,  in  addition  to  the  local  measures. 

Syphilis  of  the  Rectum. 

Lesions  of  the  rectum,  due  to  inherited  syphilis,  are  occasionally  seen  in 
childhood.  A  case  of  gummatous  infiltration  of  the  coats  of  the  rectum  in  a 
child  ten  years  of  age,  at  the  same  time  exhibiting  well-marked  symptoms  of 


590     A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

inherited  syphilis,  has  been  described  by  Ball ;  and  Oser  of  Cracow  has  re- 
ported two  cases  of  gummatous  infiltration  of  the  intestines  in  children  suffer- 
ing from  congenital  syphilis. 

The  treatment  of  syphilitic  lesions  of  the  rectum  consists  in  the  adminis- 
tration of  mercury  or  iodide  of  potassium,  as  in  the  treatment  of  corresponding 
syphilitic  lesions  in  other  parts  of  the  body. 


Fia.  9. 


Prolapsus  of  the  Rectum, 

Prolapsus  of  the  rectum  consists  in  the  protrusion  of  a  portion  of  the  rectum 
through  the  anus,  and  occurs  in  three  varieties:  1.  A  portion  of  mucous  mem- 
brane protrudes  from  the  anus  (partial  prolapsus) ;  2.  The  entire  thickness  of 
the  walls  of  the  rectum  is  included  in  the  prolapse  (complete  prolapsus) ;  3. 
There  exists  an  invagination  as  well  as  a  prolapsus  of  the  rectum.  This  affec- 
tion in  some  one  of  its  varieties  is  very  common  in  childhood,  and  the  frequencv 
of  its  occurrence  may  be  accounted  for  on  both  anatomical  and  pathological 
grounds.  The  looseness  of  the  attachment  of  the  submucous  connective  tissues 
of  the  walls  of  the  rectum  is  a  well-recognized  anatomical  fact;  and  this  con- 
dition is  an  important  factor  in  the  production  of  prolapsus.  The  straightness 
of  the  coccyx  in  children  is  also  said  to  favor  its  production.  In  infants  and 
young  children  the  great  amount  of  straining  that  seems  to  be  required  to  bring 
about  satisfactory  evacuations  is  also  productive  of  this  affection ;  this  straining 

has  been  ascribed  by  Jacobi  to  the  anatomical 
fact  that  in  children  it  is  not  uncommon  to  find 
two  or  three  angular  flexures  in  the  lower  part  of 
the  colon.  The  habit  so  common  with  mothers 
and  nurses  of  placing  children  upon  the  chamber 
utensil  and  allowing  them  to  spend  a  large  por- 
tion of  time  in  that  position  is  certainly,  to  my 
mind,  a  frequent  cause  of  the  development  of 
prolapsus,  and  is  a  custom  Avhich  cannot  be  too 
severely  condemned.  In  many  cases  the  constant 
straining  due  to  the  presence  of  vesical  calculus 
or  rectal  polypus,  or  to  a  contracted  prepuce,  may 
be  an  important  factor  in  the  production  of  this 
affection.  Improper  diet,  or  the  custom  of  allow- 
ing children  to  eat  at  all  hours  during  the  day 
— and  as  a  result  of  this  over-feeding  the  pro- 
duction of  a  large  number  of  passages — may  also  be  mentioned  as  a  cause. 
That  improper  diet  and  over-feeding  produce  prolapsus  of  the  rectum  is,  in  my 
mind,  very  clearly  proved  by  the  fact  that  at  the  Children's  Hospital  of  Phila- 
delphia we  often  have  children  admitted  to  the  wards  for  operation  who  have 
suffered  from  this  affection  for  months  :  under  the  use  of  tonics,  proper  diet, 
and  regulation  of  the  bowels  they  fail  to  further  present  prolapsus,  and  are 
thus  soon  relieved  of  the  condition  without  operative  interference.  Mr.  Holmes 
of  London  makes  a  similar  observation  as  to  his  experience  in  this  affection. 

Symptoms.  — The  characteristic  symptom  is  the  protrusion,  during  defeca- 
tion, of  a  reddish-purple  mass  covered  with  mucous  membrane  :  it  is  unac- 
companied by  pain,  and  usually  undergoes  spontaneous  reduction  as  soon  as 
the  straining  efforts  cease.  In  the  partial  variety  of  prolapsus  of  the  rectum 
little  inconvenience  is  experienced,  unless  the  prolapsed  portion  of  the  bowel 
is  allowed  to  remain  out  for  some  time,  when  it  may  become  congested  or 
ulcerated;  the  latter  condition  is  more  likely  to  occur  in  cases  of  complete  pro- 


Prolapsus    of  the   Rectum 
Bryant.) 


(After 


DISEASES    OF    THE   RECTUM.  591 

lapsus.  When  the  prolapsus  is  of  the  third  variety  and  is  accompanied  by 
invagination  of  the  rectum,  the  symptoms  of  obstruction  of  the  bowel  exist, 
and  gangrene  of  the  protruded  mass  may  occur.  Death  has  resulted  in  such 
cases  from  obstruction  as  well  as  from  peritonitis. 

Diagnosis. — Prolapsus  of  the  rectum  is  likelj^  to  be  confounded  only  with 
haemori'hoids,  which  is  an  extremely  rare  affection  in  childhood,  or  with  poly- 
pus of  the  rectum.  The  appearance  of  the  prolapse  is  very  characteristic: 
the  annular  fold  of  tissue  surrounding  the  whole  anus  with  its  depressed  central 
orifice,  and  the  fact  that  after  reduction  of  the  mass  no  tumor  can  be  found 
in  the  rectum,  would  exclude  the  presence  of  polypus.  The  cases  most 
likely  to  give  rise  to  error  are  those  of  intussusception  in  children  where  the 
intussusceptum  protrudes  from  the  rectum,  and  resembles  in  appearance  a 
prolapsus.  Such  cases  have  been  found  with  prolapsus  of  the  rectum ;  but 
if  the  surgeon  makes  a  careful  examination  of  the  protruded  mass,  and  takes 
into  consideration  the  previous  history  of  the  case,  such  as  sudden  pain  and 
collapse  or  the  occurrence  of  more  or  less  obstruction  of  the  bowels,  with  the 
passing  of  blood  and  mucus  preceding  the  appearance  of  the  tumor  through 
the  anus,  he  will  not  be  likely  to  confound  the  two  affections. 

Treatment. — The  palliative  treatment  of  this  condition  consists  in  return- 
ing the  mass  through  the  anus  as  soon  as  possible.  This  is  best  accomplished 
by  placing  the  patient  across  the  knees  and  making  gentle  pressure  with  the 
fingers  over  the  whole  mass  of  the  tumor  for  a  few  moments,  to  return  the 
contents  of  the  bowels  and  the  fluids  effused  in  the  tunics,  and  then  pushing 
up  the  central  portion  first  with  the  finger.  Little  difiiculty  is  experienced 
in  effecting  this  reduction  in  recent  cases,  but  where  the  prolapsus  has  been 
down  for  some  time  and  inflammatory  effusion  has  taken  place,  it  may  be 
necessary  to  administer  an  ansesthetic  before  the  reduction  can  be  satisfactorily 
accomplished.  The  preventive  treatment  consists  in  not  allowing  the  child 
to  make  prolonged  straining  efforts  on  the  chamber-utensil  or  to  have  the 
bowels  moved  in  a  sitting  posture.  A  child  who  is  subject  to  prolapsus  of 
the  rectum  should  have  the  bowels  moved  while  in  the  recumbent  position  on 
the  bed-pan,  or  on  the  side,  or  in  a  standing  posture ;  and  the  nurse  should 
support  the  perineum  and  anus  by  two  fingers  placed  one  on  each  side  of 
the  anus,  or  by  forcibly  drawing  the  skin  of  the  buttock  to  one  side  while  the 
child  is  passing  the  stool.  When  the  affection  depends  upon  the  presence 
of  a  vesical  calculus,  a  contracted  prepuce,  or  a  rectal  polypus  or  parasites, 
producing  great  straining  efforts,  the  removal  of  the  cause  will  usually  effect  a 
cure  promptly.  The  importance  of  carefully  regulating  the  diet  has  been  pre- 
viously mentioned,  and  care  in  this  respect  alone  may  bring  about  a  cure. 
Enemata  of  astringent  solutions,  such  as  decoction  of  oak  bark,  a  solution 
of  alum,  or  cold  water,  or  suppositories  containing  extract  of  nux  vomica  and 
ergot,  have  been  employed  ;  and  of  these  the  enemata  of  decoction  of  oak 
bark,  or  of  cold  water,  are  most  satisfactory.  In  cases  where  these  various 
palliative  measures  have  failed  to  relieve  the  condition,  I  think  the  safest  and, 
in  my  experience,  the  surest  method  of  treatment  is  that  recommended  by 
Allingham.  This  consists  in  the  application  of  nitric  acid  to  the  mucous  mem- 
brane of  the  protruded  gut.  The  child's  bowels  having  been  previously  opened 
by  the  administration  of  a  small  dose  of  castor  oil  or  by  the  use  of  an  enema,  he 
is  etherized,  and  the  surface  of  the  prolapsed  bowel  is  carefully  cleansed  and 
dried  of  mucus  by  wiping  it  with  absorbent  cotton  ;  the  whole  surface  of  the 
mucous  membrane  is  next  painted  with  nitric  acid  applied  with  a  swab,  care 
being  taken  not  to  allow  the  acid  to  come  in  contact  with  the  adjacent  skin. 
A  pledget  of  oiled  cotton  or  lint  is  next  introduced  into  the  central  depression 


592     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  the  prolapsed  mass,  and  by  pressing  it  upward  with  the  finger  the  mass  is 
reduced.  Finally,  a  pad  is  placed  over  the  anus  and  held  in  position  by  bring- 
ing the  buttocks  together  over  it  by  means  of  broad  strips  of  adhesive  plaster. 
The  bowels  should  be  kept  quiet  for  two  or  three  days  by  the  administration 
of  a  small  amount  of  opium  ;  and  at  the  end  of  that  time  they  should  be 
opened  by  a  laxative.  The  introduction  of  the  oiled  cotton  or  lint  I  have 
found  in  practice  unnecessary,  as  it  is  apt  to  be  passed  by  straining  when  the 
patient  recovers  from  the  anaesthetic ;  hence  I  generally  omit  its  use,  and 
merely  coat  the  cauterized  surface  of  the  bowel  with  olive  oil  or  vaseline 
before  reducing  it.  The  recurrence  of  the  prolapsus  may  take  place  with  the 
first  few  passages,  but  a  permanent  cure  generally  results  from  one  application 
of  the  nitric  acid.  Should  this,  however,  not  be  the  case,  cauterization  may 
be  repeated  in  a  few  weeks.  The  ligature  and  the  clamp  and  cautery  or  actual 
cautery  have  been  employed  in  the  treatment  of  this  affection,  but  as  their  use 
is  attended  with  danger  in  cases  of  complete  prolapsus  of  the  rectum,  and  as  I 
have  never  seen  a  case  in  a  child  in  which  the  simpler  and  safer  procedure, 
cauterization  by  nitric  acid,  has  fiiiled  to  give  satisfactory  results,  I  do  not 
think  their  employment  is  to  be  recommended.  In  cases  of  prolapsus  of  the 
rectum  in  which  invagination  has  occurred  and  the  patient  is  sufi'ering  from 
obstruction  of  the  bowels,  if  the  mass  cannot  be  returned  under  ether  an  arti- 
ficial anus  should  be  made  in  the  left  inguinal  region  ;  and  if  the  child  survives 
after  the  invaginated  portion  of  the  gut  has  been  removed  by  sloughing  or 
other  means,  an  attempt  may  be  made  to  close  the  faecal  fistula  in  the  inguinal 
region,  and  thus  allow  the  faeces  to  escape  through  their  natural  channel. 

HEMORRHOIDS. 

Haemorrhoids  are  vascular  tumors  which  occupy  the  lower  portion  of  the 
rectum,  and  arise  from  dilatation  or  proliferation  of  the  blood-vessels.  They 
may  be  either  internal  or  external,  and  are  covered  either  by  mucous  mem- 
brane or  skin.  Haemorrhoids  are  uncommon  in  childhood,  but  are  occasionally 
seen,  and  may  consist  either  of  dilated  veins  or  well-marked  venous  tumors. 
Allingham  records  a  case  of  well-marked  haemorrhoids  which  he  saw  in  a 
child  three  years  of  age.  I  have  myself  seen  several  cases  in  quite  young 
children,  and  have  seen  recently  with  Dr.  Starr  a  child  three  years  of  age 
who  suffered  from  well-marked  venous  haemorrhoids,  which  protruded  and  ])led 
at  stool,  and  presented  symptoms  severe  enough  to  call  for  operative  interference. 
Ball  also  has  observed  several  cases  in  young  children.  The  symptoms  presented 
by  haemorrhoids  in  children  are  similar  to  those  in  adults,  and  consist  in  pro- 
trusion of  the  tumors  and  bleeding  at  the  time  of  defecation. 

Treatment. — As  haemorrhoids  are  apt  to  occur  in  strumous  children,  the 
administration  of  iron  and  cod-liver  oil  is  often  folloAved  by  decided  benefit, 
and  locally  the  use  of  astringent  ointments  and  the  regulation  of  the  action  of 
the  bowels  may  be  followed  by  marked  amelioration  in  the  condition.  If, 
however,  the  tumors  continue  to  bleed  and  to  be  protruded  at  stool,  operative 
treatment  is  indicated,  and  the  masses  may  be  removed  either  by  the  use  of 
the  ligature  or,  as  I  prefer,  by  the  clamp  and  cautery. 

Polypus  of  the   Rectum. 

Polypus  of  the  rectum  is  a  much  more  common  disease  in  childhood  than 
haemorrhoids,  and  is  characterized  by  the  presence  of  a  follicular  tumor 
springing  from  the  mucous  membrane  of  the  rectum  at  a  point  an  inch  or  an 
inch  and  a  half  above  the  anus ;  it  is  attached  by  a  pedicle.     The  form  of 


DISEASES    OF   THE  RECTUM. 


593 


Fig.  10. 


Polypi     of 


Rectum     with 
(After  Ball.)    , 


Prolapsus. 


polypus  most  commonly  seen  in  childhood  is  of  the  follicular  or  adenoid 
variety,  and  resembles  in  structure  the  normal  mucous  membrane  of  the 
rectum,  from  which  it  originates  ;  but  fibrous  and  cystic  polypi  have  also 
been  observed.  Mr.  Thomas  Smith  has  recorded  three  cases  of  disseminated 
polypi  of  the  adenoid  variety  occurring  in  young  persons,  and  Cripps  also 
reports  cases  of  multiple  polypi  springing  from 
the  surface  of  the  rectum  and  colon. 

A  rectal  polypus  is  of  a  bright-red  color 
when  first  extruded,  but  becomes  darker  and 
more  venous  in  appearance  after  it  has  been 
protruded  for  some  time  and  its  circulation  has 
been  interfered  with  by  constriction  of  the 
sphincter.  The  growths  may  be  either  single 
or  multiple,  and  have  pedicles  varying  from  \ 
to  2  or  3  inches  in  length.  Polypus  of  the  rec- 
tum is  comparatively  rare  in  children  :  Bokai 
found  25  cases  of  this  growth  in  65,970  pa- 
tients, and  Jacobi  says  that  he  sees  from  1  to  3 
cases  annually  among  500  children.  A  rectal 
polypus  is  apt  to  produce  expulsive  eiforts  with 
tenesmus,  and  give  rise  to  a  sense  of  fulness  or 
distress  in  the  lower  part  of  the  rectum,  and  to  be  accompanied  by  the  escape 
of  glairy  or  bloody  mucus  or  of  blood. 

Diagnosis. — The  diagnosis  is  usually  not  difficult,  as  the  growth  is  apt 
to  present  at  the  anus  or  to  protrude  from  it  during  defecation,  and  a 
careful  examination  with  the  finger  will  disclose  the  presence  of  a  pedicle  to 
which  the  growth  is  attached.  Polypus  of  the  rectum  is  likely  to  be  con- 
founded with  haemorrhoids  or  prolapsus  of  the  rectum,  but  a  careful  inspec- 
tion and  examination  of  the  parts  will  disclose  the  nature  of  the  trouble.  Before 
examining  a  case  of  suspected  polypus  of  the  rectum  it  is  well  to  give  an  enema, 
and  when  this  is  passed  the  growth  is  apt  to  be  brought  to  the  lower  portion  of 
the  rectum  or  may  present  at  the  anus.  In  examining  for  polypus  it  is  well  to 
introduce  the  finger  as  far  as  possible  into  the  rectum,  and,  as  it  is  withdrawn, 
to  make  the  examination  of  the  walls  with  a  sweeping  motion,  by  which  mani- 
pulation the  pedicle  of  the  polypus  may  be  hooked  upon  the  finger. 

Treatment. — A  polypus  of  the  rectum  may  be  seized  with  the  fingers  or 
forceps  and  twisted  off,  and  the  stump  may  be  touched  with  nitrate  of  silver  or 
with  nitric  acid;  but  I  think  the  better  method  of  treatment  is  to  grasp  the 
polypus  and  draw  it  out  of  the  anus,  so  as  to  expose  its  pedicle,  and  to  sur- 
round this  with  a  ligature  close  to  the  mucous  membrane,  care  being  taken  not 
to  make  sufficient  traction  to  invert  the  wall  of  the  rectum,  Avhich  might  thus 
be  included  in  the  grasp  of  the  ligature.  The  ligature  should  next  be  firmly 
tied,  and  the  tumor  removed  by  dividing  the  pedicle  in  advance  of  the  ligature. 
If  a  number  of  polypi  exist,  the  same  procedure  should  be  repeated  for  each 
growth. 


Angeioma  or  N^vus  of  the  Rectum. 

This  is  also  a  rare  affection.  Mr.  Howard  Marsh  has  reported  the  case  of  a 
girl  ten  years  of  age  who  suffered  from  rectal  haemorrhage,  in  whom  an  exami- 
nation revealed  a  ngevoid  growth  in  the  lower  portion  of  the  rectum ;  and  Mr. 
Barker  has  also  published  a  case  of  this  nature. 

Treatment. — The  treatment  of  naevus  of  the  rectum  consists  in  the  use  of 

38 


594    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  ligature  to  strangulate  the  growth,  or  the  application  of  nitric  acid  or  Paque- 
lin's  cautery. 

Maligxaxt  Disease  of  the  Rectum. 

Malignant  disease  of  the  rectum  is  very  rarely  met  with  in  childhood,  but 
may  occur  either  in  the  form  of  cylindrical-celled  carcinoma  or  of  sarcoma. 
Allingham,  Quain,  Cripps,  and  other  observers  have  reported  a  few  cases  occur- 
rincf  in  childhood. 

Treatment. — The  treatment  consists  in  the  excision  of  the  growth  if  its 
situation  be  favorable  for  such  a  procedure;  or  linear  rectotomy,  which  consists 
in  freely  dividing  the  growth  together  with  the  lower  portion  of  the  rectum, 
including  the  sphincter,  may  be  practised  with  benefit,  if  obstructive  symptoms 
are  present.  If  the  growth  involves  the  high  portion  of  the  rectum  and  excision 
is  not  possible,  colotomy  should  be  performed. 

WouxDs  OF  the  Rectum. 

Wounds  of  the  rectum  may  be  caused  by  substances  which  reach  the 
rectum  through  the  alimentary  canal,  or  by  bodies  introduced  through  the 
perineum  or  the  anus ;  these  wounds  may  be  lacerated,  incised,  or  punctured. 
Lacerated  or  punctured  wounds  may  result  from  patients  falling  upon  sharp 
bodies  which  enter  through  the  perineum  or  anus,  or  from  fragments  of  broken 
bones  of  the  pelvis,  causing  in  many  cases  extensive  laceration  of  the  parts 
about  the  rectum  as  well  as  of  the  rectum  itself;  they  may  be  complicated  by 
injuries  of  the  bladder,  vagina,  or  peritoneum.  Lacerated  wounds  of  the  rectum 
may  also  result  from  the  careless  or  forcible  introduction  of  the  nozzle  of  an 
enema-syringe  ;  and  laceration  of  this  organ  in  children  who  have  been  sub- 
jected to  unnatural  intercourse  should  also  be  mentioned.  Incised  wounds 
of  the  rectum  may  result  from  operations  upon  this  organ  or  from  its  acci- 
dental incision  in  the  operation  of  lithotomy. 

Treatment. — The  treatment  of  incised  or  external  lacerated  wounds  which 
involve  only  the  lower  portion  of  the  rectum  consists  in  controlling  bleeding  by 
the  application  of  ligatures  to  the  bleeding  vessels;  in  washing  the  wound 
thoroughly  with  a  solution  of  bichloride  of  mei'cury,  1 :  4000  ;  in  dusting  the 
wound  with  powdered  iodoform;  and  in  providing  for  the  escape  of  discharge  by 
the  introduction  of  a  drainaoje-tube  or  catcrut  drain,  and  in  bringing  the  edges 

o  c  '  coo 

together  with  catgut  sutures.  A  gauze  dressing  should  then  be  applied,  and 
the  bowels  kept  quiet  for  a  few  days. 

In  punctured  or  internal  lacerated  wounds  of  the  rectum  which  do  not 
extend  high  enough  to  involve  the  bladder  or  peritoneum  it  is  better,  in  order 
to  secure  free  drainage,  to  convert  the  internal  punctured  or  lacerated  wound 
into  an  open  wound  by  the  division  of  all  the  tissues,  including  the  external 
sphincter  and  the  skin.  The  wounds  should  then  be  washed  with  a  solution 
of  bichloride  of  mercury,  packed  lightly  with  iodoform  gauze,  and  allowed 
to  heal  by  granulation,  the  dressing  being  changed  as  often  as  it  becomes 
soiled. 

In  a  case  of  lacerated  wound  of  the  rectum  complicated  by  wound  of  the 
bladder,  perineal  cystotomy  should  be  performed  to  provide  for  the  free  escape 
of  urine,  and  free  drainage  secured  by  division  of  the  anal  sphincter  and  the 
introduction  of  drainage-tubes  if  necessary.  If  a  punctured  wound  of  the 
rectum  involves  the  peritoneum,  with  injury  to  the  contained  viscera,  laparot- 
omy should  be  performed,  the  wounds  of  the  viscera  should  be  sutured,  and 
the  peritoneal  cavity  irrigated,  drained,  and  closed. 


DISEASES    OF   THE  BEGTUM.  595 

Foreign  Bodies  in  the  Rectum. 

Foreign  bodies  may  enter  the  rectum  from  the  alimentary  canal  or  may  be 
introduced  through  the  anus.  A  great  variety  of  foreign  bodies  have  been 
thus  introduced  either  by  accident  or  design.  Patients  suffering  from  foreign 
body  impacted  in  the  rectum  will  have  ineffectual  attempts  at  defecation,  with 
the  passage  of  mucus,  which  is  often  blood-stained.  In  a  case  presenting  these 
symptoms  a  careful  exploration  with  the  finger  will  enable  the  surgeon  to  ascer- 
tain the  presence,  the  exact  location,  and  the  character  of  the  foreign  body. 

Treatment. — The  removal  of  the  foreign  body  should  be  accomplished 
with  the  least  possible  injury  to  the  walls  of  the  rectum.  It  is  well  first  to 
anaesthetize  the  patient,  and  then  inject  into  the  rectum  a  few  ounces  of  olive 
oil.  When  the  character  and  position  of  the  foreign  body  have  been  ascer- 
tained, it  may  be  dislodged  with  the  finger  and  removed  by  forceps.  Where 
the  body  is  irregular  in  shape  or  possesses  sharp  edges  or  angles  which  may 
cause  injury  to  the  surrounding  parts,  retractors  or  a  bivalve  speculum  should 
be  introduced  to  secure  free  dilatation  of  the  anus  and  lower  portion  of  the  rec- 
tum and  facilitate  removal  without  injury  to  the  rectal  walls.  Where  the  foreign 
body  consists  of  a  large  mass  of  inspissated  material,  fragmentation  should  be 
resorted  to  in  order  to  secure  its  satisfactory  removal.  If  the  foreign  body  has 
remained  in  position  for  some  time  and  ulceration  has  resulted  from  its  presence, 
a  solution  of  nitrate  of  silver,  10  grains  to  the  ounce  of  water,  should  be  applied  to 
the  ulcerated  surface,  and  suppositories  of  iodoform  should  also  be  introduced 
into  the  rectum.  Extensive  ulceration  of  the  rectum  following  the  long-con- 
tinued presence  of  a  foreign  body  may  be  followed  by  stricture,  and  the  pos- 
sibility of  this  condition  should  be  guarded  against  by  judicious  dilatation  by 
the  finger  or  bougies. 


PART  YII. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 


SIMPLE  CEREBRAL  MENINGITIS, 

By  THOMAS  S.  LATIMER,  M.  D., 

Baltimore. 


By  simple  meningitis,  leptomeningitis,  or  purulent  meningitis,  is  usually 
meant  inflammation  of  the  arachnoid  and  pia  mater.  Writers  distinguish  an 
arachnitis,  but  as  this  probably  never  occurs  apart  from  inflammation  of  the  pia 
or  dura  it  may  be  considered  an  unnecessary  refinement.  Varieties  are  men- 
tioned dependent  on  the  situation,  grade,  or  nature  of  the  inflammation,  and 
whether  primary  or  secondary,  or  according  to  the  character  of  the  exciting 
cause.  All  practical  purposes  are  subserved  by  dividing  simple  meningitis 
into  acute,  subacute,  and  chronic  forms,  whilst  considering  in  their  appropriate 
places  those  peculiarities  in  each  form  incident  to  locality  and  origin. 

All  forms  of  meningitis  have  much  in  common,  and  a  description  of  any  one 
form  is  in  great  part  a  description  of  all  ;  more  especially  is  this  the  case  in  the 
clinical  history  and  in  the  treatment ;  it  is  therefore  expedient,  to  avoid  need- 
less repetition,  which  the  space  allotted  to  this  article  does  not  permit,  to  dis- 
cuss the  pathology  and  etiology  of  the  different  forms,  and  subsequently  the 
clinical  history  and  treatment,  which  are  essentially  the  same  in  all. 

Simple  cerebral  meningitis  may  be  defined  as  inflammation  of  the  arach- 
noid and  pia  mater  of  non-tubercular  origin. 

Etiology. — Simple  meningitis  is  said  to  occur  in  utero  (Guersant)  and 
to  be  quite  frequent  in  the  new-born.  According  to  Ramskill,  its  period  of 
greatest  frequency  is  prior  to  the  second  year,  becoming  less  so  from  that  time 
until  after  fourteen,  when  it  again  becomes  more  common,  especially  between 
sixteen  and  forty-five.  Gowers  places  the  period  of  greatest  frequency  between 
the  ages  of  one  and  ten  years,  including,  however  the  tubercular  form.  It  is 
essentially  a  disease  of  early  childhood,  and  is  more  common  than  is  admitted 
by  those  Avho  refer  all  basilar  inflammations  to  a  tubercular  origin.  In  the 
post-mortem  observations  of  Drs.  Gee  and  Barlow,  recorded  in  St.  Bartlio- 
lomew's  Hospital  Reports  for  1878,  are  6  cases  of  non-tubercular  meningitis, 
and  in  41  post-mortem  examinations  by  Dr.  Goodhart,  in  cases  Avhich  he  says 
without  examination  would  have  been  set  down  as  tuberculous,  8  were  non- 
tubercular. 

Sex  may  be  admitted  among  the  predisposing  causes,  since  Parent-Duchate- 
let  and  Martinet  found  it  to  be  three  times  as  frequent  in  males  as  in  females. 
The  occupations  peculiar  to  men  and  the  sports  of  boys,  involving  exposure  to 
vicissitudes  of  weather  and  to  mechanical  violence,  may  account  in  great  part 

596 


SIMPLE    CEREBRAL    IfENINOITIS.  597 

for  this  difference,  without  assuming  that  there  exists  any  liability  or  immunity 
due  to  sex  |)er  se. 

Injuries  to  the  head,  extension  of  middle-ear  inflammation  or  of  any  adjacent 
disease,  the  special  cause  of  many  specific  diseases,  like  pneumonia,  scarlatina, 
erysipelas,  and  measles,  ordinary  pus-producing  organisms,  emboli  and  thrombi 
— may  all  be  exciting  causes.  An  inherited  or  acquired  predisposition  is  per- 
haps not  uncommonly  present,  but  less  often  than  in  the  tubercular  form. 
Rheumatism  has  been  supposed  to  be  a  frequent  cause,  but  its  importance  has 
doubtless  been  over-estimated.  Symptoms  closely  simulating  those  of  mening- 
itis often  arise  in  the  course  of  acute  rheumatism  when  post-mortem  examina- 
tion reveals  no  trace  of  inflammation.  Trousseau  absolutely  denied  the  inflam- 
matory nature  of  these  cases,  which  he  called  neuroses.  Two  of  the  most 
characteristic  symptoms  of  meningitis,  vomiting  and  headache,  are  also  com- 
monly absent.  Doubtless  rheumatism  is  sometimes  a  cause  of  true  simple 
meningitis,  but  all  the  symptoms  may  arise  from  hyperpyrexia  alone.  Sup- 
purative endocarditis  or  any  other  septic  trouble  may  occasion  it,  as  in  the 
cases  following  operation  for  imperforate  anus  referred  to  under  Pathological 
Anatomy.  Those  cases  arising  from  adjacent  disease  may  be  limited  to  the 
convexity,  while  those  occurring  in  the  course  of  acute  specific  diseases  may 
affect  the  base  also,  though  a  preference  for  the  convexity  is  recognized  in 
all  non-tubercular  forms. 

Pneumonia  is  frequently  associated  with  simple  meningitis  and  the  pneumo- 
coccus  is  found  in  the  inflammatory  exudate.  Huguenin  states  that  at  Zurich 
it  is  a  frequent  complication  of  pneumonia,  and  Chvostek  found  it  four  times  in 
220  cases  in  Vienna. 

The  most  common  cause  of  this  affection  is  extension  from  some  local  adja- 
cent disease  ;  middle-ear  inflammation  is  a  frequent  antecedent.  Cases  have 
occurred  in  which  suppuration  of  the  eyeball  was  primary,  the  inflammation 
extending  along  the  sheath  of  the  optic  nerve.  In  some  instances  no  imme- 
diately exciting  cause  is  apparent.  Fagge  relates  several  cases  occurring  in 
Gruy's  Hospital  in  which  a  diseased  temporal  bone  was  found  post-mortem,  but 
the  meningeal  inflammation  appeared  to  start  in  one  instance  from  a  blow  with 
a  bolster,  and  in  another  an  attack  of  sunstroke  preceded  the  cerebral  symp- 
toms about  seven  days.  Moxon  gives  a  prominent  place  to  syphilis  as  causa- 
tive of  meningitis,  and  Fagge  says  5  cases,  in  which  it  occurred  without  other 
syphilitic  lesions  within  the  calvaria,  were  found  among  the  records  of  Gruy's 
Hospital.  This  writer  appears  to  approve  the  notion  that  the  direct  rays 
of  the  sun  may  produce  simple  meningitis,  or  that  even  its  reflection  from  the 
pages  of  a  book  while  reading  is  a  sufiicient  cause  ;  but  this  is  scarcely 
credible. 

Pathological  Anatomy. — When  death  occurs  in  the  early  stage  of  lepto- 
meningitis, intense  hypersemia  with  extreme  dryness  and  opacity  of  the  mem- 
branes— from  distention  of  the  lymphatic  sheaths  of  the  vessels — over  the 
whole  or  part  of  the  brain  may  be  the  only  lesion.  If  death  occur  after  a  few 
days'  duration,  effusion  of  fluid  admixed  with  cellular  elements  will  be  found  on 
the  arachnoid,  in  its  sac  and  infiltrating  the  pia  mater.  Abercrombie  relates  a 
case  in  which  it  was  so  abundant  between  the  dura  and  arachnoid  as  to  distend 
the  anterior  fontanelle.  Usually,  however,  the  quantity  of  fluid  exudate  is  not 
large.  When  life  has  been  prolonged  to  the  fifth  or  sixth  day,  the  quantity  of 
fluid  is  sensibly  diminished,  and  a  little  later  disappears.  A  membrane-like 
deposit  of  yellowish  hue  is  found  on  the  arachnoid ;  the  pia  in  greater  or  less 
partis  covered  and  infiltrated  with  "  concrete  pus,"  which  is  also  found  around 
the  vessels  and  in  the  sulci  of  the  convolutions  (Ramskill).      The   nerve- 


598    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

sheaths  may  be  reddened  and  bathed  in  semi-purulent  lymph,  which  at  times  is 
punctiform  and  resembles  tubercular  granulations.  In  long-standing  cases  this 
may  undergo  caseation  or  induration.  The  nerve-trunks  may  be  in  different 
stages  of  hyperaemia,  softening,  and  disintegration.  The  dura  and  arachnoid 
may  be  firmly  adherent,  the  arachnoid  and  pia  almost  always. 

The  ventricles  may  be  invaded,  their  lining  membrane  inflamed,  the  orifices 
of  communication  occluded,  and  the  chambers  distended  with  serum  or  pus, 
sometimes  to  the  extent  of  producing  a  true  hydrocephalus.  In  rare  cases 
they  may  contain  false  membrane.  More  frequently  they  contain  a  flocculent 
fluid  of  variable  quantity,  sometimes  sufiicient  to  distend  the  ventricle  and 
compress  the  cortex.  The  subjacent  brain-substance  may  be  oedematous  and 
softened.  This  condition  is  not  always  associated  with  unmistakable  evidence 
of  inflammation  of  their  lining  membrane ;  indeed,  the  inflammatory  changes 
in  the  ventricles  are  rarely,  if  ever,  well  marked.  In  those  cases  where  inflam- 
mation is  most  pronounced  the  eff"usion  is  seldom  limited  to  the  ventricles,  but 
may  invade  the  cord  and  escape  into  the  brain-space.  Great  distention  of  all 
the  ventricles  may  occur  without  inflammation,  from  simple  occlusion  of  the 
channels  of  communication  with  the  space  around  the  brain  (Gowers).  Rilliet 
relates  a  case  in  which  the  convexity  of  one  side  was  covered  with  false  mem- 
brane, whilst  the  pia  of  the  opposite  side  was  simply  oedematous. 

Gases  of  pneumonic  origin  are  usually  bilateral  and  limited  to  the  cortex  ; 
those  extending  from  local  foci — purulent  otitis,  caries,  etc. — are  unilateral, 
and  may  be  associated  with  thrombi  of  the  sinuses  or  with  abscess  (Osier). 
Septic  cases  and  those  associated  with  specific  diseases  are  apt  to  be  bilateral. 
The  base  is  often  involved  in  the  inflammatory  process.  An  interesting  case 
of  basilar  meningitis  following  an  operation  for  imperforate  anus,  reported  by 
W.  T.  Howard,  Jr.,  in  a  child  of  three  months,  is  related  in  Osier's  Practice 
of  Medicine^  in  which  the  ventricles  were  distended  with  pus  containing  a 
coccus  and  the  bacterium  coli  commune ;  the  ependyma  was  softened  and 
infiltrated  Avith  pus.  Dr.  Hilton  Fagge  also  reports  a  case,  occuring  in  Guy's 
Hospital,  of  a  meningeal  inflammation  following  six  days  after  an  operation  for 
imperforate  anus,  attributed  to  sepsis,  though  the  meningitis  Avas  the  only  evi- 
dence of  pyaemia.  Dr.  Fagge  says  the  presence  of  subdural  pus  may  usually 
be  taken  as  an  evidence  of  extension  from  without,  though  in  many  cases  no 
subdural  pus  is  found.  The  pia  is  usually  swollen  and  oedematous,  filling  the 
sulci ;  the  inflammation  may  extend  along  the  vessels  to  the  cortex,  which 
becomes  infiltrated,  softened,  and  so  adherent  at  times  that  the  pia  cannot  be 
removed  without  cortical  laceration.  The  whole  surface  of  the  cortex  may  be 
bathed  in  pus  or  deeply  infiltrated  with  leucocytes,  and  Huguenin  says  "  sup- 
puration of  the  brain-substance  may  reach  such  a  point  as  to  give  rise  to  a 
difiused  yellow-gray  maceration  visible  to  the  naked  eye"  (quoted  from  Fagge's 
Practice).  The  amount  of  blood  in  the  vessels  may  be  greatly  diminished 
from  pressure  of  the  exudate  and  thickening  of  their  walls. 

Symptoms. — Simple  meningitis  of  childhood  usually  begins  abruptly  with 
well-marked  rigors.  Prodromic  symptoms  are  much  less  frequent  than  in  the 
tubercular  form.  The  patient  is  petulant  and  irritable  when  disturbed,  but 
inclined  to  apathy  at  other  times,  more  especially  in  later  stages  and  when  the 
convexity  is  especially  involved.  Violent  delirium  with  or  without  convulsions 
may  be  an  early  symptom.  When  convulsions  occur  early,  they  are  apt  to 
recur  often  during  the  progress  of  the  trouble.  The  delirium  may  be  quiet  and 
the  convulsions  slight  or  absent.  Pyrexia  quickly  superVenes,  and  is  usually 
high :  a  temperature  of  103°-105°  F.  is  not  uncommon  in  the  first  week.  It 
is  sometimes  very  slight,  occasionally  scarcely  appreciable,  and  in  the  last  stage 


SIMPLE    CEBEBBAL   MENINGITIS.  599 

the  temperature  may  be  subnormal.  The  pre-mortal  temperature  is  sometimes 
as  high  as  106°-108°  F. 

The  pulse  may  be  frequent  and  tense,  usually  so  in  the  beginning,  or  slow 
and  irregular,  sometimes  as  slow  as  60,  50,  or  40  per  minute,  or  just  before 
death  it  may  rise  to  160—180  per  minute.  Henoch  considers  an  intermittent 
pulse  characteristic  of  meningitis.  It  is  of  more  significance  in  childhood  than 
in  infancy,  but  at  no  time  has  it  the  diagnostic  value  imputed  to  it.  The 
extreme  variation  in  frequency  and  quality  of  the  pulse  is  probably  its  most 
significant  character. 

Respiration  is  usually  but  little  disturbed,  but  is  sometimes  sighing,  may 
be  quickened  at  first  and  subsequently  irregular  and  slow,  and  toward  the 
close  the  Cheyne-Stokes  rhythm  may  be  present.  When  the  lesion  is  in  the 
posterior  fossa,  respiration  is  slow,  labored,  accompanied  by  cyanosis,  and  may 
stop  suddenly. 

Headache  is  perhaps  the  most  constant  symptom,  and  is  seldom  lacking.  It 
is  often  associated  with  great  tenderness  of  the  scalp  and  subjacent  region,  and 
is  sometimes  circumscribed,  but  the  localization  bears  no  constant  relation  to 
the  site  of  the  inflammation.  The  meninges  of  one  side  may  be  inflamed  and 
the  pain  and  tenderness  be  on  the  other ;  but  when  the  pain  persists  in  a  circum- 
scribed area  it  commonly  indicates  the  site  of  the  inflammation.  Cases  of 
simple  meningitis  sometimes  run  their  entire  course  without  pain,  and  when 
pain  is  present  it  seems  to  have  no  constant  relation  to  the  intensity  or  extent 
of  the  inflammation. 

Hypersesthesia  of  the  nerves  of  the  special  senses  of  sight  and  hearing, 
indicated  by  extreme  aversion  to  light  and  noise,  is  almost  invariably  present. 
This  may  be  associated  with  acute  general  hypersesthesia.  The  pupils  are  at 
first  contracted ;  as  the  photophobia  diminishes  they  become  irregular ;  one 
may  be  contracted  and  the  other  dilated,  or  at  times  contracted,  at  times 
dilated ;  finally,  both  become  dilated  and  vision  is  impaired  or  lost ;  optic 
neuritis  is  present  in  many  cases,  especially  when  the  base  is  involved.  Noises 
at  first  greatly  disturb  the  patient.  This  sensitiveness  to  sound  is  at  times  so 
great  that  the  most  softly  modulated  speech  occasions  signs  of  petulance  and 
distress.  As  the  end  approaches  this  gradually  passes  away,  and  deafness  may 
ensue. 

The  intelligence  is  sooner  or  later  afi"ected ;  the  patient  is  irritable  and 
petulant  when  questioned  or  otherwise  annoyed  ;  incoherent  speech  and 
delirium  are  often  early  symptoms.  Other  nervous  symptoms  present  at  this 
time  are  subsultus,  carphologia,  inco-ordinate  efforts  at  locomotion  if  this  be 
attempted,  and  projectile  vomiting. 

The  tache  cdr^brale  is  well  marked,  but  is  without  diagnostic  significance. 
Occasionally  the  patient  emits  short,  sharp  cries  that  do  not  always  appear  to 
be  due  to  pain,  though  in  older  children  they  often  seem  to  increase  the 
headache. 

General  convulsions  may  occur  independently  of  the  site  (Gowers),  and 
eventually  give  place  to  coma.  Rigidity  of  the  muscles  of  the  neck,  with 
retraction  of  the  head,  is  an  early  symptom  of  diagnostic  value ;  it  is  more 
frequent  in  inflammation  of  the  base  than  of  the  convexity.  When  the  base  is 
the  site  of  the  lesion,  local  spasm  may  occur  in  simple  as  well  as  in  tubercular 
meningitis.  Rolling  up  of  the  eyes,  oscillations  of  the  globes,  strabismus, 
most  marked  when  the  eyes  are  moved,  are  frequently  present  in  the  first 
stage ;  later  they  may  give  place  to  paralysis,  sometimes  limited  to  the  face 
or  a  small  part  of  it,  sometimes  to  a  single  extremity ;  or  complete  hemiplegia 
is  present. 


600    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Vomiting  is  so  commonly  present  and  of  such  distinctive  character  as  to 
possess  diagnostic  significance.  It  is  projectile,  unaccompanied  by  gastric  pain 
or  tenderness,  nausea,  or  retching.  It  may  persist  throughout  the  disease,  but 
is  most  characteristic  in  the  early  stage.  It  occurs  independently  of  the  site, 
but  is  more  common  in  inflammation  of  the  base.  It  is  not  present  in  all 
cases.  The  tongue  is  usually  somewhat  furred,  but  presents  nothing  character- 
istic. The  bowels  are  constipated  in  a  large  proportion  of  cases,  and  the 
abdomen  is  retracted  or  boat-shaped. 

Finally,  all  the  active  symptoms  subside ;  the  headache,  photophobia, 
acoustic  sensibility,  general  and  local  hyperoesthesia,  and  active  delirium,  all 
give  place  to  coma  and  general  collapse.  The  pupils  are  dilated,  the  pulse 
weak  and  irregular  and  the  skin  cold  and  clammy.  Cheyne-Stokes  respiration 
is  established,  the  sphincters  are  relaxed,  the  faeces  and  urine  are  voided 
involuntarily,  and  death  speedily  ensues. 

Subacute  Leptomexingitis  is  peculiar  only  in  the  relative  mildness  of  the 
lesions  and  the  slowness  with  which  it  develops.  It  sometimes,  though  rarely, 
succeeds  to  the  acute  form,  but  more  commonly  is  subacute  from  the  beginning. 
The  same  lesions  of  milder  grade  are  present,  and  are  due  to  the  same  exciting 
and  predisposing  causes. 

Hydrocephalus  is  perhaps  more  frequent  and  extensive;  active  delirium 
is  frequently  substituted  by  a  more  quiet  form  and  a  condition  of  mental 
torpor.  The  patient  is  less  irritable,  the  photophobia  and  acoustic  sensibility 
is  less,  and  paralyses  are  slower  to  appear.  There  is  but  little  propriety,  hoAv- 
ever,  in  recognizing  a  subacute  form ;  it  is  merged  by  such  insensible  grada- 
tions, on  the  one  hand,  into  the  acute,  and  on  the  other,  into  the  chronic  form, 
that  there  is  little  to  distinguish  it. 

A  latent  form  is  also  described,  but  in  the  judgment  of  the  writer  it  has 
no  well-established  claim  to  recognition,  and  will  not  therefore  receive  further 
consideration. 

CHRO^■IC  Leptomeningitis.  —  Chronic  leptomeningitis  may  succeed  the 
acute  form,  but  is  of  extreme  rarity  except  as  a  result  of  syphilis  or  chronic 
alcoholism,  causes  not  likely  to  occasion  it  in  childhood  except  through  inher- 
itance. 

The  symptoms  are  less  clearly  distinctive,  and  the  difficulty  in  diagnosis 
therefore  greater,  than  in  the  acute  form ;  consequently  it  may  often  be  over- 
looked and  the  frequency  of  its  occurrence  underestimated.  If.  as  Goodhart 
has  remarked,  we  accept  cervical  opisthotonos  as  evidence  of  meningitis,  it  may 
not  only  be  very  chronic,  but  also  intermittent,  and,  we  may  add,  more  fre- 
quent than  commonly  supposed. 

Its  clinical  history  is  not  to  be  separated  by  sharply-drawn  lines  from  that 
of  the  acute  disease.  It  is  essentially  the  same  in  character,  but  of  slower 
development  and  more  protracted  stay,  and  all  the  more  characteristic  symp- 
toms are  of  less  intensity.  An  apathetic  condition  Avith  headache  and  a  dis- 
position to  vomit,  a  pulse  at  first  slow,  soon  becoming  quick  and  irregular, 
double  vision,  strabismus,  and  irregularity  of  pupils,  may  usually  be  found  if 
sought  for.  The  favorite  site  of  chronic  infantile  meningitis  is  the  posterior 
fossa,  and  the  most  chai'acteristic  symptoms  are  local  and  dependent  on  the  seat 
of  the  inflammation.  Drs.  Gee  and  Barlow  observed  cervical  opisthotonos  in 
most  cases.  In  some  cases  of  rapid  development  it  may  be  attended  or  preceded 
by  convulsions,  vomiting,  pain,  and  fever;  in  others  the  retraction  of  the  head 
is  slowly  induced,  unattended  by  these  phenomena.  Rigidity  of  the  limbs  and 
epileptic  convulsions  may  occur  later,  together  with  oscillations  of  the  globe  or 
strabismus,  and  occasionally  hydrocephalus  (Gowers).     When  the  orifices  of 


SIMPLE    CEREBRAL    MENINGITIS.  601 

the  fourth  ventricle  are  closed  with  lymph,  paralyses,  facial  and  hemiplegic, 
may  complicate  the  later  period.  The  pia  is  usually  thickened  from  increase 
in  its  connective  tissue ;  a  similar  condition  is  found  in  the  walls  of  its  vessels, 
and  from  them  may  extend  to  the  cortex,  inducing  such  changes  as  may  lead 
to  insanity  and  idiocy.  The  pia  and  arachnoid  may  be  glued  together-,  oede- 
matous  and  opaque,  and  the  sulci  be  filled  with  serum  or  sero-purulent  fluid  or 
oedematous  membrane.  The  Pachionian  bodies  are  increased  in  number  and 
size. 

Chronic  lepto-meningitis  is  much  more  frequently  associated  with  syphilis 
than  is  the  acute  form.  A  swollen  and  oedematous  optic  disk,  or  optic  neu- 
ritis, may  aid  the  diagnosis,   but  cannot  confirm  it. 

One  is  a  little  at  a  loss  to  understand  why  the  cause  of  the  meningitis  should 
be  supposed  to  determine  a  difference  in  the  symptoms,  except  in  so  far  as  these 
are  due  to  associated  disease.  The  extent,  intensity,  and  locality  of  the  menin- 
geal inflammation,  with  the  nervous  susceptibility  of  the  individual,  will  deter- 
mine the  symptoms,  which  will  be  much  the  same  whatever  the  cause. 

Diagnosis. — The  positive  indications  of  simple  meningitis  are  found  in  the 
symptoms  already  mentioned,  though  they  may  any  or  all  of  them  occur  with- 
out meningeal  lesion  of  any  kind  whatever.  The  general  cerebral  symptoms 
are  valuable  according  to  their  degree  and  combination,  rather  than  by  their 
mere  presence.  "The  signiflcance  of  the  headache  depends  on  its  intensity;- 
of  the  delirium,  on  its  coexistence  with  headache;  of  vomiting,  on  its  causeless 
character  and  persistence;  of  general  convulsions,  on  their  association  with 
other  symptoms;  of  infrequency  of  pulse,  on  its  combination  with  pyrexia 
that  usually  accelerates  the  heart "  (Gowers).  It  is  not  to  be  distinguished  by 
its  symptoms  from  tubercular  meningitis,  though  in  general  it  may  be  said  to 
be  more  frequently  dependent  on  some  pre-existing  local  disease,  to  be  more 
abrupt  in  its  invasion  and  rapid  in  its  progress  in  acute  cases,  and  to  be  more 
frequently  associated  with  active  delirium.  It  is  probably  more  dependent  on 
some  local  lesion  or  association  with  specific  disease  than  is  the  tubercular  form. 
In  the  latter  the  presence  of  the  tubercle  bacilli  or  of  septic  materials  from 
degenerating  tubercles,  with  peculiar  susceptibility,  is  alone  sufiicient  for  its 
development.  The  presence,  therefore,  of  tubercle  in  other  organs,  the  detec- 
tion of  tubercle  bacilli,  and  a  tubercular  family  history  are  of  greater  value  in 
the  diflferential  diagnosis  than  any  supposed  difference  in  symptoms  directly 
due  to  the  meningitis.  Though  clear  evidence  of  tubercle  elsewhere  may  be 
wanting,  slow  invasion,  early  childhood,  and  the  absence  of  distinct  local  cause 
make  for  a  tuberculous  origin.  When  the  base  alone  is  the  site  of  the  inflam- 
mation, the  probabilities  are  strongly  in  favor  of  the  tubercular  form.  Inflam- 
mation of  the  middle  ear  or  labyrinth,  with  or  without  suppuration,  may  give 
rise  to  symptoms  that  cannot  be  distinguished,  except  by  their  duration,  from 
meningitis.  The  detection  of  an  otitis,  therefore,  may  lead  us  to  believe  in  the 
existence  of  meningitis  originating  from  it,  or  to  hope  that  the  symptoms  are 
solely  due  to  it  and  will  end  in  recovery  under  proper  treatment.  And  in  cases 
that  recover  under  such  circumstances,  the  diagnosis  must  remain  permanently 
in  doubt,  since  many  cases  of  simple  meningitis  have  been  thought  to  recover. 

It  is  also  not  altogether  unlikely  that  the  characteristic  symptoms  may  arise 
as  a  reflex  result  of  lesions  of  the  most  varied  character  in  remote  parts  of  the 
body.  From  the  cerebral  form  of  pneumonia  simple  meningitis  may  be  dis- 
tinguished by  the  physical  signs  of  the  former  and  the  detection  of  the  pneumo- 
coccus.  But  it  must  be  remembered  that  although  pneumonia  may  exist  with- 
out meningitis,  with  analogous  cerebral  symptoms,  yet  pneumonitis  and  true 
meningitis  may  coexist  and  be  due  to  the  same  cause.     I  know  of  no  way  to 


602     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

distinguish  cerebral  symptoms  occurring  in  pneumonia  without  meningitis  and 
those  occurring  under  like  circumstances  with  it,  except  by  their  duration ;  and 
even  this  in  many  cases  is  the  same,  since  pneumonia  with  marked  cerebral 
symptoms  often  runs  a  speedily  fatal  course.  Perhaps,  instead  of  trying  to 
differentiate  them,  it  Avould  be  best  to  consider  both  as  local  expressions  of  the 
same  constitutional  state. 

Pyaemia  may  present  symptoms  closely  resembling  meningitis,  especially 
when  associated  with  thrombus  of  the  lateral  sinus  and  jugular  vein,  as  in  a 
case  reported  by  Dr.  Frederick  Taylor.  Dr.  Wilson  Fox  also  relates  a  similar 
case,  and  Dr.  Andrew  two  instances  of  pyaemia  with  cerebral  symptoms  not 
distinguishable  from  menincritis;  both  of  these  recovered,  however,  so  it  can- 
not  be  said  they  Avere  not  cases  of  true  meningitis,  unless  it  be  assumed  that 
acute  simple  meningitis  never  recovers. 

Those  cases  of  typhoid  fever  likely  to  occasion  difficulty  in  diagnosis  are 
characterized  by  the  predominance  of  cerebral  symptoms  and  the  absence  or 
slight  nature  of  those  peculiar  to  the  alimentary  canal ;  but  in  typhoid  fever 
headache  precedes  delirium,  usually  ceases  with  its  advent,  and  is  sufficiently 
accounted  for  by  the  pyrexia — not  so  in  leptomeningitis.  Photophobia  and 
auditory  hypersensibility  may  occur  in  either,  but  they  are  far  more  acute  in 
meningitis.  In  typhoid  fever  vomiting  seldom  has  the  distinctive  cerebral 
character,  and  rigidity  of  the  neck  and  local  paralyses  seldom  occur.  The 
invasion  of  typhoid  fever  is  rarely  so  abrupt ;  the  pulse  is  not  so  irregular. 

Prognosis. — In  all  cases  of  leptomeningitis  but  little  hope  can  be  reason- 
ably entertained  of  recovery  when  no  error  in  diagnosis  has  been  made ;  but 
errors  of  this  kind  happen  in  the  experience  of  the  most  astute  and  well- 
informed  physicians.  Moreover,  cases  apparently  free  from  doubt  have  recov- 
ered in  sufficient  number  to  warrant  hope,  but  hope  only,  for  nothing  in  the 
condition  of  the  patient  serves  as  a  reasonable  basis  for  expectation  of  recovery. 
The  cases  which  do  best  are  those  having  their  origin  in  injuries,  necrosis, 
caries,  suppurative  otitis,  and  other  removable  causes,  and  those  that  arise  in 
the  progress  of  syphilis.  The  majority  even  of  these  will  terminate  fatally 
after  the  inflammation  is  well  established,  but  much  may  be  done,  by  the  early 
removal  or  correction  of  such  causes,  to  prevent  the  establishment  of  meningitis. 
Those  in  which  the  indications  are  that  both  the  convexity  and  base  are  affected 
run  a  rapidly  fatal  course.  Patients  in  whom  no  reasonable  cause  exists  may 
be  expected  to  succumb,  more  especially  if  the  pulse  soon  becomes  irregular  and 
weak,  accompanied  by  nausea,  with  convulsive  seizures  followed  by  profound 
hebetude. 

When  light  and  noise  no  longer  disturb  ;  when  the  pupils  become  persist- 
ently dilated ;  the  skin  cold,  pale,  and  bathed  in  perspiration ;  when  involuntary 
evacuations  occur ;  paralysis  local  or  general  becomes  established,  and  coma  or 
a  semicomatose  condition  supervenes, — all  hope  may  be  abandoned. 

Treatment. — The  treatment  in  simple  cerebral  meningitis  and  in  simple 
cerebro-spinal  meningitis  is  essentially  the  same.  A  much  larger  proportion 
of  cerebral  cases  are  due  to  local  conditions  that  may  be  treated  by  surgical 
measures,  and  whenever  they  do  arise  from  removable  causes  surgical  treat- 
ment should  be  instituted  without  delay.  Suppurative  otitis,  with  or  without 
necrosis  or  caries  of  the  temporal  bone,  is  so  often  causally  related  to  meningeal 
inflammation  that  these  lesions  should  always  receive  efficient  attention  before 
the  induction  of  the  graver  evil.  It  has  happened  to  the  writer  to  witness  two 
cases  of  supposed  leptomeningitis  in  adults,  with  fatal  terminations,  supervening 
on  chronic  suppurative  otitis  that  had  followed  scarlatina  many  years  before. 
Had  the  aural   trouble   been   efficiently  treated,  the  meningeal   inflammation 


SIMPLE    CEREBRAL   MENINGITIS.  603 

would  in  all  probability  have  been  averted.  Doubtless  many  similar  cases  have 
existed,  and,  in  view  of  the  great  fatality  of  the  secondary  affection  and  the 
impunity  with  which  surgeons  of  the  present  day  invade  the  meninges,  and 
even  the  substance  of  the  brain,  they  should  in  future  disappear  from  our 
records.  All  cases  of  injury  to  the  skull  that  carry  with  them  even  a  reason- 
able suspicion  of  injury  to  the  meninges  or  brain  should,  in  the  judgment  of 
the  writer,  be  trephined,  bone-fragments  elevated  or  extracted,  blood-clots 
removed  though  the  membranes  have  to  be  incised  for  that  purpose,  and  all 
the  parts  thoroughly  cleansed.  Analogous  procedures  are  no  less  imperatively 
called  for  in  diseased  conditions  than  after  injury. 

Cases  of  syphilitic  origin  should  receive  the  specific  treatment  proper  to 
that  disease,  with  a  not  unreasonable  hope  of  recovery  if  the  treatment  be 
begun  early. 

Apart  from  these  special  indications  for  treatment,  there  is  but  little  to  be 
expected  from  any  means  at  our  disposal  beyond  the  alleviation  of  suffering. 
Drugs  appear  to  exert  no  influence  on  the  course  of  the  disease,  and  it  may  be 
doubted,  even  in  those  cases  of  supposed  leptomeningitis  that  have  recovered, 
whether  the  remedies  administered  have  contributed  to  this  result. 

Bleeding,  local  or  general,  and  blisters  are  still  strongly  advocated  by 
German  writers  and  by  many  others.  Apart  from  relief  of  hypersemia 
of  the  cerebral  vessels,  one  sees  but  little  benefit  to  be  derived  from 
them,  and  it  would  seem  that  this  might  be  better  accomplished  by  such 
remedies  as  amyl  nitrite,  which  increase  the  vascular  area  and  so  lower  blood- 
pressure  without  the  same  impairment  of  strength  as  follows  bloodletting. 
Mercury  and  the  iodide  of  potassium  have  been  warmly  and  ably  advocated 
as  efficient  therapeutic  agents  in  this  disease,  but  they  so  often  appear  to  be 
entirely  without  effect  that  the  writer  is  sceptical  of  their  value  except  in  cases 
of  syphilitic  origin.  Nevertheless,  excellent  results  of  treatment  with  these 
agents  have  been  reported  by  most  competent  observers.  Ramskill  in 
Reynolds's  System  of  Medicine  thus  summarizes  the  treatment:  "It  resolves 
itself  into  three  great  remedial  measures :  first,  bloodletting ;  second,  hard 
purging;  third,  applications  of  cold  water  or  ice  to  the  head." 

Abercrombie's  cases  also  give  strong  support  to  the  efficiency  of  these 
measures.  Case  69,  aged  eleven,  after  an  illness  of  five  or  six  days  was  in  a 
comatose  condition,  notwithstanding  free  purging,  blistering,  and  the  use  of 
mercury  to  salivation ;  was  immediately  relieved  and  made  a  good  recovery 
after  one  bleeding  from  the  arm.  Case  72,  aged  twenty-one  years,  was 
reduced  to  a  condition  of  stupor  from  which  he  could  scarcely  be  roused,  and 
continued  in  this  way  for  eight  or  ten  days  notwithstanding  repeated  bleed- 
ing, blisters,  and  cold  applications.  But,  after  taking  full  doses  of  castor  oil 
every  three  hours  until  purgation  was  induced,  he  was  on  the  same  evening 
relieved  and  made  a  good  recovery  (quoted  in  Fagge's  Practice). 

A  brisk  purge  in  the  beginning  and  from  time  to  time  during  the  progress 
of  the  trouble  will  do  much  to  alleviate  suffering,  and  at  times  seems  to  have 
a  decidedly  beneficial  effect.  Cases,  not  a  few,  are  recorded,  especially  by  the 
earlier  writers,  which  seem  to  date  improvement,  rapidly  progressing  to  recovery, 
from  such  measures  as  free  catharsis,  bleeding,  local  or  general,  blisters  applied 
to  head  or  back  of  neck.  Whilst  it  is  difficult  wholly  to  discredit  such  state- 
ments or  to  deny  to  the  agents  employed  the  remedial  potency  claimed  for 
them,  yet  it  is  equally  difficult  to  conceive  how  with  such  means  such  ends 
could  be  attained.  When  remedies  of  this  class  are  serviceable  at  all,  it  must 
be  in  the  early  stage  before  inflammatory  exudation,  inflltration,  or  degenera- 
tive changes  have  occurred  to  any  notable  extent ;  and  one  cannot  wholly 


604    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

shake  off  the  doubt  that  they  were  cases  of  erroneous  diagnosis,  or  at  least 
belonor  to  that  rare  class  of  cases  that  would  have  recovered  without  medical 
interference. 

x\n  entirely  different  class  of  remedies  is  found  in  those  drugs  of  anodyne 
and  hypnotic  properties  which  allay  vomiting,  soothe  pain,  subdue  or  lessen 
active  delirium,  procure  sleep,  and  contribute  in  many  ways  to  make  tolerable 
for  patients  and  friends  the  last  days  of  those  for  whom  in  a  large  majority  of 
cases  we  can  hope  to  do  no  more.  And,  in  the  opinion  of  the  writer,  relief  in 
these  particulars  is  the  extent  of  the  power  of  drugs  to  be  useful  in  this  disease. 
First  rank  in  this  group  of  remedies  may  still  be  boldly  claimed  for  opium  and 
its  derivatives,  and  especially  for  morphine,  which,  because  of  the  small  dose 
required,  the  facility  with  which  it  may  be  administered  hypodermatically, 
and  its  almost  uniform  strength  and  efficiency,  takes  precedence  of  all  other 
drugs.  The  bromides  of  sodium  and  potassium,  antipyrin.  antifebrin,  sul- 
phonal,  and  many  other  similar  remedies  are  at  times  of  great  usefulness.  The 
occasional  use  of  chloroform  by  inhalation  Avhen  convulsions  occur  gives  prompt 
relief  to  some  of  the  most  distressing  symptoms,  and  is,  I  believe,  as  free  from 
danger  as  any  other  remedy  when  judiciously  employed  ;  but  nothing  can  be 
so  confidently  relied  on  to  relieve  pain,  to  procure  sleep,  to  quiet  delirium,  and 
to  arrest  vomiting  as  morphine  ;  and  this  it  does  at  as  little  cost  to  a  feeble 
heart  as  any  other  drug  that  may  be  used  ;  nor  do  I  think  is  the  tendency  to 
coma  materially,  if  at  all,  increased  by  its  judicious  administration.  But  more 
valuable  than  any  of  the  remedies  yet  mentioned  is  repose  of  body  and  mind 
as  perfect  as  may  be  had  by  the  mere  exclusion  of  disturbing  causes.  The 
room  should  be  darkened ;  no  one  not  indispensable  to  the  comfort  of  the 
patient  should  be  admitted ;  no  loud  talking  or  other  noises  should  be  allowed 
within  hearing  ;  and  no  needless  questioning  by  anxious  friends.  In  cerebral 
causes  the  head  should  be  shaved  as  soon  as  the  nature  of  the  trouble  is  clear. 
Ice  or  ice-cold  water  should  be  almost  continuously  applied  to  the  head  and — in 
cerebro-spinal  cases — to  the  back.  It  should  be  begun  early  and  continued 
steadily,  and  in  cases  of  active  delirium  this  may  be  supplemented  by  iced 
applications  to  the  large  arteries — brachials  and  carotids. 

When  coma  appears,  all  depressing  remedies  should  cease,  although  occa- 
sional recoveries  are  recorded  even  in  this  stage,  as  in  Abercrombie's  cases, 
already  quoted,  and  in  Sir  Thomas  "Watson's  case  of  recovery  on  the  application 
of  a  blister  to  the  entire  shaven  scalp  after  the  appearance  of  coma.  It  is 
certainly  more  reasonable  to  expect  good  from  the  judicious  use  of  stimulants 
in  this  stage  or  at  any  time  when  the  heart-beat  is  feeble  or  intermittent.* 
Throughout  the  disease,  as  far  as  practicable,  the  strength  of  the  patient  should 
be  maintained  with  the  most  nutritious  diet. 


SIMPLE  CEREBRO-SPmAL  MENINGITIS. 

By  THOMAS  S.  LATIMER,  M.  D., 

Baltimore. 


Simple  or  Sporadic  Cerebro-spinal  Meningitis  occurs  under  pre- 
cisely the  same  circumstances  as  simple  cerebral  meningitis,  and  is  attended  by 
the  same  lesions,  except  in  so  far  as  the  anatomical  and  physiological  character- 
istics of  the  part  invaded  necessitate  a  diiference.  Nor  can  it  be  maintained 
in  the  present  state  of  knowledge  that  any  essential  difference  exists  between 
this  and  other  forms  of  cerebro-spinal  meningitis.  The  tendency  of  recent 
observations  and  opinion  is  to  the  conclusion  that  epidemic  cerebro-spinal 
meningitis  (cerebro-spinal  fever)  has  its  origin  in  a  specific  germ,  probably  the 
diplococcus  lanceolatus,  and  observations  have  not  yet  sufficiently  multiplied 
to  enable  us  to  say  whether  or  not  this  organism  is  also  present  in  all  sporadic 
cases.  However  this  may  be,  it  is  clear  that  the  two  forms  arise  under  some- 
what different  circumstances,  and  present  such  clinical  differences  as  may  be 
seen  in  other  diseases,  such  as  dysentery,  that  prevail  at  times  epidemically  and 
at  times  sporadically — differences  chiefly  of  intensity  in  the  symptoms  and  in 
the  extent  of  the  lesions,  the  epidemic  prevalence  implying  a  concurrence  of 
suitable  conditions  in  the  individual  and  in  the  auxiliary  associated  conditions 
by  which  he  is  surrounded,  and  not  necessarily  any  difference  in  the  immediate 
exciting  cause.  In  this  restricted  sense,  then,  we  may  still  speak  of  simple 
cerebro-spinal  meningitis  as  distinguished  from  cerebro-spinal  fever.  There 
are  also  cases  occurring  from  injury,  from  sepsis,  from  local  extension,  from 
tuberculosis  or  syphilis,  that  probably  have  no  causal  connection  with  the  pneu- 
mococcus,  and  may  with  more  propriety  be  designated  "simple"  than  may 
sporadic  cases  that  appear  to  be  closely  connected  with  this  particular  organism. 

Etiology. — The  causes  of  simple  cerebro-spinal  meningitis  are  precisely 
the  same  as  those  of  simple  cerebral  meningitis,  and  need  not  be  again  con- 
sidered. They  are  injuries,  extension  from  adjacent  disease,  pyaemia,  specific 
diseases,  childhood,  sex,  season,  vicissitudes  of  temperature,  and  those  general 
malhygienic  conditions  that  predispose  to  inflammations  in  general.  Menin- 
gitis is  not,  however,  limited  to  any  class,  and  may  occur  among  the  rich  and 
poor  alike.  Efforts  have  been  made  to  connect  it  with  particular  articles  of 
food,  but  without  much  success.  Fatigue  from  over-exertion  seems  to  be  a 
favoring  condition  observed  most  frequently  in  the  adult. 

Pathological  Anatomy. — This  disease  may  be  an  extension  from  simple 
cerebral  meningitis,  in  which  case  the  anatomical  changes  heretofore  described 
in  basilar  inflammation  will  be  present,  and  to  them  must  be  added  those  due 
to  invasion  of  the  meninges  of  the  cord ;  or  it  may  originate  in  the  cord  and 
extend  up  to  the  cerebral  meninges,  which  would  not  of  course  alter  the  nature 
of  the  lesion,  only  the  order  of  occurrence  of  its  symptoms :  or  it  may  occur 
simultaneously  in  both  regions,  the  anatomical  characters  remaining  the  same. 
These  characters  are — great  hypersemia  in  the  first  stage,  to  which  soon  suc- 

605 


606   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ceed  swelling  and  hypertrophy  of  the  walls  of  the  vessels  of  the  pia  mater, 
sometimes  also  of  the"  brain  and  cord,  and  with  this  oedema  and  cellular  infil- 
tration of  adjacent  parts  may  coexist.  Sometimes  the  exudate  may  be  small 
in  amount  and  consist  of  serum,  white  corpuscles,  and  plastic  material,  by 
which  in  the  last  stage,  if  the  patient  survives,  the  membranes  may  be  bound 
together,  or  the  pia  and  surface  of  the  brain  or  cord ;  or  it  may  be  of  large 
quantity  and  purulent,  filling  the  canal  and  bathing  the  pia  and  underlying 
structures  in  a  grayish-yellow  or  distinctly  purulent  fluid,  which  may  fill  the 
entire  space  between  the  dura  and  arachnoid.  The  infiltration  may  occasion 
opacity  of  both  pia  and  arachnoid.  The  spinal  meninges  are  usually  exten- 
sively involved,  oAving  probably  to  the  readiness  Avith  which  septic  elements 
are  diffused  in  the  spinal  fluid.  The  spinal  fluid  is  more  or  less  flocculent 
from  the  presence  of  exudation  elements,  or  it  may  be,  as  before  said,  distinctly 
purulent.  A  true  myelitis  may,  and  not  unfrequently  does,  coexist,  in  which 
case  paralyses  occur  of  a  more  permanent  character  than  Avhen  the  meninges 
alone  are  involved.  The  arachnoid  is  probably  never  aff"ected  alone,  but  it  is 
always  involved  in  the  inflaunuation,  which  may  also  extend  to  the  dura  and 
to  the  spinal  nerves,  to  which  latter  circumstances  some  of  the  most  character- 
istic spinal  symptoms  are  due ;  but  they  by  no  means  always  share  in  the 
inflammation.  According  to  J.  Simon,  the  meningeal  inflammation  may 
usually  be  looked  upon  as  an  index  to  the  more  important  changes  that  occur 
in  the  cerebral  and  spinal  tissue,  "  and  hence  it  is  that  the  essential  phenomena 
of  the  disease  during  life  consist  in  disturbances,  more  or  less  grave,  of  the 
functions  of  these  all-important  organs." 

Other  organs  and  tissues  present  little  or  no  pathological  change,  except 
perhaps  the  skin,  and  the  lesions  here  found  are  commonly  limited  to  the  fulmi- 
nant cases,  which  are  found  almost  exclusively  in  the  epidemic  form  of  menin- 
gitis, and  have  therefore  been  fully  described  in  another  section. 

Symptoms. — In  this  aff'ection  the  convexity  is  seldom  involved,  and  the 
symptoms  are  for  the  most  part  those  characteristic  of  inflammation  of  the  base 
and  of  the  cord,  more  especially  of  the  cervical  region  of  the  latter.  The 
special  senses  are  not  aff"ected  to  the  same  extent  as  in  cerebral  meningitis, 
although  vision  is  sometimes  impaired ;  irregularities  of  the  pupil  and  strabis- 
mus, with  oscillation  of  the  globe,  are  usually  present  in  minor  degree,  but 
intense  photophobia  is  rarely  a  marked  symptom.  Deafness  is  quite  common, 
and  may  be  permanent ;  in  many  cases  it  is  due  rather  to  inflammation 
extending  to  the  labyrinth  and  middle  ear  than  to  direct  lesion  of  the  auditory 
nerve. 

Optic  neuritis  is  present  in  most  instances  when  vision  is  aifected,  and  may 
terminate  in  permanent  blindness  in  cases  that  recover.  Keratitis,  retinitis, 
opacity  and  ulcerations  of  the  cornea,  and  opacity  of  the  lens  may  all  occur, 
but  are  not  characteristic.  Pain  is  invariably  present,  especially  in  the  occipi- 
tal and  cervical  regions,  and  is  associated  with  general  cutaneous  hyper- 
aesthesia  ;  all  movements  of  the  patient  occasion  sufl"ering,  associated  with  rigid- 
ity of  the  spinal  extensor  muscles,  sometimes  affecting  also  the  muscles  of  the 
chest,  abdomen,  and  jaws,  producing  a  sense  of  constriction  and  slight  trismus. 
This  hyperaesthesia  and  muscular  contraction  is  probably  due  to  the  involve- 
ment of  the  roots  of  the  spinal  nerves  in  the  inflammatory  process. 

The  retracted  neck  and  back,  at  times  amounting  to  decided  opisthotonos, 
is  in  part  voluntary,  due  to  a  disposition  to  relax,  as  far  as  may  be,  irritable 
muscles  (Radcliff"e) ;  in  part  reflex,  from  irritation  of  the  sensitive  fibres  of  the 
posterior  roots  distributed  to  the  pia ;  and  in  part  from  direct  irritation  of  the 
anterior  nerve-roots,  or  to  all  these  combined.     When  the  patient  is  perfectly 


SIMPLE    GEREBBO-SPINAL   MENINGITIS.  607 

at  rest,  considerable  intervals  of  almost  complete  relaxation  exist,  but  all  efforts 
to  restore  the  normal  decubitus  are  commonly  attended  with  recurrence  of  the 
abnormal  position  and  rigidity.  Most  intense  pain  in  the  head  and  cervical 
region  is  an  early  and  continuous  symptom ;  it  seldom  entirely  intermits,  but 
severe  exacerbations  are  of  frequent  occurrence.  Pain  in  the  back  and  loins 
is  often  present — always  when  the  lower  segment  of  the  cord  is  invaded.  The 
thighs  are  flexed  upon  the  pelvis  and  the  legs  upon  the  thighs.  Firm  pressure 
over  the  spinal  column  does  not  occasion  pain,  a  point  of  distinction  between 
meningitis  and  spinal  irritation.  Local  paralysis  with  facial  distortion  is  not 
infrequently  present,  and  in  the  later  stage  the  patient  may  become  hemi- 
plegic,  which  usually  implies  the  extension  of  the  trouble  to  the  substance  of 
the  brain  or  cord.  Active  delirium  generally  exists,  sometimes  as  an  early 
symptom,  occasionally  associated  with  convulsions,  frequently  ending  in  coma. 
Reflex  irritability  is  always  present  in  the  early  stage,  but  is  less  marked  than 
in  tetanus. 

Vomiting  is  a  troublesome  symptom  in  most  cases,  and  is  difficult  to  con- 
trol. The  vomit  consists  of  ingesta,  bile,  or  a  glairy  greenish  fluid.  The 
bowels  are  usually  constipated  and  the  abdomen  retracted,  but  diarrhoea 
not  infrequently  occurs,  with  tympany.  Whilst  this  paper  is  in  progress 
the  writer  is  attending  a  case  of  well-marked  sporadic  meningitis  in  which 
diarrhoea  induced  by  purgation  continues,  together  w4th  decided  tympanites. 
The  tongue  presents  nothing  characteristic.  It  may  be  unchanged,  slightly 
furred,  or  covered  with  sordes  in  the  last  stage.  Appetite  is  no  doubt  impaired, 
but  the  desire  for  food  is  controlled  in  a  measure,  owing  to  the  trismus  and 
cervical  contracture  which  efforts  at  swallowing,  together  with  the  necessary 
movements,  induce.  Thirst  is  an  invariable  symptom  and  is  with  difficulty 
appeased. 

Pyrexia  is  present  to  a  very  variable  extent ;  it  may  be  scarcely  appreciable, 
or  it  may  range  as  high  as  105°  and  106°  F.,  and  in  the  last  stage  is  usually 
highest. 

With  pyrexia  the  usually  febrile  pulse  and  respiration  are  associated,  but 
marked  dyspnoea  may  be  superadded  from  paralysis  or  rigidity  of  respiratory 
muscles  when  the  dorsal  region  of  the  cord  is  included  in  the  inflammation.  In 
cases  complicated  with  pneumonia  additional  respiratory  difficulty  may  be  due 
to  this  cause ;  this  is,  however,  a  rare  complication  except  in  the  epidemic 
form.  The  pulse  is  almost  always  quickened,  ranging  from  80  or  90  to  120, 
and  in  the  first  stage  may  have  considerable  tension,  which  is  lost  at  an  early 
period,  a  diminished  arterial  tension  being  one  of  the  characteristic  features  of 
the  disease.  Very  much  more  frequent  pulse  is  recorded,  and  at  times  it  falls 
as  low  as  50,  but  these  instances  are  altogether  exceptional.  The  kidneys 
rarely  show  any  distinct  lesion,  but  the  urine  is  often  increased  in  quantity, 
and  occasionally  contains  a  small  amount  of  albumin.  Retention  of  urine 
from  spasm  of  the  sphincters  or  paralysis  of  the  detrusor  muscles  is  sometimes 
associated  with  reflex  spasm  and  irritable  attempts  to  urinate.  Involuntary, 
not  necessarily  unconscious,  voiding  of  urine  and  fgeces  also  happens. 

Diagnosis. — The  positive  indications  of  simple  cerebro-spinal  meningitis 
have  already  been  mentioned.  Briefly  stated,  they  are  headache,  pain  in  neck, 
back,  and  loins,  with  general  cutaneous  hypersesthesia,  exaggerated  sensibility 
to  light  and  sound,  irregular  pupils,  oscillations  and  distortions  of  the  eyeball, 
followed  at  times  by  blindness  and  deafness,  paralysis  of  cranial  or  spinal 
nerves,  delirium,  convulsions,  and  coma;  vomiting  without  apparent  gastric 
cause,  obstinately  persisting ;  trismus  and  cervical  contractures  which  may 
extend  to  nearly  all  the  muscles  of  the  body ;  pyrexia  of  inconstant  degree, 


608    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  respiratory  labor  of  varying  and  uncertain  extent.  From  the  epidemic 
form  it  is  to  be  distinguished  by  its  sporadic  occurrence,  its  less  rapid  progress, 
its  perhaps  more  extensive  involvement  of  the  spinal  membranes,  its  usually 
less  acute  course,  and  the  comparatively  infrequent  cutaneous  lesions,  espe- 
cially of  purpuric  or  hoemorrhagic  chai-acter.  It  probably  is  more  frequently 
causally  related  to  local  troubles  of  eye  and  ear,  bone  lesions,  trauma,  and 
sepsis.  Perhaps  if  a  clear  distinction  is  to  be  permanently  maintained  between 
the  simple  and  epidemic  forms,  it  will  come  to  rest  on  the  absence  of  the 
diplococcus  lanceolatus  in  the  former  and  its  presence  in  the  latter. 

With  typhoid  fever  it  may  be  confounded,  but  the  distinction  is  not  diffi- 
cult. The  severe  persistent  headache  and  spinal  pain,  the  cutaneous  hyperes- 
thesia, the  exaijrorerated  sensibility  of  special  senses,  trismus,  muscular  contrac- 

*  •  111  at 

tures,  uncontrollable  vomiting,  constipation, — all  early  symptoms, — are  suffi- 
cient for  diagnosis  before  the  later  symptoms  of  each  make  error  impossible. 

With  tetanus  it  has  little  in  common  but  retraction  of  the  head  and  slight 
opisthotonos,  trismus,  and  thoracic  constriction.  In  meningitis  the  back  is 
less  bowed,  less  rigid,  and  the  contracture  less  easily  induced ;  the  trismus  is 
seldom  severe,  often  wanting,  and  rarely  persists,  Avhilst  in  tetanus  a  touch  or 
a  breath  of  air  induces  rigid  opisthotonos,  and  trismus  is  an  early,  severe,  and 
persistent  symptom.  In  doubtful  cases,  if  any  such  occur,  the  detection  of  the 
micro-organism  of  tetanus  will  resolve  the  doubt. 

Cases  of  tubercular  origin  are  to  be  distinguished  alone  by  the  invasion  of 
other  organs  and  by  the  family  history,  a  more  protracted  course  and  an  initial 
period  of  latency,  with  a  less  acute  career. 

Prognosis. — This  is  always  grave,  but  a  ffiir  proportion  of  sporadic  cases 
recover  under  judicious  treatment.  When  the  symptoms  relate  chiefly  to  the 
cord,  a  reasonable  hope  may  be  entertained,  but  when  paralysis  of  cranial 
nerves,  stupor,  Cheyne-Stokes  respiration,  coma,  and  collapse  occur,  the  issue 
is  no  longer  uncertain.  In  some  instances  death  has  ensued  in  five  hours,  in 
from  twenty-four  to  thirty-six  hours  not  infrequently,  but  this  has  always  been 
in  fulminant  cases,  which  are  rare  in  the  simple  form.  In  sporadic  cases  life 
may  be  protracted  several  weeks,  and  in  subacute  cases  sometimes  many 
months ;  the  usual  period  is  about  from  ten  to  tAventy  days.  Cases  that 
recover  are  of  longer  duration  than  those  that  terminate  fatally,  but  even  in 
favorable  cases  the  patient  may  be  maimed  for  life,  blind,  deaf,  paralytic,  or 
with  intelligence  permanently  impaired.  In  young  children  and  in  adults  near 
middle  age  the  mortality  is  greater  than  in  youth. 

Death  may  be  due  to  asthenia  from  continued  suffering,  bed-sores,  and 
inability  to  partake  of  food ;  or  it  may  be  more  rapidly  induced  by  respiratory 
difficulty  from  involvement  of  the  respiratory  centre,  or  by  associated  pneu- 
monia ;  or  convulsions  may  be  followed  by  coma,  collapse,  and  speedy  death. 

Treatment. — The  same  treatment  advised  in  cerebral  meningitis  is  advisa- 
ble  in  cerebro-spinal  meningitis — /.  e.  perfect  rest,  exclusion  of  light  and  noise, 
of  visitors,  and  all  causes  of  disturbance;  removal  of  the  cause  when  known 
and  practicable ;  the  occasional  use  of  a  brisk  mercurial  or  other  purge ;  liquid 
food  and  stimulants  administered  per  rectum  if  not  retained  by  the  stomach  ; 
free  and  continued  use  of  cold  to  the  shaven  head  and  back — ice  preferred ; 
the  careful  but  efficient  use  of  anodynes,  of  Avhich  opium  and  its  derivatives 
are  best,  and  in  the  early  stage  such  remedies  as  the  iodide  and  bromide  of 
potassium  with  ergot.  When  the  affection  is  chiefly  or  wholly  spinal,  Bramwell 
speaks  in  terms  of  high  commendation  of  the  iodide,  and  of  ergot  in  the  second 
stage,  and  also  of  the  use  of  blisters  and  of  tincture  of  iodine  applied  along  the 
spine  in  the  region  implicated.     Pain,  cutaneous  hyperesthesia,  and  muscular 


SIMPLE    CEBEBBO-SPINAL   MENINGITIS.  609 

contractures  indicate  sufficiently  clearly  the  site  of  the  inflammation  "by  the 
correspondence  of  these  symptoms  with  the  distribution  of  the  nerves  whose 
roots  are  affected;  attention  to  the  bladder  and  rectum  is  of  course  always 
requisite.  Paralyses  may  require  special  measures  in  accordance  with  the  com- 
mon rules  of  treatment,  but  Bramwell  suggests  caution  in  the  use  of  electrical 
stimulation  during  the  period  of  meningeal  irritability. 

39 


TUBERCULOUS  MENmGITlS. 

By   JAMES   HENDRIE   LLOYD,  A.  M.,  M.  D., 

Philadelphia. 


Tuberculous  meningitis  is  an  inflammation  of  the  membranes  of  the 
brain  due  to  the  specific  action  of  the  tubercle  bacillus.  It  is  characterized 
by  the  formation  of  tubercles  in,  and  an  inflammation  of,  the  pia  arachnoid, 
Avith  eff'usion  at  the  base  of  the  brain ;  by  some  secondary  cerebritis,  and  even 
softening  of  the  brain-substance ;  and  by  eff'usion  into  the  ventricles. 

Etiology. — The  essential  cause  of  tuberculous  meningitis  is  of  course  the 
bacillus  of  tubercle,  first  demonstrated  by  Koch.  In  the  vast  majority  of 
instances — probably  in  all  cases,  in  fact — the  infection  of  the  brain-mem- 
branes is  secondary  to  a  primary  infection  in  some  other  part  of  the  body. 
This  primary  infection  may  be  in  the  mesenteric  or  bronchial  glands,  in  chronic 
ear  disease,  or  in  some  other  bone  disease,  such  as  spinal  caries  or  tuberculous 
disease  of  the  hip-joint.  It  is  not  uncommon  in  these  cases  to  find  tuber- 
culous infection  also  beginning  m  the  lungs,  or  even  in  the  spleen  and  kid- 
neys. In  some  of  these  latter  instances,  however,  the  infection  is  possibly  not 
primary,  but,  as  in  .the  case  of  the  meninges,  secondary.  Thus  in  a  number 
of  cases  seen  by  me  at  the  Home  for  Crippled  Children  the  patients  had  had 
long-standing  chronic  disease  of  bone,  and  the  infection  of  the  lung-tissue,  as 
well  as  of  the  brain-membranes,  was  evidently  secondary  and  recent. 

Heredity  is  a  predisposing  factor,  just  as  it  is  in  all  forms  of  tuberculous 
infection.  In  many  cases  it  is  possible  to  elicit  a  family  history  of  tubercu- 
losis, and  in  cases  in  which  this  family  history  cannot  be  traced  there  is 
always  a  justifiable  suspicion  of  it.  It  cannot  be  denied,  however,  that  tuber- 
culous infection  of  the  membranes  of  the  brain,  as  well  as  of  .other  organs, 
may  occur  in  rare  instances  in  patients  in  whom  there  is  no  hereditary  pre- 
disposition to  it.  As  the  disease  is  due  to  the  invasion  of  a  bacterium,  it 
might  possibly  occur  in  a  person  whose  family  history  showed  no  trace  of  it. 
Among  predisposing  causes  age  is  undoubtedly  the  most  important.  The 
great  majority  of  cases  occur  in  children.  The  disease  is  most  frequent  be- 
tween the  ages  of  two  and  seven  years.  Its  frequency  diminishes  rapidly 
after  the  fifteenth  year.  It  is  a  comparatively  rare  disease  in  adult  life, 
although  it  is  possibly  rather  more  frequent  in  long-standing  cases  of  pul- 
monary tuberculosis  than  is  generally  supposed.  Some  of  the  brain-symp- 
toms, for  instance,  occasionally  seen  in  phthisis  are  no  doubt  due  to  infec- 
tion of  the  meninges.  This  complication  may  readily  be  overlooked  at  the 
autopsy,  at  which  time  attention  is  apt  to  be  directed  too  exclusively  to  the 
thoracic  and  abdominal  organs. 

Sex  is  not  an  important  factor  in  predisposing  to  tuberculous  meningitis. 
Boys  are  usually  supposed  to  furnish  a  rather  larger  number  of  cases  than 
girls.  Trauma  has  not  been  satisfactorily  demonstrated  to  be  an  exciting 
cause. 


610 


TUBEBCUL O  US  MENINGITIS.  611 

This  disease  is  usually  supposed  to  attack  by  preference  weakly  and  deli- 
cate children,  but  this  can  readily  be  explained  by  the  fact,  already  stated, 
that  it  rarely  if  ever  occurs  except  as  a  secondary  infection,  and  consequently 
only  in  those  cases  in  which  the  health  has  already  been  impaired  by  an 
infection  of  some  other  organ  by  the  tubercle  bacillus. 

In  searching  for  a  cause  of  tuberculous  meningitis  in  any  given  case  the 
utmost  care  must  be  exercised  to  determine,  if  possible,  the  existence  of  a 
focus  of  tubercle  in  some  other  organ.  This  may  readily  be  overlooked  by  a 
careless  observer.  A  few  broken-down  bronchial  glands,  a  small  unabsorbed 
patch  from  a  precedent  pneumonia,  an  uncured  otitis  media,  or  a  small  focus 
of  caries  in  a  bone  may  have  been  the  starting-point  for  the  infection. 

Symptoms. — Tuberculous  meningitis  is  usually  described  as  a  disease 
of  progressive  stages.  This  is  rather  an  arbitrary  or  artificial  method  of 
description,  and  will  only  be  utilized  here  after  a  full  description  of  the 
various  symptoms  in  detail.  While  it  is  true  that  the  disease  does  in 
many  instances  present  more  or  less  characteristic  stages,  such  as  onset, 
progress,  and  termination,  yet  cases  vary  amongst  themselves  so  widely  in 
this  respect  that  it  seems  better  to  present  the  individual  symptoms  before 
attempting  to  group  these  into  anything  like  a  classical  type.  After  these 
symptoms  have  been  fully  described  they  can  be  presented  as  they  are  usually 
found  associated  at  the  bedside. 

The  symptoms  of  tuberculous  meningitis  are  initial  decline  in  health, 
headache,  vomiting,  constipation,  convulsions,  slow  and  irregular  pulse,  a 
variable  temperature,  emaciation,  mental  changes,  delirium  passing  into 
stupor  and  coma,  optic  neuritis,  and  various  palsies,  aifecting  not  only  the 
limbs,  but  also,  and  most  especially,  the  ocular  muscles,  and  frequently  the 
muscles  supplied  by  other  cranial  nerves. 

The  initial  decline  in  health  so  frequently  seen  in  tuberculous  meningitis 
may  be  considered  as  its  only  true  prodrome.  As  already  explained,  it  is 
usually  due  to  the  fact  that  the  patient  is  already  suffering  from  some 
primary  tuberculous  infection.  This  may  be  present  in  caseating  glands  or 
in  a  focus  of  tuberculous  bone-disease,  such  as  otitis  media  or  spinal  caries. 
The  decline  in  health,  in  fact,  is  probably  rather  due  to  this  primary  infec- 
tion than  to  the  involvement  of  the  brain-membranes.  When  this  latter 
occurs  the  characteristic  symptoms,  in  some  form  or  other,  such  especially  as 
headache  and  vomiting,  usually  soon  manifest  themselves.  Thus  the  initial 
impairment  of  health  probably  indicates  merely  that  the  patient's  system  is 
beginning  to  offer  less  resistance  to  the  tuberculous  invasion,  and  this  dimin- 
ished resistance  is  the  immediate  cause  for  the  determination  of  the  infection 
to  the  brain-membranes.  In  very  many  cases,  however,  the  onset  of  tuber- 
culous meningitis  is  rather  abrupt,  a  period  of  initial  ill-health  being  en- 
tirely absent  or  so  slight  as  to  escape  observation.  In  such  instances  the 
true  significance  of  the  earlier  symptoms,  such  as  headache,  vomiting,  and 
slight  mental  changes,  may  be  entirely  overlooked,  these  symptoms  being 
attributed  to  some  other  disorder,  especially  gastric  or  intestinal  derange- 
ment. This  initial  ill-health,  when  it  occurs,  varies  so  much  that  it  is  difii- 
cult  of  description.  It  may  consist  of  fluctuations, of  temperature,  impairment 
of  appetite  and  assimilation,  loss  of  flesh,  asthenia,  and  slight  mental  phe- 
nomena, such  especially  as  irritability,  peevishness,  and  unprovoked  explo- 
sions of  ill-temper.  The  child  under  these  circumstances  is  noted  by  the 
parents  and  attendants  to  be  losing  ground ;  the  physician's  advice  is  asked, 
and  the  cause  for  the  obvious  failure  of  health  may  be  sought  for  dur- 
ing a  short  period  in  vain.     In  such  cases  the  onset  of  the  characteristic 


612     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

symptoms  of  tuberculous  meningitis  ma}*  be  insidious  and  deceptive  in  the 
extreme.  Slight  headache  may  occur,  and  this  in  young  children  is  not 
always  easily  recognized.  Gastro-intestinal  symptoms  may  begin  to  present 
themselves,  such  as  occasional  vomiting  and  more  or  less  persistent  constipa- 
tion, and  the  meaning  of  these  may  be  entirely  misconstrued.  In  such  a 
case  a  convulsion  may  be  the  first  grave  symptom  to  attract  the  physician's 
attention  and  to  arouse  his  suspicions. 

Headache  is  usually  a  very  early  symptom  in  tuberculous  meningitis,  and 
one  of  the  most  persistent  and  characteristic.  In  very  young  children,  as 
already  said,  it  may  not  be  easily  recognized.  Its  presence  may  be  suspected 
from  an  occasional  sharp  cry  of  pain,  especially  when  the  child  is  moved  or 
disturbed.  The  patient  may  indicate  its  presence  also  by  movements  of  the 
hands  toward  the  head,  by  dread  of  light,  and  by  a  disposition  to  remain 
abnormally  quiet  and  apathetic.  The  peculiar  cry  of  the  child  suffering  with 
tuberculous  meningitis  has  been  noted  by  most  authors,  and  has  even  been 
named  the  hydrocephalic  cry.  It  is  probably  an  expression  of  severe  pain 
in  the  head,  and  is  so  characteristic  that  it  should  always  excite  suspicion. 
The  child  sometimes  gives  utterance  to  this  cry  in  the  midst  of  perfect 
calm  and  repose.  The  cry  then  has  a  sort  of  explosive  character,  and  is 
usually  piercing  and  harassing.  In  older  children  complaint  of  the  head- 
ache is  usually  an  early  symptom,  and  is  often  urgent  and  persistent.  The 
patient  seeks  the  dark,  dreads  to  be  disturbed,  and  often  begs  piteously  for 
relief.  In  some  few  cases,  however,  as  I  have  seen,  headache,  while  pres- 
ent, is  not  always  so  severe  and  prominent  in  the  early  stages.  On  close 
questioning,  how'ever,  the  presence  of  this  symptom  can  usually  be  deter- 
mined. The  child  says  that  its  head  aches,  and  will  often  raise  the  hand  to 
the  region  where  the  pain  is  most  intense.  It  is  not  unusually  referred  to  the 
frontal  region :  it  may,  however,  be  more  generally  diffused,  the  patient  being 
unable  to  state  accurately  just  where  it  is  most  severe.  This  is  partly  due, 
no  doubt,  to  the  inability  of  young  children  to  localize  and  describe  accu- 
rately their  subjective  symptoms.  The  headache  of  tuberculous  meningitis 
does  not  manifest  itself  only  during  the  waking  hours :  in  many  cases  it  is 
evidently  present  during  sleep,  and  the  nights  are  disturbed  by  an  occasional 
loud  and  agonizing  cry,  which  the  patient  emits  unconsciously.  This  hydro- 
cephalic cry,  with  its  peculiar  explosive  character,  occurring  during  sleep,  is 
especially  characteristic  and  suggestive.  Headache,  even  in  cases  in  which 
it  is  not  prominent  in  the  early  stages,  is  almost  sure  to  become  a  marked 
symptom  as  the  case  progresses.  It  is  not  always  disguised  even  by  the 
stupor  Avliich  eventually  comes  on. 

Vomiting  is  an  important  symptom  in  tuberculous  meningitis,  but  it  is 
one  the  true  significance  of  w'hich  is  often  overlooked  in  the  early  stages. 
It  is  frequently  unaccompanied  with  nausea,  and  may  then  be  propulsive 
or  spontaneous  in  character.  It  is  one  of  the  most  constant  symptoms  of 
the  disease,  and,  as  a  rule,  is  more  marked  in  the  early  than  in  the  later 
stages.  Barrier,  quoted  by  Meigs  and  Pepper,  found  it  absent  in  only  15 
out  of  80  cases.  Sometimes,  in  fact,  the  vomiting  is  the  first  really  well- 
marked  symptom  of  the  disease.  In  these  cases  it  may  be  so  persistent  as 
to  lead  to  the  belief  that  it  is  caused  by  some  obstinate  gastric  or  gastro- 
intestinal disorder.  Thus  in  one  case,  the  history  of  which  I  know,  the 
vomiting  led  to  a  diagnosis  of  cholera  morbus,  which  was  rendered  more 
plausible  by  the  fact  that  the  boy,  aged  about  eight  years,  had  had  a  few 
loose  stools  and  that  the  case  occurred  in  midsummer.  This  patient  was 
hurried  to  the  seashore,  and  a  true  diagnosis  was  not  made  until  the  onset 


TUBERCULOUS  MENINGITIS.  613 

of  stupor,  accompanied  by  convulsions,  indicated  clearly  the  true  nature 
of  the  disease.  In  the  later  stages  of  tuberculous  meningitis  the  vomiting 
may  gradually  disappear.  This  symptom  is  supposed  to  depend  upon  irrita- 
tion of  the  roots  or  intracranial  trunk  of  the  pneumogastric  nerve.  It  is  not 
such  a  common  symptom  in  meningitis  from  other  causes  at  the  convexity  or 
other  regions  of  the  brain  where  the  vagus  is  not  involved.  In  most  cases 
the  vomiting  is  not  continuous,  but  occurs  in  paroxysms  not  more  frequently 
than  two  or  three  times  a  day.  It  usually  takes  place  without  warning  and 
without  nausea,  and  thus  has  the  essential  characteristics  of  cerebral  vomit- 
ing. It  occurs  independently  of  the  presence  of  food  in  the  stomach,  and  the 
matters  vomited  are  merely  such  as  happen  at  the  time  to  be  in  that  viscus. 
Occasionally,  indeed,  there  is  little  if  any  food  in  the  stomach,  and  the 
material  rejected  is  merely  a  little  fluid  or  mucus. 

Constipation  is  very  rarely  absent  in  tuberculous  meningitis.  It  is  regarded 
by  some  observers  as  even  more  important  than  vomiting  as  a  symptom  of  thi^ 
disease.  It  is  sometimes  so  aggravated  and  obstinate  that  the  wonder  is  that 
its  significance  should  be  mistaken.  In  combination  with  the  early  headache 
and  vomiting  it  forms  a  group  of  symptoms  that  should  be  unmistakable. 
This  association  of  vomiting  with  obstinate  constipation  gives  a  peculiar 
aspect  to  these  cases,  which  is  entirely  different  from  what  would  be  seen 
if  the  symptoms  were  due  to  gastro-intestinal  irritation.  This  distinc- 
tion is  still  further  emphasized  by  the  fact  that  in  tuberculous  meningitis 
there  is  great  retraction  of  the  abdomen.  The  scaphoid  belly,  associated 
with  obstinate  constipation,  is  seen  in  the  majority  of  cases  of  tuberculous 
meningitis.  When  present- it  is  a  symptom  that  can  always  be  relied  upon, 
although  its  absence  is  not  necessarily  a  sign  that  tuberculous  meningitis 
is  not  present.  Constipation,  as  a  rule,  is  not  a  very  early  symptom  of  the 
disease ;  at  least,  it  is  not  conspicuous  until  the  lapse  of  a  number  of  days. 
For  the  first  few  days  it  may  naturally  attract  but  little  attention  or  may  be 
thought  to  be  due  to  some  trifling  or  temporary  cause.  It  is  exceedingly 
intractable  to  drugs,  and  in  some  cases  there  may  be  great  difficulty  in 
securing  a  movement  of  the  bowels.  The  cause  of  this  symptom  has  not 
been  accurately  determined.  It  is  possibly  due  to  involvement  of  the  pneumo- 
gastric nerve. ^ 

Convulsions  are  rarely  absent  at  some  stage  of  tuberculous  meningitis. 
There  is  no  positive  law,  however,  about  their  occurrence.  As  already  said, 
a  fit  is  not  usually  an  initial  symptom  of  the  disease.  It  may,  however,  be 
the  first  symptom  to  arouse  the  suspicion  of  the  practitioner.  I  have  known 
of  cases  in  which  the  correct  diagnosis  was  not  made  until  the  occurrence  of 
a  convulsion.  As  a  rule — to  w^hich,  however,  there  are  some  exceptions — 
convulsions  do  not  occur  in  the  first  stage  of  tuberculous  meningitis.  They 
usually  do  not  appear  until  there  is  some  slight  evidence  of  involvement  of 
the  psychical  faculties,  such  as  is  shown  by  apathy,  drowsiness,  or  even 
stupor.  Hence  it  may  be  said  that  convulsions  do  not  occur  much  before  the 
middle  or  end  of  the  second  week.  The  intensity  and  frequency  of  these  con- 
vulsions vary  greatly  in  diff'erent  cases.  In  some  there  may  be  but  one,  two, 
or  three  seizures  during  the  whole  course  of  the  disease,  and  these  may  occur 
at  intervals  of  some  days.  In  others  the  attacks  are  more  frequent.  The  indi- 
vidual seizures  vary  also  in  their  intensity  and  duration.  Sometimes  the  con- 
vulsive attack  is  distinctly  focal  in  character — i.  e.  it  may  be  confined  to  a  few 

^  According  to  Landois  and  Sterling,  stimulation  of  the  vagus  increases  the  movements  of 
the  small  intestine.  Hence  we  might  infer  that  the  obstinate  constipation  seen  in  tuberculous 
meningitis  is  an  evidence  of  paralysis  of  the  pneumogastric  nerve. 


614     AMERICAN   TEXT-BOOK   OF   DISEASES    OF   CHILDREN. 

muscles  or  muscle-groups ;  thus  tlie  muscles  of  the  eye,  eyelids,  or  face  may 
alone  be  involved,  or  may  be  involved  more  and  for  a  longer  time  than  the  mus- 
cles of  the  extremities.  This  is  due  probably  to  irritation  of  the  cortical  cen- 
tres that  preside  over  the  affected  muscles.  In  most  cases,  however,  the  con- 
vulsion is  general  and  accompanied  by  profound  unconsciousness,  and  may 
be  succeeded  by  a  long  period  of  coma.  In  some  instances  the  convulsive 
attack  is  more  marked  on  one  side  than  on  the  other,  and  in  these  there  may 
be  slight  paresis  of  the  affected  side  remaining  after  the  fit.  In  a  few- 
instances  convulsions  succeed  each  other  with  great  frequency,  so  that  the 
child  passes  rapidly  from  one  to  another,  and  may  even  present  a  condition 
not  unlike  epileptic  status.  In  this  state  the  temperature  rises  and  the 
danger  to  life  is  imminent.  It  is  not  unusual,  in  fact,  for  a  prolonged  con- 
vulsive seizure  to  be  the  immediate  cause  of  death. 

Alterations  in  the  circulation  are  very  common  in  tuberculous  menin- 
gitis. In  the  very  early  stages  there  is  simply  increased  rapidity  of  the 
pulse.  This  is  in  no  wise  characteristic,  and  therefore  may  simply  be  re- 
garded by  the  practitioner  as  an  indication  of  the  general  weakness  and  ill- 
health  into  Avhich  the  patient  is  passing.  Later,  however,  the  pulse  assumes 
an  entirely  different  character,  and  then  furnishes  one  of  the  most  striking 
symptoms  of  the  disease.  This  alteration  consists  in  a  slowing  and  irreg- 
ularity of  the  heart's  action.  The  pulse  falls  frefjuently  as  low  as  60,  and 
in  rare  instances  even  to  50  or  lower.  With  this  slowing  of  the  heart 
there  occurs  also  a  disturbance  of  the  rhythm  of  its  pulsation.  The  heart 
beats  irregularly,  the  intervals  between  its  pulsations  vary,  and  the  indi- 
vidual pulsations  also  vary  in  their  force.  ThuS  a  few  regular  rhythmical 
pulsations  of  even  force  may  be  followed  by  a  feeble  pulsation  at  a  longer  or 
even  shorter  interval  than  normal,  or  several  of  these  feeble  and  irregular 
beats  may  occur.  This  symptom  is  seldom  absent  in  tuberculous  meningitis. 
It  may  not,  however,  be  ecjually  apparent  at  all  times,  and  should  therefore 
be  watched  for  with  the  utmost  care.  If  the  physician  does  not  satisfy  him- 
self of  its  presence  during  his  visit,  he  should  instruct  the  nurse  or  attendant 
to  look  for  it  at  frequent  intervals  during  the  day.  If  he  finds  a  suspicious 
slowing  of  the  pulse,  he  should  especially  be  on  the  lookout  for  this  highly 
characteristic  irregularity.  Changes  of  posture  affect  the  pulse  under  these 
circumstances.  It  may  for  a  time  become  more  rapid,  and  then  be  followed 
by  a  period  of  slowing,  during  which  the  irregularity  may  be  noted.  The 
importance  of  this  symptom  is  very  great,  and  in  cases  otherwise  doubtful  it 
may  furnish  the  conclusive  sign  of  the  presence  of  the  disease.  It  is  probably 
not  seen  in  all  its  well-marked  characteristics  in  any  other  disease  of  child- 
hood. When  it  occurs  after  an  initial  period  of  headache,  vomiting,  and  con- 
stipation, even  though  no  convulsion  has  occurred,  it  may  be  regarded  as 
pointing  unerringly  to  the  diagnosis  of  tuberculous  meningitis.  Toward  the 
termination  of  the  disease  this  slowing  and  irregularity  of  the  heart  gives 
place  to  increased  frequency  and  feebleness.  The  pulse  then  rises  to  140, 
160,  or  even  higher,  and  toward  the  end  may  be  so  rapid  and  feeble  as 
scarcely  to  be  countable  at  all. 

The  temperature  in  tuberculous  meningitis  is  exceedingly  irregular.  In 
the  early  stages  it  fluctuates  from  normal  to  101°  or  102°  F.  Later  it  takes 
a  higher  range,  and  seldom  falls  to  the  normal  point.  It  cannot,  however, 
be  said  to  pursue  a  characteristic  range,  such  as  occurs  in  typhoid  fever. 
Toward  the  very  end  it  mounts  still  higher,  and  at  the  moment  of  death  may 
reach  104°  or  105°.  This  range  of  temperature  is  well  shown  in  the  accom- 
panying chart  from  the  case  of  a  girl  aged  eight  years  who  died  on  the  fif- 


TUBERCULOUS  MENINGITIS. 


615 


teenth  day  of  tlie  disease  (Fig.  1).  This  chart  shows  also  the  characteristic 
variations  in  the  pulse-rate.  On  some  days,  it  will  be  noted,  the  pulse  was 
as  low  as  80,  but  later  it  became  as  rapid  as  200.  In  some  few  cases  the  tem- 
perature, instead  of  mounting  toward  .death,  falls  to  an  abnormally  low  point. 
Thus  in  a  case  reported  by  Gee  the  temperature  on  the  day  of  death  fell  to- 
79.4°.  In  these  cases  the  breath  feels  cold  to  the  hand,  the  pulse  is  imper- 
ceptible at  the  wrists,  and  yet,  according  to  Gee,  the  appearance  of  the 
patient  is  very  misleading  and  may  even  resemble  that  of  a  healthy  child. 
In  my  observation  reduction  of  temperature  below  the  normal  point  in  the 
last  stages  of  the  disease  is  rather  rare.     It  was  well  shown  in  the  case  of  an 


Fig 

.  1. 

< 

z 

s 
f^ 

< 

z 

J 

< 

i 

S 

< 

z 

s" 

< 

i 

2 

< 

z 

s 

< 

^ 

< 

z" 

s 

E 

S 

S 

BOWELS 
NUMBER    OF 
MOVEMENTS 

1 

1 

1 

URINE 
DAILY   AMOUNT 

F. 

107° 
— > 
106° 

105° 

> 

104° 

103° 

103° 

101° 

100° 

99° 

-z. 

S 

"-i 

— 

• 

u. 

S" 

— 

r- 

0 

-Q- 

''■' 

0.1 

— 

0 

'- 

'" 

\- 

1 

\~ 

— 

LJI 

— 

— 

-<^ 

-5- 

— 

-^ 

lU 

^ 

.  cc 

-<- 

_l 

-<- 
-<- 

-<- 

-<■ 

"-J" 

-<- 

-<- 

<- 

= 

'n 

0 

' 

-I- 

-I- 

-<- 

-I- 

<- 

-<- 

-<- 

__J_ 

-<- 

r 

\ 

/ 

-1 

0 

-s- 

< 

D 

4- 

-/ 

R 

A 

\ 

/ 

/> 

1 

A 

1 

s 

/ 

\ 

i 

A 

,/ 

V 

V 

/ 

1 

\ 

/ 

V 

A 

/\ 

A 

j 

n 

h 

J 

v/ 

1 

, 

J 

f 

s, 

f 

, 

\ 

/ 

<i 

\ 

— 

V 

v 

^ 

Vi 

V 

PULSE 

102/' 
/80 

90  / 
/90 

104/ 
/82 

94/ 
/92 

10/" 

/lis 

112/ 
/28 

126/ 
/130 

124/ 
/18 

112X 

/^2 

124/ 
/08 

140/ 
/^18 

136/ 

200/ 
/102 

198/ 

/ 

RESP. 

20  / 
/21 

20/ 
/  20 

23/ 
/20 

23/ 
/23 

22/ 
/20 

28/ 
/28 

30  / 
/38 

40/ 
/24 

28    /" 
/32 

28  Z' 
/20 

32  /^ 
/48 

44/ 
/28 

60  / 

/eo 

56/ 
/62 

58/ 

DATE 

6 

7 

8 

9 

10 

11 

12 

13 

11 

c. 


-41" 


-40° 


-39° 


-37 


L-36" 


NOV. 
Temperature  Chart  from  a  Case  of  Tuberculous  Meningitis  (Methodist  Hospital). 


Italian  girl  aged  ten  years  who  died  recently  in  the  nervous  wards  of  the 
Philadelphia  Hospital  (Fig.  2).  While  the  range  of  temperature  in  tuber- 
culous meningitis  is  not  characteristic,  still  a  careful  study  of  it  in  doubtful 
cases  is  of  the  first  importance.  This  is  so  especially  in  cases  in  which  it  is 
necessary  to  make  a  differential  diagnosis  between  this  disease  and  either 
typhoid  fever  or  tumor  of  the  brain.  The  very  irregularity  serves  to  exclude 
typhoid  fever,  and  the  extreme  fluctuations  are  unlike  anything  that  is  seen, 
as  a  rule,  in  cases  of  tumor  of  the  brain. 

The  mental  changes  occurring  in  tuberculous  meningitis  are  not  without 
significance,  especially  in  the  early  stages.     Most  authors  speak  of  these 


616     AMEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


changes  as  being  in  some  degree  characteristic.  A  very  early  change  in 
tone,  as  it  were,  of  the  patient's  mind  may  be  observed,  especially  bv  those 
to  whom  the  child  is  well  known,  as  parents  and  nurses.  In  addition  to  the 
peevishness  and  fretfulness  not  uncommonly  seen  in  ailing  children,  the 
patient  with  tuberculous  meningitis  not  unfrequently  gives  vent  to  sudden 
and  even  uncalled-for  explosions  of  ill-temper.  In  very  little  children  this 
symptom,  associated  with  evidences  of  headache,  fluctuations  of  temperature, 
vomiting,  and  constipation,  may  be  of  some  value  in  helping  to  a  diagnosis. 
On  the  other  hand,  these  children  sometimes  in  the  early  stages  become 
unusually  quiet  and  apathetic.  They  appear  to  be  in  a  dream-like  state,  or. 
as  Meigs  and  Pepper  have  well  called  it.  a  state  resembling  mild  ecstasy.    In 


Fig.  2. 


C. 


F. 

m' 

103° 

102' 

101' 

0 
100 

99° 

1 

"" 

■~" 

T" 

"T" 

^ 

r- 

~ 

1 

£ 

1 

1 

1 

! 

1 

1 

] 

1 

' 

!    f 

^. 

1 

1 

1 

1 

1 

Z 

1 

; 

1 

1 

1 

1 

1    :  1 

, 

II 

I 

1 

1 

1 

1 

lO 

t- 

* 

1 

— 

1 

1 

■ 

' 

—39' 

I 

1 

1 

1 

1 

I 

1 

I 

1 

A 

f- 

1 

1 

( 

/I 

1 

F 

1 

\\ 

CO 

' 

1 

1  ( 

1 1 

! 

j 

1 

/  1 

1 

; 

; 

'  ■ 

1 

I 

1 

A 

. 

-E" 

1 

/ 

\ 

- 

/I 

) 

1 

-^' 

f 

\ 

/ 

j 

0     1 

1 

1 

1 

V 

I 

r 

"■ 

' 

^ 

1 

1 

V, 

I 

/ 

0 

-|- 

w   / 

1 

u 

1 

f  s 

1 

/ 

'1 

— ^0 

\ 

I 

1 

1 

'^ 

' 

\ 

1 

0 

-= 

1 

Jl 

! 

\ 

1 

/\ 

- 

\| 

ri 

• 

'  0 

I 

/  \ 

1 

u 

\ 

1 

j    I 

'-* 

-3f 

1 

m 

•^ 

1 

/     \ 

" 

CN 

I 

f      1 

■ 

98 
96° 

p 

1 

\ 

J 

c 

- 

1 

.    / 

^^ 

■ 

0 

I 

/ 

t 

[ 

— 

• 

1 

i  / 

I 

tz 

1 

1 

-' 

E 

f 

k 

0 

'fc 

c  1 

\*^ » 

, 

;  Q. 

' 

■  j 

UA 

—S^ 

1 

- 

i"^ 

lo/— 

/ 

I 

' 

1 

1 

1    4 

-V 

_s 

: 

1 

1  1 

, 

1/ 

1 

1 

; 

\ 

y 

V 

1 

"1 

*i 

Pulse 

so 

I'^t 

'''-'. 

c2  ,-- 

100 
120 

110/ 

/HO 

102/ 

90/ 
X80 

so/ 

/S(2 

90/ 
X82 

74/ 

/92 

102/ 

/88 

IW/ 

y^ 

—35° 

Respiration 

16/ 
/20 

20/ 
X22 

/20 

/20 

% 

24/ 

/1\ 

32  y 

24/ 
/24 

24/ 
/26 

36  y 

/30 

30  / 
/30 

44/ 

/ 

Date 

17  18 

19 

20 

21 

22 

23 

21 

25 

26 

27 

Temperature  Chart  from  a  Case  of  Tuberculous  Meningitis,  showing  subnormal  temperature  (Philadel- 
phia Hospital). 

this  condition  their  thoughts  seem  wandering  and  far  away,  and  a  distinct 
impression  must  be  made  to  recall  the  child's  attention  to  itself  or  its  sur- 
roundings. From  this  condition  it  is  but  a  step  to  true  delirium,  somnolence, 
and  stupor. 

As  a  rule,  the  intellectual  faculties  are  not  seriously  involved  in  the  early 
stages  of  tuberculous  meningitis.  The  child  does  not  pass  into  delirium  and 
stupor  until  well  on  in  the  second  week.  Exceptions,  of  course,  may  occur 
according  to  the  activity  and  extent  of  the  infection  of  the  brain-membranes 
and  to  the  resistive  power  of  the  child.  In  a  few  cases,  for  instance,  some 
delirium  or  mild  wandering  of  the  thoughts  occurs  in  the  very  early  stages, 
particularly  when  the  headache  is  intense,  and  more  especially  on  waking. 
Raving  delirium,  however,  is  not  common.     In  fact,  the  most  conspicuous 


TUBERCULOUS  MENINGITIS.  617 

mental  change  is  somnolence  with  a  tendency  to  pass  into  a  stupor  or  a 
soporose  state.  In  this  state  the  child  will  often  lie  quiet  and  uncomplain- 
ing for  hours,  making  known  few  if  any  of  its  wants.  Occasionally,  it  will 
utter  the  cry  of  pain  indicative  of  headache,  although  th-is  tendency  dimin- 
ishes as  the  disease  advances.  Still,  the  child  can  be  roused,  although,  as  a 
rule,  it  dislikes  exceedingly  to  be  disturbed,  and  cries  out,  resists,  and  gives 
evidence  of  pain  in  the  head  and  of  dread  of  light.  It  will  usually,  however, 
with  a  little  urging,  respond  to  questions  and  do  as  it  is  bidden.  Thus  it  will 
put  out  its  tongue  and  take  medicine  or  food.  As  the  case  advances,  however, 
the  stupor  increases  and  it  becomes  more  and  more  difficult  to  excite  the  child's 
mental  reflexes.  Long,  loud,  and  repeated  urging  is  necessary  to  induce  the 
child  to  respond.  Finally,  after  some  days  of  such  slow  and  gradual  progress 
that  it  is  difficult  to  establish  the  limits  of  the  various  steps,  the  condition 
passes  into  one  of  profound  coma,  from  which  the  child  never  rouses.  This 
terminal  coma  is  sometimes  of  rather  unexpected  length.  When  it  is  once 
deeply  established  it  is  usually  associated  with  such  well-marked  symptoms 
of  failing  vitality,  such  as  rapid  pulse,  emaciation,  and  shallow  respirations, 
that  the  attendants  are  inclined  to  anticipate  speedy  dissolution ;  but  this 
expectation  is  not  always  realized.  Patients,  for  instance,  who  seem  scarcely 
able  to  live  over  twenty-four  hours  will  sometimes  linger  for  a  period  of  days 
or  even  a  week  or  more. 

Various  palsies,  especially  of  the  muscles  supplied  by  some  of  the  cranial 
nerves,  are  encountered  in  tuberculous  meningitis.  The  muscles  of  the  eye 
are  most  frequently  affected.  Thus  a  very  common  symptom  is  strabis- 
mus, due  to  a  palsy  of  some  of  the  orbital  muscles.  There  may  be,  for 
instance,  an  internal  strabismus,  due  to  paralysis  of  the  sixth  nerve,  or  an 
external  strabismus  with  ptosis  and  dilatation  of  the  pupil,  from  paralysis 
of  the  third  nerve.  Inequality  of  the  pupils,  in  fact,  is  a  very  constant 
symptom  in  this  disease,  but  it  is  not  necessarily  associated  with  the  evi- 
dences of  paralysis  of  the  trunk  of  the  third  nerve.  It  is  sometimes  due,  no 
doubt,  to  an  involvement,  by  pressure  or  otherwise,  of  the  nuclei  presiding 
over  the  iris — i.  e.  the  foremost  nuclei  of  the  third  nerve  beneath  the  anterior 
portion  of  the  aqueduct  of  Sylvius  and  in  the  wall  of  the  third  ventricle. 
Of  other  cranial  nerves  involved,  the  commonest  are  probably  the  seventh 
and  the  tenth.  Facial  paralysis  or  paresis  is  occasionally  seen.  The  slow 
and  irregular  action  of  the  heart  is  possibly  due  to  some  involvement  of  the 
roots  of  the  tenth  or  pneumogastric  nerve.  Unilateral  paralysis  of  the 
tongue,  due  to  tuberculous  meningitis,  is  probably  extremely  rare.  In  some 
cases  paralysis  of  the  limbs  occurs  ;  this  is  especially  noted  when  there  have 
been  severe  and  long-continued  convulsions,  the  convulsion  being  followed 
by  a  hemiplegia  or  a  monoplegia.  These  symptoms  are  probably  due  to  an 
invasion  of  the  cortical  centres  by  irritating  toxins,  or  even  by  the  meningitis 
itself,  or  to  pressure  upon  the  motor  tracts  downward  through  the  peduncle 
and  pons,  or  to  interference  with  the  circulation  passing  upward  to  the  inter- 
nal capsule  through  the  anterior  perforated  space.  Paralyses  of  the  leg  and 
arm  are  not  nearly  so  common  as  the  palsies  of  the  cranial  nerves,  and  Avhen 
they  occur  it  is  usually  late  in  the  disease.  In  some  cases,  instead  of  distinct 
paralysis  following  a  fit,  there  may  be  a  state  of  rigidity  or  of  spastic  paresis. 
This  is  due  evidently  to  a  continuously  irritating  action  of  toxins  upon  the 
nerve-centres.  A  spastic  state,  moreover,  is  not  infrequently  seen  in  tuber- 
culous meningitis  independent  of  a  convulsion.  It  may  sometimes  appear 
rather  early  in  the  disease,  and  then  usually  attends  or  follows  a  fit.  Opis- 
thotonos is  occasionally  seen  toward  the  end  of  the  disease ;  it  is  very  rare 


618     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

in  the  early  stages.  It  is  sometimes  intermittent  or  paroxysmal  and  varies 
in  degree.  In  exceptional  cases  the  retraction  of  the  head  is  extreme,  pre- 
senting the  condition  known  as  retrocollic  spasm.  In  a  patient  recently 
seen  in  the  Philadelphia  Hospital  this  symptom  was  continuous  for  days, 
the  child  lying  on  its  side  with  its  head  retracted  to  its  full  extent,  so  that 
the  occiput  rested  on  the  shoulders,  and  when  the  child  was  placed  on  its 
back,  the  face  was  directed  fully  toward  the  head  of  the  bed.  In  some  cases 
tremor,  or,  more  accurately,  a  slight  ataxia,  occurs,  especially  in  the  hands, 
arms,  legs,  and  feet. 

Optic  neuritis,  or  congestion  of  the  optic  papilla,  is  occasionally  present 
in  tuberculous  meningitis,  and  would  probably  be  seen  oftener  if  it  were  more 
frequently  searched  for.  Tubercles  in  the  choroid  are  occasionally  seen. 
According  to  Oliver,  tuberculous  meningitis  is  more  prone  than  other  forms 
of  meningitis  to  cause  changes  in  the  optic  nerves. 

Changes  in  respiration  may  be  noted.  In  the  somnolent  or  stuporous 
condition  this  is  especially  so.  The  respirations  become  unequal  in  depth 
and  irregular  in  rhythm.  Occasionally  the  interval  between  inspirations  is 
very  prolonged,  and  then  breathing  will  be  resumed  with  a  long  sighing 
expiration.     Toward  the  end  the  respirations  may  be  rapid  and  shallow. 

True  paralvsis  of  the  bladder  and  rectum  is  not  seen,  but  incontinence 
of  urine  and  feces  may  occur,  owing  to  the  mental  state. 

Progressive  emaciation  is  usually  present  in  all  cases  of  tuberculous  men- 
ingitis, and  when  the  disease  is  unduly  protracted  this  emaciation,  with  pallor 
of  the  skin,  becomes  quite  marked.  In  some  cases,  however,  the  nutrition 
is  fairly  well  preserved,  although,  as  a  rule,  it  is  difficult  to  induce  these 
patients  to  take  sufficient  nourishment  to  repair  the  waste  going  on  in  the 
system. 

To  recapitulate  briefly,  the  symptoms  may  be  grouped  Avith  more  or  less 
accuracy,  so  that  the  disease  presents  several  stages. 

In  the  first  stage,  including  the  prodromal  period  of  ill-health,  there  may 
be  noted  slight  mental  changes,  such  as  extreme  irritability,  with  headache, 
vomiting,  fluctuating  temperature,  and  obstinate  constipation.  Occasionally 
in  this  stage  a  convulsion  occurs,  but  this  is  rare. 

In  the  second  stage  the.se  symptoms  are  aggravated,  except  that  the  vom- 
iting is  no  longer  such  a  pronounced  symptom.  Delirium  now  supervenes, 
and  the  child  pas.ses  into  a  stuporous  or  somnolent  state.  The  characteristic 
sloAv  and  irregular  pulse  appears,  a  convulsion  may  occasionally  occur,  ocular 
palsies  are  seen,  and  the  whole  appearance  of  the  case  suggests  more  unmis- 
takably the  presence  of  grave  cerebral  disorder. 

The  third  or  terminal  stage  is  marked  by  increasing  stupor,  passing  into 
coma.  The  slow  and  irregular  puLse  may  continue  for  a  time,  to  be  suc- 
ceeded by  a  very  rapid  pulse  toward  the  end.  An  occasional  convulsion  may 
occur,  and  this  may  be  followed  by  more  or  less  prolonged  monoplegia  or 
hemiplegia.  Ocular  palsies  are  more  conspicuous  and  permanent.  Spastic 
states  are  present.  Opisthotonos  and  retraction  of  the  head  may  be  present. 
Vomiting  no  longer  occurs,  as  a  rule.  Incontinence  of  urine  and  f?eces  may 
come  on.  Food  is  rejected,  or  difficult  to  administer  because  of  involvement 
of  the  muscles  of  deglutition.  The  fateful  aspect  of  the  case  increases.  The 
temperature  ranges  higher  or  falls  abnormally  low.  Profound  coma  super- 
venes, and  the  child  dies  either  from  gradual  paralysis  of  all  its  vital  func- 
tions or  from  a  convulsion. 

Prog-nosis. — In  tuberculous  meningitis  the  prognosis  is  invariably  unfavor- 
able.    A  few  authors  (Jacobi  and  others)  claim  to  have  seen  an  occasional 


/ 


TUBEBCULOUS  MENINGITIS.  619 

recovery,  but  such  cases  must  always  leave  a  doubt  as  to  the  accuracy  of  the 
diagnosis.  They  only  serve  at  least  to  emphasize  the  rule  that  tuberculous 
meningitis  is  one  of  the  most  unerringly  fatal  diseases  of  childhood. 

Duration. — This  disease,  as  a  rule,  is  rather  rapid  in  its  course.  Few 
cases  linger  beyond  the  fourth  week.  Some  are  fatal  within  the  first  ten 
days,  especially  if  severe  convulsions  supervene.  The  average  duration  of 
the  disease  is  probably  about  tw^enty  to  twenty-five  days. 

Diagnosis. — Tuberculous  meningitis  may  be  mistaken  for  simple  infantile 
convulsions,  digestive  disorders,  typhoid  fever,  brain-tumor,  and  hysteria. 
It  is  occasionally  simulated  by  pneumonia.  It  may  remotely  simulate  a  few 
other  disorders,  but  the  resemblance  is  so  slight  as  scarcely  to  demand  notice 
here. 

Infantile  convulsions  or  convulsions  occurring  in  young  children  should 
alvrays  suggest  the  possibility,  at  least,  of  tuberculous  meningitis.  If  they 
occur  in  children  who  have  previously  had  them,  this  possibility  is  of  course 
more  remote.  A  convulsion  in  a  young  child  may  be  due  to  numerous  causes, 
such  as  indigestion  or  a  beginning  exanthem.  The  only  rule  is  to  watch 
patiently  for  the  cause,  which  in  most  of  these  instances  will  usually  present 
itself.  In  a  case  of  commencing  tuberculous  meningitis  the  diagnosis  would 
be  established  especially  by  the  onset  of  headache,  vomiting,  constipation, 
fluctuations  in  temperature,  mental  changes,  and  by  the  persistence  of  these 
symptoms. 

A  careless  observer  might  mistake  the  obstinate  vomiting  of  tuberculous 
meningitis  for  an  evidence  of  gastro-intestinal  disorder.  But  the  other  symp- 
toms, such  as  headache,  constipation,  and  fluctuating  temperature,  as  well  as 
the  persistence  of  these  symptoms  and  the  mental  changes,  should  indicate 
that  the  disease  is  not  due  to  gastro-intestinal  infection.  In  the  very  early 
stage,  however,  a  mistake  is  readily  made. 

Typhoid  fever  and  tuberculous  meningitis  may  closely  simulate  each  other 
in  young  children.  The  differences  in  the  temperature  range,  however,  are 
well  marked,  while  in  typhoid  fever,  although  headache  and  vomiting  may 
occur,  they  are  usually  associated  with  some  looseness  of  the  bowels,  and  the 
slow  and  irregular  pulse  of  tuberculous  meningitis  is  not  noted.  The  charac- 
teristic eruption  of  enteric  fever,  when  present,  is  a  determinative  sign. 
Tympany,  so  common  in  typhoid  fever,  is  not  seen  in  tuberculous  meningitis. 
Great  care,  however,  is  undoubtedly  required  to  distinguish  these  two  dis- 
eases, and  this  can  only  be  done  in  some  cases  by  patient  study  during  a 
number  of  days. 

From  brain-tumor,  especially  a  tumor  of  the  cerebellum,  tuberculous  men- 
ingitis may  be  distinguished  by  its  more  abrupt  onset,  its  shorter  duration, 
its  fluctuating  temperature,  its  slow  and  irregular  pulse,  and  its  obstinate 
constipation.  The  headache  and  vomiting,  which  might  cause  it  to  resemble 
a  cerebellar  tumor,  are  usually  of  greater  intensity  at  the  beginning  and  of 
briefer  duration  in  tuberculous  meningitis.  In  this  latter  disease,  moreover, 
there  are  not  the  cerebellar  ataxia  and  other  disorders  of  motion  so  commonly 
seen  in  cases  of  tumors  beneath  the  tentorium.  Optic  neuritis,  while  not  un- 
noted in  tuberculous  meningitis,  is  not  such  a  prominent  symptom  and  does 
not  lead  to  such  distinct  post-neuritic  atrophy  as  is  seen  in  cerebellar  tumor. 

Hysteria,  which  simulates  so  many  diseases,  might  possibly  itself  be 
simulated  by  tuberculous  meningitis  in  the  child.  A  little  care  in  observa- 
tion, however,  should  clear  up  the  diagnosis.  The  persistent  headache,  vom- 
iting, slow  and  irregular  pulse,  obstinate  constipation,  and  elevation  of  tem- 
perature would  be  against  hysteria  in  a  child,  while  an  absence  of  some  of  the 


620     AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

characteristic  mental  and  physical  stigmata  of  the  great  neurosis  would 
usually  be  noted.  It  must  be  recalled,  however,  that  hysteria  may  compli- 
cate grave  organic  diseases,  and  this  might  be  so  in  the  early  stages  of  tuber- 
culous meningitis  ;  but  the  symptoms  just  enumerated  should  guard  the  physi- 
cian against  error. 

Pneumonia  in  young  children,  especially  if  complicated  with  marked 
cerebral  symptoms,  may  simulate  tuberculous  meningitis.  The  crucial  test 
is  of  course  the  detection  of  the  physical  signs  of  the  pneumonia.  The 
brain-symptoms,  while  intense  in  pneumonia,  are  not  associated  with  the 
characteristic  slow  and  irregular  pulse.  On  tlie  other  hand,  tuberculous 
meningitis  is  more  apt  soon  or  late  to  present  ocular  palsies  and  convulsions 
with  paresis.  In  the  early  stages,  however,  the  main  reliance  should  be 
placed  upon  the  physical  signs,  the  rapidity  of  respiration,  the  evidence  of 
pain  in  the  chest,  and  a  rather  higher  and  more  persistent  range  of  tem- 
perature. 

Quincke's  operation  of  lumbar  puncture  has  given  some  satisfactory 
results.  Fiirbringer  in  37  cases  of  tuberculous  meningitis  found  the  tubercle 
bacillus  in  30,  thus  verifying  the  diagnosis  in  80  per  cent,  of  the  cases,  among 
which  several  were  so  doubtful,  from  a  clinical  standpoint,  as  not  to  warrant 
a  positive  opinion.  In  1  case  a  creamy  pus  was  obtained,  aud  this  per- 
mitted the  establishment  of  a  diagnosis  of  cerebro-spinal  meningitis.  In 
still  another  case,  with  the  symptoms  of  combined  myelitis  and  pneumonia, 
the  pneumococcus  was  found, 

.  Morbid  Anatomy. — The  essential  process  in  tuberculous  meningitis  is 
the  development  of  small  tubercles.  These  are  really  the  scenes  of  activity 
of  the  bacilli.  These  tubercles  are  usually  distributed  most  freely  along 
the  course  of  blood-vessels,  and  are  consequently  located,  as  a  rule,  in  the 
pia-arachnoid  membrane,  and  are  found  especially  in  the  main  clefts  or 
fissures  of  the  brain,  such  especially  as  the  fissure  of  Sylvius.  They  vary 
in  size,  many  being  as  small  as  a  millet-seed,  while  others  are  much  larger. 
In  some  places,  in  fact,  the  tubercles  grow  together  or  coalesce.  Occa- 
sionally these  large  masses  form  veritable  tumors,  although  this  is  rare  in 
disseminated  tuberculous  meningitis.  The  formation  of  the  tubercles  is  the 
primary  process.  As  a  secondary  process  there  is  inflammation,  character- 
ized by  exudation  of  cells  and  fibrinous  tissue,  by  thickening  and  consequent 
opacity  of  the  membranes,  and  bv  the  exudation  of  a  copious  sero-gelatinous 
fluid. 

The  thickening  and  opacity  of  the  membranes,  especially  of  the  pia- 
arachnoid,  are  very  marked  in  tuberculous  meningitis.  The  exudation  within 
the  meshes  of  this  membrane  is  usually  yellowish  or  greenish-yellow  in  color 
and  of  a  gelatinous  consistency.  It  contains  many  cells,  the  result  of  inflam- 
matory action,  but  these  are  not  usually  numerous  enough  to  give  this  fluid 
the  character  of  pus.  The  brain-membranes,  in  addition  to  being  opaque, 
are  usually  the  seat  of  more  or  less  intense  hypergemia.  Some  free  blood- 
corpuscles  may  also  be  found  in  the  exudate,  and  occasionally  the  fluids  may 
even  present  a  slightly  bloody  tinge  to  the  naked  eye. 

The  vascular  changes  have  been  studied  with  great  care  recently  by 
Hektoen  in  a  series  of  nine  cases.  Extensive  vascular  changes  were  found 
in  all  these  cases,  and  these  changes  indicated  that  the  invasion  of  the  wall 
of  the  blood-vessel  frequently  occurred  from  within.  Changes  in  the  intima 
played  the  essential  part.  Tubercles  were  even  found  in  the  intima,  accom- 
panied by  extensive  endarteritis,  the  presence  of  which,  without  changes  in 
the  other  layers  of  the  wall,  seems  to  prove  that  this  intravascular  leston  is 


TUBERCULOUS  MENINGITIS.  621 

primary  and  due  to  irritating  agents  circulating  in  the  blood.  Endarteritis, 
ho^Yever,  may  possibly  develop  from  an  agent  acting  from  without.  Tuber- 
cles on  the  intima,  however,  are  probably  always  due  to  a  direct  infection 
from  the  blood-current  itself.  In  these  cases  the  tubercle  bacilli  are  probably 
engrafted  directly  upon  the  intima.  Hektoen  concludes  that  tuberculous 
endarteritis,  with  the  formation  of  intimal  tubercles,  may  be  due  to  implanta- 
tion of  the  bacilli  from  the  blood.  Infiltration  may  then  spread  into  the 
muscular  coat  and  the  adventitia.  On  the  other  hand,  tuberculous  prolifera- 
tion in  the  adventitia  may  invade  the  media  and  the  intima — i.  e.  infection 
may  be  from  without.  The  veins  are  constantly  the  seat  of  extensive  infil- 
tration resulting  from  infection  from  without. 

The  lesions  of  tuberculous  meningitis  are  usually  found  at  the  base  of  the 
brain ;  hence  the  disease  has  been  called  basilar  meningitis.  The  under 
surface  of  the  frontal  and  temporal  lobes,  the  optic  chiasm,  pons,  and 
medulla,  and  even  the  cerebellum,  may  be  obscured  by  the  products  of  the 
disease.  Sometimes,  as  already  said,  the  aifection  passes  up  the  fissure  of 
Sylvius,  and  may  appear  on  the  lateral  aspects  of  the  brain.  The  nerve- 
trunks  are  imbedded  in  the  exudate  or  inflamed  membranes.  It  occasionally 
happens,  however,  that  tuberculous  meningitis  is  not  confined  to  the  base  of 
the  brain.      Striimpell  and  others  have  noted  exceptions  to  the  general  rule. 

In  many  cases  the  substance  of  the  brain  itself  is  more  or  less  involved 
in  the  inflammatory  jjrocess.  Thus  there  may  be  a  diifused  cerebritis 
beneath  the  inflamed  and  opaque  membranes.  Some  areas  even  of  softening 
and  disintegration  may  be  observed.  This  process,  however,  is  usually  con- 
fined to  the  cortex.  The  deep  structures  of  the  brain  are  not,  as  a  rule, 
involved. 

The  lateral  ventricles  in  most  cases  are  distended  with  fluid.  From  this 
circumstance  the  disease  was  called  acute  hydrocephalus  by  the  older  observers. 
The  ependyma  of  the  lateral  ventricles,  however,  is  not  involved.  The  cho- 
roid plexus  is  occasionally  the  seat  of  tubercles. 

In  brief,  the  disease-process  consists  in  the  formation  of  tubercles  as  a 
result  of  the  specific  activities  of  the  bacilli,  and  a  consequent  inflammation 
and  thickening  of  the  membranes,  with  exudation  of  a  characteristic  fluid. 

Treatment. — The  treatment  for  tuberculous  meningitis  is,  of  course, 
highly  unsatisfactory.  We  know  of  no  drug  that  Avill  control  the  speciflc 
action  of  the  bacillus  of  tubercle.  Mercurials,  especially  calomel,  have  for 
a  long  time  enjoyed  a  reputation  in  all  forms  of  meningitis.  Whether  this 
is  based  upon  any  specific  action  of  this  drug  upon  the  bacillus  it  is  not  pos- 
sible to  state.  It  is  doubtful  whether  the  whole  mass  of  the  blood  can  be 
rendered  so  aseptic  by  mercurial  salts  as  to  retard  appreciably  the  activities 
of  this  microbe.  Certainly  clinical  experience  does  not  warrant  any  such 
claim.  This  disease  is  never  cured  by  the  most  active  use  of  mercurials. 
In  one  case  I  saw  salivation  to  an  extreme  degree  obtained  without  the 
slightest  beneficial  eff"ect  being  noted.  Such  heroic  treatment,  it  is  needless 
to  say,  cannot  be  recommended.  If  a  mercurial  is  desired,  the  most  appro- 
priate is  probably  calomel,  which  should  be  given  in  doses  of  from  one-fourth 
to  one-eighth  of  a  grain  three  or  four  times  a  day,  the  effects  being  carefully 
noted.  Iodide  of  potassium  is  probably  without  value  in  tuberculous  men- 
ingitis.    The  activity  of  the  bacilli  is  not  in  the  least  retarded  by  its  use. 

The  treatment  of  the  individual  symptoms  in  this  disease  is  of  importance. 
Something,  at  least,  can  be  done  to  palliate  the  suffering  of  the  patient  and 
thus  to  relieve  the  distress  of  the  parents.  Cold  applications  to  the  head, 
especially  an  ice-bag,  are  strongly  indicated.     This  bag  should  be  wrapped 


622     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Avith  a  few  thicknesses  of  flannel  and  applied  to  the  vertex.  It  acts  bene- 
ficially by  relieving  headache,  and  possilily  also  by  reducing  temperature. 

The  vomiting,  which  is  a  sudden  and  urgent  symptom  at  first,  is  not 
easily  controlled  by  drugs.  It  is  probably  due  to  irritation  of  the  roots  of 
the  vacrus  nerve,  and  there  is  no  druo;  that  will  control  this. 

The  obstinate  constipation  is  best  relieved  by  large  enemata  of  warm 
water  and  soapsuds.  The  small  doses  of  calomel  before  referred  to  may  act 
favorably  also  by  promoting  the  bowel  movement,  but,  as  a  rule,  the  consti- 
pation is  exceedingly  rebellious  to  drugs. 

The  convulsions  and  general  nervous  irritability,  shown  by  rigidity  and 
spastic  states  of  the  muscles,  are  best  relieved  by  bromides  and  chloral.  In 
cases  in  which  convulsions  succeed  each  other  with  rapidity,  and  the  child 
threatens  to  sink  into  an  epileptic  status,  very  moderate  inhalations  of  ether 
may  be  given.  This  agent,  cautiously  administered  for  this  one  purpose,  is 
not  open  to  objection. 

Opium  or  some  of  its  derivatives  can  be  used  with  advantage  in  some 
stages  of  the  disease.  When  the  nervous  symptoms  predominate,  such  as 
extreme  irritability,  restlessness,  headache,  jactitation,  convulsions,  and 
spastic  rigidity,  the  full  effect  of  an  opiate  may  be  sought.  This  drug 
probably  acts  better  than  either  the  bromides  or  chloral  to  relieve  some  of 
these  symptoms,  but  it  has  several  disadvantages,  chief  of  which  is  its 
tendency  to  still  further  aggravate  the  obstinate  constipation. 

As  the  vital  powers  fail,  toward  the  end  of  the  disease,  alcohol  in  small 
doses  is  indicated.  It  can  do  little  more,  however,  than  support  the  patient 
temporarily. 

Baths  mav  be  of  some  benefit.  A  warm  bath  during  a  convulsion  is 
sometimes  not  without  advantage.  In  cases  in  which  the  temperature  ranges 
very  high  a  cold  bath  may  control  this  symptom  and  relieve  some  of  the 
patient's  sufferings. 

For  the  various  palsies  that  appear  in  the  terminal  stage  of  the  disease 
no  remedies  avail.  Thev  are  usuallv  indications  of  grave  orgranic  changes  in 
the  nerve-centres  or  nerve-trunks,  and  then  only  too  truly  foretell  the  end. 

Quincke's  operation  of  lumbar  puncture  has  been  tried  both  for  diagnosis 
and  as  a  means  of  treatment  in  tuberculous  meningitis.  The  second,  third,  or 
fourth  intervertebral  space  in  the  lumbar  spine  is  chosen.  A  needle  is 
plunged  through  one  of  these  spaces  and  an  amount  of  fluid  withdrawn. 
Fiirbringer  reports  his  observations  upon  86  patients,  37  of  whom  had  tuber- 
culous meningitis.  The  puncture  should  be  made  on  the  plane  of  the  junc- 
tion of  the  superior  and  middle  third  of  a  spinous  process,  about  two  fingers' 
breadth  from  the  median  line.  Heubner  prefers  the  lumbar  puncture  to  tap- 
ping of  the  ventricles  in  chronic  hydrocephalus.  Rotch  and  AVentworth, 
however,  report  alarming  symptoms  in  a  child  two  years  old.  After  lumbar 
puncture  the  patient  grew  restless,  respiration  became  superficial,  the  pulse 
rose  above  200.  and  the  skin  was  cool  and  livid.  The  child  recovered. 
Lizard  claimed  that  he  succeeded  in  checking  convulsions  in  a  case  of  tuber- 
culous meningitis  by  lumbar  puncture.  The  child,  however,  died  in  twenty- 
four  hours.  On  the  whole,  this  method  appears  to  have  value  for  purposes 
of  diagnosis,  but  is  without  permanent  benefit  to  the  patient,  and  is  not  unat- 
tended with  risks. 

Great  care  should  be  exercised  in  all  cases  of  tuberculous  meningitis  to 
guard  against  bed-sores  and  the  evils  attendant  upon  an  overloaded  bladder 
and  bowel.  In  children,  of  course,  the  tendency  to  bed-sores  is  not  so  great 
as  in  adults,  because  they  can  be  lifted  about  more  readily.     Distention  of  the 


TUBERCULOUS  MENINGITIS.  623 

bladder  is  not  very  common  in  this  disease.  It  should  be  remembered,  how- 
ever, that  constant  dribbling  of  urine  may  be  a  sign  of  distention ;  hence  this 
symptom  should  never  be  ignored. 

Jansen  reports  a  case  presenting  typical  symptoms  of  tuberculous  menin- 
gitis in  which  the  patient  recovered  under  the  administration  of  900  grains 
of  iodide  of  potassium  a  day.  W.  Hale  White  reports  a  case  in  which  two 
old  caseous  nodules  in  the  fissure  of  Sylvius  were  found  in  a  child  dead  of 
tuberculous  meningitis.  The  author  infers  that  the  old  nodules  proved  that 
a  former  attack  had  been  cured. 

Counter-irritation  to  the  scalp  and  the  back  of  the  neck  is  useless.  It  is 
doubtful  whether  it  even  relieves  the  headache.  It  certainly  cannot  retard 
the  progress  of  the  disease. 


HYDROCEPHALUS. 

By  JAMES  HENDRIE  LLOYD,  A.  M.,  M.  D., 

Philadelphia. 


Hydrocephalus,  or  dropsy  of  the  brain,  is  a  condition  in  which  the  brain 
is  distended  by  an  excessive  accumulation  of  the  cerebro-spinal  fluid  within 
the  ventricles.  This  distention  of  the  brain  may  or  may  not  be  accompanied 
with  distention  of  the  skull  also. 

Hydrocephalus  has  usually  been  divided  in  the  past  into  several  varieties; 
thus  an  acute  and  chronic  variety  Avere  recognized.  By  the  former  was  meant 
the  now  well-recognized  tuberculous  menino-itis.  This  was  called  acute  hvdro- 
cephalus,  for  the  simple  and  wholly  inadequate  reason  that  it  caused,  as  a 
mere  secondary  symptom,  some  accumulation  of  fluid  within  the  skull.  This 
term  has  now  fallen  into  well-merited  neglect.  The  term  chronic  hydro- 
cephalus was,  on  the  other  hand,  reserved  for  the  aff'ection  which  we  are  now 
considering  and  which  has  already  been  defined.  Chronic  hydrocephalus, 
however,  has  been  subdivided  into  two  forms — the  internal  and  external.  By 
the  former  was  meant  that  variety  in  which  the  fluid  is  exuded  and  retained 
in  the  cavities  of  the  brain ;  by  the  latter,  that  form  in  which  the  fluid  is 
retained  in  the  subarachnoid  space  on  the  surface  of  the  brain.  This  distinc- 
tion is  now  recognized  as  somewhat  artificial  and  entirely  unnecessary.  As 
the  ventricles  of  the  brain  are  practically  continuous  with  the  subarachnoid 
space,  through  the  foramen  of  Magendie,  an  excess  of  fluid  in  the  latter  must 
be  associated  with  an  excess  of  fluid  in  the  former,  unless  this  foramen  is  ob- 
structed. True  hydrocephalus  is  the  hydrocephalus  internus,  in  which  the  ven- 
tricles of  the  brain,  and  secondarily  the  brain  itself,  and  even  the  skull,  are 
distended  with  fluid.  An  accumulation  of  a  slight  excess  of  fluid  in  the  sub- 
arachnoid space  is  such  a  common  occurrence  in  such  a  large  number  of  path- 
ological states  of  the  brain  that  there  is  no  occasion  for  such  a  distinctive  term 
for  it  as  hydrocephalus  externus.  This  is  the  more  so  because  this  use  of  the 
term  serves  to  beget  a  confusion  of  this  subarachnoid  oedema  with  the  true  hy- 
drocephalic distention  of  the  ventricles  of  the  brain  which  we  are  here  consid- 
ering. Among  the  causes  which  may  determine  a  subarachnoid  oedema  are — 
meningitis,  cerebral  haemorrhage,  brain-tumor,  senile  atrophy,  dementia  para- 
lytica, and  gross  defects  of  the  brain,  such  as  porencephalon.  None  of  these, 
except  the  latter,  is  a  developmental  defect,  and  none  of  them  is  attended  with 
an  expansion  of  the  skull  such  as  is  seen  in  true  hydrocephalus.  Finally, 
hydrocephalus  is  said  by  some  to  be  either  congenital  or  acquired.  In  the 
former  variety  great  distention  of  the  skull  may  occur  while  the  child  is  still 
ill  utero,  and  this  may  prove  a  cause  of  serious  dystocia  :  in  the  latter  the  con- 
dition arises  after  birth.  But  as  in  either  of  these  cases  the  essential  cause  is 
equally  obscure,  and  may  even  be  identical,  the  distinction  is  not  important  in 
one  sense.  In  another  sense,  however,  the  distinction  between  an  early  and  a 
lately  acquired  hydrocephalus  is  important.    Only  in  the  former  cases — i.  e.  those 

624 


HYDROCEPHALUS.  625 

in  which  the  affection  originates  before  the  complete  ossification  of  the  bones 
of  the  skull — can  there  occur  the  characteristic  hydrocephalic  enlargement  of 
the  head.  Hence  this  term,  hydrocephalus,  is  practically  narrowed  down  to  the 
condition  in  which  distention  of  the  ventricles  of  the  brain,  with  distention  of 
the  skull,  is  the  essential  characteristic,  and  which  can  only  occur  before  ossi- 
fication is  complete,  and  from  causes  that  must  still  be  regarded  as  obscure. 
The  adult  form  of  the  disease — upon  which  some  writers  still  insist — is  prob- 
ably an  entirely  different  affection  from  the  internal  hydrocephalus  of  eai^ly 
life.  It  is  not  a  disease  at  all,  but  simply  a  ventricular  effusion,  such  as  may 
be  caused,  just  like  subarachnoid  oedema,  by  a  variety  of  diseases,  as  tumor, 
haemorrhage,  meningitis,  and  atrophy  of  the  brain.  The  claim  that  distention 
of  the  skull  can  occur  in  adult  life  must  be  received  with  caution,  and  should 
not  be  allowed  for  cases  in  which  an  intracranial  tumor  has  eroded  the  skull, 
and  perhaps  caused  slight  thinning,  or  even  expansion,  at  some  point  in  the 
course  of  a  cranial  suture. 

Etiology. — The  causes  of  chronic  internal  hydrocephalus  have  not  been 
satisfactorily  determined.  In  the  intra-uterine  cases  all  sorts  of  hypothetical 
causes  have  been  advanced,  such  as  disease  of  the  uterus  itself  and  even  mater- 
nal impression.  It  is  probable  that  the  same  general  cause  or  causes  acts  in 
both  the  pre-natal  and  post-natal  cases.  Injury  may  be  one  of  these  causes. 
Syphilis  and  alcoholism  in  the  parents  may,  but  are  not  known  positively  to, 
act  as  causes.  Two  classes  of  causes,  or  rather  modes  of  action  of  causes,  are 
generally  recognized  as  possible :  First,  a  morbid  process,  especially  in  the 
ependyma,  that  induces  a  free  exudation  of  fluid.  Such  a  morbid  process  may 
be  inflammatory  in  character,  and  this  is  thought  by  some  to  be  proved  by 
the  fact  that  the  ependyma  of  the  lateral  ventricles  is  sometimes  thickened 
and  beaded.  But  the  exciting  cause,  in  turn,  of  this  ependymitis  has  not 
been  stated.  Second,  mechanical  obstruction  either  to  the  return  flow  of 
blood  from  the  skull  or  to  the  free  circulation  of  the  cerebro-spinal  fluid  is 
looked  upon  by  many  as  a  probable  cause  of  hydrocephalus.  With  reference 
to  the  blood-vessel  system  this  explanation  is  not  merely  theoretical,  but  may 
be  considered  as  having  been  demonstrated.  Tkxxs  any  lesion  that  obstructs 
the  veins  of  Galen  may  readily  cause  an  excessive  exudation  of  fluid  in  the  ven- 
tricles. Tumors,  tuberculous  exudates  or  nodules,  thrombi,  and  the  various 
forms  of  meningitis  may  act  thus.  The  only  difiiculty  in  the  way  of  accepting 
obstructive  lesions  as  causes  of  hydrocephalus  arises  from  the  fact  that  they 
explain  so  few  of  these  cases.  In  many  instances  no  obstructive  lesion  is  found. 
As  for  the  circulation  of  the  cerebro-spinal  fluid,  it  is  rather  difiicult  to  under- 
stand exactly  what  this  is,  and  hence  how  an  obstruction  to  it  can  cause  dis- 
tention of  the  ventricles.  It  is  not  positively  clear  that  this  fluid  constantly 
circulates  through  the  foramen  of  Monro,  the  aqueduct  of  Sylvius,  and  the 
so-called  foramen  of  Magendie.  These  orifices  no  doubt  permit  free  communi- 
cation between  the  ventricles  themselves  and  between  them  and  the  subarach- 
noid space,  but  this  does  not  prove  that  the  fluid  is  circulating  through  them 
in  a  steady  stream.  It  may  be  a  practically  stationary  body  of  fluid.  The 
claim  that  obstruction  of  either  or  any  or  all  of  these  orifices  is  a  cause  of 
hydrocephalus,  independent  of  obstruction  of  the  circulation  of  the  venous 
blood,  needs  demonstration.  It  is  highly  probable  that  in  cases  in  which 
obstruction  of  the  foramen  of  Monro  or  of  the  aqueduct  of  Sylvius  has  been 
found  some  obstruction  of  the  venous  system  also  existed  and  may  have  been 
overlooked.  Browning,^  however,  has  recently  collected  a  series  of  cases  in 
which  obstructive  lesions  at  or  near  these  openings  have  apparently  caused 

^  Normal  and  Pathological  Circulation  in  the  Central  Nervous  System,  1897. 
40 


626    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

distention  of  the  ventricles ;  but  the  lesions  in  some,  at  least,  of  these  cases 
were  such  as  to  suggest  that  the  blood-vessels  also  had  been  obstructed.  This 
whole  subject  is  still  somewhat  obscure. 

Symptoms. — The  most  characteristic  symptom  of  hydrocephalus  is  the 
enlargement  of  the  head.  This  usually  begins  to  show  itself  in  early  infancy, 
before  the  ossification  between  the  bones  of  the  skull  has  had  time  to  advance. 
The  head  enlarges  in  all  directions,  but  the  distention  is  usually  greatest  in  the 
frontal  and  vertical  regions.  The  head  becomes  globose  in  shape,  and  projects 
especially  in  the  frontal  region.  The  orbital  plates  are  often  somewhat  de- 
flected downward,  and  this  causes  a  ilownward  deviation  of  the  eyes,  which 
may  be  almost  or  quite  covered  by  the  lids.  The  fontanelles  and  sutures 
are  widely  distended,  and  may  bulge  from  the  increased  pressure  of  the  fluid 
within.  Some  authors  describe  an  alteration  in  the  percussion  note  of  the 
head;  thus,  according  to  them,  there  may  be  a  "cracked-pot"  sound  on  per- 
cussion. The  scalp,  of  course,  is  greatly  distended,  and  may  be  thin  and 
smooth  and  covered  with  a  scanty  growth  of  hair.  This  enlargement  of  the 
head  is  in  some  cases  immense.  In  such  cases  the  child  is  usually  quite  unable 
to  lift  the  head.  Its  great  weight  and  the  weakness  of  the  muscles  cause  it  to 
lie  helpless  on  the  pillow.  In  cases  that  do  not  prove  fatal  in  early  life  gradual 
ossification  may  occur,  and  the  patient  may  live  to  adult  life  with  an  immense 
cranium.  Such  a  patient  at  present  under  my  care  in  the  Philadelphia  Hos- 
pital has  also  a  spastic  hemiplegia. 

The  mental  symptoms  in  hydrocephalus  vary  much.  In  the  worst  cases 
complete  idiocy  results ;  in  the  milder  cases,  in  which  the  process  apparently 
stops  and  the  patient  lives  for  years,  there  is  usually  mental  impairment.  The 
degree  of  this  impairment  varies  according  to  the  case.  Even  the  milder  cases 
present  some  degree  of  hebetude,  inability  to  learn  and  to  fix  the  attention, 
weak  memory,  and  possibly  defects  in  speech. 

In  the  early  acute  stage  pain  is  apparently  a  symptom.  The  child  gives 
an  occasional  shrill  or  piercing  cry,  the  muscles  of  the  brow  and  face  are  con- 
torted, and  the  appearance  is  that  of  suffering. 

The  motor  symptoms  are  usually  prominent,  but  they  also  vary.  Different 
decrees  of  paralysis  are  observed.  In  the  worst  cases  the  child  may  have 
scarcelv  any  use  whatever  of  the  limbs.  The  extreme  distention  and  deformity 
of  the  brain  evidently  impair  the  cortex  and  the  motor  paths,  so  that  in  some 
cases  few  if  any  motor  impulses  can  be  either  generated  or  transmitted.  In 
long-standing  chronic  cases  spastic  diplegia,  hemiplegia,  or  monoplegia  may 
be  present.  The  patient  may  learn  to  walk,  but  with  a  much  impaired  gait. 
The  deep  reflexes  in  such  cases  are  usually  exaggerated,  and  contractures  may 
be  gradually  established. 

Convulsions  are  not  uncommon.  They  are  seen  especially  in  the  early 
infantile  cases,  and  may  even  be  the  immediate  cause  of  death.  In  the  cases 
of  patients  who  survive,  epileptic  seizures  may  or  may  not  be  occasional 
symptoms. 

The  eyes  may  be  deflected  downward  by  the  deformity  of  the  skull,  as 
already  said :  they  may  also  be  deflected  outward  or  inward,  thus  presenting 
various  types  of  strabismus.  Nystagmus  and  oscillatory  movements  are  occa- 
sionally seen.  Complete  optic  atrophy  has  been  observed,  and  is  caused  no 
doubt  by  the  compression  upon  and  the  stretching  of  the  optic  nerves,  chiasm, 
and  tracts. 

In  the  worst  cases  the  child  may  have  no  control  over  the  bladder  and 
rectum,  but  this  is  not  a  common  symptom  in  cases  that  survive,  unless  a  low 
grade  of  idiocy  results.     Even  in  such  cases  there  is  not  a  true  paralysis  of  the 


HYDROCEPHAL  US. 


627 


bowel  and  bladder,  but  only  the  involuntary  evacuation  that  results  from  men- 
tal enfeeblement. 

In  grave  cases  the  nutrition  of  the  child  suffers.  Emaciation  may  be 
extreme.  The  skin  is  sallow  and  wrinkled.  The  face  has  a  pinched  and, 
often,  a  curiously  senile  appearance. 

In  pre-natal  cases  the  enlargement  of  the  head  may  be  great,  and  may  be  a 
cause  of  serious  difficulty  in  the  labor.  Instrumental  aid  may  be  required,  or 
even  the  evacuation  of  the  head.     Occasionally,  however,  labor  may  terminate 

Fig.  1. 


Hydrocephalus  with  Spina  Bifida. 

without  assistance,  but  with  long  delay  and  much  suffering  to  the  mother. 
In  such  cases  the  head  after  birth  presents  an  appearance  of  frightful  deformity, 
caused  by  its  long  detention  in,  and  gradual  moulding  by,  the  parturient  canal. 
I  once  saw  such  a  case :  the  head  was  elongated,  and  was  like  a  great  sac 
containing  fluid.  In  the  walls  of  this  sac,  but  not  nearly  filling  them,  could 
be  felt  the  cranial  bones.     The  head  was  scarcely  recognizable  as  such. 

Occasionally  hydrocephalus  is  associated  with  other  defects  in  the  develop- 
ment of  the  cerebo-spinal  axis.  Thus  it  may  coexist  with  spina  bifida.  An 
example  of  this  is  illustrated  here  (Fig.  1)  from  the  writer's  service  in  the 


628     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Methodist  Hospital.  This  association  tends  to  prove  still  more  clearly  that 
hydrocephalus  is  essentially  a  developmental  defect,  rather  than  the  result  of 
an  active  disease-process. 

The  duration  of  cases  of  hydrocephalus  varies.  In  many  cases  the  disease 
is  rapidly  fatal,  the  child  dying  in  a  convulsion  or  from  inanition.  The  dis- 
ease, however,  is  not  always  incompatible  with  a  long  life.  Many  patients 
live  to  adult  life  and  even  to  old  age.  In  such  cases,  along  with  the  deformity 
of  the  head,  there  is  some  degree  of  mental  and  motor  impairment.  The  opin- 
ion that  hydrocephalus — at  least  the  chronic  internal  form  that  begins  in  early 
childhood — is  not  incompatible  with  intellectual  vigor,  and  even  genius,  is  not 
well  founded.  Hence  it  is  doubtful  Avh ether  either  Cuvier  or  Swift,  as  has 
been  asserted,  ever  had  true  hydrocephalus. 

Morbid  Anatomy. — As  can  be  readily  understood  from  the  nature  of  the 
disease,  the  changes  within  the  cranium  are  striking.  The  lateral  ventricles 
are  greatly  distended,  one  sometimes  more  than  the  other.  The  ependyma 
may  be  thickened,  and  roughened  on  its  surface.  The  foramen  of  Monro  and 
the  aqueduct  of  Sylvius,  one  or  both,  have  been  reported  occluded  by  some 
observers.  In  severe  cases  the  brain  is  stretched  so  as  to  be  little  more  than 
a  mere  shell.  The  cortex  is  thus  much  deformed ;  it  is  thin  and  its  convolu- 
tions flattened  and  its  sulci  almost  obliterated.  The  essential  elements,  the 
neurons  and  their  processes,  are  diminished  in  number  and  degenerated. 

Not  only  the  lateral,  but  also  the  third  and  fourth,  ventricles  may  be  dis- 
tended, but  this  is  not  so  common.  The  structures  at  the  base  of  the  brain, 
as  the  basal  ganglia  and  the  mid-brain,  cerebellum,  and  pre-  and  post-oblongata, 
may  be  compressed  and  undeveloped.  Occasionally  the  aqueduct  of  Sylvius 
is  distended  in  the  shape  of  a  funnel,  its  larger  opening  being  toward  the  third 
ventricle.  The  choroid  plexus  may  be  thickened  and  distended  ;  but  more 
exact  observations  are  needed  on  the  state  of  the  veins,  especially  the  veins  of 
Galen,  in  these  cases. 

The  bones  of  the  skull,  in  cases  in  which  the  distention  is  great  and  death 
has  occurred  early,  are  thin  and  translucent.  The  diploe  may  be  obliterated. 
The  sutui-es  and  fontanelles  are  widely  distended,  the  former  as  much  even  as 
an  inch.     Small  Wormian  bones  may  be  found  in  some  of  these  spaces. 

The  membranes  over  the  vault  are  usually  not  involved.  At  the  base  they 
may  be  thickened. 

The  optic  tracts,  chiasm,  and  nerves  may  be  totally  degenerated. 

In  most  cases,  as  reported,  the  pathological  findings,  although  so  striking 
in  appearance,  have  not  satisfactorily  demonstrated  the  primary  cause  of  the 
disease.  They  are  merely  the  results  of,  not  the  essential  cause  of,  the  process 
itself.  This  probably  consists  of  some  accident  in  development,  the  exact 
nature  of  which  is  still  obscure. 

Treatment. — Hydrocephalus  cannot  be  cured  with  drugs.  All  such  reme- 
dies as  purgatives,  diuretics,  and  alteratives  have  only  the  slightest  temporary 
effect,  if  they  have  even  that.  It  has  been  claimed  that  an  active  diarrhoea 
relieves  the  distention,  but,  even  if  this  be  so,  it  furnishes  no  safe  indication 
for  treatment.  Any  temporary  depletion  of  the  cranium  by  this  means  would 
speedily  be  counterbalanced  by  renewed  exudation  of  fluid  within  the  skull. 
Mercury  and  iodide  of  potassium  are  absolutely  inefficacious  as  alteratives  in 
this  disease. 

Surgical  means  are  the  most  direct  and  rational,  but,  unfortunately,  they 
have  proved  of  but  little  value.  Puncture,  with  drainage  by  the  anterior 
fontanelle,  has  been  performed,  but  the  results  are  usually  not  permanently 
beneficial.      Keen   has   employed   continuous   drainage.      Lumbar  puncture 


HYBB  O  CEPHA  L  US.  629 

according  to  the  method  of  Quincke  may  be  tried.  Such  surgical  procedures, 
however,  only  act  by  removing  the  fluid :  they  do  not  reach  the  cause,  and  are 
only  too  apt  to  be  followed  by  disappointment,  and  even  by  death.  Trephin- 
ing is  scarcely  called  for,  as  the  cranium  can  readily  be  opened  through  the 
fontanelle.  It  is  too  soon  yet  to  judge  fairly  of  the  somewhat  heroic  opera- 
tion, lately  performed  by  several  surgeons,  of  trephining  the  occipital  bone 
and  draining  directly  from  the  fourth  ventricle  (Browning),  Strapping  with 
adhesive  plaster  is  an  old-time  procedure,  but  it  need  only  be  mentioned  now 
to  be  rejected. 

Altogether,  it  must  be  said  that  the  promise  of  relief,  much  less  of  cure, 
for  hydrocephalus  is,  with  our  present  knowledge,  slight  indeed. 


ABSCESS  OF  THE  BRAUNT, 

By  FREDERICK  PETERSON,  M.  D., 

New  York. 


Abscess  may  form  in  any  part  of  the  brain,  but  is  much  more  common  in 
the  cerebrum  than  in  the  cerebellum,  and  is  extremely  rare  in  the  basal  ganglia, 
pons,  and  medulla.  The  white  substance  is  more  apt  to  suffer  than  the  gray. 
As  a  rule,  there  is  a  single  collection  of  pus,  but  occasionally  there  are  multiple 
abscesses. 

Etiolog-y. — Abscess  is  the  result  of  a  suppurative  encephalitis,  due  gen- 
erally to  an  infectious  irritant.  The  septic  material  may  be  derived  from 
many  sources,  mostly  local,  but  some  distant.  Of  the  local  causes  of  brain- 
abscess,  in  all  cases,  ear  disease  is  the  most  frequent.  Next  follow,  in  their 
order,  traumata  of  the  skull  and  scalp,  diseases  of  the  nasal  cavity,  non- 
traumatic caries  of  the  cranial  bones,  and,  rarely,  orbital  disease  and  intra- 
cranial tumors.  Metastatic  abscesses  of  the  brain  from  distant  sources  have 
been  known  to  follow  pulmonary  gangrene,  empyema,  typhoid  fever,  ulcera- 
tive endocarditis,  measles,  scarlet  fever,  small-pox,  and  other  general  septic  dis- 
eases. Males  are  more  commonly  affected  than  females.  No  age  is  exempt 
from  the  disorder,  but  it  is  exceedingly  rare  during  the  first  year  of  life.  In 
223  cases  collected  by  Gowers,  24  occurred  under  ten  years  of  age  and  72 
under  twenty  years.  In  childhood  traumatic  abscess  is  rather  more  frequent 
than  any  other  form.     In  some  cases  no  cause  of  any  kind  can  be  discovered. 

Pathology. — The  close  connection  of  structures  about  the  head,  such  as 
the  scalp,  bones,  ear,  and  nasal  cavity,  with  the  brain,  by  means  of  vascular 
and  lymphatic  channels,  accounts  for  the  conveyance  of  septic  material  from 
these  parts  to  that  viscus.  The  first  stage  of  suppurative  encephalitis  is  known 
as  "  red  softening."  There  are  inflammatory  oedema  and  swelling,  with  lessen- 
ing of  the  consistence  of  the  affected  part,  and  reddening  from  distention  of 
the  minute  blood-vessels,  together  with  extravasations  of  blood  into  the  tissues. 
There  is  infiltration  of  leucocytes.  At  first  there  is  no  strict  delimitation 
of  the  diseased  area.  The  ganglion-cells,  nerve-fibres,  and  neuroglia  are 
secondarily  affected  and  undergo  necrotic  degeneration.  As  the  encephalitis 
progresses,  the  pus-corpuscles  become  more  numerous,  until  a  greenish-tinted 
abscess  is  produced.  At  first  the  cavity  containing  the  collection  of  pus  is 
irregular  and  not  strictly  demarcated  from  surrounding  tissues  by  a  capsule.  If 
the  process  continues  long  enough,  the  capsule  begins  to  form  in  the  shape  of  a 
delicate  pseudo-membrane,  which  gradually  becomes  thick  and  firm,  and  gives 
the  abscess  a  more  or  less  spheroidal  form.  Usually  some  two  months  are 
required  for  the  formation  of  encapsulated  abscess,  but  often  a  much  longer 
time.  The  capsule  may  be  completely  closed,  or  there  may  be  a  fistulous  con- 
nection with  the  surface  of  the  brain,  or  communication  by  rupture  with  either 
the  outer  surface  or  the  ventricles.  Inflammatory  and  degenerative  changes 
may  be  found  immediately  about  the  encapsuled  abscess  in  the  neighboring 

630 


AB8CE8S    OF    THE  BRAIN.  631 

tissues.  These  abscesses  vary  in  size  from  a  centimetre  to  several  inches  in 
diameter,  though  from  one  to  two  inches  is  the  usual  dimension.  Multiple 
abscesses  are  generally  very  small,  and  are  sometimes  miliary.  There  is  a  dis- 
agreeable fetor  in  a  considerable  number  of  brain-abscesses.  An  abscess  may 
remain  for  long  periods  of  time,  even  for  years,  in  a  stationary  condition,  or,  as  is 
more  frequently  the  case,  it  enlarges  until  death  is  produced  by  interference 
with  brain  functions  or  by  its  bursting  into  the  lateral  ventricles  or  upon  the 
outer  surface  of  the  brain,  when  purulent  ependymitis  or  meningitis  is  excited. 

While  blows  and  falls  upon  the  head  are  common  causes  in  children,  some- 
times these  traumata  leave  no  traces,  and  the  abscess  resulting  subsequently 
may  not  be  considered  due  to  so  trifling  a  source.  Even  when  injuries  are 
visible  in  the  scalp,  there  may  be  no  hurt  of  bone  apparent,  and  the  abscess 
may  lie  deep  in  the  brain.  Usually,  however,  there  is  actual  fracture  or 
necrosis  of  bone,  and  the  abscess  is  likely  to  be  superficial  and  connected  with 
the  point  of  injury,  though,  even  then,  it  may  be  isolated  deep  in  the  brain. 
The  following  case,  observed  by  me  in  1884  in  a  boy  of  twenty,  is  an  illus- 
tration :  In  a  street-row  he  was  struck  with  a  small  heavy  snuff-box  on  the 
forehead  a  little  to  the  left  of  the  middle  line,  causing  a  scalp  wound  and  a 
small  circumscribed  depressed  fracture  of  both  tables.  These  pieces  of  bone 
were  removed.  The  dura  was  normal.  The  parts  were  antiseptically  treated. 
On  the  third  day  the  temperature  rose  to  100°  F.  The  wound  looked  well. 
On  the  thirteenth  day  he  began  to  grow  stupid,  and  three  days  later  he  died  in 
coma.  The  autopsy  showed  the  wound  quite  healed.  The  skull  was  exceed- 
ingly thin.  The  opening  in  the  bone  was  f  by  ;j  of  an  inch  and  contained  a 
trifling  amount  of  pus.  The  dura  mater  was  perfectly  normal,  as  were  also  the 
pia  and  arachnoid.  There  was  evidence  of  brain-pressure,  but  no  apparent 
injury  to  the  superficies.  In  the  white  matter  of  the  left  frontal  lobe  an 
abscess  the  size  of  a  small  hen's  egg  was  found  which  had  no  connection  what- 
ever with  the  exterior  of  the  brain.  The  ventricles  and  all  other  parts  of  the 
brain  were  normal. 

Sometimes  a  month  or  even  a  year  or  two  may  pass  without  the  manifesta- 
tion of  cerebral  symptoms.  This  may  be  explained  by  supposing  that  at  first 
a  very  small  abscess  is  formed,  and  that  it  remains  quiescent  for  a  long  period 
before  development. 

The  ear  disease  giving  rise  to  abscess  is  usually  a  chronic  disorder  that  may 
have  existed  for  years,  even  as  long  as  twenty-five  years,  before  there  is  an 
extension  of  the  trouble  and  the  septic  material  is  conveyed  to  the  brain.  The 
abscess  generally  forms  in  the  temporo-sphenoidal  lobe  of  the  cerebrum  or  in 
the  cerebellum.  Here,  too,  the  common  seat  of  the  affection  is  in  the  interior 
of  the  brain,  separated  from  the  point  of  origin  by  normal  brain-tissues.  In 
some  cases  it  is  more  or  less  superficial. 

Symptoms. — The  symptoms  are  of  two  kinds — those  which  are  especially 
due  to  the  nature  of  the  process,  and  those  which  are  shared  by  abscess  in  com- 
mon with  other  new  formations,  such  as  tumors,  in  the  brain. 

In  the  first  category  we  have  the  symptoms  of  inflammation,  more  or  less 
severe  according  to  the  acuteness  or  chronicity  of  the  inflammatory  change. 
There  may  be  every  grade  of  inflammation,  from  a  severe,  rapid,  and  quickly- 
fatal  process  to  the  slow,  long-continued  formation  of  an  abscess,  Avith  remissions 
frequently  amounting  to  complete  quiescence  and  latency.  Consequently, 
symptoms  may  be  furibund  or  vague  and  indefinite.  Changes  of  temperature, 
generally  a  rise  of  only  one  or  two  degrees,  are  noted ;  sometimes  the  tempera- 
ture is  subnormal.  The  pulse  may  at  times  be  rapid,  but  is  apt  more  com- 
monly to  be  much  reduced  in  frequency.     There  are  anorexia,  constipation, 


632    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

general  malaise,  and  cliilly  sensations  amounting  at  times  to  rigors.  Headache 
is  as  frequent  as  in  tumor,  and  similar  in  its  character.  Quite  frequently  it 
indicates  to  a  certain  extent  the  position  of  the  lesion,  especially  when  the 
abscess  is  of  traumatic  origin.  Sometimes  there  is  vomiting.  Convulsions 
are  uncommon  in  the  early,  but  frequent  in  the  later  stages.  When  general, 
they  show  the  severity  and  extent  of  the  abscess  ;  Avhen  Jacksonian,  they 
reveal  its  position  in  or  beneath  the  motor  cortical  area.  As  the  disease  pro- 
gresses delirium  may  appear,  followed  by  stupor,  gradually  passing  into  coma. 
During  the  "latent"  period — which  is  noted  in  many  cases,  and  w^hich  may 
last  for  months  or  years — some  of  the  above  symptoms  may  be  manifested  in 
slight  degree  and  with  intermissions :  but  the  latent  period  usually  terminates 
abruptly  with  all  of  the  indications  of  acute  abscess.  Vomiting  and  giddiness 
are  very  common  in  cerebellar  abscess,  but  may  also  occur  in  cerebral  forms. 
Paralysis  is  present  in  nearly  one-half  of  the  cases.  The  cranial  nerves  may  be 
affected.  Mental  symptoms  are  more  difficult  to  study  in  the  child  than  in  the 
adult. 

Optic  neuritis  is  often,  but  not  always,  present  in  cerebral  abscess.  It  is 
inclined  to  be  milder  than  in  the  cases  of  tumor,  and  more  apt  to  be  unilateral. 
It  is  very  rarely  observed  in  cerebellar  abscess.  Altogether,  choked  disk  is 
not  so  frequently  met  with  in  abscess  as  in  tumor. 

Focal  symptoms  are  not  so  common  as  in  tumor,  because  abscess  is  more 
often  situated  in  parts  like  the  temporo-sphenoidal  and  frontal  lobes,  where  lesions 
are  less  apt  to  give  definite  objective  symptoms,  and  because  the  pressure  of 
abscess  is  often  less  pronounced  and  more  gradually  developed  than  is  the  case 
in  tumor. 

Rupture  of  the  abscess  usually  produces  sudden  evidences  of  acute  puru- 
lent meningitis  or  symptoms  resembling  those  of  ventricular  haemorrhage. 

Prognosis. — The  outlook  in  all  these  cases  is  exceedingly  grave.  Acute 
abscess  mixy  run  its  course  to  a  fatal  termination  in  from  one  week  to  a  month. 
Chronic  abscess  with  a  period  of  latency  runs  a  very  uncertain  course,  sometimes 
terminating  suddenly,  sometimes  slowly  developing  acute  symptoms.  Even 
where  abscess  remains  latent  for  years  (in  one  case  twenty  years),  death  is  apt 
to  follow  from  some  unexpected  renewal  of  its  activity.  This  may  occur  even 
after  calcification  of  its  capsule  and  inspissation  of  its  contents. 

Diagnosis. — Usually  a  diagnosis  may  be  made  from  the  history  of  an 
onset  after  ear  or  nasal  disease  or  traumatism  of  the  head,  and  from  the  symp- 
toms characteristic  of  a  suppurative  encephalitis  and  of  a  foreign  body  in  the 
brain.  In  acute  abscess  it  is  necessary  to  distinguish  between  it  and  menin- 
gitis, though  this  is  often  extremely  difficult  where  the  meningitis  is  of  the  sup- 
purative form.  The  two  may  coexist,  and  both  are  often  due  to  the  same 
causes.  The  stiffness  of  the  neck,  tendency  to  opisthotonos  and  convulsions, 
and  the  more  frequent  implication  of  the  cranial  nerves  in  meningitis  must  be 
our  guide.  In  the  chronic  form  of  abscess  the  distinction  from  tumor  is  often 
difficult ;  but  here,  too,  the  matter  of  cause  is  of  great  importance,  though 
injury  may  indeed  give  origin  to  either.  Definitely  localizing  symptoms, 
gradually  extending  and  tending  to  involve  the  cranial  nerves,  together  Avith 
more  marked  optic  neuritis,  and  the  greater  frequency  of  tumor  than  abscess, 
are  strong  indications  in  favor  of  the  former. 

Treatment. — Surgical  procedures  are  advisable  in  almost  all  cases,  as 
abscess  is  almost  certainly  fatal,  even  in  cases  where  latency  may  last  for  years. 
Trephining  and  the  removal  of  pus,  either  by  free  opening  and  drainage  or  by 
the  aspirating  needle  where  deeply-seated,  have  been  successful  in  a  number 
of  instances,  especially  in  those  following  injury  to  the  cranial  bones  and  in 


ABSCESS    OF    THE   BBAIN.  633 

ear  disease.  As  prophylactic  measures,  local  bone  disease  from  trauma  or 
aural  inflammations  should  be  most  thoroughly  and  conscientiously  treated. 
The  mastoid  operation  should  be  undertaken  at  the  earliest  appearance  of  a 
tendency  to  extension  of  the  inflammatory  process  to  the  meninges  and  brain. 
Rest,  the  application  of  cold,  the  use  of  derivatives  in  the  way  of  counter-irri- 
tants, and  the  improvement  of  general  health  by  means  of  tonics  and  hygienic 
measures,  have  at  times  their  importance  in  these  cases,  but  too  much  reliance 
should  not  be  placed  upon  these  illusory  measures. 


TUMORS  OF  THE  BRAIN  AND  MENINGES. 

By  FREDERICK   PETERSON,  M.  D., 

New  York. 


Neoplasms  within  the  cavity  of  the  skull  are  quite  as  frequent  in  child- 
hood and  youth  as  in  adult  life,  and  are  to  be  met  with  even  in  earliest  infancy. 
They  occur  in  any  part  of  the  brain,  either  as  metastatic  growths  from  tumors 
elsewhere,  or  as  primary  developments  from  the  neuroglia,  vascular  channels, 
membranes,  or  cranial  bones.  Sometimes  a  scalp  neoplasm  may  erode  the 
bones  and  affect  the  substance  of  the  brain,  as  in  a  case  reported  by  Braun, 
where  a  girl  of  fourteen  had  a  carcinoma  of  the  scalp  which  partially  destroyed 
some  of  the  cerebral  cortex  after  eroding  the  bone. 

Etiology. — Males  are  much  more  frequently  affected  by  tumors  than  females, 
the  proportion  as  given  by  M.  Allen  Starr  being  two  to  one.  Up  to  the  age 
of  twenty  years  cerebral  neoplasms  are  commoner  before  the  age  of  eight 
years  than  after  it.  There  are  a  few  cases  in  which  the  cause  may  be  ascribed 
to  blows  or  falls  upon  the  skull,  yet  the  traumatic  factor  is  probably  not  so 
great  as  is  generally  believed.  Heredity,  fright,  mental  strain,  and  the  like 
seem  to  have  little  to  do  with  their  origin.  Primary  tumors  of  the  brain  are 
not  as  frequent  as  secondary  growths,  and  tubercles,  sarcomata,  and  carcino- 
mata  are  especially,  almost  always,  secondary  to  neoplasms  in  other  parts  of 
the  body. 

Pathology. — In  Keating's  Cyclopaedia,  M.  Allen  Starr  has  collected 
300  cases  of  tumors  of  the  brain  in  children  from  current  medical  journals 
and  including  the  collections  of  Bernhardt  and  Steffan,  thus  bringing  his  list 
up  to  the  beginning  of  the  year  1888.  To  these  I  have  added  some  35  others, 
obtained  from  current  literature  since  that  date.  Upon  these  cases  and  those 
collected  by  Starr  and  upon  Knapp's  monograph  [Litracranial  Growths,  Bos- 
ton, 1891)  this  study  is  mainly  based. 

The  comparative  frequency  of  the  various  kinds  of  tumor  in  children  may 
be  seen  from  the  following  table : 

Form  of  Tumor.  -  No.  of  Cases. 

Tubercle  .      166 

Glioma 42 

Sarconia 37 

Cyst 35 

Carcinoma 11 

Glio-sarcoma 5 

Angio-sarcoma 1 

Myxo-sarcoma  •    ■ 1 

Papillary  epithelioma 1 

Gumma 1 

Not  stated 35 

Total 335 

It  will  thus  be  seen  that  tubercular  tumors  are  by  far  the  most  common  in 

634 


TUMORS    OF   THE  BRAIN  AND    MENINGES.  635 

children,  occurring  four  times  as  frequently  as  gliomata  and  five  times  as  fre- 
quently as  sarcomata.  Another  feature  of  great  interest  is  the  rather  common 
development  of  more  than  one  neoplasm  in  the  same  brain.  This  is  particu- 
larly noteworthy  in  the  case  of  tubercle,  43  of  the  above-mentioned  166  cases 
having  presented  multiple  tumors.  Thus  in  a  case  described  by  West,  a  boy 
aged  fourteen  had  twelve  tubercular  tumors  in  the  brain,  although  there  were 
symptoms  of  but  one.  Moreover,  sarcomata  and  cysts  are  occasionally  mul- 
tiple, 4  of  the  37  cases  of  sarcomata  and  4  of  the  35  cases  of  cysts  having 
been  found  to  be  multiple. 

Tubercular  Tumors. — Though  occasionally  primary  in  the  brain,  these 
tumors  are  usually  due  to  secondary  infection  from  tubercular  processes  else- 
where, in  glands,  lungs,  or  bones.  Infection  may  be  carried  to  the  membrane 
from  a  tubercular  tumor  in  the  brain,  thus  giving  rise  to  a  secondary  tubercular 
meningitis.  About  a  fourth  of  the  cases  have  multiple  brain-tumors,  the  neo- 
plasms varying  from  the  size  of  a  millet-seed  to  that  of  an  egg.  Usually  round 
or  nodular  and  encapsulated,  they  are  at  times  very  irregular  and  diffuse  with- 
out marked  delimitation.  They  nearly  always  arise  from  the  membranes  of  the 
brain,  chiefly  the  pia  or  its  prolongations,  though  occasionally  they  are  to  be 
found  in  the  interior,  and  not  connected  with  the  meninges.  They  owe  their 
existence  to  the  entrance  of  tubercle  bacilli  by  way  of  the  blood-vessels  or 
lymphatics.  Like  gumma,  the  tubercular  tumor  is  a  form  of  granuloma,  and 
histologically  they  are  very  much  alike,  the  periphery  being  composed  of  the 
round-cells  of  granulation  tissue,  giant-cells,  and  often  epithelioid  cells,  while 
the  centre  is  caseous.  A  few  tubercle  bacilli  may  be  found  in  the  outer  parts, 
and  in  the  tubercle  the  caseous  mass  is  confluent,  while  in  the  gumma  there  are 
apt  to  be  several  separate  caseous  masses.  Characteristic  vascular  changes, 
such  as  endarteritis  obliterans  and  periarteritis,  often  aid  in  the  diff"erentiation 
of  the  syphiloma.  The  extreme  rarity  of  gumma  in  children,  as  seen  in  the 
above  table,  must  be  borne  in  mind.  In  fact,  this  one  case  of  gumma  was  in 
a  youth  of  eighteen. 

Gliomata. — These  tumors  come  next  after  tubercle  in  point  of  frequency. 
They  are  due  to  a  hyperplasia  of  the  peculiar  connective  tissue  of  the  nervous 
system,  the  glia  or  neuroglia.  As  is  well  known,  this  connective  substance  is 
allied  in  some  respects  to  mucous  tissue.  The  glioma  resembles  neuroglia  in 
its  histological  characters,  but  the  cells  are  more  numerous  and  vary  much  in 
size.  This  tumor  is  a  peculiarly  nervous  one,  growing  especially  in  the  central 
nervous  system,  though  sometimes  developing  in  the  eye  from  the  retina.  Some 
gliomata  are  hard,  from  the  greater  proliferation  of  fibrous  tissue,  but  the  major- 
ity are  rather  soft  and  cellular,  and  are  prone  to  undergo  secondary  changes, 
such  as  fatty  degeneration  and  caseation.  Often  they  are  rich  in  delicate 
blood-vessels  which  by  rupture  give  rise  to  haemorrhages.  Such  haemorrhages 
may  terminate  a  case,  as  in  ordinary  apoplexy,  or  the  clot  may  become  caseous 
or  form  a  cyst.  The  glioma  being  essentially  a  tumor  of  nervous  connective 
tissue,  it  is  found  generally  in  the  interior  of  the  nervous  organs,  almost  never 
connected  with  the  membranes.  It  grows  slowly,  and  is  not  malignant,  though 
it  has  a  tendency  to  return  after  removal.  It  is  always  solitary.  When  hard, 
it  is  usually  easy  to  distinguish  it  from  surrounding  brain-tissue;  when  soft, 
its  limits  are  not  always  readily  defined.  The  development  of  mucous  tissue 
in  the  tumor  leads  to  the  designation  of  myxo-gliomia,  and  of  numerous  round 
and  spindle-shaped  cells  to  that  of  glio-sarcoma.  Glioma  varies  much  in  size, 
but  may  attain  greater  proportions  than  any  other  tumor. 

Sarcomata. — In  children  sarcoma  is  not  quite  as  frequent  as  glioma.  It 
is  a  rapidly-growing  tumor,  developing  anywhere  in  the  brain  or  from  its  mem- 


636    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

branes.  Usually  solitary,  it  may  in  rare  instances  be  multiple.  It  is  generally 
primary,  but  may  be  metastatic  from  sarcoma  elsewhere.  It  may  be  of  any 
size,  but  as  a  rule  it  is  rounded  or  nodular  in  shape,  and  well  differentiated  from 
the  normal  tissues.  Wlien  fibrous  tissue  is  present  in  unusual  proportion,  the 
tumor  is  hard ;  Avhen  the  cellular  elements  (round,  spindle-shaped,  giant,  and 
stellate  cells)  are  more  abundant,  it  is  soft.  The  interior  may  undergo  second- 
ary changes,  such  as  caseation,  fatty  degeneration,  haemorrhage,  and  the  forma- 
tion of  cysts.  The  proliferation  of  particular  histological  elements  gives  rise 
to  such  designations  as  myxo-,  glio-,  fibro-,  lympho-,  cysto-,  angio-,  melano-, 
round-celled,  spindle-celled,  and  endothelial  sarcoma.  This  neoplasm  is 
malignant. 

Cysts. — Cysts  may  result  from  secondary  changes  in  old  haemorrhages,  and 
such  are  frequently  found  in  the  brains  of  children  suffering  from  infantile 
cerebral  palsies  and  organic  idiocy.  Newly-formed  cysts  are  generally,  how- 
ever, due  to  echinococcus  or  cysticercus  cellulosse.  These  are  more  common  in 
Europe  and  Australia,  apparently,  than  in  America.  The  cyst  of  the  former 
(hydatid)  is  usually  single,  but  may  reach  a  large  size.  The  cysticercus  is 
commonly  small,  producing  few  symptoms,  and  frequently  multiple.  The  cysts 
may  grow  anywhere  in  the  brain,  but  their  development  is  very  slow.  Both 
may  be  recognized  by  the  peculiar  cystic  character  or  by  the  examination  of 
their  booklets,  those  of  the  cysticercus  being  very  much  larger  than  those  of 
the  hydatid. 

Cakcinomata. — About  one-thirtieth  of  the  brain-tumors  in  children  are 
carcinomata,  and  are  always  secondary  to  growths  developed  elsewhere,  or  extend 
directly  from  the  scalp,  bones,  or  orbital  tissues. 

Miscellaneous. — Gumma  is  apparently  so  rare  in  early  youth  that  it  may 
be  said  not  to  exist.  I  have  not  been  able  to  find  in  literature  any  case  except 
the  one  given  in  the  table,  occurring  at  the  age  of  eighteen  years.  Aneurism, 
psammoma,  lipoma,  papilloma,  myxoma,  fibroma,  osteoma,  neuroma,  adenoma, 
cholesteatoma,  teratoma,  and  enchondroma  are  amonor    the  greatest    rarities. 

Symptoms. — In  very  young  children  the  head  may  be  enlarged,  either 
generally,  as  in  hydrocephalus,  or  there  may  be  actual  protrusion  of  certain 
limited  portions  of  the  skull,  as  in  a  case  I  saw  some  years  ago  of  extreme 
oxycephalus.  The  neoplasms  at  times  erode  the  cranial  bones  and  bulge  out 
beneath  the  scalp.  Displacement  of  the  eyeball  has  been  noted  in  cases  where 
the  tumor  has  extended  into  the  orbit. 

But  in  most  cases  there  is  no  outward  indication  of  the  presence  of  an  intra- 
cranial growth,  and  we  must  diagnosticate  its  presence  by  certain  general  mani- 
festations, such  as  headache,  vertigo,  vomiting,  sleeplessness,  visual  disorders, 
mental  changes,  spasms,  fever,  and  the  like,  and  by  localizing  symptoms,  as 
paralysis,  limited  spasm,  anaesthesia,  disordered  locomotion,  and  disturbances 
in  the  functions  of  cranial  nerves.  Some  or  all  of  the  general  symptoms  may 
be  present  in  almost  every  case  of  intracranial  tumor,  no  matter  what  may  be 
its  situation,  but  the  exact  seat  of  the  neoplasm  must  be  determined  by  a  care- 
ful study  of  the  motor,  sensory,  reflex,  and  psychic  symptoms,  and  based  upon 
an  accurate  knowledge  of  the  physiological  anatomy  of  the  brain.  In  rare 
instances  tumor  of  the  brain  may  exist,  giving  rise  to  scarcely  any  symptoms 
at  all. 

Headache. — This  is  found  in  the  majority  of  cases  of  brain-tumor,  accord- 
ing to  Mary  Putnam  Jacobi  in  about  two-thirds  of  the  cases.  It  is  more  fre- 
quent and  more  severe  in  cerebellar  growths  hemmed  in  beneath  the  tense 
tentorium.  The  pain  is  doubtless  chiefly  due  to  pressure  upon,  or  irritation  of, 
the  sensitive  dura  mater.     It  may  be  in  any  part  of  the  head,  but  is  usually 


TUMORS    OF   THE  BBAIN  AND   MENINGES.  637 

frontal  or  occipital,  without  reference  to  the  seat  of  the  tumor.  Occasionally 
the  pain  is  distinctly  and  constantly  localized  at  one  place,  and  here  there  may 
be  tenderness  of  the  scalp  and  head  on  percussion,  this  being  under  such  cir- 
cumstances of  value  as  a  localizing  symptom.  The  pain  is  dull  and  continuous 
or  intermittent  and  severe.  Infants  probably  suifer  less,  owing  to  the  greater 
distensibility  of  the  skull ;  and  in  them  pain  may  be  inferred  from  restless- 
ness, irritability,  sharp  cries,  sleeplessness,  and  burrowing  movements  of  the 
head. 

Nausea  and  Vomiting. — These  symptoms  are  noted  in  from  one-fifth  to 
one-fourth  of  the  cases.  They  are  commoner  in  children  than  in  adults.  The 
vomiting  may  occur  without  nausea,  irrespective  of  the  taking  of  food,  and 
intermittently  or  more  or  less  continuously.  It  may  be  associated  with  vertigo, 
and  frequently  accompanies  severe  headache.  It  is  often  brought  on  by  move- 
ment of  the  body.     It  is  most  common  in  cerebellar  tumor. 

Vertigo. — This  symptom  is  not  uncommon,  and  is  particularly  frequent 
with  cerebellar  neoplasms.  As  it  accompanies  so  many  divers  affections  out- 
side of  the  cranial  cavity,  it  cannot  be  regarded  as  of  great  diagnostic  value. 

Optic  Neuritis. — The  optic  nerves  are  affected,  according  to  Starr,  in  80 
per  cent,  of  cases  of  brain-tumor,  and  hence  this  constitutes  one  of  the  most 
significant  objective  symptoms.  It  must  be  always  looked  for,  since  neuritis 
may  exist  to  a  very  great  extent  without  visual  defect.  Usually  double,  it 
may  at  first  appear  in  one  eye,  and  generally  one  disk  is  more  affected  than 
the  other.  This  symptom,  too,  is  more  common  in  tumors  of  the  cerebellum 
and  at  the  base  of  the  brain.  It  must  be  remembered,  however,-  that  it  occurs 
in  other  disorders  beside  brain-tumor,  such  as  meningitis,  hydrocephalus,  and 
abscess.      Optic  atrophy  may  follow  the  neuritis. 

Convulsions. — Spasms  are  of  frequent  occurrence  in  the  brain-tumors  of 
childhood.  They  may  be  slight  (petit  mat)  or  severe,  limited  to  certain  mem- 
bers, or  general,  infrequent  or  frequent — twenty  to  thirty  per  day.  General 
convulsions  have  no  significance  as  to  the  seat  of  the  lesion,  nor  can  partial 
epilepsy  (Jacksonian)  always  be  relied  upon  to  indicate  the  situation  of  the 
tumor. 

Mental  Changes. — In  at  least  half  of  the  cases  some  psychical  disturbance 
is  manifest.  This  is  naturally  much  varied  according  to  the  amount  of  brain 
injury  and  the  age  of  the  child.  It  may  show  itself  in  mere  fretfulness  and 
irritability,  or  there  may  be  dulness,  lethargy,  hebetude.  In  some  cases  there 
may  be  delirium,  maniacal  excitement,  or  an  enfeeblement  of  the  mental  pro- 
cesses amounting  to  dementia.  Somnolence  is  a  common  symptom  in  children. 
As  the  disease  progresses  this  often  deepens  into  coma. 

Tremor,  insomnia,  fever,  neuralgia,  slow  or  rapid  pulse,  disturbances  of 
respiration,  and  constipation,  are  symptoms  occasionally  observed  in  certain 
cases,  but  from  these  no  significant  deductions  can  be  made.  Increase  of  head- 
temperature,  local  or  general,  as  measured  by  the  surface  thermometer,  has  not 
yet  been  sufficiently  studied  to  be  practically  available  as  a  symptom  in  brain- 
tumor. 

Localizing-  Symptoms. — After  due  and  careful  consideration  of  these 
general  symptoms,  we  must  examine  the  focal  manifestations,  which  are  either 
irritative  or  destructive.  Localizing  symptoms  depend  altogether  upon  the 
seat  of  the  tumor,  whether  adjacent  to  the  motor  area  of  the  cortex  (partial 
epilepsy)  or  in  the  motor  tract  (monoplegia  or  hemiplegia) ;  in  the  sensory  areas 
or  tracts  (anaesthesia,  hemiansesthesia,  hemianopsia,  etc.) ;  in  motor  or  sensory 
speech-centres  or  tracts  (aphasia  in  various  forms) ;  or,  finally,  impinging  upon 
cranial  nerve  nuclei  or  trunks  (paralysis  of  cranial  nerves). 


638    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Crradual  onset  and  spread  are  the  rule  in  brain-tumor.  There  are  occa- 
sional exceptions,  since  a  secondary  meningitis  or  a  haemorrhage  in  the  new 
growth  may  produce  a  sudden  exacerbation ;  and  there  are  in  rare  instances 
intermissions,  remissions,  or  even  retrogressions,  in  the  course  of  its  develop- 
ment. 

Usually  the  symptoms  of  cerebral  or  cerebellar  tumor  are  unilateral, 
whereas  those  of  neoplasm  at  the  base  affecting  the  cerebral  axis  are  often 
bilateral. 

The  relative  frequency  with  which  tumors  aflFect  the  various  parts  of  the 
brain  may  be  learned  from  the  following  table : 

Site  of  Tumor.  Number  of  Cases. 

Cerebellum 105 

Pons  Varolii      42 

Centrum  ovale 41 

Basal  ganglia  and  lateral  ventricles 30 

Corpora  quadrigemina  and  crura  cerebri 25 

Cortex  cerebri 23 

Medulla  oblongata 7 

Fourth  ventricle 6 

Base  of  brain 8 

Total 287 

From  this  it  will  be  seen  that  tumors  of  the  cerebellum  are  slightly  in  excess 
of  those  of  the  cerebrum  proper  (105  to  94),  while  the  remaining  88  cases  were 
of  new  growths  in  the  structures  about  the  base  of  the  brain  (crura,  pons,  and 
medulla). 

Tumors  of  Cortical  and  Subcortical  Regions. — These  are  mostly 
tubercles,  sarcomata,  gliomata,  and  cysts.  It  is  difficult  to  differentiate  cortical 
from  subcortical  tumors,  the  symptoms  being  about  the  same,  and  neoplasms  in 
either  portion  tending  by  extension  to  involve  the  other.  The  manifestations 
will  vary  according  to  the  functions  of  cortical  centres  or  descending  tracts 
involved.  A  study  of  Figs.  1  and  2  will  show  what  functions  will  be  destroyed 
by  tumors  affecting  the  different  portions  of  cortex  there  represented,  while  in 
Fig.  3  the  tracts  of  fibres  which  convey  impulses  to  and  from  these  various 
centres  are  shown.  The  chief  points  to  be  noted  in  relation  to  new  growths 
here  may  be  briefly  stated  as  follows : 

Fig.  1. 

'>'^=-  ^-       AUDITORY  A  op/ 

LANGUAGE 

^^^^ 

■■"^^^^^^  ^ 

^^Gj-^y.     'I  Occipital 
^ __  -^-V^        ,1    Lobe 

Lohe. 
Scheme  of  Localization  in  Cortex  of  Convex  Surface  of  Hemisphere. 


TUMORS    OF   THE   BBAIN  AND    MENINGES. 


639 


Tumors  of  the  Frontal  Lobe  often  present  no  marked  symptoms.  If  they 
impinge  downward  upon  the  olfactory  bulb,  they  may  give  rise  to  loss  of  the 
sense  of  smell.     There  are  often  mental  changes,  such  as  difficulty  in  concen- 


FiG.  2. 


CUNEUS 


Localization  on  Inner  Surface  of  Hemisphere. 

trating  attention,  of  thinking  connectedly,  of  exercising  self-control,  of  com- 
prehending with  ease,  or  of  acquiring  and  retaining  new  knowledge.  Some- 
times there  is  great  mental  torpor  and  enfeeblement  amounting  to  imbecility. 

Fig.  3. 

,W\OTOR  AREA 


Temporal 


Scheme  of  Position  of  Fibre-tracts  descending  from  the  various  areas. 


But  irritation  from  the  frontal  cortex  may  extend  backward  to  the  motor  areas, 
and  thus  produce  hemi-epilepsy  or  general  convulsions.  If  the  tumor  exerts 
much  pressure  backward  or  extends  into  the  motor  area  or  tracts,  paresis  or 


640   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

paralysis  of  the  opposite  side  of  the  body,  beginning  often  as  a  monoplegia,  is 
developed. 

Tumors  Affecting  the  Third  Frontal  Convolution  of  the  left  hemisphere  in 
right-handed  persons  give  rise  to  motor  aphasia,  and  occasionally  agraphia,  of 
imperfect  type.  In-  a  slowly-growing  lesion,  like  tumor,  the  opposite  hemi- 
sphere may  often  gradually  compensate  for  the  loss  of  function  in  the  aflFected  side. 
This  matter  of  aphasia,  however,  is  not  so  important  a  localizing  symptom  in 
children  as  in  adults.  From  studies  I  have  made  of  hemiplegia  in  children  I 
have  been  led  to  conclude  that  during  the  first  years  of  life  (perhaps  up  to 
eight  or  ten  years  or  more)  the  two  hemispheres  share  equally  the  motor  and 
sensory  functions  of  speech,  and  that  it  is  only  during  adolescence  that  the  left 
hemisphere  (in  right-handed  persons)  takes  upon  itself  gradually  the  greatest 
part  of  this  burden. 

Tumors  about  the  Fissure  of  Rolando,  or  Motor  Area,  cause  convul- 
sions or  paralysis  of  the  side  opposite  to  the  lesion,  affecting  later  the  face, 
arm,  or  leg,  or  all  together,  according  to  the  size  and  exact  position  of  the 
growth.  These  local  spasms  are  known  as  partial  or  Jacksonian  epilepsy. 
When  the  spasm  precedes  paralysis,  the  probability  is  that  the  cortex  is  first 
affected.  When  the  paralysis  precedes  the  onset  of  spasm,  we  may  reasonably 
conclude  that  the  neoplasm  began  to  develop  in  the  white  matter  beneath  the 
cortex.  There  may  be  some  ansesthesia  in  connection  with  the  paresis,  for  it 
is  generally  believed  that  the  motor  area  subserves  sensation  also  to  a  great 
extent.  In  all  of  these  cases  it  is  important  to  study  the  character  and 
manner  of  onset  of  the  spasms,  whether  partial  or  general.  The  aura  of  the 
epileptic  attack  is  often  of  great  value  in  determining  the  exact  seat  of  the 
lesion.  This  aura  may  be  a  sensation  of  numbness  or  tingling,  arising,  for 
instance,  in  the  fingers,  hands,  or  toes.  Seguin  has  given  to  this  phenomenon 
the  name  "  signal  symptom."  It  indicates  the  starting-point  of  the  cortical 
excitation.  The  order  of  extension  of  the  spasm  after  the  signal  symptom 
must  also  be  noted,  for  it  indicates  the  path  of  extension  of  the  discharge 
along  the  cortex.  In  the  paralyzed  parts  the  deep  reflexes  are  of  course  exag- 
gerated, as  in  all  forms  of  cerebral  palsy,  and  there  is  no  actual  atrophy, 
though  disuse  often  leads  to  a  diminution  in  the  size  of  the  affected  mem- 
bers. 

Tumors  of  the  Parietal  Lobe,  like  those  of  the  frontal,  often  give  no  localizing 
symptoms,  though  the  studies  of  M.  Allen  Starr  and  Dana  are  quite  conclusive 
as  to  the  frequency  of  sensory  disturbances  (muscular,  tactile,  pain,  and  tem- 
perature sense)  in  lesions  at  this  point.  Thus  at  times  parsesthesia  and  anaes- 
thesia may  be  found  in  the  opposite  limbs.  But  irritation  may  extend  from 
the  parietal  ai-ea  forward  to  the  motor,  and  thus  produce,  as  in  the  case  of  fron- 
tal neoplasms,  partial  or  general  convulsions.  And  by  progressive  extension 
the  tumor  may  invade  neighboring  structures,  and  thus  give  rise  to  focal  mani- 
festations (motor  symptoms  by  forward  extension,  hemianopsia  by  dowmvard 
extension  to  the  visual  tract).  In  adults  tumor  in  the  inferior  parietal  lobule 
of  the  left  side  produces  word-blindness,  but  this  indication  is  of  doubtful  value 
in  children.  We  do  not  yet  possess  suflicient  information  on  this  point  to 
make  any  definite  statements.  The  same  is  applicable  to  the  matter  of  affec- 
tions of  the  auditory  speech-centre  indicated  in  Fig.  1. 

Tumors  of  the  Occipital  Lobe,  in  addition  to  general  symptoms,  give  rise 
to  the  very  important  one  of  blindness  of  a  half  of  each  eye  opposite  to  the 
the  lesion  (homonymous  hemianopsia).  The  blindness  is  opposite  to  the  lesion, 
but  of  course  the  affected  half  of  the  retina  of  each  eye  is  on  the  same  side  as 
the  lesion.     From  the  occipital  cortex,  also,  discharges  may  extend  forward  to 


TUMORS    OF   THE   BRAIN  AND   MENINGES. 


641 


the  motor  area  and  produce  convulsions,  as  in  a  case  now  under  the  care  of"  Starr 
and  myself,  where  a  lesion  (hsemorrhage  at  birth)  in  a  girl  of  fifteen  has  given 
rise  to  hemianopsia  and  genuine  epilepsy.  A  tumor  by  continued  growth  may 
aifect  parts  forward,  such  as  the  sensory  tract  (hemiansesthesia)  and  even  the 
motor  (hemiplegia). 

Tumors  of  the  Temporo-sphenoidal  Lohe  will  be  apt,  especially  in  chil- 
dren, to  cause  no  definite  localizing  symptoms.  The  sense  of  hearing  has  its 
centre  in  the  first  and  second  temporal  convolutions,  and  smell  and  taste 
have  been  assigned  to  the  tip  of  this  lobe.  In  adults  it  is  probable  that  the 
form  of  sensory  aphasia  known  as  word-deafness  may  be  produced  by  lesion  in 
one  part  of  the  left  temporo-sphenoidal  lobe.  We  have  still  much  to  learn  in 
this  connection  in  the  pathology  of  childhood. 

Tumors  of  the  Basal  Ganglia,  Lateral  Ventricles  and  Island  of 
Reil,  by  their  encroachment  upon  the  internal  capsule,  through  which  so  many 
important  tracts  pass  (see  Fig.  3),  are  prone  to  give  rise  to  marked  and  wide- 
spread symptoms,  such  as  hemiplegia  (when  anterior  part  of  capsule  is  afi'ected) 
and  hemiansesthesia  and  hemianopsia  (when  the  posterior  part  of  the  capsule 
is  involved).  Other  than  these  no  definite  localizing  symptoms  will  be  noted 
in  children.  At  times  other  structures  (such  as  the  cranial  nerves)  may  be 
affected  by  pressure  or  distortion  by  tumors  in  these  regions. 

Tumors  about  the  Crura  Cerebri  give  rise  to  a  variety  of  symptoms 
according  to  the  parts  affected  and  the  extent  of  the  lesion.  The  crus  contains 
the  motor  and  sensory  tracts,  and  the  two  third  nerves  (motor  oculi)  rise  from 
the  crura  very  close  together  (Fig.  4).     Thus  if  one  crus  is  involved,  there  will 


Fig.  4. 


OPTIC  NERVE 


Fourth  Nerve 
Fifth  Nerve 


Ninth 
Tenth 
^Eleventh 


Structures  at  Base  of  Brain,  to  show  topography. 


be  complete  hemiplegia  of  the  opposite  side  (occasionally  hemiansesthesia  also), 
and  third-nerve  paralysis  on  the  same  side  (ptosis,  etc.).  This  is  called  alter- 
nate or  crossed  hemiplegia.     The  optic  tract  is  near  at  hand   also,   and   if 

41 


642    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

affected,  which  is  seldom,  will  give  rise  to  homonymous  liemianopsia  (probably 
with  hemiopic  pupillary  inaction).  There  may  be  unilateral  incoordination. 
If  the  tumor  be  interpeduncular,  some  of  the  symptoms  here  mentioned  will  be 
bilateral.     Optic  neuritis  is  apt  to  develop  early  in  these  cases. 

Tumors  of  the  Quadrigeminal  Region  are  among  the  rarities.  Some 
fibres  of  the  optic  nerve  enter  the  corpora  quadrigemina,  and  the  centre  for  the 
reflex  to  light  lies  in  them.  Contiguous  to  them  lie  the  nuclei  of  all  of  the 
motor  nerves  of  the  two  eyes  (third  and  fourth  and  fibres  of  sixth).  Nothnagel 
has  made  a  study  of  tumors  of  this  region  based  upon  10  cases  collected  by 
Bernhardt  and  4  cases  of  his  own,  so  that  the  symptomatology  is  pretty  well 
established.  There  is  staggering  gait,  resembling  cerebellar  titubation,  and  a 
progressive  double  ophthalmoplegia.  The  ataxia  may  be  the  earliest  symptom. 
AVhen  this  is  followed  by  the  condition  of  immovable  bulbi,  we  may  be  quite 
sure  of  our  diagnosis.  The  ocular  paralyses  may  be  unequal  on  the  two  sides. 
Nystagmus  has  been  observed  in  but  one  case.  As  the  tumor  develops,  hydro- 
cephalus is  produced  by  pressure  upon  the  aqueduct  of  Sylvius.  A  hemiparesis 
and  hemiansesthesia,  or  irregular  paralytic  and  anaesthetic  symptoms,  may  be 
produced  by  extension  of  the  growths  toward  the  crus  on  either  or  both  sides. 
The  optic  neuritis  and  blindness  observed  are  due  to  the  same  causes  at  work 
in  conjunction  with  neoplasms  elsewhere.  Three  years  ago  I  observed  a  case 
of  quadrigeminal  tumor  in  a  little  girl  at  the  New  York  Polyclinic.  Her  first 
symptom  was  staggering  gait.  Then  there  was  gradual  development  of  oculo- 
motor paralysis  and  blindness,  and  finally  slight  hemiparesis.  At  the  autopsy 
I  found  a  tubercle  the  size  of  a  hazel-nut  in  the  quadrigeminal  region.  There 
was  also  tubercular  meningitis,  and  a  few  small  tubercles  in  the  cerebellum. 
The  case  has  been  reported  by  Sachs. 

Tumors  of  the  Pons  Varolii  give  generally  distinctive  localizing  symp- 
toms, because  of  the  cranial  nerves  which  arise  from  or  are  adjacent  to  it.  Thus 
the  third  nerve  rises  from  the  crus  close  to  its  upper  border,  the  fifth  from  its 
lateral  aspect ;  the  sixth  lies  upon  it ;  the  seventh  and  eighth  have  their  super- 
ficial origin  below  its  lower  border.  In  the  interior  of  the  pons  are  the  motor 
and  sensory  tracts  for  both  sides  of  the  body,  and  the  nuclei  of  several  nerves 
(fifth,  sixth,  and  seventh).  If  unilateral,  the  tumor  is  apt  to  give  rise  to 
crossed  paralyses  or  alternating  hemiplegia  and  alternating  anaesthesia.  In 
the  upper  half  of  the  pons  a  tumor  involving  part  of  the  crus  may  cause 
ptosis  and  external  strabismus,  and  anaesthesia  upon  one  side,  hemiplegia  upon 
the  other.  In  the  lower  part  the  growth  may  produce  internal  strabismus 
(sixth  nerve),  facial  paralysis,  and  deafness,  associated,  possibly,  with  paralysis 
of  the  arm  and  leg  of  the  opposite  side.  If  the  tumor  affects  the  root  or  trunk 
of  the  sixth  nerve,  as  may  be  the  case  in  neoplasms  growing  from  the  base  of 
the  skull,  the  loss  of  power  is  only  in  the  muscle  supplied  by  that  nerve.  But 
if  the  nucleus  of  the  sixth  nerve  be  involved,  there  is  a  peculiar  disorder  of 
both  eyes ;  that  is,  a  loss  of  power  in  the  internal  rectus  of  the  opposite  eye 
also,  which  is  only  shown  in  the  impossibility  of  conjugate  movement  of  the 
two  eyes  toward  the  side  of  the  lesion,  since  the  external  rectus  of  one  eye  and 
the  internal  rectus  of  the  other  habitually  act  together.  There  is  in  such 
lesions  a  conjugate  deviation  of  both  eyes  to  the  side  opposite  to  the  lesion. 

A  lesion  may  be  so  placed  in  the  pons  that  none  of  the  cranial  nerves  are 
involved,  and  only  a  hemiplegia  is  produced,  indistinguishable  from  a  capsular 
hemiplegia.  If  both  motor  paths  are  involved,  we  may  have  a  paraplegia. 
Such  a  lesion  is  generally  accompanied  by  cranial  nerve  involvement  on  one 
or  possibly  both  sides. 

Both  sensoi-y  and  motor  paths  may  be  involved  in  primitive  lesions,  but 


TUMORS    OF    THE   BRAIN  AND    MENINGES.  643 

these  paths  are  rather  widely  separated  by  the  deep  transverse  fibres  of  the 
pons,  and  in  such  cases  the  lesion  must  be  large. 

Tumors  affecting  the  Medulla  Oblongata  are  prone  to  give  rise  to 
striking  symptoms,  such  as  dysphagia,  disturbances  of  the  respiration  and 
pulse,  severe  vomiting,  polyuria,  glycosuria,  etc.,  from  involvement  of  important 
nerves  (glosso-pharyngeal,  pneumogastric,  hypoglossal,  and  spinal  accessory), 
and  widespread  paralyses  and  anaesthesias  from  their  impinging  upon  the  great 
motor  and  sensory  tracts  contained  in  the  medulla.  These  symptoms  are  gen- 
erally bilateral. 

In  growths  aifecting  either  pons  or  medulla  all  sorts  of  combinations  of 
symptoms  may  be  observed,  too  numerous  to  be  described  here.  The  general 
symptoms,  such  as  headache,  vertigo,  and  vomiting,  are  common,  but  convul- 
sions are  rare. 

Tumors  of  the  Cerebellum  are  among  the  most  common  of  the  intra- 
cranial growths  in  children.  In  the  middle  lobe  they  produce  cerebellar  tituba- 
tion,  a  staggering  gait  much  resembling  that  of  a  drunken  man.  Vertigo  is 
also  an  important  symptom,  and  is  more  severe  and  continuous  than  that  caused 
by  growths  elsewhere.  If  the  middle  peduncle  of  either  side  be  involved,  the 
staggering  is  more  to  one  side  than  the  other.  Tumors  of  the  hemispheres  of 
the  cerebellum  give  rise  to  no  focal  symptoms  unless  they  impinge  upon  the 
middle  lobe  or  the  peduncles.  Cerebellar  neoplasms  by  extension  are  apt  to 
injure  cranial  nerves  about  the  pons  or  medulla.  Hydrocephalus  is  often 
observed :  it  is  due  to  pressure  upon  the  fourth  ventricle  or  veins  of  Galen. 

Tumors  at  the  Base  of  the  Brain  in  the  anterior,  middle,  or  posterior 
,  fossae  are  diagnosticated  by  the  symptoms  characteristic  of  pressure  upon  or 
destruction  of  the  important  structures  already  mentioned. 

Differential  Diagnosis. — The  presence,  site,  and  nature  of  a  neoplasm  must 
be  determined  by  the  facts  given  in  the  preceding  pages.  Brain-abscess  is 
differentiated  by  its  own  peculiar  symptoms,  described  in  another  part  of  this 
volume.  Tubercular  meningitis  sometimes  presents  symptoms  similar  to  those 
of  intracranial  neoplasms,  particularly  when  chronic.  Ordinary  forms  are 
easily  distinguished.  Chronic  hydrocephalus  and  cerebral  haemorrhage,  when 
unusual  in  character,  may  simulate  tumor,  but  careful  study  of  the  mode  and 
order  of  development  of  their  manifestations  will  generally  serve  to  distinguish 
them. 

Prognosis. — The  prognosis  is  death  unless  the  tumor  be  removed.  M. 
Allen  Starr  gives  the  average  duration  of  life  as  two  years.  Death  occurs 
ordinarily  by  gradually  increasing  coma,  sometimes  with  convulsions.  Occa- 
sionally haemorrhage  in  or  about  the  tumor  (especially  in  gliomata)  may 
terminate  life.  At  times  a  sudden  meningitis  (in  tubercular  forms)  brings 
about  a  fatal  end.      Sudden  death  from  unknown  cause  may  occur. 

Treatment. — It  is  evident  that  medicinal  treatment  of  intracranial  tumor 
must  be  in  most  cases  merely  palliative.  Gumma  of  the  brain  being  a  growth 
almost  never  met  with  in  children,  the  question  of  antisyphilitic  treatment  need 
not  be  discussed  here.  While  it  is  always  wise  to  make  use  of  anti tubercular 
treatment  in  cases  suspected  to  be  of  this  nature,  it  is  doubtful  if  much  can  be 
done  to  diminish  the  extent  or  stop  the  progress  of  such  neoplasms. 

The  routine  treatment  with  cod-liver  oil,  tonics,  fresh  air,  and  the  like, 
should  certainly  be  carried  out.  It  is  possible  that  tuberculin  or  tuberculocidin 
may  after  a  time  be  made  available  for  such  cases,  but  as  yet  the  subject  is  too 
new  to  form  any  pronounced  opinion.  Klebs's  experience  with  tubercu- 
locidin in  tubercular  disease  of  the  lungs,  skin,  bones,  and  joints  is  pro- 
mising. 


644  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

It  is  usual  in  most  cases  of  brain-tumor,  of  whatever  nature,  to  employ 
iodide  of  potassium  in  10-  to  20-grain  doses,  three  times  daily  after  eating,  in 
an  abundance  of  menstruum  (water  or  milk).  Arsenic  is  occasionally  as 
useful. 

In  all  cases  there  are  symptoms  requiring  treatment,  such  as  headache,  intra- 
cranial pressure,  insomnia,  and  convulsions.  Antipyrin  (2  to  10  grains  accord- 
ing to  age),  cannabis  Indica  (|  to  3  minims  of  the  fluid  extract),  and  morphine 
(^  to  yV  of  a  grain)  are  good  agents  in  headache  due  to  this  cause.  Intra- 
cranial pressure  may  be  relieved  to  some  extent  by  purges,  prolonged  warm 
baths,  the  hot  wet  pack,  and  wet  leg  compresses.  These  remedies  may  quiet 
headache,  vertigo,  and  vomiting,  and  will  relieve  insomnia.  The  bromides  are 
often  useful  for  insomnia,  pain,  restlessness,  and  vomiting,  and  are  always  indi- 
cated, combined  with  chloral,  in  cases  with  a  tendency  to  convulsions. 

The  question  of  surgical  interference  will  arise,  for  in  this  lies  the  only 
hope  of  effective  relief  against  impending  death.  The  question  of  the  uses  and 
value  of  cerebral  surgery  in  children  is  still  under  consideration.  Operations 
on  the  brain  in  children  are  more  dangerous  than  in  adults.  The  mortality  is 
very  great.  There  is  a  greater  difficulty  in  diagnosis  and  localization  in  chil- 
dren. There  is  a  larger  percentage  of  cases  of  multiple  tumors  in  childhood. 
Some  25  per  cent,  of  the  tubercular  tumors  of  childhood  are  multiple.  Con- 
siderably more  than  half  of  the  neoplasms  of  the  brain  in  childhood  are  situated 
in  structures  in  the  posterior  fossa  of  the  skull,  and  this  region  deserves  the 
name  of  the  surgical  noli-me-fanc/ere  much  more  in  children  than  in  adults. 
Infiltrating  tumors,  of  no  well-defined  limitation,  are  not  uncommon.  Thus 
we  are  forced  to  the  conclusion  that  we  must  be  much  more  conservative  in 
advising  surgical  procedures  in  the  brain-tumors  of  children  than  we  need  be  in 
those  of  adults.  When  we  have  pretty  certain  evidence  of  the  presence  of  a 
solitary  new-growth  in  the  cortex  or  centrum  ovale  of  the  cerebrum,  we  may 
attempt  removal  with  a  fiiir  hope  of  accomplishing  a  good  result.  The  large 
percentage  of  tumors  with  a  recedivial  tendency  must,  however,  not  be  for- 
gotten. The  whole  matter  of  brain  surgery  as  regards  children  is  still  in  an 
experimental  stage. 


THE  AFFECTIONS  OF  THE  NERVOUS   SYSTEM 
DUE  TO  INHERITED  SYPHILIS. 


By  CHARLES  W.  BURR,  M.  D., 

Philadelphia. 


It  has  long  been  known  that  inherited  syphilis  may  lead  to  disorders  of 
the  nervous  system,  but  the  matter  was  little  studied  until  recent  years.  Many 
cases  have  been  reported,  and  a  review  of  the  literature  shows  that  as  in 
the  acquired  disease  any  part  of  the  nervous  system,  central  or  peripheral,  may 
be  affected.  It  is  noteworthy,  however,  that  in  children  born  alive  the  nervous 
system  is  much  less  frequently  the  seat  of  disease  than  are  the  other  organs. 
The  exact  percentage  cannot  for  obvious  reasons  be  determined.  We  have  no 
positive  data  concerning  the  proportion  of  stillborn  or  aborted  syphilitic  infants 
with  lesions  of  the  nervous  system.  Much  remains  to  be  learned  of  the  pathol- 
ogy of  the  disease,  and  the  present  paper  will  be  confined,  in  large  measure, 
to  its  clinical  aspect. 

Fournier  claims  that  persistent  headache  with  nocturnal  exacerbations  is  one 
of  the  most  frequent  symptoms.  Accompanying  it,  indeed  often  its  only  evi- 
dence, are  extreme  irritability,  sleeplessness,  and  spells  of  screaming.  Demme 
records  a  case  in  which  the  following  cycle  recurred :  headache  followed  by 
anger,  then  torpor,  and  finally  diabetes  insipidus.  Convulsions  are  very  com- 
mon, and  are  probably  one  of  the  most  frequent  immediate  causes  of  death. 
They  are  usually  bilateral,  and  with  tonic  and  clonic  contractions.  Laryngis- 
mus and  tetany,  though  most  apt  to  be  due  to  rachitis,  sometimes  occur.  Bar- 
low and  Bury  record  the  case  of  a  child  who  had  ten  to  twelve  fits  daily  from 
the  fourteenth  day  to  the  seventh  month.  In  another  case  which  came  to 
autopsy  at  the  fourth  month  extensive  meningeal  changes  were  found ;  and  in  a 
third,  there  were  no  cortical  changes  in  the  convexity,  but  symmetrical  gum- 
mata  were  present  on  several  cranial  nerves.  In  this  last  case  there  were  con- 
vulsive seizures  in  which  the  mouth  was  widely  opened  and  the  child  became 
very  dusky. 

A  few  cases  of  apparently  idiopathic  epilepsy  have  been  recorded  in  which 
the  only  discoverable  cause  was  inherited  syphilis.  Gowers  cites  eight,  in  six 
of  which  the  fits  began  after  infancy.  Abner  Post  relates  an  interesting  case 
in  which  the  attacks  began  wdth  vertigo,  the  patient  feeling  as  if  she  were  in  a 
boat  which  was  rocking  violently.  They  lasted  about  half  an  hour,  and  were 
followed  by  nausea  and  vomiting.  There  was  never  unconsciousness.  The 
attacks  occurred  as  often  as  three  times  a  week,  and  disappeared  under  the  use 
of  iodide  of  potassium.  According  to  Fournier,  the  condition  is  apt  to  be  accom- 
panied by  pain  in  the  head,  noises  in  the  ears,  dimness  of  vision,  vertigo,  and 
intellectual  failure.  In  the  greater  number  of  cases  there  are  added  to  the  fits, 
sooner  or  later,  other  symptoms  of  cerebral  or  spinal  mischief. 

The  differential  diagnosis   between  tuberculous  meningitis  and  syphilis  is 

645 


646  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

often  impossible  unless  a  history  of  hereditarv  taint  or  evidence  of  it  can  be 
found.  According  to  Horatio  C.  AVood,  a  general  indefiniteness  of  symptoms 
and  slowness  of  progression  should  arouse  suspicion,  especially  if  the  absence 
of  the  pulse  retardation  indicates  that  the  vault  rather  than  the  base  of  the 
cranium  is  in  fault.  Stoeber  gives  the  following  points  in  diagnosis :  Tuber- 
culous meningitis  is  rare  under  one  year ;  there  is  seldom  palsy  at  the  beginning ; 
pyrexia  is  present ;  and  the  pulse  is  slow.  Syphilis,  on  the  other  hand,  may 
occur  soon  after  birth  ;  palsy  is  often  present  from  the  first ;  frequently  fever 
is  absent,  and  the  pulse  is  irregular.  Stoeber  further  regards  retraction  of  the 
abdomen,  projectile  vomiting,  constipation,  delirium,  contractures,  and  rapid 
wasting  as  characteristic  of  the  former  disease.  Too  often,  however,  diagnosis 
can  only  be  made  when  it  is  no  longer  needed.  *  Recovery  means  syphilis,  as 
it  is  more  probable  that  an  error  in  diagnosis  has  been  made  than  that  a  tuber- 
culous case  has  recovered. 

Hemiplegia  is  infrequent.  In  Osier's  series  of  120  cases  only  1  presented 
a  pretty  definite  history  of  syphilis.  On  the  other  hand,  in  Abercrombie's 
series  of  50  cases  at  least  4  were  syphilitic.  Barlow  and  Bury  report  an  inter- 
esting case  in  which  there  was  at  first  loss  of  speech  with  right-sided  paresis. 
After  about  four  months  of  mercurial  treatment  the  patient  recovered  almost 
completely,  only  to  be  again  attacked,  this  time  by  left  paresis  and  loss  of  speech. 
Finally  there  was  complete  recovery.  The  authors  believe  that  there  was 
endoarteritis  of  symmetrical  branches  of  the  middle  cerebral  arteries  and 
degeneration  of  the  cortical  centres,  especially  of  the  third  frontal,  on  both 
sides.  A  case  of  left-sided  hemiplegia  in  a  girl  ten  years  old,  described  by 
Hughlings-Jackson,  is  made  doubly  interesting  by  the  fact  that  two  years 
before  she  had  had  chorea  confined  to  the  same  side.  Marfan  relates  a  case  in 
a  child  four  months  old  in  which  recovery  followed  two  weeks'  mercurial  treat- 
ment. Ordinarily,  one-sided  fits  precede  the  palsy,  and  quite  often  convulsions 
continue  in  the  palsied  members ;  but  it  may  come  on  without  convulsions — 
without,  indeed,  warning  of  any  kind.  The  child  simply  falls  unconscious, 
and  retui'ns  to  consciousness  palsied.  In  rare  cases  even  consciousness  is  not 
disturbed.  On  the  other  hand,  there  may  be  restlessness,  vomiting,  and  head- 
ache. The  presence  or  absence  of  aphasia  depends  of  course  upon  the  situation 
of  the  lesion. 

The  most  common  anatomical  basis  of  cerebral  syphilis  is  endoarteritis  and 
thrombosis  with  sclerosis  and  meningeal  thickening.  Angel  Money,  however, 
showed  a  specimen  to  the  Pathological  Society  of  London  in  which  there  were 
atrophy  and  sclerosis  of  the  left  hemisphere  without  disease  of  the  arteries  or 
membranes.  Gummata  are  very  rare.  Rumpf  cites  but  two,  and  M.  Allan 
Starr  in  a  table  of  299  brain  tumors  occurring  in  persons  under  nineteen  years 
of  age  records  one  only,  and  that  in  a  youth  of  eighteen.  It  is  very  probable, 
however,  that  the  small,  yellow,  and  indurated  foci  found  in  various  parts  of 
the  brain  by  Chiari  and  others  are  gummatous. 

Chronic  hydrocephalus  is  sometimes  of  syphilitic  origin.  Ruff'er  in  a  care- 
ful review  of  the  literature  says  that  it  is  mentioned  as  the  cause  in  20  per 
cent,  of  the  cases.  Mendel  regards  it  as  a  frequent  cause.  Lancereaux  speaks 
of  a  syphilitic  woman  who  gave  birth  to  several  hydrocephalic  children.  The 
anatomical  cause  of  the  condition  is,  according  to  Sandoz,  inflammation  of  the 
ventricular  ependyma  and  plexuses.  In  some  instances,  as  in  a  case  reported 
by  Negree,  instead  of  the  usual  thinning  of  the  cranial  bones  they  are  much 
thickened.  Heubner  reports  a  case  in  which  the  enlargement  of  the  skull  was 
found  post-mortem  to  be  due  not  so  much  to  dilatation  of  the  ventricles  as  to  a 
pachymeningitis  haemorrhagica. 


SYPHILITIC  NERVOUS  AFFECTIONS.  647 

Paraplegia  may  result  from  disease  either  of  the  cord  and  its  membranes 
or  of  the  spinal  column.  Fournier  records  a  case  of  hyperostosis  affecting 
several  of  the  dorsal  vertebrae  and  causing  symptoms  of  compression  myelitis. 
Many  signs  of  syphilis  were  present,  and  the  patient  improved  under  specific 
treatment.  Laschkewitz  cured  in  two  months  a  palsy  of  all  the  extremities 
due  to  a  similar  condition  in  the  cervical  region.  We  have  no  positive  know- 
ledge whether  distinctly  syphilitic  lesions  occur  in  the  spinal  cord  in  the  inher- 
ited disease,  or  whether  the  inheritance  acts  only  as  a  strong  predisposing  cause. 
So  far  as  we  have  been  able  to  learn,  no  autopsy  has  ever  been  made  in  a  case 
of  purely  cordal  inherited  syphilis. 

Dixon  Mann  reports  a  case  in  a  boy  fifteen  years  old  who,  after  two  years 
of  progressing  weakness  in  the  legs,  became  completely  paraplegic  and  anses- 
thetic.  Muscular  rigidity,  increased  reflexes,  girdle  pain,  paralysis  of  the 
bladder,  and  a  slight  bed-sore  were  present.  Fever  was  absent.  The  patient 
recovered  after  four  months'  treatment.  The  author  considered  the  symptoms 
to  be  due  to  thrombosis  with  circumscribed  softening. 

In  none  of  the  cases  of  Friedreich's  ataxia  recorded  in  Grifiith's  paper, 
and  in  none  which  we  have  seen,  is  there  clear  evidence  of  inherited  syphilis, 
while  almost  all  of  the  few  known  cases  of  locomotor  ataxia  occurring  in  chil- 
dren had  distinct  hereditary  taint.     Remak  and  Fournier  detail  several  such. 

Moncorvo  relates  three  cases  of  disseminated  sclerosis,  two  of  which  im- 
proved under  specific  treatment.  Ozenne  relates  a  case  of  latent  infantile 
syphilis  which  was  treated  for  some  time  for  infantile  palsy,  and  which  pre- 
sented the  symptoms  of  that  disease,  except  that  fever  was  continuously  pres- 
ent. A  month's  specific  treatment  resulted  in  recovery.  True  acute  anterior 
poliomyelitis  rarely  occurs  in  children  with  such  hereditary  taint, 

Eustace  Smith  describes  a  peculiar  form  of  palsy  which  affects  the  anterior 
branches  of  the  brachial  plexus.  It  causes  a  more  or  less  complete  palsy  of 
the  arms,  sensation  and  temperature  remaining  normal.  He  quotes  two  cases 
from  Henoch  in  which  the  flexor  muscles  of  the  fino-ers  alone  retained  slight 
traces  of  contractility.  Under  specific  treatment  the  palsy  disappeared.  In 
some  cases  a  peculiar  twisting  of  the  head  backward  has  been  noticed  when 
the  child  has  been  placed  in  a  sitting  position. 

Some  years  ago  Sinkler  reported  cases  of  chorea  occurring  in  syphilitic 
children,  and  others  have  been  reported  since.  The  total  number  is,  however, 
so  very  small — in  Rachford's  61  cases,  for  example,  there  being  only  1  with  a 
syphilitic  family  history — that  the  relation  cannot  be  more  than  coincidental. 

The  peripheral  nerves  are  quite  apt  to  be  affected,  the  lesion  being  either 
gummatous  or  inflammatory.  Nettleship  reported  to  the  Pathological  Society 
of  London  a  case  of  a  girl  in  whom  there  Avas  palsy  of  the  third,  fifth,  and 
sixth  nerves  on  one  side.  She  was  under  observation  for  four  years,  during 
which  time  the  condition  persisted.  Hutchinson  relates  two  cases  of  ophthal- 
moplegia externa,  in  one  of  which  optic  atrophy  was  present.  Bury  and 
Barlow  speak  of  two  cases  in  which  the  seventh  nerve  was  involved.  In  one 
there  was  found  post-mortem  symmetrical  gummata  on  the  third,  sixth,  seventh, 
and  eighth  pairs.  Lawford  reports  two  cases  of  ocular  palsy,  and  quotes  one 
from  von  Graefe  in  which  there  was  complete  palsy  of  the  third  nerve. 

It  is  probable  that  the  form  of  deafness  described  by  Hutchinson  as  occur- 
ring within  a  few  years  of  puberty,  and  being  bilateral,  painless,  and  without 
discharge,  is  often  due  to  disease  of  the  internal  ear  or  the  nerve. 

The  most  remarkable  case  of  spinal-nerve  disease  is  that  reported  by 
Omerod,  in  the  person  of  a  woman  twenty-three  years  old  with  a  tumor  of  the 
median  nerve,  probably  gummatous. 


648    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Examination  of  the  cases  given  above  will  show  conclusively  that  inherited 
nervous  syphilis  is  not  a  disease  confined  to  infancy,  but  that,  on  the  contrary, 
the  symptoms  may  first  appear  at  puberty  or  even  later. 

Idiocy  is  rarer  than  would  be  expected.  The  probable  explanation  is  that 
given  by  Fournier — namely,  that  the  lesions  which  would  cause  it  are  apt  to  be 
fatal.  Shuttleworth  and  Beach  found  syphilitic  taint  in  only  28  of  2380  cases 
which  they  investigated.  Ireland  regards  it  as  rare.  Mental  disturbance 
coming  on  after  infancy  is  more  common.  Many  cases  present  the  same  symp- 
toms as  are  found  in  birth-palsy — spastic  paralysis,  fits,  and  weak-mindedness. 
According  to  Barlow  and  Bury,  juvenile  dementia  is  more  often  due  to  syphilis 
than  is  usually  recognized.  Under  the  title  of  "  general  paralysis  occurring 
about  the  period  of  puberty  "  Wiglesworth  speaks  of  eight  cases,  the  two  most 
prominent  causative  factors  being  hereditary  and  congenital  syphilis.  Mendel 
reports  a  case  of  mania  with  hallucinations  occurring  in  a  child  fifteen  years 
old. 

Diagnosis  depends  entirely  upon  the  history  and  the  presence  of  signs  of 
syphilis.  There  are  no  pathognomonic  symptoms.  There  is  a  form  of  syphilitic 
pseudo-paralysis,  the  so-called  Parrot's  disease,  which  may  be  supposed  to  be 
of  nervous  origin  if  careful  examination  is  not  made.  The  apparent  palsy, 
which  may  be  monoplegic  or  diplegic,  comes  on  spontaneously  after  birth  with- 
out fever  or  convulsions  and  unaccompanied  by  any  trophic  changes.  Exami- 
nation will  reveal  that  there  is  hyperostosis  of  the  long  bones  or  crepitation  at 
the  epiphyses  from  spontaneous  fractures.  Parrot  believed  the  condition  to 
be  almost  always  incurable,  but  this  has  been  disproved  in  quite  a  number  of 
cases. 

Treatment  is  the  same  as  in  the  acquired  disease. 


INFANTILE  CEREBRAL  PALSIES. 

By  FBEDERICK  PETERSON,  M.  D., 

New  York. 


The  infantile  cerebral  palsies  are  symptoms  of  a  variety  of  pathological 
lesions  in  the  brain,  just  as  in  adult  life  such  paralyses  depend  upon  processes 
of  different  kinds  taking  place  in  various  regions  at  different  levels  in  that 
organ.  We  may  have  a  monoplegia  of  the  face,  arm,  or  leg,  or  a  liemi'plegia^ 
or  a  double  hemiplegia  {diplegia)  ;  or  we  may  have  the  two  lower  extremities 
affected  {paraplegia),  for  the  amount  of  paralysis  depends  upon  the  extent  of 
the  lesion.  The  cerebral  palsies  of  early  life,  then,  are  symptoms  merely,  and 
our  most  important  duty  in  connection  with  them  is  to  discover  the  nature  of 
the  lesion  which  causes  them,  and  to  localize  the  seat  of  the  pathological  pro- 
cess within  the  brain.  But  while  the  paralysis  is  the  paramount  symptom  of 
the  destructive  process  occurring  in  the  brain,  there  are  many  concomitant 
clinical  conditions  which  it  behooves  us  to  recognize  and  study.  As  a  basis 
for  this  article  I  shall  make  use  of  a  paper  by  Dr.  Sachs  and  myself,  published 
in  the  Journal  of  Mental  and  Nervous  Disease  for  May,  1890,  in  which  one 
hundred  and  forty  cases  were  analyzed ;  and,  in  addition,  shall  include  the 
results  of  my  personal  observations  of  considerably  over  one  hundred  cases 
studied  at  the  Vanderbilt  Clinic,  in  my  nervous  wards  at  Charity  Hospital,  and 
in  private  practice,  making  a  total  of  about  two  hundred  and  fifty  cases.  There 
have  been  added  to  the  literature  since  1890  many  valuable  articles,  clinical, 
pathological,  and  therapeutic,  dealing  with  these  palsies,  from  which  I  have 
drawn  liberally  such  material  as  has  been  deemed  useful. 

The  French  are  the  earliest  contributors  to  the  study  of  these  palsies.  In 
1827,  Cazauvielh  published  a  paper  upon  the  palsies  appearing  shortly  after 
birth,  and  described  the  pathological  conditions  which  he  found  in  the  brain  in 
six  autopsies.  He  speaks  of  a  primary  idiopathic  agenesis  and  of  a  form  of 
agenesis  secondary  to  a  variety  of  cerebral  disorders.  Dug^s,  Breschet,  and 
Cruveilhier  about  the  same  time  and  later  contributed  to  the  study  of  the 
atrophied  brains  of  children,  though  Cotard  did  more  than  other  Frenchmen 
to  elucidate  the  pathology  of  the  infantile  cerebral  paralyses.  He  found  cere- 
bral atrophies  to  be  accompanied  by  yellow  plaques,  cysts,  cicatrices,  cell-infil- 
trations, defects,  and  primary  or  secondary  diffuse  lobar  sclerosis.  The  earliest 
German  writer  upon  this  subject  was  Henoch,  who  in  1842  ^rote  De  Atrophia 
Cerebri ;  while  the  earliest  English  writer  to  describe  these  palsies  was  Little; 
and  the  earliest  American,  Sarah  McNutt.  While  these  are  mentioned  as  the 
pioneers  in  the  unravelling  of  the  mysteries  surrounding  these  disorders,  there 
have  been  contributions  of  enormous  importance  by  many  authors  of  different 
nationalities.  Kundrat  in  1882  produced  an  able  dissertation  on  porencephaly, 
a  name  given  by  Heschl  to  the  defects  of  brain-substance  found  in  many  such 
cases.     Kundrat  differentiated  between  congenital  and  acquired  porencephaly, 


650    AMEBIC  AX  TEXT-BOOK  OF  DISEASES  OF  CHILDBEX. 

and  ascribed  the  origin  of  these  defects  to  anaemic  necrosis  from  circulatory 
disturbances.  Audry  added  much  to  our  knowledge  of  porencephaly  by  the 
collection  of  103  cases,  while  Bourneville,  Richardiere,  AVuillamier,  and  Jen- 
drassik  and  Marie,  on  the  other  hand,  carefully  studied  lobar  sclerosis. 
Striimpell  endeavored  to  explain  most  cases  of  spastic  hemiplegia  of  children 
by  his  theory  of  an  acute  porencephalitis,  but  this  theory  is  now  altogether 
rejected  in  the  light  of  recent  research,  especially  that  of  Sachs.  Heine, 
Benedikt.  Bernhardt.  Wallenberg,  Kast,  Hoven,  Mbbius,  Feer,  P.  ^larie, 
Gaudard,  Gibotteau.  Ross,  Hadden,  Gowers,  Abercrombie,  Ashby,  and  Freud 
and  Rie,  in  Europe,  have  all  at  various  times  made  valuable  additions  to  our 
clinical  and  pathological  knowledge  of  these  disorders.  In  America,  Weir 
Mitchell.  Hammond,  Sinkler,  J.  Lewis  Smith,  Knapp,  Lovett,  Gibney,  J. 
Madison  Taylor,  and  Imogeue  Bassette  have  materialh'  increased  the  literature 
of  the  subject,  while  the  monograph  of  Professor  Osier  is  a  rich  storehouse  of 
clinical  and  patholocrical  facts  relatintr  thereto. 

Statistics. — The  relative  frequency  of  the  cerebral  palsies  of  early  life,  as 
compared  with  the  infantile  spinal  palsies,  is  in  the  proportion  of  more  than 
one  of  the  former  to  two  of  the  latter,  so  that  it  is  a  much  commoner  malady 
than  has  generally  been  supposed.  Boys  are  somewhat  more  frequently 
afflicted  than  girls.  In  452  cases  collected  to  determine  the  relative  frequency 
of  the  various  forms,  there  were  332  cases  of  hemiplegia,  73  of  diplegia,  and  46 
of  paraplegia.  Cerebral  monoplegia  is  extremely  rare,  there  being  only  1  in 
this  entire  number.  In  hemiplegia  the  right  and  left  sides  are  about  equally 
affected,  the  difference  in  favor  of  the  right  being  very  small.  Thus,  of  the 
332  cases  of  infantile  hemiplegia,  175  were  of  the  right  and  157  of  the  left 
side.  In  bilateral  hemiplegia  or  diplegia  usually  all  four  extremities  were 
affected,  but  occasionally  only  three  (both  legs  and  one  arm).  As  contrasted 
with  the  cerebral  palsies  of  adult  life,  the  enormous  frequency  of  diplegias 
and  paraplegias  in  the  cerebral  palsies  of  early  life  is  striking. 

As  regards  the  age  at  onset,  most  cases  of  diplegia  and  paraplegia  are  con- 
genital, while  most  cases  of  hemiplegia  are  acquired  after  birth.  Two-thirds 
of  the  acquired  palsies  have  their  onset  during  the  first  three  years  of  life. 
But  it  is  worth  while  to  remember  that  at  least  lY  per  cent,  of  infantile  hemi- 
plegias are  congenital.  With  Sachs,  I  found  5  cases  where  the  hemiplegia 
occurred  at  the  age  of  eight  years,  and  4  cases  between  eight  and  fifteen  years 
of  age ;  while  Osier  gives  14  cases  with  an  onset  between  the  ages  of  four  and 
ten  years.  It  is  a  fact,  however,  that  cerebral  palsies  are  often  congenital  in 
origin,  though  the  symptoms  may  not  become  apparent  until  some  three  or 
four  months  after  birth,  so  that  doubtless  many  are  ascribed  to  the  first  year 
of  life  which  had  their  origin  during  intra-uterine  existence  or  at  the  time  of 
labor. 

Etiolog-y. — The  infantile  cerebral  palsies  fall  naturally  into  three  groups : 
I.  Those  which  have  their  inception  during  intra-uterine  life  ;  II.  Those  which 
result  from  injury  at  parturition  ;  III.  Those  which  are  acquired  subsequent  to 
birth. 

The  pahies  of  prenatal  origin  are  numerous.  Trauma  to  the  mother 
during  gestation  is  a  frequent  cause  of  injury  to  the  cerebrum  of  the  foetus. 
Serious  diseases  affecting  the  mother  while  "^carrying  the  child  are  common 
causes,  particularly  such  as  are  septic  in  character  or  interfere  Avith  the  normal 
circulation.  Thus,  fevers  like  typhoid,  pneumonia,  uraemic  conditions,  convul- 
sions, and  similar  affections  have  in  my  experience  resuked  in  maldevelopments 
of  the  foetal  brain.  Fright  also  has  seemed,  in  one  or  two  cases,  to  have 
brought  about  such  a  catastrophe,  and  doubtless  other  psychical  strains  may 


INFANTILE    CEREBRAL    PALSIES.  651 

produce  like  results.  Premature  birth  at  the  seventh  or  eighth  month  was  a 
coincidence  in  four  or  five  congenital  cases.  Syphilis  is  extremely  rarely  a 
cause  in  congenital  cases. 

The  chief  cause  of  the  cerebral  paralyses  occurring  during  parturition  is 
undoubtedly  tedious  labor.  Delivery  is  especially  apt  to  be  slow  in  primiparse, 
and  the  older  the  primipara  the  more  tedious  is  the  labor  usually.  In  such 
cases  the  long-continued  pressure  upon  the  head  is  apt  to  work  mischief  to  the 
child's  brain.  While  instruments  are  often  employed  in  precisely  these  con- 
ditions, and  sometimes  themselves  cause  injury  to  the  cranium,  it  is  quite  cer- 
tain that  the  effects  of  compression  in  tedious  labor  are  more  commonly  the 
cause  of  congenital  paralysis  and  idiocy  than  the  application  of  forceps — a  point 
that  the  obstetrician  should  keep  in  mind. 

The  third  group  of  cerebral  palsies  of  children,  the  acquired  paralyses, 
have  a  great  variety  of  etiological  factors,  chief  among  which  are  the  acute 
infectious  diseases  of  childhood,  giving  origin  to  about  20  per  cent,  of  all 
cases.  These  palsies  may  follow  measles,  scarlatina,  small-pox,  typhoid  fever, 
whooping-cough,  vaccinia,  pneumonia,  cerebro-spinal  meningitis,  gastro- 
enteritis, and  tonsillitis.  In  pneumonia  and  whooping-cough  the  strain  and 
engorgement  produced  by  the  coughing  are  probably  important  factors  in  the 
production  of  the  palsy.  Other  causes  of  the  acquired  palsies  are  simple 
fright,  trauma  to  the  skull,  hereditary  syphilis,  the  status  epilepticus,  and 
infantile  convulsions.  There  is  no  evidence  of  the  existence  of  an  acute 
polio-encephalitis  analogous  to  poliomyelitis. 

Symptoms. — Onset  with  convulsions  is  exceedingly  common,  the  convul- 
sions sometimes  being  a  concomitant  symptom  of  the  brain  lesion,  and  some- 
times the  actual  cause.  Since  so  large  a  proportion  of  the  cerebral  palsies  of 
early  life  are  due  to  lesions  affecting  the  cortex,  it  is  not  surprising  that  con- 
vulsions should  be  so  frequently  observed.  For  the  same  reason  coma  is  very 
common  at  the  onset  of  the  paralysis.  The  repetition  of  convulsions  as  the 
disorder  progresses,  especially  in  the  form  of  epilepsy,  is  the  strongest  indication 
of  involvement  of  the  cortex  in  the  pathological  process. 

The  form  of  the  paralysis  is  either  monoplegia,  hemiplegia,  bilateral  hemi- 
plegia, diplegia,  or  paraplegia.  The  first  mentioned  is  extremely  rare.  In 
hemiplegia  the  leg  recovers  more  rapidly  than  the  arm,  as  in  the  adult,  but  in 
rare  instances  the  leg  is,  and  remains,  more  affected  than  the  arm.  While  the 
face  is  frequently  included  in  the  paralysis,  it  rarely  continues  to  be  paralyzed, 
but  is  among  the  first  parts  to  recover.  Traces,  however,  of  facial  paralysis 
may  often  be  discovered  in  these  cases  on  close  investigation.  Strabismus  is 
found  at  times  in  all  the  forms  of  infantile  cerebral  palsy. 

In  children  that  have  learned  to  talk,  aphasia  may  accompany  the  palsy, 
probably  quite  as  frequently  a  left  as  a  right  hemiplegia,  for  the  motor  speech- 
centre  does  not  seem  to  be  specialized  in  the  left  hemisphere  during  the  early 
years  of  life.  But  a  defective  development  of  articulate  speech  is  common  in 
all  forms,  and  particularly  in  the  congenital  cases  and  the  earliest  acquired 
cases. 

I  have  observed  hemianopsia  in  two  or  three  cases  of  infantile  hemiplegia, 
and  Henschen  has  noted  several  such  in  his  great  work.  Freud  has  described 
two.  In  the  great  majority  of  cases  the  reflexes  on  the  affected  side  (knee-, 
elbow-,  ankle-,  and  wrist-jerks)  are  exaggerated,  but  in  about  5  per  cent,  they 
may  be  normal,  diminished,  or  absent  in  the  paralyzed  extremities.  Some- 
times they  are  difficult  to  obtain  on  account  of  rigidity  and  contractures.  This 
is  especially  true  of  ankle-clonus  and  the  triceps-jerk.  Frequently  the  deep 
reflexes  are  exaggerated  also,  as  in  the  adult,  in  the  normal  as  well  as  in  the 


652    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Fig.  1. 


paralyzed   extremities ;    nevertheless,    they  are  more   marked   in   the  parts 
involved  in  the  palsy. 

Morbid  movements  are  remarkably  common  in  the  paralyzed  muscles  of 
hemiplegic  and  diplegic  children.  The  most  frequently  observed  of  these 
motor  disturbances  is  athetosis,  occurring  in  some  20  per  cent,  of  all  cases  of 
hemiplegia,  and  occasionally  in  diplegia.  Next  in  point  of  frequency  are  asso- 
ciated movements  ;  that  is,  the  more  or  less  exact  imitation  by  the  paralyzed 
hand  and  fingers  of  voluntary  movements  made  by  the  normal  hand  and 
fingers,  and  vice  versa.  Such  associated  movements  are  to  be  observed  in 
healthy  children,  the  tendency  in  childhood  being  to  make  use  of  the  tAvo 
hands  simultaneously  ;  but  in  cerebral  palsy  this  tendency  is  often  so  greatly 
exaggerated  that  such  nicely  co-ordinated  movements  as  are  required  in 
writing  and  buttoning,  when  executed  by  the  sound  hand  are  closely  imi- 
tated by  the  affected  hand.  Choreiform  movements  are  found  in  some  5 
or  6  per  cent,  of  the  hemiplegics,  but  are  much  more  rare  in  diplegia.  Ataxia^ 
rhythmical  contractions,  tremor,  and  tetanoid  contractions  are  occasionally 
to  be  noted.  Nystagmus  is  found  apparently  only  in  cases  of  diplegia. 
I  have  remarked  nystagmus  in  three,  and  Osier,  in  two  such  cases.  I  have 
recently  described  as  present  in  two  congenital  hemiplegias  a  hitherto  unnoted 
morbid  movement  to  which  I  have  given  the  name  post-hemiplegic  poly  myo- 
clonus. The  movements  are  neither  choreiform  nor 
athetoid,  but  are  constant  clonic  contractions  of  most 
of  the  muscles  in  the  limbs  affected,  not  occurring 
synchronously,  and  the  rhythm  being  about  that  of 
paralysis  agitans  (five  per  second).  All  of  these  move- 
ments indicate  interference  with  motor  conduction  due 
to  lesions  in  some  part  of  the  voluntary  and  inhibitory 
tracts. 

Rigidity  and  contractures  are  striking  symptoms 
in  almost  all  these  palsies,  and  for  this  reason  they 
often  fall  into  the  hands  of  the  orthopaedic  surgeons, 
who  are  besought  to  remedy  the  rigidly-flexed  elbows, 
wrists,  knees,  and  the  various  deformities  that  interfere 
with  locomotion.  Adductor  spasm  in  the  thighs, 
causing  cross-legged  progression,  is  nearly  constant  in 
diplegia  and  paraplegia.  Talipes  equino-varus  is  the 
most  frequent  pedal  deformity  in  hemiplegia.  Double 
talipes  equino-varus  is  observed  at  times  in  both  diplegia 
and  paraplegia.  Rarely  talipes  equinus  and  talipes 
equino-valgus  are  to  be  found  in  hemiplegia.  While 
rigidity  with  contracture  is  the  rule  in  all  of  these 
forms  of  infantile  cerebral  palsy,  occasionally,  but  very  seldom,  cases  will  be 
met  with  in  which  the  muscles  are  all  completely  flaccid. 

The  chief  trophic  disturbance  encountered  in  these  cases  is  retardation  in 
growth  of  the  paralyzed  members.  The  paralyzed  limbs  do  grow,  but  at  a 
much  slower  rate  than  the  sound  extremities.  Hence  the  disproportion  is 
often  very  striking.  The  eai'lier  the  onset  of  the  palsv,  the  greater  is  this  dis- 
proportion. Another  peculiarity  that  I  have  noted  is  that  the  growth  of  tlie 
whole  organism  is  to  a  certain  extent  interfered  with,  the  injury  to  the  brain 
seeming  to  stunt  development  and  to  prevent  the  patient  attaining  his  normal 
stature.  The  patients  are  more  or  less  undersized  and  dwarfed.  This  point 
was  particularly  made  evident  to  me  in  a  case  of  hemiplegia.  The  mother 
brought  to  me  her  two  boys,  twins,  six  years  of  age,  for  the  examination  of  the 


Cross-legged  Progression. 


INFANTILE    CEREBRAL    PALSIES. 


653 


one  affected.  One  was  a  tall,  well-built  lad ;  the  hemiplegic  boy  was  small- 
bodied  and  fully  seven  inches  shorter  than  his  healthy  brother.  In  all  of  these 
cases  the  muscles  of  the  paralyzed  and  undeveloped  extremities  react  normally 
to  the  faradic  current.  In  many  cases  the  affected  limbs  may  be  blue  and 
cold,  as  in  paralysis  of  the  spinal  type.  A  very  rare  phenomenon  in  these  cases 
is  a  hypertrophy  of  the  muscles,  usually  combined  with  athetosis. 

EjnlejDsy  is  undoubtedly  the  worst  feature  of  these  cases,  affecting  as  it  does 
over  45  per  cent,  of  all  forms.     In  the  hemiplegic  form  fully  one-half  of  the 


Fig. 


Fig.  3. 


Right  Hemiplegia,  with  contracture  and  retarded 
growth  of  arm. 


Eight  Hemiplegia,  from^  age  of  nine 
months,  in  a  woman  thirty-six  years ; 
contracture  and  retarded  develop- 
m.ent  of  paralyzed  side. 


cases  suffer  from  epilepsy,  in  diplegia  30  per  cent.,  and  in  paraplegia  36  per 
cent,  of  all  cases.  In  most  of  them  the  epileptic  seizures  are  general,  but 
about  15  per  cent,  of  the  cases  of  infantile  cerebral  palsy  suffering  from  epi- 
lepsy exhibited  the  Jacksonian  type  of  seizure.  I  have  observed  petit  nial  in 
two  or  three  cases.  A  very  important  fact  has  been  brought  out  in  this  con- 
nection, and  that  is  that  many  cases  that  have  been  diagnosticated  as  epilepsy 
alone  are,  upon  close  and  careful  investigation,  found  to  present  traces  of  a  palsy 
often  so  rudimentary  in  character  that  it  has  escaped  attention.  In  all  cases 
of  what  appears  to  be  idiopathic  epilepsy  search  should  be  made  for  the  residua 
of  paralyses.  There  are  undoubtedly  cases  of  genuine  epilepsy  having  its 
origin  in  similar  pathological  processes  which  beget  the  palsies  of  early 
life,  yet  in  which  no  vestige  of  the  organic  lesion  may  be  discovered  at  all. 
It  would  naturally  be  expected  that  as  most  of  the  lesions  causing  cerebral 
paralyses  in  early  life  are  cortical,   the  epilepsy  would  be  Jacksonian  rather 


654    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


than  general,  but  the  contrary  is  the  case.  The  reason  for  this  is  that  the 
original  focal  lesion  disappears,  and  a  general  atrophy  and  sclerosis  take  its 
place. 

Feeble-mindedness,  imbeciliti/,  and  idioci/  in  connection  with  these  palsies 
are  more  frequently  observed  even  than  epilepsy.  The  proportion  of  mental 
enfeeblement  is  in  a  direct  ratio  to  the  extent  of  the  pathological  process,  and 
hence  in  the  diplegias  and  paraplegias  a  large  degree  of  imbecility  and  idiocy  is 

Fig.  4. 


Paraplegia:  Photographed  in  Epileptiform  Convulsion. 

usually  encountered,  for  here  both  hemispheres  are  involved.  In  hemiplegias, 
on  the  other  hand,  idiocy  is  relatively  rare,  though  the  lower  degrees  of  feeble- 
mindedness and  imbecility  are  to  be  noted  in  nearly  one-half  of  all  cases. 

Among  the  phi/sical  defects,  or  stigmata  degenerationis,  are  often  found 
various  cranial  deformities,  such  as  asymmetry  of  face  and  skull,  microcephalus, 
leptocephalus,  macrocephalus,  and  cranium  progan?eum.  The  Gothic  palate, 
imperfectly  developed  or  supernumerary  teeth,  hirsuteness,  and  deformed  ears 
are  other  physical  evidences  of  imbecility  and  idiocy  at  times  encountered.  I 
have,  in  a  paper  with  Fisher,  called  attention  to  the  flattening  of  the  skull 
often  observed  on  the  side  opposite  the  paralysis  in  infantile  spastic  hemi- 
plegia. 

Pathological  Anatomy. — It  is  seldom  that  cases  of  infantile  cerebral 
palsy  come  to  autopsy  at  the  time,  or  near  the  time,  of  their  onset,  while  there 
are  large  numbers  that  have  been  carefully  studied  and  described  after  the  late 
secondary  pathological  changes  have  become  manifest.  But  it  is  precisely  the 
initial  lesion  that  it  is  very  important  to  understand.  For  a  full  discussion  of 
the  pathology  I  would  refer  the  reader  to  the  original  paper  written  by  Dr. 
Sachs  and  myself,  and  in  particular  to  the  chapter  on  "  Cerebral  Haemorrhage, 
Thrombosis,  and  Embolism,"  by  the  former,  in  Keating's  Cyclop(edia  of  the 
Diseases  of  Children. 

At  the  post-mortem  examination  the  physician  usually  finds  atrophy  of  a 
part  of  the  brain,  evidences  of  sclerosis,  one  or  more  cysts,  or  the  condition 
known  as  porencephalus.  All  of  these  are  terminal  conditions.  Cysts  are 
secondary,  as  a  rule,  to  haemorrhage.  Porencephaly  may  follow  upon  haemor- 
rhage, upon  anaemic  necrosis,  or  upon  other  long-antecedent  processes.  Atrophy 
and  sclerosis,  too,  are  the  results  of  a  variety  of  initial  lesions,  such  as  haemor- 
rhage, thrombosis,  and  embolism.  While  it  is  barely  possible  that  encephalitis 
may  be  a  forerunner  of  some  of  these  terminal  conditions,  there  is  not  sufficient 
evidence  of  the  existence  of  the  polioencephalitis  of  Striimpell  to  establish  it 
as  a  fact.     We  may  group  the  pathological  processes,  after  Sachs,  as  follows : 


INFANTILE    CEREBRAL    PALSIES. 


655 


Groups. 


I.  Paralyses  of  intra-uterine  onset 


II.  Paralyses  occurring  during  labor 


III.  Paralyses  acquired  after  birth 


Pathological  Changes. 


Large  cerebral  defects  (true  porenceph- 
aly). 
HEMORRHAGES  OF  INTRA-UTERINE  Origin  (soft- 
ening? ) 
Agenesis  Corticalis. 

Meningeal  Hemorrhage  (very  seldom  intra- 
cerebral). 

Eesulting  conditions :    meningo-encephal- 
itis  chronica  ;  sclerosis ;  cysts ;  atrophies 
(porencephalies). 
Meningeal  Haemorrhage  (very  seldom  intra- 
cerebral ) ;  Embolism  ;  Thrombosis  ( in  ma- 
rantic conditions  and  occasionally  from  syphi- 
litic endarteritis). 

Pesults  of  these   vascular   lesions:    cysts; 
softening ;  atrophy ;  sclerosis  (diffuse  and 
lobar). 
Chronic  Meningitis. 
Hydrocephalus  (seldom  the  sole  cause). 
Primary  Encephalitis  (Striimpell)  (?) 


The  pathology  of  the  congenital  cases  is  very  clear.  In  a  certain  number 
of  cases  there  is  defective  development,  so  that  often  large  portions  of  the  brain 
are  wanting.  These  defects  are  possibly  due  to  vascular  disorders  during  foetal 
life.  In  other  cases  the  defects  are  circumscribed,  and  the  chief  seat  of  these 
lesions  is  the  motor  areas.  That  haemorrhages  in  the  foetal  brain  during  gesta- 
tion may  occur  is  proven  by  a  case  of  Cotard.  Sometimes  the  defects  are  not 
gross  and  large,  but  evident  only  upon  close  scrutiny,  or  are  even  microscopic. 
Such  instances  are  the  confluence  of  fissures,  simplicity  of  configuration, 
exposure  of  the  island  of  Reil,  and  the  like.  In  these  the  chief  feature  is 
defect  in  the  highest  nerve-elements,  the  cortical  cells,  a  veritable  agenesis 
corticalis.  In  all  such  cases  of  defective  development,  whether  gross  or  micro- 
scopic, idiocy  is  a  marked  symptom,  while  epilepsy  is  rarely  if  ever  present. 
The  absence  of  epilepsy  may  therefore  be  cautiously  considered  as  an  evidence 
of  the  nature  of  the  lesion  ;  it  seems  to  prove  a  simple  maldevelopment,  an 
active  process  being  thus  excluded. 

Meningeal  hcemorrhage  is  the  chief  cause  of  all  cases  of  cerebral  palsy 
occurring  during  labor,  although  at  autopsy  the  conditions  found  may  be 
chronic  meningo-encephalitis,  sclerosis,  cysts,  atrophy,  or  porencephaly.  These 
haemorrhages  are  produced  by  the  compression  which  the  head  undergoes  in  the 
pelvis  during  parturition.  In  this  connection  I  cannot  forbear  referring  to  the 
recent  researches  of  Herbert  R.  Spencer.  Among  130  stillborn  children  he 
found  4  cases  of  thrombosis  of  the  longitudinal  sinus,  1  of  intracerebral  haemor- 
rhage, and  53  of  haemorrhage  from  the  pia  and  arachnoid  ;  29  times  there 
was  bilateral  hgemorrhage,  10  times  in  the  right  side  of  the  brain  only,  10  times 
in  the  left,  7  times  into  the  lateral  ventricles,  and  6  times  limited  to  the  base 
of  the  brain.  He  finds  the  frequency  of  central  haemorrhage  greatest  with  for- 
ceps delivery,  next  with  breech  presentation,  and  least  with  natural  head  pre- 
sentations. He  believes  that  softness  of  the  skull-bones  and  their  ilicreased 
mobility  may  be  determining  factors  in  the  production  of  haemorrhage.  In  30 
cases  he  found  haemorrhages  into  the  spinal  canal  and  cord,  and  I  cannot  but 
believe  that  some,  though  a  very  small  percentage,  of  the  cases  of  paraplegia 
especially,  and  perhaps  diplegia,  may  be  due  to  cord  lesions  at  birth  after  all, 
and  not  to  cerebral  lesions.     Otherwise  it  is  difficult  to  explain  the  great  intel- 


656    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ligence  and  freedom  from  epilepsy,  athetosis,  and  the  like,  of  a  select  few  of  the 
palsies  of  these  forms. 

As  regards  the  third  group,  or  the  acute  acquired  palsies,  haemorrhage, 
embolism,  and  thrombosis  are  the  chief  causes  of  cerebral  paralysis  in  children 
after  their  birth,  just  as  they  are  in  the  adult.  We  have  apoplexies  in  child- 
hood as  in  later  life.  I  have  named  these  causes  in  the  order  of  their  frequency. 
Sachs  and  myself  collected  and  analyzed  the  results  of  78  autopsies  in  infantile 
hemiplegia  as  follows : 

Lesions  Found.  No.  of  Cases. 

Terminal  conditions : 

Cysts,  atrophy,  sclerosis 40 

Porencephaly 2 

Hsemorrhage         23 

Embolism - ~ 

Thrombosis o 

Tubercle 1 

Total 78 

It  would  be  impossible  to  determine  the  initial  lesion  in  the  terminal  condi- 
tions cited  in  the  above  table,  but  doubtless  most  of  these  also  were  vascular  in 
their  nature.  Haemorrhage  in  children  and  adults  differs  both  as  to  cause  and 
position.  In  adults,  as  is  well  known,  the  bursting  of  miliary  aneurisms  in 
atheromatous  vessels  is  the  common  cause  of  haemorrhage.  Miliary  aneurisms, 
as  well  as  large  ones,  are  occasionally  found  in  children,  but  in  them  fatty 
degeneration  of  the  vessel-walls,  as  described  by  Von  Recklinghausen,  is  more 
frequent.  In  adults  haemorrhage  generally  takes  place  in  the  neighboi'hood 
of  the  internal  capsule :  in  children,  in  the  meninges  and  about  the  cortex. 
Exceptionally,  intracerebral  haemorrhages  do  occur  in  childhood.  In  the 
paralyses  following  acute  rheumatism,  endocarditis,  and  scarlet  fever,  it  would 
be  natural  to  suspect  an  embolic  process,  as  in  the  adult ;  and  in  hereditary 
syphilis  and  marantic  conditions  thrombosis  would  be  the  lesion  most  likely  to 
supervene :  but  as  compared  with  haemorrhage  both  embolism  and  thrombosis 
must  be  looked  upon  as  rather  infrequent  causes. 

The  pathological  process  here  described  as  so  common  in  children  may 
occur,  it  must  be  remembered,  without  producing  paralysis ;  for  where  other 
parts  than  the  motor  areas  are  involved  other  symptoms  may  result,  such 
as  epilepsy  alone  or  the  various  degrees  of  idiocy.  A  beautiful  case  in  point 
was  one  sent  to  the  Vanderbilt  Clinic  some  two  years  ago,  a  young  girl  with 
epilepsy  and  a  left  homonymous  hemianopsia,  congenital  in  origin,  showing 
undoubtedly  a  cortical  lesion  over  the  right  occipital  region  (reported  by  M. 
Allen  Starr). 

Differential  Diagnosis. — The  hemiplegic,  diplegic.  or  paraplegic  form  of 
the  paralyses,  the  rigidity,  the  exaggerated  reflexes,  the  normal  electric  reaction 
of  the  muscles,  the  absence  of  actual  atrophy  in  the  limbs,  the  presence  of 
epilepsy  or  idiocy  or  of  morbid  movements  of  one  kind  or  another,  usually 
serve  to  easily  distinguish  this  disorder  from  infantile  spinal  paralysis.  It 
would  be  only  in  some  of  the  mildest  types  of  either  of  these  affections,  or  in  the 
case  of  a  monoplegia,  that  any  difficulty  might  present  itself ;  and  even  here 
some  one  or  two  of  these  indications  would  suffice  for  a  diagnosis.  It  is  a  fact, 
however,  that  in  many  cases  of  epilepsy,  athetosis,  chronic  chorea  (especially  hemi- 
chorea),  and  in  some  of  imbecility  or  idiocy,  a  hemiparesis  is  often  overlooked. 

Prognosis. — Death  as  a  result  of  infantile  apoplexy  is  very  rare.  The 
duration  of  life  in  such  palsies  is  generally  short.  Few  cases  of  diplegia  and 
paraplegia  reach  the  age  of  twenty  years.  A  certain  small  number  of  hemi- 
plegics  may  attain  the  age  of  forty  years.     In  most  cases  it  may  be  stated  that 


INFANTILE    CEREBRAL   PALSIES.  657 

the  face  will  recover,  and  that  the  leg  will  become  sufficiently  useful  for  loco- 
motion. In  the  bilateral  palsies  the  prognosis  as  regards  walking  cannot  be 
quite  so  favorable.  Except  in  the  severest  forms  speech  will  be  recovered 
more  or  less  perfectly.  After  the  lapse  of  a  few  months  an  idea  can  be  obtained 
as  to  the  mental  state,  and  as  to  whether  imbecility  or  idiocy  is  to  be  appre- 
hended. The  probability  of  epilepsy  is  the  feature  in  prognosis  requiring  the 
greatest  exercise  of  judgment.  Epilepsy  may  not  appear  for  a  year  or  two  after 
the  onset  of  the  paralysis,  and  the  statistics  already  given  as  to  the  enormous 
percentage  of  these  cases  thus  affected  must  be  borne  in  mind. 

Treatment. — In  cases  seen  shortly  after  birth,  showing  symptoms  of  cere- 
bral lesion,  quiet  and  careful  handling  are  the  chief  indications.  Minimal  doses 
of  bromide  of  potassium  or  chloral,  or  chloroform  inhalation  may  be  employed 
if  convulsions  occur.  In  the  initial  stages  of  the  acute  acquired  palsies  we  treat 
the  infantile  apoplexy  in  much  the  same  manner  as  we  would  apoplexy  in  the 
adult.  Absolute  quiet,  cold  applications  to  the  head,  and  emptying  of  the 
bowel  are  the  first  steps  in  treatment.  In  a  few  days  the  bromides  may  be  used 
to  ensure  greater  rest  to  the  brain,  and  subsequently,  combined  with  an  iodide, 
continued  for  some  time,  though  not  so  long  as  to  interfere  with  nutrition.  In 
the  chronic  stages  relief  is  generally  sought  for  secondary  conditions,  such  as 
deformities  from  contractures,  and  idiocy  and  epilepsy.  Excellent  results  are 
achieved  by  tenotomy  and  orthopaedic  apparatus  properly  applied  for  the  cor- 
rection of  the  various  deformities,  particularly  of  the  lower  extremities.  In 
one  case  in  this  city  athetosis  in  the  right  arm  was  so  extreme  that  the  limb 
was  amputated  at  the  shoulder,  to  the  great  relief  of  the  patient.  Electricity 
(especially  the  faradic  current)  may  be  used  to  exercise  the  paralyzed  muscles, 
and,  combined  with  massage,  may  go  far  to  prevent  and  remedy  contractures. 

The  epilepsy  is  treated  with  the  usual  agents,  the  bromides,  chloral,  and 
the  like,  though,  it  must  be  confessed,  without  much  success.  To  remedy  the 
mental  defects  very  much  can  be  done  by  careful  manual  and  intellectual 
training.  In  fact,  surprising  results  are  often  achieved  in  the  development  of 
the  mind,  speech,  capabilities,  and  character  of  these  cases  when  placed  in 
schools  especially  adapted  for  such  purpose,  as  is  evidenced  by  the  experience 
at  Bicetre  and  some  of  the  private  schools  in  this  country. 

As  regards  surgical  procedures  in  any  of  these  cases,  either  for  relief  of 
epilepsy  or  for  the  improvement  of  the  mental  condition,  the  most  that  can  be 
said  at  the  present  time  is  that,  upon  the  whole,  little  or  nothing  is  to  be  ex- 
pected from  trephining,  craniectomy,  and  the  like.  Possibly  future  experience 
may  justify  operative  interference  in  a  small  percentage;  but  the  great  majority 
of  infantile  cerebral  palsies  are  better  left  to  the  treatment  of  the  family  phy- 
sician, to  the  orthopgedic  surgeon,  and  to  the  developmental  influences  of  special 
schools.  M.  Allen  Starr  states,  in  a  very  recent  paper,  that  he  has  collected 
some  fifty  cases  of  operations  in  these  and  allied  conditions  (like  microcephalus). 
Many  of  these  he  publishes  in  a  list,  and  an  examination  of  his  table  showing 
the  results  obtained  is  certainly  not  very  encouraging.  In  addition  to  these, 
Sachs  gives  notes  of  three  of  his  own  cases  operated  upon,  all  hemiplegics  with 
epilepsy,  in  two  of  which  the  seizures  returned  after  operation  in  three  and  six 
months  respectively,  and  the  other  was  not  seen  after  three  months,  up  to  which 
time  no  attacks  had  supervened.  Wildermuth,  however,  reports  two  cases  of 
hemiplegia  with  epilepsy,  in  which  the  seizures  seemed  to  have  ceased,  one 
having  not  been  observed  for  three  years  and  the  other  ten  months  subsequent 
to  operation.  Besides  the  apparent  futility  of  cerebral  surgery  in  most  of  such 
cases,  children  do  not  undergo  these  operations  with  as  little  danger  as  adults, 
and  the  proportion  of  deaths  in  the  cases  thus  far  published  is  rather  large. 

42 


SPEECH  DEFECTS  AND  ANOMALIES. 

By  CHARLES  K.  MILLS,  M.  D., 

*  Philadelphia. 


Physicians  are  frequently  consulted  with  reference  to  absence,  deficiency, 
or  peculiarity  of  speech  in  children  at  different  ages  from  birth  to  puberty,  but 
particularly  in  those  under  six  or  seven  years  old.  Healthy  infants  acquire 
articulate  speech  at  varying  ages,  according  to  inherited  qualities,  the  general 
health,  the  influence  of  some  acute  disease,  or  the  surroundings  of  the  child. 
The  child  of  deaf  and  dumb  parents,  or  one  placed  where  it  hears  or  sees  but 
little,  or  one  not  much  thrown  into  the  company  of  talking  adults  or  older 
children,  may  be  delayed  in  the  initial  stages  of  articulate  language.  Some- 
times at  the  age  of  nine  or  ten  months  unusual  precocity  is  shown.  Ordinarily, 
about  the  end  of  the  first  year  or  the  beginning  of  the  second,  parents  and 
physicians  look  for  some  decided  efforts  at  speaking,  and  when  eighteen  months 
or  two  years  have  been  reached  without  these,  anxiety  begins  to  be  experienced 
and  inquiries  to  be  made.  The  problem  presented  is  by  no  means  a  simple  one. 
The  physician  must  carefully  weigh  a  number  of  facts  and  must  investigate 
from  a  variety  of  standpoints.  Starting  with  the  peripheral  apparatus  of 
speech  and  proceeding  toward  the  central  nervous  system,  he  must  examine  into 
the  muscles  and  nerves  of  articulation,  phonation,  and  respiration  ;  the  external 
and  internal  apparatus  of  hearing,  the  nuclear  centres  of  several  of  the  cranial 
nerves ;  and  the  hearing,  speech,  and  visual  centres  of  the  cerebrum  and  their 
commissures.  He  must  fully  consider  the  mental  status  of  the  child,  and  if 
this  be  settled  adversely,  the  rest  may  need  little  attention ;  but  if  not  so 
decided,  then,  step  by  step,  each  of  the  parts  and  processes  concerned  directly 
or  indirectly  in  the  mechanism  of  speech  must  receive  close  scrutiny. 

Is  the  child  idiotic  or  imbecile  ?  Is  it  suffering  from  aphasia,  congenital  or 
acquired  at  or  since  the  time  of  birth  ?  Is  the  speech  loss  due  to  brain  arrest? 
Is  the  child  simply  backward  in  speech  ?  Is  it  suffering  from  some  functional 
or  hysterical  affection  ?  Is  the  child  a  deaf-mute,  and,  if  so,  what  is  the 
character  of  this  deaf-mutism  ?  Is  it  dependent  upon  periosteal  or  bone 
disease  ?  Is  it  the  result  of  old  or  recent  inflammatory  disease  of  the  ear, 
either  primary  or  the  sequel  of  some  acute  infection,  as  scarlet  fever  or  measles? 
Is  the  deficiency  of  speech  due  to  paralysis  of  any  of  the  nerves  or  muscles  of 
articulation  ?  Is  it  a  spasmodic  affection  of  these  nerves  and  muscles  ?  What 
is  the  shape  and  size  of  the  oral  cavity,  and,  if  deformity  of  the  vault  of  the 
palate,  of  the  pharynx,  or  of  any  part  of  the  oral  cavity  be  present,  is  it  or  is 
it  not  associated  with  true  idiocy  and  imbecility  ?  Is,  as  mothers  so  often 
wrongly  imagine,  the  child  tongue-tied,  the  friTenum  being  so  attached  as  to 
prevent  free  movements  of  this  organ  ?  Are  adenoids  or  other  growths  or 
enlargements  present? 

658 


SPEECH  DEFECTS  AND    ANOMALIES.  659 

Speech  Defects  due  to  Idiocy  or  Imbecility. 

Dysphrasia,  a  term  applied  by  Kussmaul  (Ziemssens  Cycl.  Pract.  Med.) 
to  defective  or  absent  speech  due  to  intellectual  impairment,  is  more  frequent 
in  children  than  any  of  the  varieties  of  aphasia,  but  is  of  course  usually 
then  an  accompaniment  of  idiocy  or  imbecility.  The  child  cannot  speak,  or 
talks  imperfectly  or  foolishly  because  of  an  absence  or  deficiency  of  ideas ;  it 
does  not  speak,  as  Griesinger  has  said,  because  it  has  nothing  to  say.  It 
does  not  know  anything  that  would  be  ordinarily  transmuted  into  language. 
Even  in  idiocy  the  cortical  organs  of  speech,  considered  as  special  areas,  are 
doubtless  often  arrested  or  diseased,  but  in  addition  other  parts  of  the  brain 
concerned  in  mentation  may  be  lacking  or  altered.  As  is  well  known  to  those 
connected  with  institutions  for  the  feeble-minded,  not  a  few  cases  with  some 
intelligence  cannot  by  the  greatest  perseverance  be  taught  to  speak;  some 
can  be  taught  a  few  words  and  sentences,  but  cannot  get  beyond  a  certain  point, 
which  is  limited  by  their  ability  to  assimilate  knowledge.  Others  perhaps  can 
be  taught,  parrot  fashion,  to  repeat  words  or  even  phrases  or  sentences  of 
the  meaning  of  which  they  have  no  idea.  Many  interesting  observations 
upon  the  development  of  speech  have  been  made  in  all  such  institutions. 
Physicians  will  be  called  upon  to  give  opinions  not  only  as  to  arrest  of 
mental  growth,  but  also  as  to  the  capabilities  of  future  development  in  such 
children ;  and  such  opinions  can  be  only  of  value  when  they  are  based  upon 
a  close  study  of  the  conditions  present  at  the  time  of  examination,  and  of 
the  life  and  family  history  of  the  child.  Mierzejewsky,  cited  by  Kussmaul, 
has  described  in  great  detail  the  history  of  an  aphasic  idiot  who  lived  to 
be  about  fifty  years  of  age,  and  whose  mental  powers  and  speech  were  about 
as  developed  as  those  of  a  one  or  one  and  a  half  year  old  boy.  He  could  only 
give  utterance  to  a  few  of  the  simplest  syllables.  His  brain  was  examined, 
and  resembled  in  the  shape  and  the  arrangement  of  the  convolutions  that  of  a 
human  foetus  of  the  ninth  month.  The  methods  of  diagnosticating  idiocy  and 
imbecility  will  be  considered  in  the  next  section,  and  it  will  therefore  not  be 
necessary  to  call  further  attention  to  this  subject  here. 

Aphasia. 

The  term  "aphasia"  is  sometimes  carelessly  applied  to  almost  any  variety 
of  speech  disorder,  but  it  is  best  restricted  to  the  description  of  complete  or 
incomplete  loss  of  speech  from  a  local  cerebral  affection.  It  is  conveniently 
divided  into  motor  or  expressive  and  sensory  or  receptive  aphasia,  and  these 
have  special  forms,  some  of  which  need  to  be  borne  in  mind  even  in  studying 
the  disorders  of  speech  from  which  children  suffer.  Sensory  aphasia  has  several 
varieties,  as  word-deafness  and  word-blindness,  which  define  themselves,  and 
apraxia  or  paind-blindness,  in  which  the  ability  to  recognize  the  use  or  mean- 
ing of  an  object  is  lost.  Aphasia  may  be  both  sensory  and  motor,  as  when 
the  receptive  and  emissive  sides  of  the  brain  are  both  involved  in  disease. 
Agraphia  is  loss  of  power  of  writing;  amimia,  inability  to  express  thought  by 
signs  and  pantomime.  Besides  varieties  of  aphasia  resulting  from  cortical 
lesions,  others  may  be  due  to  destruction  or  interference  with  the  commissures 
or  lines  of  connection  between  various  centres,  and  these  are  known  in  gen- 
eral terms  as  paraphasias  or  conduction  aphasias.  Alexia  is  abolition  of  the 
power  of  reading,  as  agraphia  is  that  of  writing ;  dyslexia  refers  to  difficulty 
or  fatigue  in  reading ;  paralexia,  to  the  misuse  by  transposition  or  substitu- 
tion of  either  words  or  syllables,  while  paramimia  is  the  misapplication  of  signs 


660    AMEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

or  pantomime.  AVhether  a  child  can  have  alexia,  dyslexia,  agraphia,  or  amimia 
will  of  course  depend  on  its  acquirements — on  its  ability  to  read,  to  write,  to 
talk,  or  to  express  itself  by  gestures  or  pantomime.  Children  under  six  or 
seven  years  old  would  need  to  be  studied  from  difterent  standpoints  from  those 
over  this  age,  and  children  between  six  and  ten  would  need  a  consideration 
which  would  diflFer  for  those  from  ten  to  fourteen. 

True  aphasia  is  sometimes  congenital :  a  deficiency  of  speech  not  depend- 
ent upon  lack  of  general  intellectual  power  may  be  present,  or,  in  other  words, 
a  distinction  can  sometimes,  althoui!;!!  perhaps  rarely,  be  made  between  a  dys- 
phrasia  and  an  aphasia  of  prenatal  origin.  Broadbent  (cited  by  Kussmaul) 
has  reported  an  interesting  case  of  congenital  aphasia  in  an  intelligent  boy. 
When  twelve  years  of  age  he  understood  everything  that  was  said  to  him  and 
did  what  he  was  told  to  do,  but  could  not,  as  a  rule,  say  anything  but  "Yes," 
"No,"  and ''Father"  and  "Mother,"  pronouncing  the  last  two  words  imper- 
fectly. He  used  also  an  indirect  expression  in  answer  to  all  questions ;  occa- 
sionally he  uttered  a  few  other  words,  such  as  "All  right!"  "Thank  you,"  and 
he  had  other  interesting  peculiarities.  A  few  cases  have  been  reported  which 
seem  to  show  that  the  arrest  of  the  organs  of  articulation  was  tlie  particular 
condition  present,  as  one  in  which  the  idiot  could  utter  only  a  few  scarcely 
intelligible  words,  but  could  express  himself  Avell  by  an  animated  and  intelli- 
gible pantomime,  and  was  even  able  to  report  on  different  things  that  occurred 
in  the  asylum. 

Aphasia  the  result  of  acute  lesions  occurring  after  birth  is  rare  in  children 
as  compared  with  adults,  as  haemorrhage,  embolism,  and  thrombosis  are  of  infre- 
quent occurrence  in  childhood.  Of  the  three,  embolism  as  an  accompaniment 
of  rheumatism  or  endocarditis  is  probably  the  most  common.  When  a  lesion 
does  invade  the  speech-areas  of  the  brain  on  the  left  side,  the  other  hemisphere 
more  quickly  assumes  the  lost  function  than  in  adults.  Sachs  {Keating' s  Gycl. 
Dis.  of  Qhildren)  records  seventeen  cases  of  hemiplegia  with  aphasia.  His 
experience  is  in  accord  with  that  of  Bernhardt,  who  found  that  aphasia  in 
children  accompanied  left  as  well  as  right  hemiplegia.  Other  acute  causes 
of  aphasia  in  children  are  meningitis,  tumor,  and  abscess.  Occasionally  in 
tubercular  meningitis  a  form  of  aphasia  or  paraphasia  may  be  developed,  and 
this  particularly  when  the  tubercular  deposits  or  conglomerates  are  in  and 
around  the  Sylvian  fossa.  Sometimes  in  basal  meningitis  in  children,  owing 
to  inflammation  and  exudation  in  the  pons-oblongata  region,  a  form  of 
dysarthria  or  articulatory  paralysis  will  show  itself. 

The  position  and  size  of  a  neoplasm  will  determine  how  far  speech  or  any 
of  its  elements  or  tributaries  will  be  affected.  Word-deafness  may  be  present 
when  the  first  and  second  left  temporal  convolutions  or  the  white  matter  beneath 
and  near  these  areas  are  invaded,  although  such  word-deafness  may  soon  in 
part  be  recovered  from  if  the  right  hemisphere  be  intact.  Word-blind- 
ness in  a  child  that  can  read  or  write  may  result  from  a  tumor  situated  in 
the  zone  where  the  left  parietal  borders  the  anterior  occipital  region.  Of 
course  a  tumor  of  any  description  involving  the  hinder  part  of  the  left 
third  frontal  will  cause  more  or  less  motor  aphasia  in  a  child  that  has  acquired 
speech,  and  may  arrest  the  development  of  the  faculty  in  one  of  tenderer 
years.  When  the  island  of  Reil  is  invaded,  either  aphasia  or  paraphasia  may 
result. 

Intracranial  abscess  sometimes  is  the  cause  of  word-deafness  or  some  other 
variety  of  aphasia  in  children.  Such  cases  are  usually  associated  with  aural 
disease,  as  when  purulent  disease  of  the  mastoid  or  of  the  tympanic  cavity 
leads  to  meningeal  inflammation  and  abscess  of  the  temporal  lobe. 


SPEECH  DEFECTS  AND    ANOMALIES.  661 

Aphasia  usually  with,  but  sometimes  without,  monoplegia  or  hemiplegia 
may  be  a  consequence  of  hereditary  syphilis.  These  cases  may  have  several 
attacks  of  aphasia  with  partial  paralysis,  sometimes  affecting  different  sides  of 
the  body.  The  lesions  are  usually  the  outcome  of  endarteritis  or  chronic 
meningitis,  particularly  leptomeningitis,  and  in  some  cases  they  are  forms  of 
cortical  sclerosis  with  atrophy.  The  child  will  often  show  some  of  the  other 
well-known  evidences  of  inherited  taint,  as  notched  or  pegged  teeth,  crack- 
ing of  the  corners  of  the  mouth,  flattening  of  the  nose  and  face,  or  interstitial 
keratitis.  It  is  important  to  recognize  the  syphilitic  origin  of  these  cases,  and 
to  treat  them  accordingly  with  mercurial  inunction,  calomel,  iodide  or  bichloride 
of  mercury,  or  the  iodides  of  sodium  or  potassium. 

In  children,  as  in  adults,  aphasia  has  been  noticed  in  the  course  of  typhoid 
and  other  fevers :  probably  in  most  of  these  cases  the  affection  is  not  due  to 
a  local  lesion,  such  as  a  clot  or  the  closure  of  a  vessel,  but  to  a  to:s;ic  influence 
exerted  by  the  poison  of  the  disease  on  the  brain.  Bassette  (Jour.  New.  and 
Ment.  Dis.,  July,  1892)  has  reported  two  cases  of  this  kind,  one  in  a  girl  nine 
years  of  age,  who  in  the  second  week  of  typhoid  fever  became  markedly  deaf 
without  middle-ear  complications,  and  also  had  partial  hemiplegia.  The  para- 
lysis passed  off,  and  she  began  to  recover  her  speech  about  the  sixth  week. 
Another,  a  girl  of  five  years,  ceased  to  speak  for  eleven  days. 

Children,  through  fright  or  other  cause,  sometimes  suddenly  become  speech- 
less. Hysterical  children  also  have  attacks  of  mutism.  Langdon  Down  (cited 
by  Ashby  and  Wright  in  Diseases  of  Children)  records  the  case  of  two  brothers, 
who  had  spoken  well  and  understood  two  languages,  completely  losing  the 
power  of  speech  at  the  second  dentition. 

In  rare  cases  children  who  are  not  idiotic,  and  who  are  not  suffering  from 
either  central  or  peripheral  disease,  are  nevertheless  exceedingly  slow  in  learn- 
ing to  speak,  and  in  particular  for  a  long  time  may  fail  to  acquire  the  proper 
method  of  articulating  and  pronouncing  certain  letters  and  sounds.  Some- 
times such  children  are  otherwise  intelligent,  and  eventually  develop  up  to  the 
full  standard  of  mental  health  and  activity.  In  some  remarkable  cases  chil- 
dren, even  to  the  age  of  ten  or  twelve,  have  habitually  made  use  of  only  a  few 
letters.  Deferred  or  retarded  speech  development  must  be  distinguished  from 
congenital  or  acquired  aphasia  of  more  permanent  type.  According  to  Bastian, 
cases  allied  to  congenital  idiocy  are  observed,  in  which,  owing  to  some  intra- 
cranial lesion  occurring  before,  during,  or  soon  after  birth,  the  child's  mental 
condition  is  greatly  degraded  as  well  as  his  motor  power.  In  some  of  the  less 
severe  examples  of  this  type  speech  is  merely  deferred,  perhaps  until  the 
fourth,  fifth,  or  even  sixth  year,  and  may  become  after  a  time  established 
in  a  natural  manner.  Bateman  (Aphasia,  or  Loss  of  Speech,  2d  ed.,  1890) 
mentions  a  case  of  this  tardy  development  of  the  faculty  of  speech  which  came 
under  his  observation.  The  child  never  spoke  at  all  until  he  was  six  years  old, 
and  it  was  thought  that  he  would  remain  dumb.  At  six  years  of  age  he  began 
to  talk,  and  was  able  to  receive  an  education  suitable  to  his  condition  in  life, 
but  he  grew  up  to  manhood  a  person  of  feeble  intellectual  and  also  of  feeble 
physical  power. 

ECHOLALIA   AND    COPROLALIA. 

In  the  affections  known  as  echolalia,  coprolalia,  and  by  various  other  names, 
convulsive  or  choreic  movements  are  associated  with  a  sudden  explosion  of 
speech.  The  patient  with  a  grimace,  contortion,  or  violent  movement  of  some 
kind  -suddenly    bursts    into   obscene,    profane,  or   absurd   expression.     This 


662    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

expression  may  be  the  echo  of  something  overheard — hence  the  name,  echolalia 
— or  it  may  be  a  spontaneous  outcry.  It  is  not  simply  a  hysterical  affection, 
controllable  and  curable,  but  is  a  true  monomania,  the  affection  of  speech  being 
bevond  the  patient's  volition ;  it  could  properly  be  discussed  under  morbid 
impulses  as  well  as  here.  One  patient  of  mine,  a  boy  twelve  years  old,  at 
times,  without  warning,  would  in  a  street-car  or  other  public  place,  as  well  as 
in  private,  suddenly  give  utterance  to  a  filthy  expression  two  or  three  times, 
accompanying  it  with  a  violent  movement  of  the  head,  shoulders,  and  one  arm. 

Deaf-mutism. 

Deaf-mutism  must  be  carefully  distinguished  from  aphasia  and  other  affec- 
tions of  speech.  "While  some  cases  are  congenital  and  associated  with  more 
or  less  profound  idiocy,  the  number  of  these,  according  to  good  authority,  does 
not  equal  those  which  can  be  fairly  attributed  to  disease  and  accident  after 
birth.  Even  congenital  deafness  and  dumbness  are  sometimes  due  to  peripheral 
causes,  as  to  periostitis,  ostitis,  or  imperfect  development  of  the  petrous  bone. 
The  semicircular  canals  or  other  portions  of  the  internal  ear  may  be  wanting 
or  altered  by  intra-uterine  disease.  Colloid  degeneration  of  the  labyrinth  is 
said  to  be  a  frequent  cause  of  the  absence  of  hearing,  and  various  diseases  of 
different  parts  of  the  auditory  apparatus,  particularly  of  the  internal  and 
middle  ear,  may  occur  before  birth.  These  cases  must  be  separated  from  those 
of  mutism  or  deaf-mutism  associated  with  idiocy.  A  diagnosis  may  sometimes 
be  made  by  careful  physical  examination  and  a  study  of  the  mental  condition  of 
the  patient.  Purulent  otitis  or,  what  is  more  difficult  of  decision,  Yoltolini's 
labvrinthine  otitis,  or  some  other  form  of  labyrinthine  non-purulent  inflamma- 
tion, may  cause  absolute  deafness,  and  owing  to  this  deprivation  the  child  may 
be  supposed  to  be  mentally  deficient.  Indeed,  such  a  child  may,  under  unfa- 
vorable circumstances,  fail  to  develop  to  any  considerable  degree.  A  process 
of  experimental  training  of  the  senses  which  are  left  will  sometimes  enable  a 
decision  to  be  reached  in  a  comparatively  short  time.  The  patient  who  is  simply 
deaf-mute,  from  whatever  peripheral  cause,  will  under  proper  incitements  be 
able  to  fix  his  attention  and  show  intelligent  interest  in  his  surroundings. 

The  exact  age  under  Avhich  a  child  will  lose  its  speech  because  of  loss  of 
hearing  cannot  be  absolutely  fixed  ;  but  when  total  deafness  is  caused  by 
purulent  disease  of  the  ear  or  other  destructive  affections  before  the  age  of  six 
or  seven  years,  the  child  is  likely  to  become  mute  as  well  as  deaf  unless  special 
training  has  at  once  been  started,  and  even  in  spite  of  this  a  certain  degree  of 
loss  or  imperfection  of  speech  will  result.  The  original  capacity  and  the 
acquirements  of  the  child  at  the  age  when  deafness  occurs  will  of  course  have 
a  bearing  upon  the  question  of  deaf-mutism.  Occasionally  children  who  have 
had  scarlet  fever,  measles,  or  infectious  diseases  at  the  age  of  two  or  three 
years,  and  have  become  totally  deaf  in  consequence,  are  supposed  to  be  idiotic. 
Such  children,  if  naturally  intelligent,  will  exhibit  great  interest  in  everything 
that  comes  within  the  range  of  the  senses  that  are  left.  Slow  or  stupid  chil- 
dren deprived  of  hearing  and  speech,  particularly  if  treated  with  neglect  or 
indifference,  will  sometimes  sink  into  a  state  of  inertia  which  simulates  a  true 
imbecility  or  fatuity,  leaving  them  with  defective  mental  powers.  A  physician 
should  be  acquainted  with  the  usual  time  when  a  child  of  average  mental  capa- 
city acquires  the  ability  to  respond  to  general  sounds  and  noises,  and  then 
to  special  sounds,  voices,  and  eventually  to  definite  words,  and  also  when  it 
first  gives  vent  to  feelings  of  pain  or  pleasure,  Avhen  it  makes  special  response 
to  particular  sounds,  when  it  imitates  sounds  connected  or  not  connected  with 


SPEECH  DEFECTS  AND    ANOMALIES.  663 

ideas,  and  when,  finally,  speech  becomes  a  method  of  expressing  centrally 
initiated  thought,  no  matter  how  elementary  this  may  be.  It  is  not  as  difiicult, 
as  at  first  sight  might  appear,  to  learn  to  follow  and  analyze  such  processes  of 
development  and  to  determine  as  to  their  retardation  or  advancement.  Mothers 
acquire  great  facility  in  this  way  by  comparison  of  the  progress  of  their  dif- 
ferent children. 

Preyer  {The  Mind  of  the  Child,  part  I.,  transl.  by  H.  W.  Brown,  1889)  has 
made  a  practical  study  of  the  development  of  the  different  senses  and  mental 
faculties,  based  largely  upon  the  close  study  of  his  own  child.  According  to 
him,  the  new-born  are  always  deaf,  because  of  temporary  local  conditions, 
such  as  lack  of  air  in  the  tympanic  cavity,  collections  of  liquid  or  gelatinous 
substances  in  the  middle  ear,  and  closure  by  foreign  matter  of  the  external 
auditory  canals.  Whether  this  be  absolutely  true  or  not,  it  is  certain  that  all 
healthy  children  in  a  few  hours  or  in  a  day  or  two  at  least  react  to  impressions 
of  sound.  Of  fifty  children  who  were  tested  by  Mollenhauer,  ten,  less  than 
twelve  hours  old,  reacted  to  a  brief  disagreeable  sound.  Preyer  was  not  con- 
vinced until  the  first  half  of  the  fourth  day  that  his  child  was  not  deaf.  In  the 
eighth  week  he  showed  pleasure  at  piano-playing,  and  in  the  ninth  the  sound 
of  a  repeating  watch  aroused  his  attention  to  the  highest  pitch,  while  in  the 
eleventh  week  he  moved  his  head  in  the  direction  of  the  sound  heard  ;  and 
soon  this  was  always  done  with  great  promptitude  and  certainty.  After  a  half 
year  he  enjoyed  single  notes  and  military  music,  and  soon  he  showed  evidence 
of  intellectual  advance.  After  the  first  year  the  child  rapidly  advanced  in  his 
exhibition  of  logical  activity  in  connection  with  hearing.  The  statement  that 
children  from  three  to  four  months  old  possess  normally  very  slight  capacity 
for  hearing  must  be  pronounced  false,  according  to  Preyer,  for  long  before  the 
third  month  the  human  voice  is  heard  by  the  normal  infant,  and  before  the 
close  of  the  first  week  normal  children  react  to  the  stimulus  of  loud  sound. 

Kussmaul  distinguishes  three  periods  in  the  development  of  articulation. 
Within  the  first  four  months,  and  about  the  time  of  the  earliest  movements  of 
prehension,  children  give  vent  to  spontaneous  sounds  indicating  their  feelings 
of  joy.  These  are  chiefly  lip  and  vowel  sounds,  but  sometimes  they  are  also 
lingual  and  palate  sounds.  In  a  second  period  these  savage  noises,  are  grad- 
ually crowded  out  by  the  conventional  sounds  of  the  national  language,  but 
even  these  are  of  a  very  simple  character.  Some  of  them  are  imitated  and 
some  are  not.  With  the  commonly  used  words  ma,  ma,  and  pa,  pa,  the  child 
at  first  does  not  connect  any  idea,  but  by  degrees  learns  to  do  this.  At  a  third 
stage  speech  becomes  an  expression  of  thought,  a  child  learning  to  associate 
certain  definite  objects  with  the  words  acquired  by  practice.  All  this  may  be 
accomplished  in  the  most  elementary  way  by  the  end  of  the  first  year. 

"Sounds  such  as  m-m,  ha-ha,  da-da,''  say  Ashby  and  Wright,  "maybe 
repeated  in  a  meaningless  sort  of  way,  but  before  long  are  applied  to  persons 
and  things.  During  the  second  year  the  vocabulary  increases  fast,  and  the 
child  quickly  imitates  and  repeats  the  words  it  hears,  so  that  by  the  end  of  the 
second  year  it  not  only  uses  a  number  of  words,  but  can  string  together  a  few 
nouns  and  adjectives  or  has  learned  the  meaning  of  short  sentences.  At  this 
period,  and  for  the  next  year  or  two,  words  are  indistinctly  or  improperly 
pronounced,  with  a  tendency  to  clip  them  short  or  to  drop  consonants.  Some 
consonants  present  greater  difficulty  to  the  young  child  than  others,  and  are 
constantly  dropped  out  of  words  ;  thus  s,  especially  when  it  precedes  another 
consonant,  is  omitted,  as  cool  for  school,  hiveek  for  squeak,  no  for  snow.  Difficul- 
ties often  arise  with  the  aspirate  dentals,  as  th  and  sh.  Ruth  becomes  roof ; 
the  vibratory  consonant  r  is  a  great  stumbling-block,  and  the  distinct  pronun- 


664    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

elation  of  it  is  perhaps  never  acquired ;  grub  is  apt  to  become  gwuh,  and  roof, 
woof.'' 

Affections  of  Speech  due  to  Peripheral  Paralysis. 

After  acute  infectious  diseases,  and  particularly  after  diphtheria,  palatal  or 
pharyngeal  paralysis  may  be  present.  Occasionally  an  attack  of  diphtheria  is 
overlooked  or  supposed  to  be  some  other  throat  affection,  and  even  so-called 
latent  cases  sometimes  result  in  forms  of  paralysis.  Facial  paralysis  in 
children  would  be  determined  by  the  appearance  of  the  face,  and  indeed  the 
affection  of  speech  in  such  cases  is  usually  very  slight.  Lingual  paralysis  of 
peripheral  origin  is  rare  both  in  adults  and  in  children. 

Stuttering  and  Stammering. 

The  presence  and  meaning  of  stuttering  and  stammering  in  children  may 
demand  careful  consideration.  Boys  are  much  more  likely  to  be  afflicted  with 
this  disorder  than  crirls.  Stuttering  can  be  distinguished  from  stammering, 
although  this  distinction  is  often  not  made.  According  to  Kussmaul,  individ- 
ual sounds  are  difficult  for  the  stammerer,  but  not  for  the  stutterer,  with  the 
latter  the  syllabic  combinations  offering  the  greatest  obstacles.  In  stuttering 
a  spasm  accompanies  the  impeded  utterance,  but  not  in  stammering ;  and 
greater  nervous  embarrassments  underlie  stuttering.  Other  differences  are 
given  by  Kussmaul,  but  the  one  which  is  perhaps  of  the  most  practical  import- 
ance in  making  a  differential  diagnosis  is  that  stammering  is  often  accompanied 
by  anomalies  of  the  tongue,  lips,  and  articulating  organs  in  general,  Avhile 
malformations,  defects,  paralysis,  etc.  are  rarely  observed  in  connection  with 
stuttering.  It  is  important  for  the  practitioner  to  study  the  duration,  possi- 
bility of  improvement,  and  underlying  causes  of  such  defects  when  presented 
by  young  children.  Usually  stuttering  does  not  show  itself  so  as  to  attract 
attention  before  the  age  of  six  or  seven,  although  rare  cases  have  been  observed 
in  young  children.  Sometimes  stuttering  or  stammering  is  a  temporary  affec- 
tion, coming  on  in  children  who  have  been  overworked  or  undernourished  or 
both,  who  have  been  subjected  to  unusual  strain  or  excitement,  or  who  have  had 
an  attack  of  fever ;  and  in  the  last  case  it  may  or  may  not  be  curable.  Some 
forms  of  stuttering  are  distinctly  hysterical,  and  may  be  relieved  by  attending 
to  the  general  nervous  health  of  the  patient.  The  condition  of  the  tongue  and 
mouth  of  a  little  patient  who  has  been  attacked  with  a  spasmodic  chronic  dis- 
turbance of  speech  should  not  be  overlooked,  as  now  and  then  some  affection 
of  the  tongue,  lips,  and  palate  may  be  the  cause  of  the  difficulty.  A  spasm  of 
the  muscles  of  articulation  and  deglutition  may  cause  an  affection  of  speech 
that  will  simulate  ordinary  stuttering.  Putting  aside  all  these  causes  of  tem- 
porary and,  it  may  be,  remedial  forms  of  spasmodic  utterance,  the  vast  majority 
of  cases  will  be  found  to  depend  upon  some  original  defect  in  the  central 
nervous  apparatus.  By  prolonged  and  careful  training  a  few  of  these  cases  can 
be  cured,  others  can  be  helped,  while  a  large  percentage  are  absolutely  beyond 
remedy. 

Deformities  and  Defects  in  the  Mouth  and  Pharynx. 

Sometimes  in  children  who  are  not  mentally  defective  the  palate,  and  even 
the  jaws,  may  be  of  some  particular  shape,  interfering  to  some  extent  with  easy 
and  perfect  speech.  The  possibility  of  such  cases  should  always  be  remem- 
bered, but,  on  the  other  hand,  it  should  be  clearly  before  the  physician  that 


SPEECH  DEFECTS  AND   ANOMALIES,  665 

among  the  commonest  somatic  evidences  of  idiocy  and  imbecility  are  the  shape 
and  condition  of  the  palate  and  jaws.  In  some  types  of  congenital  idiocy  both 
upper  and  lower  jaw  may  be  narrow,  the  roof  unusually  vaulted  or  gothic,  while 
in  others  the  vault  may  be  unusually  low  and  flat.  All  varieties  of  palatal 
deformity  or  aberration  are  present  in  various  types  of  idiocy.  Teeth  also  are 
likely  to  be  imperfect  in  such  cases,  and  the  tongue  may  be  disobedient  to  the 
behests  of  the  will.  A  fair  judgment  of  the  mental  status  of  such  a  child  and 
the  meaning  of  its  defective  speech  can  often  be  reached  by  a  study  of  these 
peculiarities  and  deformities  of  the  head,  face,  mouth,  tongue,  teeth,  jaw,  and 
palate. 

Mothers  are  always  much  inclined  to  regard  a  defect  of  speech  in  their 
children  as  due  to  what  is  popularly  called  tongue-tie.  In  rare  cases  a  frsenum 
which  reaches  too  far  forward  may  be  present  and  cause  some  interference  with 
the  pronunciation  of  a  few  sounds ;  in  still  rarer  cases  the  tongue  itself  may 
be  congenitally  short  or  deformed,  but  such  conditions  are  easily  determined  or 
dismissed  by  careful  examination. 

Adenoid  Growths. 

Adenoid  growths  of  the  vault  of  the  pharynx  may  be  the  cause  of  diffi- 
culties and  peculiarities  of  speech,  as  well  as  of  interference  with  hearing 
even  to  the  extent  of  deafness.  It  will  happen  now  and  then  that  a  child  of 
two,  three,  or  four  years  of  age,  supposed  to  be  idiotic  or  imbecile,  will  in 
reality  be  suffering  from  adenoid  deaf-mutism,  the  lack  of  mental  development 
being  apparently  due  to  privation  of  two  of  the  most  important  channels  of 
communication  with  others.  In  all  doubtful  cases  careful  examination  of  the 
mouth  should  be  made.  Even  if  the  deafness  be  not  curable,  great  relief  will 
be  afforded  to  the  parents  by  the  knowledge  that  the  child  is  not  idiotic,  and 
special  efforts  can  be  made  at  training  and  education  in  accordance  with  the 
principles  and  methods  which  bear  the  most  fruit  in  dealing  with  deaf-mutes 
who  are  not  primarily  deficient  in  mind. 

Various  impediments  in  enunciation  and  pronunciation  may  also  result  from 
the  peculiar  obstruction  produced  by  these  papillomata  when  of  large  size. 
The  voice  is  often  considerably  changed,  and  in  enunciating  certain  letters 
muffling  may  occur;  but  hasty  opinions  should  not  be  given  as  to  the  future 
simply  because  of  the  discovery  of  these  growths,  as  they  are  sometimes  present 
in  idiotic  children  or  in  stammerers  or  stutterers. 

Bad  Habits  of  Speech. 

In  studying  cases  of  imperfect  or  nervous  utterance  attention  should  be 
given  to  the  subject  of  bad  habits  of  speech.  Children,  through  carelessness, 
through  the  foolish  management  of  those  around  them,  or  of  their  own  motion, 
may  acquire  certain  habits  of  speech  which  will  cling  to  them  to  such  an  extent 
as  to  become  serious  impediments  in  the  way  of  development  of  good  methods 
of  speaking.  Among  these  habits  are  frequently  hesitating,  unduly  repeating, 
drawling  or  hurrying,  using  babyish  or  foolish  expressions.  Children  should 
be  coaxed  or  disciplined  out  of  such  habits  when  once  acquired,  but  it  is  far 
better  not  to  let  them  take  possession  of  the  child. 

Treatment  op  Speech  Defects. 

The  treatment  of  different  forms  of  defective  speech  must  depend  upon  the 
nature  and  degree.     Aphasia  from  an  acute  lesion,  such  as  haemorrhage  or 


666    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

embolism,  or  as  one  of  the  effects  of  inherited  syphilis,  may  often  be  benefited 
by  time,  medicine,  and  training.  The  medicinal  treatment,  after  the  first 
period  of  rest  and  care  during  the  apoplectic  stage,  would  be  chiefly  the  use  of 
absorbents  and  tonics,  such  as  iodides,  arsenic,  iron,  and  strychnine.  Diligent 
efforts  should  be  made  to  train  an  aphasic  child.  Even  some  cases  of  congenital 
origin  can  under  appropriate  and  persistent  training  be  much  improved.  Here 
the  diagnosis  as  to  the  presence  or  absence  of  true  idiocy,  and  as  to  the  degree 
of  mental  deficiency,  is  of  great  importance  in  deciding  as  to  how  far  to  push 
the  treatment  by  efforts  at  education  and  training,  •  In  aphasia  coming 
on  gradually  with  more  or  less  dementia  in  a  child  previously  bright,  or  at 
least  ordinarily  intelligent,  the  probability  of  inherited  syphilis  should  always 
be  considered  with  the  view  of  judiciously  using  iodide  of  potassium,  iodide 
of  iron,  and  similar  remedies.  The  diagnosis  of  acquired  deaf-mutism  having 
been  made,  institutional  or  very  careful  individual  treatment  should  at  once 
be  given.  The  oral  system  of  educating  deaf-mutes  is  particularly  valuable 
for  such  patients,  and  much  advance  in  the  direction  has  been  made  in  recent 
years.  Great  patience  and  skill  are  required  even  in  acquired  deaf-mutism. 
Some  congenital  cases  improve,  others  make  no  advance,  the  former  being 
cases  in  which  the  causes,  whether  prenatal  or  at  the  time  of  birth,  have  acted 
upon  the  organs  of  hearing  or  their  encasements,  and  not  upon  the  brain  as  a 
whole.  It  is  said  to  be  best  to  commence  the  instruction  of  congenital  deaf- 
mutes  at  the  age  of  about  six  years,  but  neglect  of  some  training  even  before 
this  age  may  at  times  be  a  great  disadvantage.  Practically,  instruction  should 
be  begun  as  soon  as  it  is  possible  to  engage  the  attention  of  the  child,  but  the 
amount  of  this  instruction  should  be  carefully  considered.  Where  there  are 
special  impediments  of  speech,  instruction  directed  to  the  relief  of  these  may 
be  successful.  Of  course  all  local  surgical  conditions  should  be  carefully 
attended  to,  such  as  the  rare  cases  of  attached  frgenum,  and  those  conditions 
which  are  more  common,  such  as  enlarged  tonsils  and  naso-pharyngeal  adenoids. 
Cleft  palate  and  other  forms  of  hard  or  soft  palate  must  receive  the  attention 
of  the  surgeon  and  surgical  mechanism.  Stammering  and  stuttering  can  occa- 
sionally be  greatly  benefited  by  treatment,  although  in  some  cases  all  methods 
prove  to  be  discouraging  failures.  The  greatest  attention  should  be  paid  to  the 
maintenance  of  the  best  physical  health,  as  by  good  food,  careful  hygiene,  mus- 
cular and  respiratory  gymnastics.  Systems  of  respiratory  and  vocal  exercises 
are  given  in  special  works  on  the  subject.  Such  treatment  must  necessarily 
be  in  the  hands  of  one  who  has  specially  trained  himself  to  carry  it  out. 


IDIOCY  AND  IMBECILITY, 

By  CHARLES  K.  MILLS,  M.  D., 

Philadelphia. 


Idiocy. — Three  great  classes  of  mental  arrest  or  deficiency  are  known  as 
idiocy,  imbecility,  and  cretinism.  Idiocy  is  an  affection,  either  congenital  or 
acquired  in  very  early  life,  characterized  by  extreme  mental  deficiency,  although 
it  may  be  of  varying  grades  of  severity.  Sometimes  the  idiot  scarcely  rises  in 
brain  power  above  the  level  of  the  lower  animals,  or  he  may  be  able  to  some 
extent  to  take  care  of  himself,  or  again  he  may  be  capable  of  limited  intellectual 
improvement.  The  mental  deficiencies  of  idiocy,  as  a  rule,  go  hand  in  hand 
with  physical  infirmity. 

"  The  term  idiocy,"  says  Langdon  Down  (Ttike's  Diet.  Psychol.  Med.),  "has 
a  very  vague  significance.  It  is  associated  in  many  minds  with  one  type  only 
of  mental  and  physical  condition,  very  often  an  imaginary  type  or  one  which 
rarely  exists.  It  will  be  well  to  break  down  such  contracted  views  and  to 
efface  the  incorrect  and  distorted  image.  Looking  around  a  large  assemblage 
of  children  whose  mental  condition  brings  them  under  this  generic  term,  it  is 
very  evident  that  they  can  be  broken  into  well-marked  groups,  and  that 
instructive  life-pictures  may  be  drawn  of  typical  representations  of  this  inter- 
esting class.  Looked  at  en  masse,  they  would  give  the  impression  of  being 
heterogeneous  to  the  last  degree,  but  it  will  be  found  on  closer  investigation 
that  it  is  possible  to  arrange  them  into  groups  with  strong  natural  afiinities 
among  the  constituents,  and  that  in  many  cases  a  very  remarkable  family  like- 
ness may  be  traced." 

The  terms  "imbecility"  and  "  feeble-mindedness  "  may  perhaps  be  regarded 
as  nearly  synonymous  in  common  medical  usage.  Although  between  idiocy 
and  imbecility  no  absolute  line  of  demarcation  can  positively  be  drawn,  a  dis- 
tinction is  made  for  some  practical  purposes  in  clinical  medicine  and  medical 
jurisprudence;  but  it  is  not  correct  to  attempt  to  differentiate  idiocy  and  imbe- 
cility by  regarding  the  former  as  congenital  and  the  latter  as  due  to  some  cause 
acting  after  birth.  Imbecility,  like  idiocy,  may  be  congenital,  developmental, 
or  accidental,  but  true  imbecility  is  nearly  as  often  congenital  as  idiocy.  Im- 
becility is  therefore  best  defined  as  an  affection  congenital  or  acquired  very 
early,  and  characterized  by  mental  deficiency  less  in  degree  than  idiocy.  It 
must  be  distinguished  from  dementia,  which  in  rare  cases  comes  on  in  children 
who  have  been  born  with  average  capability  and  intelligence.  Under  congen- 
ital imbecility  Clouston  {Clinical  Lectures  on  Mental  Diseases)  places  cases 
which  show  every  degree  of  mental  deficiency,  from  the  smallest  amount  of 
mental  weakness  down  to  idiocy.  Such  imbeciles  may,  according  to  this 
authority,  have  attacks  of  maniacal  excitement  or  of  melancholia ;  they  may 
become  dangerous  and  even  homicidal ;  they  may  after  an  attack  have  secondary 
stupor,  or  may  become  demented  as  compared  with  their  primitive  condition ; 
and  they  are  often  terrible  masturbators.  The  clowns  and  fools  of  all  ages 
would,  as  a  rule,  come  under  the  head  of  imbeciles. 

667 


668    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  medico-legal  aspects  and  bearings  of  idiocy  and  imbecility  should  not 
be  entirely  neglected  in  general  medical  works,  as  not  infrequently  the  family 
physician  is  the  first  to  be  called  to  give  an  opinion,  which  may  have  present 
or  future  importance,  with  reference  to  the  mental  status  of  the  child  under  his 
care,  although  the  more  difficult  and  intricate  problems  associated  with  ques- 
tions as  to  the  mental  capacity  of  the  idiotic  and  feeble-minded  are  generally 
submitted  for  final  decision  to  medical  and  legal  experts.  Ingenious  efforts  to 
frame  legal  definitions  of  idiocy  which  would  stand  the  test  of  experience  and 
practice  have  from  time  to  time  been  made.  The  idiot,  for  example,  has  been 
designated  by  judicial  authority  as  one  who  from  his  nativity  by  a  perpetual 
infirmity  is  non  compos  mentis ;  or  one  who  cannot  count  or  number  twenty 
pence,  or  tell  Avho  Avas  his  father  or  mother,  or  how  old  he  is,  so  that  it  may 
appear  that  he  hath  no  understanding  of  reason  what  shall  be  for  his  profit  or 
what  shall  be  for  his  loss;  but  if  he  have  sufficient  understanding  to  know  and 
understand  his  letters,  and  to  read  by  teaching  or  information,  he  is  not  an 
idiot.  The  defects  and  shortcomino-s  of  this  ingenious  definition  are  evident 
even  to  careless  examination,  and  have  often  been  indicated  both  in  courts  of 
law  and  by  writers.  The  whole  question  of  the  legal  relations  and  consequences 
of  true  idiocy  can  be  dismissed  Avith  the  assertion  that  if  it  has  once  been 
clearly  established  by  competent  mental  and  physical  examination,  it  deprives 
the  subject  of  the  legal  right  and  capability  of  performing  acts  which  Avill  stand 
in  law  and  equity,  and  also  relieves  its  subject  from  civil  and  criminal  respon- 
sibility. It  is  simply  a  matter  of  careful  determination  in  a  given  case.  It  is 
somewhat  different,  however,  when  the  issue  is  that  of  imbecility  or  of  back- 
wardness. 

The  elder  Seguin  and  others  have  erected  a  class  of  hachivard  children,  in 
whom  functional  torpidity  or  backwardness  of  the  nervous  apparatus  is  present, 
while  not  sufficiently  abnormal  to  be  classed  as  idiots  or  even  imbeciles.  These 
children  are  behindhand  in  mental  development,  and  in  some  physical  develop- 
ment is  also  retarded.  They  do  not  learn  to  creep  or  to  walk  until  a  much  later 
period  than  others.  Probably  most  of  them  could  be  classed,  were  it  not  for 
the  sensitiveness  of  those  to  whom  they  belong,  Avith  the  highest  grades  of 
imbeciles.  Such  children  shoAv  a  tendenc}^  to  be  behind  their  fellow-children 
in  school  and  Avork,  and  even  at  play  and  in  their  sportive  relations  Avith  other 
children.  They  become  the  butts  and  slaves  of  their  better-equipped  compan- 
ions, by  whom  they  are  teased  and  hazed,  and  in  various  ways  have  their  lives 
made  a  burden. 

Moral  Imbecility. — Moral  imbecility  is  an  affection  sometimes  classed 
under  juvenile  insanities  as  moral  insanity;  but  a  distinction  can  be  made, 
although  not  with  the  same  certainty  as  in  the  adult,  between  moral  imbecility 
and  moral  insanity  in  the  young.  In  some  instances  it  would  appear  that  per- 
version of  the  moral  or  affective  life  is  brought  about  through  injury,  disease, 
or  vicious  habits  in  children  who  have  been  previously  of  a  healthy  moral  and 
mental  tone;  but  the  subject  of  true  moral  imbecility  is  the  victim  of  heredity; 
his  condition  is  manifested  as  soon  after  birth  as  it  is  possible  to  clearly  recog- 
nize by  conduct  deficiencies  in  the  moral  sense.  Whatever  views  may  be  held 
as  to  the  substrata  of  conscience  and  morals,  it  is  convenient  to  use  such  terms 
as  moral  faculty  and  moral  sense  in  their  commonly  understood  significance. 
The  moral  sense  covers  that  which  causes  a  human  being  to  weigh,  consider, 
approve,  or  disapprove  his  own  conduct;  it  includes  that  which  in  common 
language  is  called  conscience.  This  faculty  or  sense,  like  others,  should  be 
regarded  as  a  function  or  effect  of  organization,  although  one  school  contends 
for  its  separation  from  the  physical  man  and  would  relegate  it  to  some  super- 


IDIOCY  AND    IMBECILITY.  669 

natural  sphere.  I  am  not  here  particularly  concerned  with  discussions  of  this 
kind,  but  as  a  physician,  and  in  common  with  others  who  have  seen  much  of 
nervous  and  mental  disorder,  I  have  become  only  too  familiar  with  a  class  of 
cases  which  must  be  recognized  as  the  subject  of  disease,  and  the  mental  care 
and  treatment  of  which  are  forced  upon  us  by  every  scientific  and  humane  con- 
sideration. Maudsley  speaks  of  cases  of  this  kind  as  a  group  of  persons  of 
unsound  mental  temperament,  '"who  are  born  with  an  entire  absence  of  the 
moral  sense,  destitute  even  of  the  possibility  of  moral  feeling ;  they  are  as  truly 
insensible  to  the  moral  relations  of  life,  as  deficient  in  this  regard,  as  a  person 
color-blind  is  to  certain  colors,  or  as  one  who  is  without  ear  for  music  is  to  the 
finest  harmonies  of  sound.  Although  there  is  usually  combined  with  this 
absence  of  moral  sensibility  more  or  less  weakness  of  mind,  it  does  happen  in 
some  instances  that  there  is  a  remarkably  acute  intellect  of  the  cunning  type." 
Such  children  are  incorrigible  to  reproof  and  training.  Punishment  has  no 
effect  upon  them,  or  will  only  be  so  heeded  as  to  allow  of  their  escape  from 
immediate  difficulty. 

Much  diiference  of  opinion  has  arisen  among  authorities  almost  equally 
competent  with  reference  to  the  exact  nature  of  such  cases.  One  contention  is 
that  such  a  thing  as  moral  insanity  or  imbecility  does  not  exist,  and  that  close 
investigation  will  show  in  all  alleged  cases  that  intellectual  disorder  is  present. 
It  is  held  that  we  should  not,  even  by  a  convenient  label,  separate  these  cases 
from  others  of  accepted  or  acknowledged  intellectual  disorder.  The  difference 
is  probably  largely  one  of  terms.  In  a  well-studied  class  of  cases  the  brunt  of 
whatever  defect  or  disease  is  present  has  fallen  upon  what  every  one  regards  as 
the  moral  nature  of  the  individual.  Recognizing  morality  and  immorality  as 
facts,  no  reason  exists  for  not  regarding  these  cases  as  instances  of  moral  arrest 
or  departure;  it  is  as  scientifically  correct  to  do  this  as  it  is  to  subdivide  the 
forms  of  insanity  into  intellectual,  perceptional,  emotional,  and  other  well-known 
psychological  varieties. 

According  to  Herbert'  Spencer,  higher  feeling  is  merely  the  centre  of  co- 
ordination by  which  the  less  complex  aggregations  are  brought  under  proper 
relations.  In  the  process  of  evolution  this  centre  of  co-ordination  may  never 
be  developed  and  moral  imbecility  may  result,  or  great  waywardness  of  moral 
conduct  without  marked  disorder  of  intellect.  The  doctrines  of  moral  imbecil- 
ity and  moral  insanity  are,  then,  as  Tuke  says,  in  full  accord  with  the  mental 
rules  of  evolution  and  dissolution  laid  down  by  Spencer. 

Ray  {^Medical  Jurisprudence  of  Insanity)  gives  numerous  examples  of  moral 
imbecility,  some  of  the  most  extraordinary  character.  One  of  these  of  historical 
interest  is  that  of  "  Count  Charolais,  brother  of  the  duke  of  Bourbon-Cond^, 
whose  sanguinary  character  has  been  commemorated  by  Lacretelle.  He  man- 
ifested an  instinct  of  cruelty  in  the  very  sports  of  his  childhood.  He  took 
pleasure  in  torturing  animals  and  committing  the  most  ferocious  acts  of  violence 
against  his  domestics.  He  would  stand  at  the  window  and  shoot  the  artisans  at 
work  on  neighboring  buildings,  merely  for  the  pleasure  of  seeing  them  tumble 
from  roofs  and  ladders.  It  is  said  he  loved  to  stain  even  his  debaucheries  with 
blood,  and  committed  many  murders  from  no  motives  of  interest  or  anger." 

Works  on  medical  jurisprudence  and  on  mental  diseases,  and  periodical 
literature  connected  with  studies  of  this  character,  have  furnished  many  illus- 
trations of  what  is  best  classed  as  moral  imbecility.  Kerlin  {Med.  News^  March 
19, 1887)  has  presented  short  histories  of  four  children — the  first,  illustrative  of 
the  incipient  prostitute  whose  mental  incapacity  should  be  her  protection ;  the 
second  case,  that  of  an  incipient  burglar ;  the  third,  a  hereditary  religious  hyp- 


670    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ocrite  and  egotist,  who,  if  not  permanently  sequestered,  would  fill  a  dramatic  if 
not  an  awful  role  in  crime  ;  the  fourth,  a  confirmed  juvenile  confidence-man. 

Under  the  head  of  idiots  savants  has  been  described  a  class  of  idiots  a  few 
examples  of  which  are  to  be  found  in  almost  every  large  institution.  They 
exhibit  in  some  special  direction  extraordinary  or  apparently  extraordinary 
mental  power.  They  may,  for  example,  be  extremely  skilful  in  some  simple 
handicraft ;  may  have  a  wonderful  ear  for  music  or  great  skill  in  playing  upon 
musical  instruments  ;  or  they  may  show  a  remarkable  faculty  of  making  diffi- 
cult calculations.  They  are  usually  instances  of  over-development  in  some  one 
direction,  the  individual  faculties  in  general  being  stunted  and  imperfect. 

Varieties. — A  thoroughly  scientific  classification  of  idiocy  is  in  the  present 
state  of  our  knowledge  impossible.  Idiocy  and  imbecility  may  with  reference 
to  classification  be  briefly  considered  together.  Kerlin  {Med.  and  Surg.  Re- 
porter^ ^-fay  20  and  27, 1882)  has  made  a  practically  useful  classification  of  these 
affections  into  idiocy,  idio-imbecility,  and  imbecility,  considering  separately,  as 
I  shall  also,  forms  of  juvenile  insanity  Avhich  cannot  properly  be  included  under 
either  idiocy  or  imbecility.  Under  idiots  are  placed  groups  of  the  lowest  grades 
of  intelligence  and  possible  development ;  under  imbeciles,  those  of  low  intelli- 
gence and  development,  but  of  higher  grade  than  true  idiocy  and  capable  of 
various  degrees  of  improvement ;  and  under  idio-imbeciles,  those  which  form  a 
connecting  link  between  the  others.  Following  Griesinger,  the  same  authority 
divides  idiots  into  the  apathetic  and  the  excitable,  and  imbeciles  into  a  low, 
middle,  and  high  grade.  Various  other  attempts  at  classification  have  been 
made,  but  it  would  serve  no  good  purpose  to  consider  each  of  these  in  detail. 
All  are  more  or  less  deficient,  as  standards  of  classification  are  commingled  and 
confused.  Some  classes  are  founded  upon  teratological  and  others  upon  path- 
ological data ;  some  upon  ethnological  and  others  upon  anatomical,  etiological, 
psychological,  or  other  features.  The  best  classification  eventually  will  be  one 
based  upon  a  study  of  groups  of  clinical  phenomena  which  can  be  readily 
referred  to  teratological  and  pathological  conditions. 

A  useful  general  classification  of  idiocy  is  one  suggested  by  Langdon  Down 
(Tuke's  Diet.  Psycliol.  Med.)  into  congenital,  developmental,  and  accidental. 
Congenital  idiots  are  born  deficient  as  the  result  of  causes  usually  unknown, 
except  that  bad  heredity  is  commonly  present ;  and  the  majority  of  cases  of  true 
idiocy  belong  to  this  class,  although  some  authorities  improperly  exclude  from 
it  cases  whose  pathology  seems  evident,  as  porencephalic,  hydrocephalic,  and 
microcephalic  cases. 

Congenital  idiocy  is  usually  recognized  at  an  early  period,  within  a  few 
months  or  even  a  few  weeks  after  birth,  although  in  exceptional  instances  it  is 
overlooked  until  the  child  has  reached  a  year  or  more. 

Developmental  idiocy  receives  its  name  from  the  fact  that  it  originates  at 
certain  developmental  epochs,  as  at  first  or  second  dentition,  or  perhaps  at  the 
beginning  of  puberty,  typical  cases  being  up  to  a  certain  age  normal  and  of 
good,  or  at  least  ordinary,  physical  health.  FolloAving  a  convulsion  or  a  series 
of  spasms,  the  child  may  show  a  marked  intellectual  change  and  variation  of 
character,  or  this  deterioration  may  come  on  gradually,  without  any  history  of 
spasm  or  any  abrupt  attack,  in  children  perfectly  normal  as  to  intelligence  up 
to  the  age  of  eighteen  months  or  five,  six,  or  even  seven  years,  or  perhaps 
nearly  or  quite  to  the  age  of  puberty.  In  some  of  the  cases  which  have  been 
reported  the  mother  has  been  acted  upon  by  malign  or  depressing  influences  or 
has  been  the  subject  of  disease  or  deprivation  of  some  kind  during  pregnancy. 
Down  has  advanced  the  reasonable  supposition  that,  according  to  the  period  of 
embryonic  life  at  which  the  causative  impression  is  made  upon  the  mother,  may 


IDIOCY  AND    IMBECILITY.  671 

be  the  time  of  development  of  the  manifestations  of  idiocy ;  occurring  at  an 
early  period,  such  disturbances  result  in  congenital  idiocy. 

Accidental  idiocy  is  a  form  of  mental  arrest  which  is  caused,  as  its  name 
indicates,  by  some  accident  at  or  after  birth.  In  not  a  few  such  cases  the  pre- 
disposition to  mental  weakness  may  have  existed,  but  even  in  these  it  might 
not  have  shown  itself  in  so  marked  a  manner  or  at  all.  Haemorrhage  or 
depressed  fracture  or  abscess  from  aural  disease  may  have  been  present,  and 
meningitis  of  either  the  hard  or  the  soft  membranes  is  sometimes  found  post- 
mortem. While  recognizing  these  three  etiological  varieties  as  of  great  impor- 
tance and  value  for  purposes  of  study,  one  cannot  get  a  clear  idea  of  the  types 
of  idiocy  without  a  different  subdivision,  as  under  the  congenital,  develop- 
mental, and  accidental  classes  idiots  differing  widely  in  appearance  and  in  their 
mental  and  physical  possessions  are  found,  although  the  differences  are  greater 
in  congenital  idiocy  than  in  the  other  forms. 

Down  has  also  proposed  a  more  elaborate  and  differentiated  classification, 
giving  many  different  forms,  and  arranging  these  into  more  than  twenty  sub- 
classes under  the  general  heads  already  considered.  He  has  paid  particular 
attention  to  ethnological  features,  describing  such  varieties  as  the  Caucasian, 
Ethiopian,  Calmuck  or  Mongolian,  Malayan,  and  Negroid.  The  patients  bear 
a  real  or  fancied  resemblance,  particularly  in  face  and  head,  to  individuals  of 
the  different  races  indicated  by  the  names.  The  Calmuck  or  Mongolian 
appears  to  be  the  most  clearly  recognizable  of  these  varieties.  Among  its 
characteristics  are  short  stature,  deficiency  of  the  posterior  part  of  the  head, 
sparse  hair,  obliquely-placed  and  widely-separated  eyes,  and  depressed  nose. 
Mongolian  idiots  are  grotesque,  seeing  the  humorous  side  of  things ;  they  are 
all  characterized  by  strong  self-will  and  wonderful  imitative  power,  and  they 
have  other  physical  and  mental  peculiarities  to  which  our  space  Avill  not  permit 
us  to  refer. 

Among  other  varieties  of  idiocy  recognized  by  Down,  Shuttleworth,  and 
others  are  those  the  names  of  which  are  based  upon  peculiarities  in  the  size 
and  shape  of  the  head ;  but  this  method  of  classification,  like  that  based 
upon  ethnological  marks,  is  not  capable  of  being  carried  out  over  the  entire 
range  of  cases.  Different  shapes  of  head  are  found  in  cases  of  idiocy  with  the 
same  or  similar  mental  and  physical  features,  or,  on  the  other  hand,  either  dif- 
ferent or  the  same  or  similar  symptoms,  syndromes,  or  conditions  are  presented 
by  idiots  with  heads  unlike  in  shape  and  size.  It  is  true,  nevertheless,  that 
some  of  the  varieties  present  more  or  less  common  features,  and  the  terms  used 
are  at  least  convenient  for  the  purpose  of  investigation  and  record.  Macro- 
cephalic  idiocy  in  such  a  classification  might  describe  cases  due  to  hydro- 
cephalus or  to  hypertrophy  of  the  bone  or  intracranial  structures,  or  to  both. 
Microcephalic  is  a  term  applied  to  idiots  with  very  small  heads,  technically  to 
those  whose  heads  are  less  than  seventeen  inches  in  circumference ;  hydro- 
cephalic idiocy  is  the  result  or  accompaniment  of  hydrocephalus  ;  brachycepha- 
lic  means  broad  and  short-headed,  and  dolichocephalic  long-headed — long  in 
proportion  to  breadth.  The  terra  cephalic  index  is  applied  to  the  breadth  of 
the  skull  multiplied  by  100  and  divided  by  its  length,  and  if  above  80  the 
skull  is  called  brachycephalic.  In  plagiocephalic  idiots  the  skull  is  out  of 
shape,  so  that  the  features  lie  in  an  oblique  plane  ;  scaphocephalic,  from  a  word 
meaning  the  hull  of  a  ship,  is  a  term  applied  to  that  form  of  idiocy  in  which 
the  head  is  shaped  like  the  keel  of  a  boat  turned  upside  down. 

Ireland,  the  author  of  a  well-known  text  book  on  idiocy  and  imbecility 
{Idiocy  and  Imbecility^  London,  1887).  has  proposed  a  classification  which  has 
been  much  followed  and  has  much  to  commend  it,  but  it  is  by  no  means  suffi- 


672    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cient  to  cover  all  cases.  It  is  a  mixed  classification,  based  on  pathological, 
etiological,  and  semiological  features,  and  has  ten  classes,  as  follows :  1,  Gene- 
tous ;  2,  Microcephalic  ;  3,  Eclamptic ;  4,  Epileptic  ;  5,  Hydrocephalic ;  6, 
Paralytic ;  7,  Cretinism ;  8,  Traumatic ;  9,  Inflammatory ;  10,  Idiocy  by 
deprivation. 

The  term  "  genetous  idiocy,"  as  used  by  Ireland,  practically  means  the  same 
as  congenital,  but  other  varieties  in  his  classification  are  just  as  truly  genetous 
or  congenital.  Eclamptic  and  epileptic  idiocy  are  two  varieties,  in  both  of 
which  spasm  or  convulsion  plays  a  prominent  part,  but  in  the  eclamptic  occurs 
soon  after  birth,  and  is  supposed  to  be  due  to  convulsive  seizures,  these  not 
infrequently  stopping,  but  leaving  the  mind  permanently  affected  and  arrested; 
while  in  epileptic  idiocy  the  convulsion  and  the  idiocy  may  both  come  on  at 
different  ages,  and  the  epilepsy  remain  as  a  permanent  accompaniment  of  the 
idiocy.  According  to  Brush  {Keating' 8  Cycl.  Dis.  Children,  vol.  iv.),  an  epi- 
leptic idiot  is  one  whose  mental  growth  has  been  arrested  by  the  occurrence  of 
epilepsy  in  infancy  or  childhood.  From  this  point  of  view  epileptic  idiocy 
would  belong  to  the  etiological  variety,  while  eclampsic  might  or  might  not. 
Microcephalic  and  hydrocephalic  have  been  already  discussed.  Paralytic 
idiots  have  forms  of  monoplegia,  hemiplegia,  paraplegia,  and  diplegia,  as 
described  in  this  work  by  Peterson.  Very  commonly  the  paralysis  is  of  the 
spastic  variety.  Various  forms  of  idiocy  might  be  classed  under  traumatic.  Not 
a  few  cases  are  supposed  to  result  from  injuries  inflicted  during  prolonged  labor 
by  bruising  and  squeezing  of  the  child  or  by  instruments  in  assisting  at  its 
delivery.  Some,  but  by  no  means  the  majority,  of  paralytic  cases  are  attribu- 
table to  traumatism  ;  many  arc  dependent  upon  sclerosis,  arrest  of  development, 
neoplasms,  meningitis,  meningo-cerebritis,  or  cerebritis,  and  the  pathological 
process  may  occur  either  before  or  soon  after  birth.  Of  course  inflammation 
may  be  set  up  by  traumatism,  Avlien  the  case  might  be  regarded  as  either  trau- 
matic or  inflammatory.  Hydrocephalus  is  sometimes  the  result  of  a  tubercular 
or  other  inflammation  of  the  membranes  or  ependyma  of  the  ventricle.  Con- 
firmed idiocy  and  forms  of  juvenile  insanity  occasionally  occur  during  or  after 
the  infectious  febrile  affections  of  infancy  or  early  childhood,  such  as  cerebro- 
spinal fever,  scarlet  fever,  measles,  whooping-cough,  diphtheria,  etc.,  and  these 
are  either  toxic  or  inflammatory  affections,  or  both.  Sensorial  idiocy,  or  idiocy 
by  deprivation,  is  the  result  of  the  lack  or  the  loss  of  important  senses  like 
sight  or  hearing.  Some,  but  by  no  means  many,  of  these  cases  may  by  care- 
ful education  and  training  be  lifted  out  of  this  idiotic  state  ;  in  others  the 
loss  of  hearing,  of  sight,  or  of  other  senses  may,  like  the  mental  defects  in 
general,  be  dependent  upon  embryonal  arrest.  Sensorial  idiocy  and  imbecility, 
therefore,  need  to  be  subdivided  into  at  least  the  two  varieties  of  congenital 
and  acquired  or  accidental.  It  may  be  of  great  practical  importance  to  be 
able  to  decide  to  which  of  these  two  varieties  a  case  belongs.  Cretinism  will 
be  treated  of  in  a  separate  article. 

Shuttleworth's  classification  {British  Med.  Jour.,  Jan.  30,  1886),  which 
includes  the  varieties  of  Ireland  with  some  additional  classes,  is  as  follows  : 

"  Class  A — Congenital. — 1,  Microcephalic  ;  2,  Hydrocephalic  (also  non- 
congenital)  ;  3,  Scrofulous  (Mongol  type) ;  4,  Sensorial  (also  non-congenital) ; 
5,  Primarily  neurotic ;  6,  Paralytic  (also  non-congenital) ;  7,  Choreic  (also 
non-congenital) ;  8,  Cretinoid  ;  (a)  sporadic,  {b)  endemic.  Class  B — Non- 
congenital. — a.  Developmental. — 9,  Eclamptic;  10.  Epileptic;  11,  Syphil- 
itic ;  12,  Post-febrile  (also  accidental) ;  b,  Accidental  or  Acquired. — 13,  Toxic ; 
14,  Traumatic;  15,  Emotional;  16,  From  mixed  causes." 

Strumous  or  scrofulous  forms  of  idiocy  can  be  clearly  placed  to  the  strumous 


PLATE  Xr^^. 


Fig.  1.  Congenital  Idiot  of  Low  Grade. 
Fig.  2.  Epileptic  Imbecile. 


Fig.  3.  Insane  Imbecile. 

Fig.  4  Congenital  Idiot  of  Low  Grade. 


IDIOCY  AND   IMBECILITY.  673 

or  scrofulous  diathesis  ;  they  belong  to  the  congenital  class.  The  primarily 
neurotic  are  those  with  bodies  comparatively  well  developed  and  with  signs  of 
irregular  nervous  action. 

The  term  "choreic,"  as  applied  to  idiocy,  has  been  used  in  several  ways 
■ — as  descriptive  of  the  motor  phenomena  presented  by  the  patient ;  or  of  idiocy 
resulting  in  a  child  born  of  a  mother  choreic  during  pregnancy  ;  or  of  cases 
in  which  violent  or  persistent  chorea  seems  to  induce  idiocy  in  the  developing 
child. 

Congenital  idiocy  due  to  inherited  syphilis  is  probably  but  not  certainly 
rarer  than  a  form  of  juvenile  dementia,  which  usually  develops  some  years 
after  birth,  and  is  described  in  another  section.  Some  syphilitic  children  are 
idiotic  from  birth,  and  in  these  cases  treatment  is  generally  as  useless  as  in 
cases  due  to  other  causes,  while  in  syphilitic  juvenile  dementia  specific  treat- 
ment may  be  very  efficient.  Shuttleworth  applies  the  term  "toxic  idiocy"  to 
idiots  who  without  bodily  deformity  suifer  from  malnutrition  of  the  brain,  which 
he  supposes  to  be  due  to  some  unknown  toxic  influence.  Emotional  or  excitable 
idiocy  is  that  which  shows  shrinking,  fear,  apprehension,  excitement  as  its  chief 
features. 

Etiology. — A  bad  heritage  is  the  great  predisposing  cause  of  idiocy.  The 
idiot's  ancestor  may  not  have  been  insane,  imbecile,  or  idiotic,  but  in  the  majority 
of  cases  some  constitutional  taint  or  tendency,  as  syphilis,  struma,  or  tuberculosis ; 
some  toxic  affection,  as  alcoholism;  some  form  of  mental  disease  or  defect; 
some  neurosis  as  epilepsy,  hysteria,  neuralgia,  or  neurasthenia,  or  some  organic 
disease  of  the  brain,  as  meningitis,  sclerosis,  softening,  or  hsemorrhage,  will 
with  sufficient  investigation  be  found  to  have  been  present  in  near  or  remote 
progenitors.  Intemperance,  alone  or  combined  with  other  causes,  such  as 
epilepsy  or  insanity,  has  been  shown  by  reliable  statistics  to  be  one  of  the  com- 
monest predisposing  causes.  Far  too  frequently  imbeciles  of  high,  or  in  some 
cases  of  comparatively  low  grade,  marry,  with  degenerate  offspring  as  the  result. 
Numerous  studies  of  heredity  in  connection  with  this  question  of  the  causation  of 
idiocy  have  been  made.  According  to  Shuttleworth  and  Beach  (^Tukes  Diet. 
Psychol.  Med.),  the  most  frequent  combination  of  two  causes  of  insanity  is  that 
of  insanity  with  epilepsy.  Even  deaf-mutism,  with  perhaps  in  most  cases  the 
addition  of  some  other  lowering  agency,  has  resulted  in  idiocy  and  imbecility  in 
the  second  and  third  generation.  By  the  authors  above  quoted  syphilis  was 
found  certainly  to  be  the  predisposing  cause  in  17  per  cent,  of  more  than  two 
thousand  cases.  Good  authorities  place  2  per  cent,  as  covering  the  cases  of 
syphilitic  idiocy,  although  others  would  put  it  much  higher.  The  question  of 
consanguineous  marriages  has  been  much  discussed  in  connection  with  the  causa- 
tion of  both  insanity  and  idiocy,  and  authorities  are  somewhat  at  variance ;  but 
it  may  be  regarded  as  certain  that  the  marriage  of  relatives  in  one  or  both  of 
whom  mental  or  neurotic  defects  or  constitutional  or  toxic  conditions  are  present 
will  predispose  to  idiocy  and  imbecility  as  to  other  degenerative  diseases.  It 
is  better,  as  a  rule,  that  relatives  should  not  intermarry,  as  few  stocks  are 
absolutely  without  taint  or  weakness. 

Bad  health  in  the  mother  and  impressions  made  on  her  during  pregnancy, 
the  father's  health  or  condition  at  the  time  of  procreation,  age  or  premature 
senility  of  parents,  and  acute  diseases  during  pregnancy, — all  have  some  etio- 
logical importance. 

Among  causes  acting  at  the  time  of  birth  are  prolonged  and  difficult 
labor  in  mothers  with  small  or  deformed  pelves;  injuries  by  instruments  or 
other  manipulations  or  by  the  umbilical  cord,  and  suspended  animation  from 
whatever  cause.     The  use  of  instruments  is,  however,  a  much  less  frequent 

43 


674    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cause  of  idiocy,  infantile  paralysis,  and  convulsions  than  is  commonly  supposed. 
Tliey  are  often  used  after  the  injury  has  been  done  by  long-continued  pressure. 
The  prompt  and  skilful  use  of  forceps  sometimes  saves  life  and  health  for  both 
mother  and  child,  oftener  than  the  reverse.  In  these  pressure  and  forceps 
cases  skull  depressions  and  haemorrhages  sometimes  occur.  The  causes  acting 
after  birth  are  comparatively  few,  but  among  these  are  injuries  from  falls  or 
blows,  convulsions  of  unknown  origin,  fright,  febrile  diseases,  and  in  rare  cases 
the  ingestion  of  toxic  substances. 

Symptoms. — To  briefly  give  the  symptomatology  of  idiocy  in  general 
is  an  almost  impossible  task.  The  signs  and  symptoms  will  vary  widely  with 
classes,  and  to  a  certain  extent,  in  considering  the  varieties  of  idiocy,  I  have 
already  described  its  symptomatology ;  but  certain  physical  and  mental 
characteristics  belong  to  almost  any  form  of  idiocy,  and  from  studying  these 
the  practitioner  of  medicine,  even  without  special  knowledge  of  the  subject, 
may  be  able  to  come  to  a  conclusion  as  to  the  nature  of  such  a  case  at  an  early 
period.  Much  can  be  learned  as  to  the  physical  features  of  idiocy  by  mere 
inspection,  and  much  more  by  careful  and  detailed  investigation.  The  size 
and  shape  of  the  head  and  face  and  defects  of  feature  may  prove  serviceable 
in  coming  to  a  decision.  I  have  already  spoken  of  varieties  dependent  on 
the  shape  of  the  head  to  which  special  names  have  been  given,  as  microcephalic, 
and  brachycephalic.  Unusual  smallness  or  largeness  of  the  head,  or,  what  is 
more  common,  deformity  or  asymmetry  in  its  shape,  is  often  the  first  to  attract 
attention.  In  some  types  of  idiocy,  as  the  Mongolian,  a  remarkable  deficiency 
of  the  posterior  part  of  the  cranium  is  often  observed ;  in  others  it  may  be  that 
one  side  of  the  head,  or  even  one  special  region  of  the  cranium,  will  show 
marked  depression  or  arrest.  In  almost  every  instance  of  true  idiocy  some 
peculiarity  of  face  or  feature  is  present :  this  may  be  abnormal  position  or 
separation  of  the  eyes  ;  deformity,  unusual  size,  or  peculiar  implantation  of  the 
external  ear ;  depression  or  flattening  of  the  nose,  or  general  asymmetry  of  the 
face.  The  oral  cavity  of  idiots  has  been  the  subject  of  much  investigation,  and 
great  varieties  in  the  shape  of  the  mouth  and  pharynx  are  found  ;  it  is  high  and 
gothic  ;  or  low  and  flat ;  or  irregular  ;  or  a  cleft  or  partially  cleft  palate  is  pres- 
ent ;  and  sometimes  the  entire  buccal  and  pharyngeal  cavities  are  contracted 
as  well  as  irregular  in  shape.  The  greatest  possible  variations  in  the  shape, 
size,  and  implantation  of  the  teeth  are  to  be  observed :  they  are  notched  or 
pegged  or  serrated  ;  they  overlap  and  are  irregularly  crowded  :  frequently  they 
decay  at  an  early  period.  The  jaws  may  be  too  narrow  or  may  fail  to  be 
properly  apposed  to  each  other  ;  occasionally,  instead  of  being  small,  the  lower 
jaw  is  prognathian — of  unusual  size  and  projection.  The  tongue  may  be  too 
large,  or  even  too  small,  and  frequently  refuses  to  obey  the  behests  of  the  will. 
The  head  cannot  be  held  erect  or  is  carried  badly. 

The  control  which  the  patient  has  over  ocular  movements  and  facial  expres- 
sion is  often  of  great  value  to  the  diagnostician.  Strabismus  is  common,  and 
this  may  be  of  one  eye  or  both,  or  of  an  alternating  or  varying  type.  Of  other 
simple  tangible  phenomena,  drooling  or  slavering  is  an  important  manifestation. 
Inability  to  stand  or  walk  at  the  usual  age  may  lead  to  suspicion  as  to  the  true 
condition,  and  even  if  the  child  can  walk  his  carriage  and  gait  may  be  very 
significant.  Some  idiots  stoop,  some  have  a  lopsided  method  of  progression ; 
many  are  slouching  in  station  and  in  walk ;  some  run  when  they  should  walk, 
or  walk  when  they  should  run;  the  gait  is  often  ataxic  or  incoordinate,  or, 
rather  than  this  in  a  technical  sense,  it  may  be  simply  maladroit  or  awkward. 
The  hands  and  arms  are  not  used  with  the  same  precision,  accuracy,  and  adap- 
tation of  means  to  ends  as  by  other  children. 


IDIOCY  AND    IMBECILITY.  675 

Below  the  head  and  neck  defects  and  peculiarities  may  be  as  various  as 
above.  Curvatures  and  twistings  of  the  trunk,  asymmetry  in  the  development 
of  the  legs  and  arms ;  flexures,  curvatures,  or  other  deformities  of  the  limbs ; 
knock-knees  or  bow-legs  or  parrot-toes,  and  numerous  other  deformities,  mal- 
positions and  arrests,  may  be  present.  According  to  the  variety  of  idiocy  there 
may  be  paralysis,  with  or  without  local  spasm  or  contracture,  in  limbs  or  face ; 
sometimes  this  is  one-sided— that  is,  monoplegic  or  hemiplegic ;  sometimes  both 
legs,  or  both  legs  and  one  arm,  or  all  four  limbs,  may  be  involved  in  the  pare- 
tico-spastic  condition. 

The  skin  may  be  harsh  or  dry  or  coarse;  it  may  show  evidences  of 
impaired  or  imperfect  circulation  in  coldness  or  duskiness  of  the  extremities,  in 
blotches  or  discolorations,  or  even  in  a  tendency  to  trophic  affections,  such  as 
ulcerations  and  eruptions.  Not  seldom  the  hair  is  scanty  or  coarse  or  badly 
nourished,  and  the  nails  may  be  of  bad  shape  or  abnormal  in  appearance.  The 
sexual  organs  may  show  unusual  smallness  or  deformity  or  peculiarity  of  some 
kind. 

Speech  may  show  many  varieties  of  defect  and  aberration,  and  these  have 
to  some  extent  been  considered  in  another  section.  The  incapacity  to  attend 
to  what  is  said  or  what  should  be  done  is  one  of  the  first  things  to  attract 
attention  to  an  idiotic  child.  At  an  age  when  infants  and  small  children  ordi- 
narily attend  to  many  matters  of  passing  interest,  such  a  child  cannot  be  made 
to  fix  its  attention  even  by  the  most  strenuous  efforts;  indeed,  a  close  study 
of  this  faculty  will  perhaps  throAv  more  light  than  anything  else  upon  the 
degree  of  mental  development  in  children.  Self-will,  undue  emotionality,  lack 
of  ordinary  obedience,  impetuous  and  unreasonable  behavior,  inattention  to 
natural  wants  and  demands,  are  all  points  of  importance  in  the  mental  investi- 
gation of  supposed  idiocy. 

While  some  or  many  of  the  physical  peculiarities  enumerated  may  be  present 
in  cases  of  idiocy,  it  must  not  be  forgotten  that  in  some  types  at  least  they  are 
nearly  all  wanting.  In  the  so-called  accidental  idiocy,  for  example — that  which 
has  resulted  from  injury  at  the  time  of  or  after  birth — there  may  be  a  striking 
absence  of  the  usual  physical  defects  and  deviations.  Such  children  are  some- 
times scarcely  to  be  distinguished  in  head,  face,  form,  attitude,  or  movements 
from  those  retaining  their  mental  faculties,  although  the  traumatism  may  have 
left  its  mark  in  depressed  skull  or  paralytic  or  spastic  limbs. 

Pathology. — Many  facts  with  reference  to  the  pathology  of  idiocy  will  be 
found  discussed  under  such  heads  as  the  cerebral  paralyses  of  childhood, 
hydrocephalus,  brain  atrophy  or  hypertrophy,  porencephaly,  sclerosis,  cortical 
arrest,  cysts,  softening,  hpsmorrhage,  embolism,  thrombosis,  chronic  menin- 
gitis, meningo-encephalitis,  and  encephalitis ;  while  many  of  the  symptoms 
peculiar  to  idiocy  have  been  or  will  be  considered  under  such  headings  as 
speech  defects  and  anomalies,  nystagmus,  athetosis  and  athetoid  affections,  and 
epilepsy. 

Idiocy  has  no  fixed  pathology,  but  numerous  exceedingly  interesting  patho- 
logical appearances  and  conditions  have  been  reported,  as  anaemia  and  hyper- 
jemia  of  the  brain  ;  hypertrophy  and  atrophy,  general  and  partial ;  softening, 
usually  local ;  sclerosis  of  various  forms  ;  hydrocephalus  and  porencephalus, 
meningitis,  and  tumors  ;  thickening  of  the  arteries;  thrombosis  of  the  sinuses; 
asymmetry  or  unusual  simplicity  of  the  hemispheres  and  convolutions ;  alter- 
ations in  the  relative  amount  of  white  and  gray  matter  of  the  brain.  Disease 
of  other  organs  than  the  cerebrum  is  often  associated  with  cerebral  disease,  as, 
for  example,  atrophy,  tumors,  and  cysts  of  the  cerebellum,  or  spinal  affections, 


676  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

such  as  poliomyelitis  ;  congenital  arrest  of  development  of  the  pyramidal  tracts  ; 
descending  sclerosis  ;  chronic  myelitis  ;  or  pseudo-hypertrophic  paralysis. 

Wilmarth  {Alienist  and  Neurologist,  October,  1890),  has  given  the  results 
of  the  study  of  one  hundred  brains,  and  his  condensed  statement  pre- 
sents in  an  unusually  interesting  and  practical  form  the  pathology  of  most 
cases  of  idiocy.  I  had  the  opportunity  of  studying  some  of  the  brains  and 
skulls  which  are  included  in  this  list  of  cases.  Sclerosis  with  atrophy,  12  ; 
scleroso-tubereuse,  6  ;  diffuse  sclerotic  change,  7 ;  degenerative  changes  in 
vessels,  ganglionic  cells,  or  medullary  substance,  not  constituting  the  true 
sclerosis,  15 ;  hydrocephalus,  5 ;  general  cerebral  atrophy,  2 ;  non-develop- 
ment in  various  forms,  16  ;  infantile  hsemorrhages,  1  ;  extensive  adhesions 
of  membranes  from  old  meningitis,  3;  angeiomatous  condition  of  the  cere- 
bral vessels  (with  degenerative  changes),  1  ;  glioma  (with  sclerosis),  1  ; 
porencephalus,  1 ;  and  31  cases  where  actual  disease  or  imperfect  development 
of  the  brain  proper  was  not  demonstrated  ;  there  was  hypertrophy  of  the  skull, 
6 ;  acute  softening  (recent),  2 ;  demi-microcephalic,  2 ;  1  brain  was  above 
the  usual  weight,  but  the  convolutions  were  large  and  very  simple  in  their 
arrangement. 

In  75  cases,  or  in  all  in  which  injections  of  chloride  of  zinc  or  extensive 
destruction  had  not  made  weighing  valueless,  the  brain  was  carefully  weighed. 
The  average  weight  was  38.3  ounces ;  in  14  cases  the  weight  was  below  30 
ounces ;  thickening  of  the  skull  to  an  extent  to  constitute  hypertrophy  was 
found  in  8  instances ;  while  in  8  the  skull  was  unusually  thin,  not  including 
cases  in  which  there  was  distention  from  hydrocephalus. 

An  attempt  at  a  pathological  classification  of  idiocy  might  be  made, 
although  this  undoubtedly  would  contain  many  imperfections.  The  classes  will 
be  sometimes  found  to  blend  and  commingle,  cases  will  repeat  themselves  under 
different  headings,  and  other  objections  will  appear;  but,  on  the  whole,  such  a 
classification  will  indicate  in  a  general  way  the  groups  as  they  would  be  found 
in  any  large  institution. 

The  most  important  of  these  classes  are  as  follows : 

1.  Idiocy  due  to  gross  organic  lesions,  ihe  history  of  which  can  be  deter- 
mined with  more  or  less  accuracy — lesions  such  as  haemorrhage,  embolism, 
thrombosis,  tumors,  meningitis,  meningo-encephalitis,  and  encephalitis. 

2.  Idiocy  due  to  various  forms  of  sclerosis,  as  the  diffuse,  multiple,  or 
disseminated ;  sclerosis  with  atrophy,  and  lobar  or  tuberous  sclerosis. 

3.  Idiocy  due  to  arrest  of  cortical  development,  a  true  agenesis  corticalis, 
or  absence  of  normal  cells,  Avhich  has  been  well  studied  and  described  by 
Sachs  of  New  York  (Jour.  New.  and  Ment.  Dis.,  August,  1892). 

4.  Idiocy  due  to  large  cerebral  deficiencies,  but  sometimes  originating  in 
haemorrhage,  thrombosis,  embolism,  sclerosis,  meningitis,  etc. — such  conditions 
as  general  atrophy  or  hypertrophy,  porencephalus,  and  hydrocephalus. 

5.  Idiocy  due  to  inherited  or  congenital  syphilis,  which  perhaps  might  be 
included  under  some  other  subdivision,  but  the  cases  are  supposed  by  some 
authorities  to  have  a  peculiar  history  and  special  appearances,  and  therefore 
may  be  placed  for  practical  purposes  in  a  separate  group. 

6.  Idiocy  of  toxic  origin,  under  which  head  would  be  included  cases  result- 
ing from  acute  poisoning  or  following  infectious  diseases,  such  as  measles, 
scarlet  fever,  etc. 

Diagnosis. — The  diagnosis  of  idiocy  will  only  be  difficult  in  early  infancy 
and  in  a  few  rare  cases.  The  facts  to  be  learned  by  observing  whether  or  not 
the  child  pursues  a  regular,  or  at  least  an  average,  method  of  development 
have  already  been  considered  with   reference  to  the  sense  of   hearing,    the 


IDIOCY  AND   IMBECILITY.  677 

acquirement  of  speech,  and  the  development  of  ideas,  when  discussing  anom-* 
alies  and  defects  of  speech.  Different  children  of  the  same  family  or  healthy 
children  who  are  known  to  the  physician  can  be  compared  with  the  one 
alleged  to  be  idiotic.  Careful  consideration  must  be  given  to  the  question  of 
normal  retardation  or  mere  backwardness,  or  the  existence  of  a  true  insanity, 
such  as  syphilitic  dementia.  The  diagnosis  of  idiocy  and  imbecility  is  always 
most  assisted  by  a  careful  study  of  the  physical  conditions  presented  by  the 
child — the  shape  and  size  of  the  head,  which  have  already  been  discussed  ;  the 
condition  of  the  eyes  and  the  ocular  muscles  ;  the  appearance  of  the  palate, 
jaw,  and  tongue ;  the  presence  or  absence  of  drooling ;  ataxic,  athetoid,  or 
choreic  movements ;  peculiarities  of  expression ;  deformities  of  the  ear,  nose, 
or  mouth ;  ungainly,  limping  gait ;  paralysis  or  contractures,  or  both  in  the 
same  case.  The  more  marked  and  numerous  these  arrests  and  aberrations  of 
bodily  development,  the  more  likely  it  will  be  that  the  diagnosis  of  idiocy  is 
correct.  In  every  part  of  this  article  mental  disturbances  and  deficiencies  are 
under  consideration,  and  it  is  only  necessary  to  say  here  that  such  faculties 
as  attention,  memory,  and  inhibition  should  be  particularly  studied. 

Prognosis. — The  prognosis  of  idiocy  as  to  cure  is  of  course  altogether  bad, 
but  it  should  be  remembered  that  improvement  can  be  made  in  the  condition 
of  idiots  even  of  comparatively  low  grade.  They  can  be  made  more  comfort- 
able, happier,  less  offensive,  less  destructive,  and  even,  in  a  limited  number  of 
cases,  more  useful,  by  care,  discipline,  education,  training,  and,  to  a  limited 
degree,   by  the  use  of  nutrient  and  medicinal  agencies. 

"During  the  fifty  years  over  which  efforts  for  the  amelioration  of  the  imbecile 
have  extended,"  says  '^Yiw.tilQ'iNOYth.i^Tuke's  Diet.  Psych.  Med.),  "the  sanguine 
prognostications  of  early  enthusiasts  may  not  have  been  realized,  but  neverthe- 
less a  large  percentage  of  benefit  has  been  recorded.  An  imbecile,  however  well 
trained,  will  always  need  some  kindly  aid  and  consideration  from  those  with  Avhom 
he  is  associated.  It  is  not  to  be  expected  he  will  be  able  to  manage  his  own  affairs 
or  compete  in  the  labor-markets  of  the  world.  Placed  in  a  niche,  however, 
where  he  can  without  molestation  exercise  his  acquired  talents,  he  will  in  many 
cases  turn  out  more  or  less  remunerative  work  ;  and,  failing  this,  he  will,  in 
consequence  of  having  some  resources  within  himself,  cease  to  be  a  nuisance  to 
his  friends.  Even  the  improvement  of  habits  by  systematic  training  is  not  to 
be  despised  in  relation  to  the  comfort  of  the  family ;  and  it  must  be  borne  in 
mind  that  the  idiot  left  untrained  is  sure  to  deteriorate.  A  review  of  twenty 
years'  experience  at  one  of  the  large  English  institutions  furnishes  the  follow- 
ing results :  Of  patients  discharged  after  full  training,  10  per  cent,  are  self- 
supporting,  whilst  another  10  per  cent,  would  be  so  if  they  had  obtained  suit- 
able positions,  and  about  20  per  cent,  were  reported  as  useful  to  their  friends 
at  home." 

Treatment. — In  considering  treatment  the  subject  might  be  variously  sub- 
divided, as  into  prophylactic  and  direct;  into  hygienic,  educational,  gymnastic, 
and  medicinal;  into  measures  for  the  affection  itself,  and  for  diseases  and  con- 
ditions that  are  intercurrent  or  resultant.  Habitation,  diet,  and  clothing  should 
be  carefully  selected ;  and  in  doing  this  particular  attention  should  be  paid  to 
the  variety  of  idiocy  and  to  the  diathesis  from  which  it  may  have  resulted.  The 
ventilation  of  rooms  at  night  and  proper  beds  and  clothing  should  receive 
attention.  Cleanliness  must  be  enforced  by  bathing,  which  can  also  be  used 
as  an  invigorating  and  strengthening  measure.  All  idiots  should  have  exercise 
graded  to  their  physical  condition  and  powers;  mistakes  may  be  made  in 
attempting  to  do  too  much  in  this  direction  or  by  not  duly  considering  their 
differences  from  other  children.     Systematized  gymnastic  exercises  or  calls- 


678    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

thenics  can  be  used  with  great  advantage,  both  for  physical  development  and 
to  a  limited  extent  to  promote  mental  power,  and  to  a  larger  degree  to  add  to 
the  happiness  of  these  defective  children. 

Whether  or  not  an  idiotic  child  should  be  removed  from  its  home  to  an 
institution  is  a  question  that  the  physician  must  frequently  meet,  and  in  general 
terms  it  may  be  said  that  a  well-conducted  institution,  as  a  rule,  is  the  best 
place,  both  for  him  and  for  other  members  of  the  family.  The  danger  of  being 
made  worse  by  contact  with  others — an  argument  which  is  so  often  used  against 
sending  a  patient  to  an  insane  hospital,  and  occasionally  with  force — does  not 
apply,  or  to  an  exceedingly  limited  extent.  In  institutions  of  large  size  the 
defective  children  can  be  so  classified  that  their  training  can  be  carried  out  sys- 
tematically and  without  much  jarring  and  strain,  or,  if  incapable  of  any  im- 
provement, so  that  they  can  be  cared  for  and  their  happiness  promoted  in  tlie 
best  possible  manner.  The  pi'esence  of  an  idiot  in  a  family  is  often  painful  and 
deteriorating  both  to  parents  and  to  other  children.  Home  treatment  may  be 
pursued  where  parents  have  large  means  and  the  care  and  training  of  an  idiotic 
child  can  be  managed  apart  from  the  rest  of  the  family.  For  the  Avealthier 
classes  the  institutions  which  take  only  a  small  number  of  children,  if  these  are 
conducted  on  thoroughly  scientific  as  well  as  humane  principles,  offer  some 
advantages.  Amusements,  exercises,  and  social  intercourse  are  all  regulated 
to  excellent  purpose  in  institutions  like  those  at  Elwyn,  Pennsylvania,  at  Vine- 
land,  New  Jersey,  and  at  Barre,  Massachusetts. 

The  educational  treatment  or  training  of  the  feeble-minded  has  received 
much  attention  in  recent  years.  In  1801  the  first  great  incentive  was  given 
by  Itard  to  this  method  of  bettering  the  condition  of  the  idiotic  by  his  inter- 
esting account  of  his  own  experiences  with  a  child  that  had  been  found  savage 
in  the  woods,  but  to  the  elder  Seguin  {Idiocy  and  Its  Treatment  by  the  Phy- 
siological Method,  1866),  the  greatest  of  credit  is  due.  He  was  truly  the  first 
apostle  of  the  idiot.  Volumes  have  been  devoted  to  this  most  interesting 
subject,  but  to  these  I  can  scarcely  do  more  than  refer.  This  training  and 
education  should  be  patiently  directed  to  the  development  of  the  deficient 
senses ;  to  the  training  of  the  hands  and  feet ;  to  the  improvement  of  carriage 
and  gait;  to  stimulating  the  slow  and  to  braking  the  morbidly  active;  to  the 
development  and  improvement  of  speech  ;  to  arousing  attention,  imitation, 
imagination,  comparison  and  judgment;  and  to  the  awakening  and  cultivation 
of  the  moral  senses  and  power  of  control. 

Not  much  can  be  said  about  the  medical  and  surgical  treatment  of  idiocy. 
Attention  should  first  be  directed  to  the  probability  of  the  idiocy  being  due 
to  such  possibly  remedial  causes  as  inherited  syphilis  or  traumatisms.  The 
iodides  of  potassium  and  sodium,  hydriodic  acid,  and  various  mercurial  prepara- 
tions may  be  tried  in  cases  presumably  due  to  inherited  syphilis,  but  too  much 
must  not  be  expected,  as  syphilis  in  the  progenitor  has  established  a  condition 
of  arrest  rather  than  an  active  and  removable  lesion.  It  is  different  in  infantile 
and  juvenile  dementia  due  to  syphilis,  which  have  been  treated  of  in  another 
article ;  here  the  treatment  may  promise  much,  and,  as  the  diff"erentiation  is 
sometimes  difficult,  it  may  sometimes  be  employed  as  a  diagnostic  measure. 
Everything  should  be  done  to  promote  the  nutrition  of  the  idiot — malt,  maltine, 
cod-liver  oil,  and  nourishing  food  for  the  strumous  ;  the  same  with  preparations 
of  iodine,  arsenic,  and  tonics  in  general  for  the  rachitic ;  digestants  like  pepsin, 
pancreatin,  the  mineral  acids,  and  stomachics  for  those  of  weak  digestion ; 
astringents,  antifermentatives,  and  intestinal  tonics  for  those  afflicted  with 
diarrhoeas  and  dysenteries;  lime-juice,  vegetable  acids,  bitters,  quinine,  iron, 
and  fresh  food  for  the  scorbutic ;  ointments  for  the  skin,  washes  for  the  mouth, 


IDIOCY  AND   IMBECILITY.  679 

lotions  for  the  eyes, — but  these  will  not  be  to  the  working  of  a  cure,  but  to  the 
relief  of  annoying  and  depressing  symptoms  and  conditions.  For  convulsions, 
bromides,  chloral,  sulphonal,  antipyrine,  and  similar  inhibitors  of  cortical  exci- 
tability, guarded  by  arsenic  and  supported  by  nutrients,  may  be  administered. 
For  excitement  trional  and  tetronal  have  been  found  valuable. 

What  to  do  with  backward  children  is  often  a  serious  problem.  They 
certainly  should  not  be  sent  to  the  institutions  for  the  idiotic  and  feeble-minded, 
nor  can  they  always  with  advantage  be  kept  at  schools  of  ordinary  or  high  grade. 
When  their  parents  can  aiford  the  expense,  it  is  best,  for  a  time  at  least,  to 
have  them  instructed  by  tutors  or  to  send  them  to  small  schools,  with  the 
understanding  that  special  attention  shall  be  paid  to  them,  and  that  their 
instruction  shall  be  regulated  as  far  as  possible  in  accordance  with  their  needs 
and  capabilities.  The  physician  should  be  careful  not  to  be  too  hasty  in  his 
prognosis  or  prophecies  in  reference  to  such  children.  A  practical  point  worth 
while  to  be  always  borne  in  mind  is  that  sometimes  mental  backwardness,  like 
physical  backwardness  or  peculiarity,  is  due  to  the  rachitic  diathesis.  Just  as 
in  well-defined  types  of  rachitic  pseudo-paralysis,  the  bony  and  other  forms  of 
arrest  or  deformity  will  yield  to  an  abundance  of  good  air,  good  food,  and 
treatment  with  such  preparations  as  cod-liver  oil,  arsenic,  iron,  and  iodides  in 
various  forms,  so  some  cases  of  intellectual  slowness  and  torpor  will  be  greatly 
improved  or  cured  by  similar  measures. 

For  evident  cranial  depression  and  fracture  trephining  may  be  resorted 
to,  though  in  long-standing  cases  the  outcome  is  generally  doubtful.  The 
surgical  treatment  of  idiocy  has  recently  received  an  impetus  through  the  ope- 
rations performed  first  in  France  by  Lannelongue  {L'  Union  MecUcale,  July  8, 
1890),  in  England  by  Horsley  (Brit.  Med.  Jour.,  September  12,  1891),  and 
in  this  country  by  Keen  (3Ied.  JVetos,  Nov.  29,  1890,  and  Amer.  Jour.  Med. 
iSci.,  June,  1891),  and  others.  At  the  French  Surgical  Congress  in  1891 
twenty-eight  cases  of  craniectomy  were  reported,  with  but  one  death,  and. con- 
siderable improvement  was  claimed  in  some  of  the  cases,  but  a  careful  reading 
of  the  reports  of  cases  shows  that  the  real  benefit  has  not  been  great. 

The  best  method  of  training  moral  imbecility  must  be  sometimes  considered. 
In  most  genuine  cases,  education  or  philanthropy,  kindness  or  cruelty,  the 
sugar-plum  or  the  whip,  the  Sunday-school  or  the  reformatory,  the  asylum  or 
the  penitentiary,  will  equally  fail ;  or  perhaps  I  should  not  say  equally,  as  in  a 
few  instances  some  strengthening  of  the  weak  and  imperfect  coordinating 
centres  may  be  possible.  To  the  typical  case,  to  the  vast  majority  of  cases 
that  would  come  under  this  designation,  belongs  the  term  incorrigible.  Some 
of  the  most  practical  and  most  experienced  authorities,  as  Tuke  and  Kerlin, 
believe  that  education  in  its  ordinary  meaning  should  be  largely  withheld 
from  this  class.  The  former  says  of  them :  "  The  early  detection  of  these 
cases  is  not  difl&cult :  they  should  be  subjects  for  life-long  detention;  their 
existence  can  be  made  happy  and  useful,  and  they  will  train  into  comparative 
facility  and  harmlessness  if  kept  under  a  uniform,  temperate,  and  positive 
restriction.  The  school-room  fosters  the  ill  we  would  cure  :  in  teaching  them 
to  write  we  give  them  an  illimitable  power  of  mischief;  in  educating  them  at 
all,  except  to  physical  work,  we  are  adding  to  their  armament  of  deception  and 
misdemeanor."  As  Kerlin  puts  it,  we  should  refuse  them  the  ordinary  routine 
of  education,  because  "  we  believe  that  in  educating  moral  imbecility  we  are 
training  experts  for  the  later  role  of  so-called  moral  insanity." 


CRETINISM.'^ 

By  CHARLES  K.  MILLS,  M.  D., 

Philadei,phia. 


Cretinism  is  a  form  of  arrested  phj-sical  and  mental  development,  chronic 
and  usually  endemic,  characterized  bv  peculiar  appearances  and  malformations, 
but  especially  by  smallness  of  stature,  distortion  or  deformity  of  the  face,  head, 
and  body,  unhealthiness  of  the  skin,  enlargement  or  absence  of  the  thyroid 
gland,  or  fatty  growths  above  the  clavicle.  The  derivation  of  the  word 
"cretin"  is  involved  in  curious  uncertainty.  Its  origin  has  been  assigned,  for 
example,  to  creta,  chalk;  to  cretira,  stupid,  silly:  and  to  Chretien,  Christian, 
because  cretins  are  supposed  to  be  as  happy  as  Christians  ought  to  be.  In 
different  regions  and  by  different  writers  cretins  have  been  called  by  various 
names,  as  cagots  ;  but  the  cagots  are  not  true  cretins,  but  a  proscribed  people 
living  in  Beam  and  Gascony  who  may  at  one  time  have  suffered  from  a  form 
of  leprosy.  In  Germany  cretins  are  called  Kreidlings  and  Kretins  ;  in  Austria, 
Gacken  and  Trottehi ;  in  Italy,  Gavas,  Totolas,  Cristiani ;  and  in  South 
America,  Bovos  and  Tontos  (Tuke). 

Cretinism  is  endemic  in  various  countries,  but  nearly  always  in  mountain- 
ous regions,  as  in  the  Pyrenees  and  Alps,  in  the  Highlands  of  Scotland,  and 
in  the  Himalayas.  In  this  country  a  few  cases  are  occasionally  found  together, 
as  in  the  mountains  of  Vermont  and  California,  but  the  affection  is  chiefly  of 
interest  to  American  physicians  as  a  sporadic  disease.  Probably  it  is  found  to 
some  degree  all  over  the  world.  In  a  few  countries  in  which  it  is  most  prev- 
alent, as  in  Switzerland,  France,  Italy,  and  Spain,  it  often  shows  a  curious 
tendency  to  limit  itself  to  particular  spots,  even  in  a  region  of  the  same  general 
climatic  and  geological  features — to  blight  one  valley  or  village,  while  another 
close  by,  and  apparently  not  different  in  environment,  escapes.  While  pro- 
nounced cretinism  is  rare  in  this  country,  cretinoid  cases  are  seen  with  more 
frequency ;  and  by  cretinoid  cases,  in  this  connection,  I  do  not  refer  to 
ordinary  cases  of  myxoedema,  although  Sir  William  Gull  described  myxoedema 
under  this  term,  but  rather  to  cases  which  I  now  and  then  see  in  which  neither 
myxoedema  nor  true  cretinism  is  present,  but  in  which  the  patient  in  face,  head, 
expression,  stature,  skin,  mental  capacity,  or  other  points  reminds  one  of  the 
cretin. 

Symptoms. — The  symptomatology  of  cretinism  and  cretinoid  disease  can 
perhaps  be  best  presented  by  first  describing  one  or  two  cases.  One  studied 
by  me  at  the  New  Jersey  Home  for  the  Feeble-minded,  a  girl  aged  nine 
years,  was  the  seventh  child,  born  after  difficult  labor,  but  seemed  strong 
until  she  was  sixteen  or  eighteen  months  old,  and  until  this  time  was  bright 
and  active  and  did  not  seem  defective.  At  this  time  she  had  a  severe  fall. 
Her  mother  was  a  hard-working  woman ;  the  father  had  rheumatism  and  was 
unable  to  work,  and  at  times  was  a  hard  drinker.      She  had  one   brother 

1  This  article  has  been  carefullv  revised  for  the  present  edition  by  Wm.  G.  Spiller,  M.  D. 
680 


CRETINISM.  681 

and  three  sisters  living  and  healthy.  She  was  a  well-marked  cretinoid  case, 
with  flat  face  and  open  mouth,  the  tongue  filling  it,  but  not  protruding.  She 
had  a  soft,  but  not  large,  swelling  above  each  clavicle.  Her  mental  condition 
was  very  low.  She  never  gave  a  direct  answer  to  any  question,  and  had  no 
words  at  her  command  ;  but  she  knew  her  own  name,  could  feed  herself,  and 
could  walk  a  short  distance  with  assistance.  She  was  almost  as  broad  as  she 
was  long.  I  have  seen  a  fair  number  of  such  cases  of  cretinoid  idiocy,  but 
generally  of  much  higher  grade,  in  private  and  hospital  practice  and  in  the 
institutions  for  the  feeble-minded  both  at  Elwyn,  Pa.,  and  at  Vineland,  N.  J. 

In  the  nervous  wards  of  the  Philadelphia  Hospital  is  a  typical  example 
of  sporadic  cretinism,  which  I  have  frequently  studied  and  discussed  before 
my  classes.  A  description  of  this  case  has  been  published  by  Lloyd  {Inter- 
national Clinics.,  1892).  The  cretin,  thirty-five  years  old,  was  born  in 
the  outskirts  of  Philadelphia.  He  has  a  myxoedematous  face  with  large 
lips  and  hypertrophied,  protruding  tongue;  small  limbs,  even  as  compared 
with  his  body ;  protuberant  belly  ;  the  sexual  apparatus  of  a  small  child  ;  no 
hair  about  the  pubes  or  on  the  face,  and  a  scanty  supply  on  the  head  ;  bad 
teeth  and  gums ;  eyelids  red,  tumid,  and  nearly  closed  ;  the  skin  yellowish- 
white  and  dry,  and  sweating  only  on  the  forehead  and  forearms.  His  height 
is  35|  inches.  He  can  walk  a  little,  but  is  very  weak  on  his  limbs.  Knee- 
jerks  and  the  reflexes  are  normal;  sensation  seems  to  be  everywhere  preserved, 
and  sight  and  hearing  likewise  appear  to  be  good.  The  thyroid  gland  is 
wanting,  but  above  the  clavicles  on  each  side  is  a  soft  mass,  probably  a  fatty 
growth.  While  his  mental  capacity  is  very  low,  it  is  more  than  his  appearance 
and  lack  of  speech,  which  is  confined  to  a  few  words,  would  indicate.  He  is 
observant  of  much  that  goes  on  in  the  wards,  understands  much  that  is  said  to 
him,  recognizes  physicians  and  old  friends,  and  is  appreciative  of  favors.  He 
has  lived  along  with  scarcely  any  change  during  the  many  years  that  he  has 
been  in  the  hospital,  escaping  intercurrent  disease.  His  temperature  is 
almost  constantly  subnormal,  and  during  one  week  in  which  it  was  carefully 
taken,  he  being  in  his  usual  health,  it  never  reached  the  normal  but  once, 
and  most  of  the  time  ranged  below  97.4°  F.  (The  plate  representing  this 
case  is  from  Lloyd's  paper.) 

For  many  years  in  the  neighborhood  of  the  hospital  was  another  example 
of  typical  sporadic  cretinism,  presenting  most  of  the  features  of  the  case  just 
described. 

In  describing  the  above  case  I  have  practically  given  the  symptomatology 
of  cretinism.  The  word  stunted  describes  the  conditions,  physical  and  mental, 
better  than  any  other.  The  cretin  is  small  in  stature  except  in  very  rare 
cases ;  thus  Lombroso  has  described  a  family  of  cretins  of  unusual  stature. 
The  head  is  frequently  contracted  from  the  front  backward  or  in  some  way 
is  asymmetrical.  In  typical  cases  the  features  are  striking — short,  flattened 
nose ;  eyes  wide  apart ;  pufiy,  drooping  lids ;  small  face  and  protruding 
tongue.  Not  only  temperature,  but  pulse  and  respiration,  and  all  the  vital 
processes,  are  sluggish  ;  digestion,  secretion,  and  excretion  go  on  torpidly ; 
menstruation  is  established  late  or  not  at  all. 

Speech  varies  much  in  diff'erent  cases,  and  efibrts  have  been  made  to  classify 
cretins  with  reference  to  their  possession  of  this  faculty,  the  lowest  grade  con- 
sisting of  those  who  are  deprived  entirely  of  language  or  have  so  little  as  to 
amount  to  nothing.  Cretins  of  this  class  lead  little  more  than  a  vegetative 
life,  and  are  not  capable  of  being  improved  much  by  education,  training,  or 
change  of  environment.  By  a  study  both  of  their  speech  and  of  their  mental 
deficiencies  in  general  they  are  sometimes  placed  in  two  higher  classes  than 


682    AMEBTCAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  one  just  described.  In  one  the  cretins  have  some  language  which  is 
capable  of  being  extended  ;  they  improve  somewhat  by  imitation  ;  they  have 
limited  powers  of  reproduction,  but  they  have  little  spontaneity  or  real  intel- 
ligence, and  generally  their  efforts  are  confined  to  matters  absolutely  necessary 
to  their  existence  and  comfort.  A  higher  class  of  semi-cretins  often  possess 
a  fair  amount  of  physical  and  mental  development.  They  can  take  care 
of  families,  which,  unfortunately,  they  sometimes  have,  and  they  are  capable 
of  considerable  intellectual  improvement ;  in  a  few  cases,  indeed,  they  have  so 
little  the  characteristics  of  true  cretinism  that  the}'^  are  only  to  be  recognized  as 
belonging  to  these  people  by  one  or  two  peculiarities. 

A  peculiar  class  of  cases  of  foetal  or  congenital  rachitis  has  been  observed, 
the  children  being  born  with  deformed  bones,  beaded  ribs,  etc.,  the  bones  in 
some  cases  being  soft.  By  some  the  terms  infantile  osteomalacia  and  cretinism 
have  been  applied  to  these  cases,  chiefly  because  they  have  failed  to  present 
the  macroscopic  and  microscopic  appearances  of  rachitis.  They  have  been 
described  by  Bode,  Barlow,  and  Marshall  of  Preston,  who  are  referred  to 
by  Ashby  and  Wright. 

Through  the  kindness  of  Dr.  D.  T.  Laine  of  Media,  Pa.,  I  had  the  oppor- 
tunity of  seeing  an  interesting  case  of  this  rachitic  pseudo-cretinism.  The 
child  was  three  years  and  seven  months  old.  The  sutures  were  closed,  and 
the  head  showed  a  prominence  in  the  right  parietal  region,  and  also  a  large 
depression  in  the  frontal  bone  of  the  same  side.  The  face  was  broad,  eyes 
wide  apart,  nose  flattened,  eyelids  drooping,  and  she  had  slight  right  internal 
strabismus.  The  bones  of  the  upper  arm  were  slightly  curved ;  the  lower 
ends  of  the  radius  and  ulna  enlarged  and  knobbed,  these  bones  being  also 
slightly  bent ;  the  ribs  were  beaded  or  irregularly  knobbed  and  the  chest 
contracted ;  the  bones  of  the  legs  showed  some  bowing  and  curving.  The 
spine  showed  a  rachitic  dorso-lumbar  curve,  more  prominent  on  the  left. 
Liver  and  spleen  were  greatly  enlarged.  The  child  could  barely  sit  up  and 
hold  up  her  head,  and  had  never  been  able  to  stand  alone.  In  appearance 
she  reminded  one  at  first  glance  of  a  cretin,  and  was  probably  a  case  of  infan- 
tile osteomalacia.  She  weighed  eight  pounds  when  born,  sixteen  when  five 
months  old,  ten  when  one  year  of  age,  and  thirty  at  the  time  of  observation. 
When  born  she  was  very  dark-skinned  and  hairy  all  over  the  body.  During 
most  of  her  life  her  bowels  had  been  much  disturbed,  and  she  had  one  attack 
of  convulsions  when  about  five  months  old.  She  cut  her  first  teeth  at  fifteen 
months.  During  the  year  previous  to  the  time  that  I  saw  her  she  had  slept 
from  twelve  to  fifteen  hours  out  of  the  twenty-four.  As  a  rule,  she  was  not 
cross  and  cried  very  little.  The  family  history  was  not  good.  The  maternal 
great-grandparents  Avere  cousins ;  the  maternal  grandmother  had  paralysis 
agitans ;   the  paternal  grandmother  had  "bowel  consumption." 

Etiology. — Cretinism  is  especially  prevalent  in  high  mountain-ranges 
remote  from  the  coast ;  wet  or  undrained  soil  appears  to  have  some  influence 
in  its  development ;  and  Avater  charged  with  lime  and  magnesia  is  common 
in  the  regions  in  which  it  is  endemic.  Practically,  the  ultimate  cause  of 
cretinism  is  unknown.  Brissaud  says  that  goitrous  parents  necessarily  have 
cretinoid  children.  Although  goitre  may  be  present  and  cretinism  absent,  it 
is  undoubtedly  true  that  where  goitre  exists  to  any  large  extent  cretins  are 
likely  to  be  found.  When  the  goitre  is  not  present,  and  even  in  some  cases 
where  it  is,  peculiar  soft,  fatty  growths  may  be  found  in  various  parts  of  the 
body,  but  usually  above  the  clavicle.  In  the  Philadelphia  Hospital  case 
goitre  was  absent,  and  also  apparently  the  thyroid,  but  soft  movable  masses 
were  found  in  the  neck.     By  some  these  are  regarded  as  distinguishing  the 


PLATE  XV. 


SPORADIC  CRETINISM. 


CBETIXIS3r.  683 

sporadic  from  the  endemic  and  epidemic  forms  of  the  disease,  but  this  is  a 
mistake. 

Pathology. — The  pathology  of  cretinism  is  ill-defined.  The  statements 
of  Virchow  regarding  the  premature  ossification  of  the  several  parts  of  the 
bones  at  the  base  of  the  skull  have  frequently  been  misunderstood.  Ordi- 
narily, these  parts  remain  separate  until  puberty,  but,  according  to  Virchow, 
in  cretins  synostosis  may  occur  at  a  very  early  period :  this,  however,  is  not 
the  cause  of  cretinism.  While  this  osseous  peculiarity  has  been  found  in 
many  cretin  skulls,  in  some  instances  of  undoubted  cretinism  it  has  not  been 
present,  and  Ewald  also  says  that  it  is  by  no  means  pathognomonic. 

Various  changes  have  been  found  post-mortem  and  under  the  micro- 
scope which  are  of  minor  importance;  the  brain-membranes,  and  partic- 
ularly the  dura,  are  sometimes  thickened  and  adherent,  as  it  is  in  not  a 
few  other  forms  of  arrest ;  great  variety  in  the  shape  and  arrangement  of 
the  convolutions  is  found,  the  tendency  being  to  undue  simplicity  and  small- 
ness  of  size  of  important  regions  :  the  important  fissures  of  the  brain  are  ill 
defined  or  in  unusual  positions,  and  shallowness  of  the  fissures  is  common. 
Asymmetry  of  both  the  cerebrum  and  cerebellum  has  been  noted,  and  a  few 
observations  have  been  made  on  the  relative  thickness  of  the  different  layers 
of  the  cortex,  showing  great  abnormalities  in  this  respect ;  but  all  these  are 
conditions  frequently  found  in  the  feeble-minded,  and  are  in  no  way  peculiar 
to  cretinism. 

Much  more  important  are  the  alterations  observed  in  the  thyroid  gland. 
Barker  (cited  by  (Jsler,  Amer.  Journ.  of  the  Jled.  Sci.,  1897)  found  changes 
in  this  gland  in  a  case  of  sporadic  cretinism  confirmatory  of  those  observed 
in  previous  cases  of  endemic  cretinism.  The  thyroid  gland  in  most  cases  of 
sporadic  cretinism  is  small  or  absent,  and  no  statement  regarding  its  normal 
appearance  is  of  great  value  unless  microscopic  examination  has  been  made. 
Goitre  is  usually  associated  with  endemic  cretinism,  and  seems  to  be  in  causal 
relation.  It  is  of  little  moment  whether  the  gland  is  pseudo-hypertrophied, 
atrophied,  or  absent,  for  if  its  functions  are  seriously  affected  early  in  life, 
the  cretinoid  appearance  is  likely  to  be  presented.  It  is  proper  to  state  that, 
according  to  Hermann  Munk,  our  views  in  regard  to  the  importance  of  the 
thyroid  gland  in  the  animal  economy  must  be  greatly  modified.  The  gland 
is  not  essential  to  life,  although  its  removal  endangers  life ;  again,  the  symp- 
toms which  are  supposed  to  result  from  its  removal  do  not  always  follow  its 
extirpation. 

Diag-nosis. — While  cretinism  may  be,  and  usually  is,  regarded  as  a  form 
of  idiocy  or  imbecility,  or  closely  related  to  these  affections,  it  differs  from 
them  in  several  essential  particulars,  as  has  been  shown  by  various  authori- 
ties. The  cretin  is  not  necessarily  born  to  this  state,  although  after  several 
generations  the  offspring  are  likely  to  be  cretins  or  cretinoid  cases.  For  a 
Ions;  time  the  individual  may  show  no  sign  of  cretinism,  althougrh  doubtless 
having  within  him  the  potentiality  of  the  disorder.  Removal  from  a  given 
locality  to  a  higher  situation,  even  during  the  pregnancy  of  the  mother,  will 
sometimes  prevent  the  development  of  cretinism.  It  differs  from  idiocy  in 
being  so  often  endemic,  in  the  comparative  improvability  of  some  of  its 
grades,  in  the  presence  of  symptoms  not  seen  in  cases  of  ordinary  idiocy, 
and  in  its  apparent  dependence  upon  conditions  of  air,  water,  or  soil. 

It  may  be  occasionally  important,  as  in  the  case  of  Dr.  Laine  referred  to 
under  Symptomatology,  to  distinguish  between  true  cretinism  and  osteo- 
malacia, as  treatment  in  either  case  may  be  of  very  great  service  if  begun 
sufficiently  early.     The  diagnosis  can  be  made  by  a  close  investigation  for 


684    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  well-known  signs  of  rickets,  such  as  enlarged  liver,  beaded  ribs,  and  soft 
or  deformed  bones,  though  it  must  be  remembered  that  the  administration  of 
the  thyroid  gland  to  cretins  may  cause  softness  of  the  bones. 

The  idiotie  myxoedernateui^e  of  Bourneville,  as  shown  in  the  picture  of  the 
"Pacha"  of  the  Bicetre,  is  so  similar  to  the  case  of  cretinism  at  the  Phila- 
delphia Hospital  that  one  photograph  might  almost  answer  for  either  case. 
Many  of  the  distinctions  which  are  made  between  myxoedematous  idiocy, 
cretinoid  idiocy,  juvenile  myxoedema,  endemic  cretinism,  sporadic  cretinism, 


Fig.  1. 


Dr.  J.  P.  \\ 


and  even  some  forms  of  infantilism,  are  artificial  ones.  Ewald  says  there  is 
no  distinct  difference  between  sporadic  cretinism  and  infantile  myxoedema. 
The  cachexia  strumipriva.  which  develops  after  removal  of  the  thyroid  gland 
in  youth,  has  the  typical  features  of  sporadic  cretinism.  All  these  conditions 
just  mentioned  are  closely  connected  Avith  absence  or  degeneration,  total  or 
partial,  of  the  thyroid  gland,  and  the  clinical  appearance  varies  according  to 
the  degree  of  development  of  the  gland  and  the  age  at  which  the  first  symp- 


CRETINISM. 


685 


toms  present  themselves.  The  cretinoid  type  is  most  marked  when  the  func- 
tion of  the  gland  is  insufficiently  performed  at  the  period  of  greatest  develop- 
ment of  the  body.  The  endemic  cretin  comes  into  the  world  as  the  oifspring 
of  goitrous  parents  or  is  himself  goitrous,  and  his  appearance  necessarily  differs 
from  that  of  the  sporadic  cretin  who  has  attained  a  certain  degree  of  develop- 
ment before  the  thyroid  gland  has  become  functionally  inactive.  Although 
many  writers  hesitate  to  say  that  these  various  diseases  mentioned  are  one 
and  the  same,  most  recognize  the  close  clinical  connection  between  them. 

Fig.  2. 


Dr.  J.  P.  West's  case  of  infantile  myxrcdema,  after  six  montlis'  tliyroid  treatment 


Infantilism  must  frequently  be  regarded  as  a  forme  fruste  of  infantile 
myxoedema,  and,  indeed,  it  is  not  uncommon  to  find  evidences  of  the  latter 
disease  in  cases  in  Avhich  the  adult  development  has  been  delayed.  Idiots 
of  the  Mongol  type  are  also  closely  related  to  cretins. 

Prognosis. — The  prognosis  of  cretinism  depends  largely  on  the  persist- 
ency of  treatment  and  the  age  at  which  this  is  begun.  In  such  a  case  as 
the  one  at  the  Philadelphia  Hospital  little  or  nothing  could  be  expected,  but 


686     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

when  the  cretin  is  treated  in  early  childhood  persistently  and  carefully,  the 
results  are  frequently  most  brilliant  (Figs.  1  and  2). 

Treatment. — Cretinism,  once  fully  developed,  always  leaves  its  stamp 
upon  the  individual,  but  even  a  low-grade  cretin  is  capable  of  a  surprising 
degree  of  mental  improvement,  as  has  been  demonstrated  by  the  enthusiastic 
philanthropic  eiforts  of  Guggenbuhl  and  others  in  Europe.  In  cretinism  the 
physical  and  mental  arrest  or  deterioration  go  hand  in  hand  to  a  greater 
degree  than  in  idiocy,  although,  of  course,  in  the  latter  the  truth  of  this 
assertion  will  be  measured  somewhat  by  the  peculiar  form  of  idiocy  which  is 
under  consideration. 

Monographs  and  even  treatises  have  been  written  to  show  that  cretinism 
is  due  to  this  or  that  atmospheric,  telluric,  or  other  cause.  Perhaps  in  a 
work  of  this  kind  it  is  better  to  dismiss  any  consideration  of  this  matter, 
except  as  it  may  bear  upon  the  prophylaxis  of  the  disease.  It  has  been 
found  by  abundant  experience  that  the  tendency  to  cretinism  is  combated  by 
making  careful  selection  of  drinking  waters  which  are  contaminated  with 
peculiar  salts,  as  magnesium,  iron,  etc. ;  also,  that  the  removal  of  the  mothers 
who  are  pregnant,  or  of  the  young  children  who  are  born  in  the  neighbor- 
hoods where  cretinism  has  a  tendency  to  become  endemic,  to  remote  and 
higher  districts  will  sometimes  prevent  the  development  of  the  affection. 

Experimental  investigations  have  shown  that  a  myxoedematous  condition 
develops  after  removal  of  the  thyroid  gland,  and  transplantation  of  the 
thyroid  gland  from  one  animal  into  the  abdominal  cavity  of  another  in  whicji 
the  gland  had  been  removed  has  been  attended  with  beneficial  results.  Act- 
ing on  these  suggestions,  a  number  of  physicians  were  led  to  experiment 
Avith  the  feeding  of  the  raw  thyroid  gland  of  the  sheep.  The  dish  was  most 
unpalatable  to  many,  and  a  disgust  was  often  created  which  was  frequently 
sufficient  to  interfere  Avith  the  administration  of  the  remedy.  Tablets  Avere 
then  manufactured,  and  in  this  way  the  remedy  is  noAv  more  easily  given. 
Wonderful  changes  have  been  observed,  and  even  cures,  in  cases  in  Avhich 
the  treatment  was  commenced  early  in  childhood.  Osier  begins  the  admin- 
istration with  a  grain  of  the  desiccated  gland  three  times  a  day  in  young 
cretins,  and  watches  for  increase  in  the  pulse-rate  and  the  appearance  of 
fever.  Older  patients  may  take  five  grains  daily,  and  this  amount  may  be 
increased.  After  a  satisfactory  degree  of  restoration  has  been  attained  one 
or  two  five-grain  tablets  a  week  are  sufficient  to  prevent  relapse.  A  physi- 
cian should  not  rest  content  after  giving  a  prescription  for  the  administra- 
tion of  thyroid  gland,  but  the  effects  of  the  treatment  should  be  carefully 
watched.  Not  infrequently  very  unpleasant  symptoms  arise.  Tachycardia, 
pyrexia,  insomnia,  tremor  of  the  extremities,  exophthalmia,  polyuria,  albu- 
minuria, and  glycosuria — in  fact,  a  complete  picture  of  Graves'  disease — 
have  been  observed  after  excessive  doses  of  thyroid  gland.  Occasionally  the 
rapidity  of  growth  produced  by  the  administration  of  the  gland  may  lead  to 
curvature  of  the  legs,  and  this  condition  has  been  observed  in  an  extreme 
degree.     General  hygienic  measures  should  not  be  forgotten. 


MYOTONIA,  OR  THOMSEN'S  DISEASE. 

By  CHARLES  K.  MILLS,  M.  D., 

Philadelphia. 


Myotonia,  or  Thomsen's  disease,  like  other  family  forms  of  disease,  such  as 
Friedreich's  ataxia  and  several  types  of  dystrophy,  should  receive  attention  in 
a  treatise  on  diseases  of  children;  for,  although  it  may  develop  after  puberty, 
it  is  most  frequently  detected  before  the  age  of  ten  years,  and  it  has  been 
observed  and  studied  even  in  infants.  The  name  by  which  it  is  best  known  is 
derived  from  Dr.  J.  Thomsen  of  Schleswig-Holstein  [Arch.  f.  Psych.,  1876, 
vol.,  vi.),  who  wrote  of  the  affection  as  occurring  in  himself  and  in  numerous 
members  of  his  own  family  in  different  generations,  although  before  his  time 
it  had  been  described  by  Leyden  and  had  been  referred  to  by  Sir  Charles  Bell. 
In  1886,  Erb  published  a  valuable  monograph  on  this  subject  and  a  few  other 
articles  of  more  or  less  value  have  appeared  during  the  last  ten  years,  one  of 
the  most  important  of  these  by  G.  W.  Jacoby  {Jour.  Nerv.  and  Mental  Dis., 
March,  1887).  I  recorded  a  case  under  the  title  of  "Myotonia  and  Inertia 
on  Voluntary  Effort"  [Intern.  Clinics,  April,  1891),  and,  although  this  patient 
was  first  seen  by  me  when  he  had  reached  the  age  of  nearly  forty  years,  he 
could  trace  back  some  of  the  symptoms  of  the  affection  to  childhood.  When 
a  boy  ten  years  old  his  father  had  taken  him  to  a  medical  college  to  get  advice 
about  his  hands,  which  were  even  then  in  some  way  afflicted  with  weakness 
or  with  clumsiness  and  difficulty  in  using  them.  His  feet  were  also  slightly 
affected  in  childhood,  and  he  was  somewhat  stiff  in  his  movements. 

Symptoms. — The  special  symptom  of  myotonia,  or  Thomsen's  disease, 
is  a  tonicity  or  stiffness  of  the  muscles,  with  inertia  or  inhibition  of  movements 
coming  on  with  voluntary  effort  after  a  long  period  of  rest,  the  morbid  phe- 
nomena not  being  present  or  not  attracting  attention  during  the  latter  period. 
The  prompt  and  easy  performance  of  all  movements  is  sooner  or  later  interfered 
with  by  the  spastic  state.  After  the  muscles  have  been  used  for  a  short  time  the 
stiffness  may  pass  off,  so  that  the  patient  who  has  the  greatest  difficulty  in 
initiating  movements  will  soon  be  able  to  walk  with  increasing  ease,  and  once 
fairly  afoot  may  continue  to  walk  without  trouble  for  hours ;  but  after  an  inter- 
val of  rest  the  whole  morbid  process  will  be  repeated.  As  a  rule,  the  muscles 
of  the  face  are  not  affected,  but  this  is  not  invariable,  and  in  one  of  the  cases 
of  myotonia  reported  by  me  some  of  tlie  most  striking  phenomena  were  exhib- 
ited by  the  muscles  of  mastication,  and  in  a  second  case  of  myotonia  and  athe- 
toid  spasm  the  facial  contortions  and  snapping  of  the  eyelids  were  very  marked. 
These  cases  were  adults,  although  in  one  of  them  the  affection  had  originated 
in  childhood,  and  was  probably  congenital.  Usually  the  phenomena  are  most 
marked  in  the  lower  extremities.  Sensation  is  not  affected.  Trophic  changes 
are  not  present,  but  the  muscles  are  bulky,  although  their  strength  is  not 
commensurate  with  their  size.  Erb  and  Jacoby  have  called  attention  to  the 
peculiar  changes  in  the  mechanical  and  electrical  excitability  of  the  muscles. 

687 


688    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Erb  believes  that  Thomsen's  disease  may  be  diagnosticated  by  a  few  clo- 
sures of  the  galvanic  current  and  a  few  blows  with  a  percussion  hammer,  but  this 
is  doubtful,  except  perhaps  in  absolutely  typical  cases.  The  electrical  response 
has  been  termed  the  myotonic  reaction.  In  examining  patients  for  this  a  large 
electrode  is  placed  upon  the  sternum  or  back  of  the  neck,  and  another  of 
smaller  size  in  the  palm  of  the  hand.  Using  a  galvanic  current  of  sixteen  or 
eighteen  cells  and  allowing  the  current  to  flow,  a  tonic  spastic  condition  of  the 
muscles  of  the  arm  occurs.  In  a  little  while,  particularly  after  changing  the 
poles  with  the  commutator,  curious  wave-like  contractions  take  place  in  a  serial, 
rhythmical  order.  These  undulations  move  upward  or  downward  according  to 
the  position  of  the  anode  and  cathode — downward  when  the  anode  is  in  the 
hand,  upward  when  the  cathode  is  in  the  same  position.  They  move  inward 
from  the  negative  to  the  positive.  Erb  has  compared  the  single  waves  to  those 
produced  by  a  stone  falling  in  water.  He  considers  that  the  best  places  for 
the  application  are  the  flexors  of  the  forearm,  the  palm  of  the  hand,  or  the 
volar  surfaces  of  the  wrist-joint  and  nape  of  the  neck.  The  amount  of  current 
requisite  for  the  production  of  the  phenomena  varies  from  six  to  twenty  mil- 
liamperes  (Jacoby).  Briefly,  the  peculiarities  of  the  so-called  myotonic  reac- 
tion are  increase  and  change  in  the  faradic  muscular  response,  while  the  excita- 
bility of  the  nerves  to  this  current  remains  normal.  Similarly,  to  the  galvanic 
current  the  muscles  show  increased  excitability  and  qualitative  changes,  the 
nerve-reaction  not  being  aff'ected.  With  Jacoby,  I  have  not  been  able  to  verify 
the  diff"erence  between  nerve  and  muscle  application.  The  mechanical  as  well 
as  the  electrical  excitability  of  the  muscle  is  changed,  so  that  in  a  typical  case 
tapping  on  the  muscles  will  cause  unusual  response,  a  slight  blow,  for  instance, 
producing  a  marked  grooving  or  furrowing  of  the  muscles. 

Etiology. — Heredity  is  the  most  important  factor  in  the  production  of 
the  common  types  of  myotonia.  It  is  pre-eminently  a  family  disease,  although 
not  infrequently,  instead  of  a  family  history  of  the  affection  clearly  myotonic 
in  character,  the  ancestors,  direct  or  collateral,  may  have  suifered  from  some 
form  of  neurotic  degeneration  or  may  have  been  the  subjects  of  some  con- 
stitutional taint  or  toxic  affection,  as  alcoholism.  In  one  family,  that  of  a  patient 
recorded  by  Bernhardt,  consanguineous  marriages  were  frequent,  but  these 
may  simply  have  intensified  a  pre-existing  tendency.  It  is  more  often  a  disease 
of  males  than  of  females.  Fright,  intense  emotion,  and  injuries,  have  been 
assigned  as  exciting  causes.  Of  the  cases  occurring  after  puberty,  Gowers 
records  one  as  having  resulted  from  prolonged  and  severe  exertion  continued  for 
two  years  in  a  man  without  hereditary  tendency,  and  the  same  author  cites  a 
lightning  stroke  as  a  clearly  proved  exciting  cause. 

Patholog-y. — No  autopsy  supported  by  careful  microscopical  examination, 
so  far  as  I  know,  has  as  yet  been  made.  As  a  rule,  the  disease  has  been  regarded 
as  essentially  muscular,  rather  than  of  central  or  peripheral  nervous  origin, 
but  this  must  be  regarded  as  an  unsettled  question.  The  relations  between  the 
muscular  and  the  connecting  and  controlling  nervous  apparatus  are  so  intimate 
that  in  the  absence  of  pathological  proof  the  real  nature  of  this  or  any  similar 
affection  must  remain  in  doubt.  The  primary  change  may  be  in  the  nerve-cells 
of  the  cord,  of  the  basal  centres,  or  even  of  the  cerebral  cortex,  or  it  may 
be  at  the  other  extremity  of  the  system,  in  the  end-plates  in  the  muscles. 
The  evidence  so  far  is  in  favor  of  the  disease  being  muscular  and  functional. 
In  several  instances  pieces  of  muscles  have  been  excised  during  life,  and  have 
been  submitted  to  a  careful  microscopical  examination,  and  Erb  and  Jacoby, 
among  others,  have  made  interesting  reports  upon  the  conditions  present.  Erb 
found  an  enormous  hypertrophy  of  all  muscular  fibres  and  great  proliferation 


MYOTONIA,    OB    THOMSEN'S  DISEASE.  689 

of  nuclei,  with  alterations  of  the  minute  structure  and  a  slight  increase  of  the 
perineurium.  Jacoby  demonstrated  another  characteristic  change — the  distinct 
division  of  the  muscle-fibres  into  angular  fields,  the  threads  of  connecting  pro- 
toplasm being  broken  almost  everywhere.  The  motor-nerves  and  the  motor 
end-plates  show  no  deviation  from  the  normal. 

"  In  Thomson's  disease,"  says  Jacoby,  "  the  motor  nerves  and  motor  end- 
plates  do  not  show  any  deviation  from  the  normal,  so  that  the  nerve  impulse  is 
transmitted  into  the  muscle-fibre  in  the  same  manner  as  in  the  normal  condition. 
The  result  of  the  reception  of  impulse  will  be  a  contraction,  which,  especially 
after  a  certain  rest,  will  be  a  hypercontraction,  or,  rather,  tetanus.  This 
tetanus  leads  to  an  agglomeration  of  a  certain  number  of  sarcous  elements 
which  break  into  a  continuity  of  the  contracted  clusters.  In  consequence  of 
this  tetanus  the  nerve-influence  is  inhibited  for  so  long  as  the  tetanus  lasts. 
After  the  lapse  of  a  few  seconds  the  tetanic  contraction  will  subside,  the  con- 
tinuity between  the  hitherto  separated  groups  of  sarcous  elements  will  become 
re-established,  and  the  propagation  of  nerve  influence  will  be  again  rendered 
possible.  We  can  thus  understand  the  peculiar  reaction  of  the  muscles  to  the 
various  stimuli  when  applied  directly  to  them,  but  why  the  muscles  should  react 
difi"erently  to  indirect  stimulation  is  still  inexplicable." 

Diagnosis. — Diseases  which  have  some  likeness  to  myotonia  are  tetany, 
pseudo-muscular  hypertrophy,  and  some  forms  of  sclerosis.  I  have  also  seen  a 
hysteroidal  affection  which  somewhat  closely  resembles  this  disease,  but  the 
characteristic  spastic  phenomena  and  the  conditions  of  electrical  and  mechanical 
irritability  will  prevent  mistake  on  the  part  of  a  careful  investigator.  A  form 
of  myotonia,  designated  paramyotonia,  has  been  described,  which  diff"ers  some- 
what from  Thomsen's  disease,  but  is  also  a  family  affection.  One  diff"erence 
which  has  been  noted  is  that  the  spasticity  is  not  initiated  by  voluntary  move- 
ments, but  may  be  by  exposure  to  cold.  Myotonia  as  a  symptomatic  aff'ection 
is  observed  in  several  forms  of  spinal  and  cerebro-spinal  disease  ;  it  has  been 
described,  for  instance,  as  occurring  in  connection  with  ataxia. 

Prognosis. — The  prognosis  of  myotonia  is  unfavorable,  although  the 
disease  does  not  particularly  shorten  life. 

Treatment. — No  treatment  is  of  any  practical  avail.  The  patients  may 
live  long  lives.  Thomson,  speaking  from  personal  experience,  believes  that 
active  muscular  exercise  is  beneficial.  Patients  learn  by  experience  to  take 
care  of  themselves.  One  of  the  most  serious  evils  of  the  disease  in  one  of  my 
cases  was  the  tendency  of  the  patient  to  have  sudden  falls,  owing  apparently  to 
the  spastic  locking  of  his  muscles.  He  learned  by  watching  his  movements  to 
control  the  occurrence  of  these  falls.  Usually  in  childhood  the  disease  has  not 
advanced  sufficiently  to  call  for  special  protective  measures,  unless  it  be  the  avoid- 
ance of  cold  and  emotional  excitement. 

44 


ACROMEGALY. 

By  CHARLES  K.  MILLS,  M.  D., 
Philadelphia. 


Acromegaly,  sometimes  termed  Marie's  disease,  was  first  described  hy 
Marie  about  1886.  As  the  derivation  of  the  word  indicates,  it  means  enlarge- 
ment of  the  extremities.  Acromegaly,  as  a  rule,  occurs  between  the  ages  of 
eighteen  and  thirty  years,  and  therefore  the  subject  is  not  of  first  importance 
in  a  work  on  the  diseases  of  children,  but  a  few  cases  have  been  recorded  as 
occurring  in  early  childhood,  and  even  as  congenital.  Recently  Moncorvo  of 
Rio  Janeiro  (Revue  Menmelle  des  3Ialadies  de  VEnfance^  Dec,  1892)  reported 
a  well-marked  case  observed  in  conjunction  with  microcephalus  in  a  female 
infant  fourteen  months  old.  The  mother  was  a  delicate,  nervous  woman,  who 
during  her  pregnancy  had  been  subject  to  violent  emotion.  At  fourteen 
months  the  child  exhibited  congenital  microcephalus,  idiocy,  aphasia,  para- 
plegia, and  contractures,  and  the  fundamental  symptoms  of  acromegaly — 
namely,  the  retreating  forehead ;  the  vertical  elongation  of  the  oval  of  the  face ; 
the  great  enlargement  of  the  nose ;  the  prominence  of  the  superior  maxilla ; 
the  thickening  and  advancement  of  the  lower  lip ;  the  cervico-dorsal  kyphosis, 
with  lumbar  lordosis  and  projection  of  the  anterior  plane  of  the  chest,  compen- 
sated for  by  flattening  of  the  abdominal  wall ;  and,  finally,  the  spade-like  hands, 
with  prominent  thickening  of  the  palmar  surfaces,  and  short  fingers  of  uniform 
width  and  sausage-like  appearance.  In  another  case,  cited  by  Moncorvo  from 
Freund,  the  disease  commenced  as  early  as  puberty. 

In  a  series  of  cases  studied  by  me  at  the  New  Jersey  Home  for  the  Educa- 
tion and  Care  of  Feeble-minded  Children,  at  Vineland,  one  remarkable  case 
was  found  in  a  boy  who  was  at  the  time  of  examination  sixteen  years  old,  but 
who  had  suff"ered  for  years  from  the  disease  then  present.  This  boy  was  the 
first-born  after  difficult  labor;  his  mother  was  feeble-minded,  his  father  a 
chronic  alcoholic;  he  could  dress  and  feed  himself;  his  speech  was  imperfect, 
but  he  could  read  and  write  a  little;  he  was  excitable  and  inclined  to  be 
gluttonous.     He  attended  school  with  very  poor  results  for  seven  years. 

He  exhibits  two  diff"erent  conditions  according  to  the  time  when  he  is  studied. 
For  weeks  he  will  be  in  fairl}'  good  health,  happy,  lively,  and  disposed  to  make 
himself  genei-ally  useful.  His  hands  and  feet  are  dusky  and  cold.  When  the 
hands  are  pendent,  the  dusky  area  reaches  to  at  least  two  inches  above  the  wrists, 
but  when  they  are  held  above  the  head  the  entire  limbs  become  to  a  less  degree 
of  the  same  hue.  He  has  a  marked  tendency  to  indolent  ulceration,  particularly 
in  the  distal  portions  of  the  extremities.  At  the  end  of  the  index  finger  of  the 
left  hand  are  the  remains  of  a  formation  similar  to  one  which  appears  from  time 
to  time  at  the  end  of  any  of  the  fingers.  The  finger-tip  SAvells,  and  in  a  little 
time  contains  serum  and  sometimes  pus.  The  toe-nails  are  black  or  brownish 
and  ridged  roughly.     Both  hands  and  feet  are  abnormally  large  (Fig.  1).     No 

690 


ACBOMUGALY. 


691 


loss  of  sensation  was  determined.  Knee-j  erk  and  muscle-j  erk  are  about  normal. 
He  remains  in  about  the  same  condition  for  weeks,  when  a  change  comes  on, 
almost  acutely.  His  face,  arms,  hands,  legs,  and  feet  swell  perceptibly,  increas- 
ing sometimes  almost  one  half,  and  this  swollen  state  will  last  a  month  or  six 

Fig.  1. 


An  Acromegaloid  Case. 

weeks,  and  then  gradually  disappear,  leaving  him  very  weak,  his  pulse  at  the 
end  of  these  periods  being  scarcely  perceptible.  During  the  attacks  he  is 
obliged  to  keep  his  bed  most  of  the  time,  and  is  in  a  condition  of  general  las- 
situde and  depression.  i     •    • 

While  this  case  may  not,  strictly  speaking,  be  one  of  acromegaly,  it  is  a  most 
interesting  allied  vaso-motor  and  trophic  disorder,  with  permanent  enlargement 
and  transfent  changes  in  the  extremities,  these  increasing  at  periods.  _ 

Symptoms.— Acromegaly  is  a  trophic  disease  characterized  chiefly  by  a 
D-radual  increase  in  size  of  the  extremities,  and  usually  also  of  the  face.  Acro- 
megaly usually  begins  with  progressive  enlargement  of  the  hands,  feet,  and 
head.  The  hands  and  feet  may  become  of  enormous  size,  the  other  related 
parts  not  increasing  proportionately.  Marie  has  suggested  the  name  of  battle- 
dore hands,  while  the  English  have  sometimes  described  them  as  spade-like. 
Of  the  parts  of  the  head,  the  face  is  usually  most  strikingly  involved,  being 
enlarged  particularly  from  above  downward.  The  hypertrophy  attacks  both 
the  soft  and  hard  parts.  Sometimes  the  tongue,  lips,  nose,  and  lower  jaw 
become  enormously  increased  in  size.  Rheumatic  or  neuralgic  pams  may  be 
present.  The  skin  is  often  dry.  The  special  senses  are  sometimes  affected ; 
vision,  in  particular,  is  likely  to  suffer.    Forms  of  hemianopsia  or  sector  defects 


692   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

in  vision  have  been  observed.  Aneesthesia  is  not  commonly  present.  The 
affection  as  seen  in  children,  so  far  as  reported  cases  are  concerned,  has  been 
chiefly  in  those  who  exhibit  evidences  of  idiocy  or  imbecility. 

Pathology. — The  pathology  of  acromegaly  is  practically  unsettled.  In  a 
number  of  autopsies  which  have  been  made,  in  almost  every  case  some  enlarge- 
ment of  the  pituitary  body  has  been  present ;  still,  this  change  is  not  constant, 
and  some  diseases  of  this  organ  certainly  do  not  cause  acromegaly.  A  case  of 
pernicious  ansemia  at  the  autopsy,  in  which  I  took  part,  revealed  a  hasmorrhagic 
tumor  of  the  pituitary  body,  but  the  patient  had  none  of  the  phenomena  of 
acromegaly.  In  this  case,  however,  as  in  acromegaly,  the  fundamental  perver- 
sion was  of  nutrition.  Efforts  have  been  made  to  relate  the  occurrence  of  the 
disease  to  lesions  or  absence  of  other  organs,  as,  for  instance,  of  the  thymus  or 
thyroid  gland.  The  truth  is  that  the  exact  pathology  of  the  disease  is  as  yet 
unknown,  although  interesting  autopsies  have  been  reported.  More  is  known 
about  the  peculiarities  of  the  pathological  conditions  present  in  various  organs 
and  tissues  of  the  body.  The  bones,  particularly  the  vertebme,  the  clavicles, 
and  the  long  bones  of  the  limbs,  are  the  seat  of  hypertrophic  processes.  The 
bone  enlargement  is  regarded  as  a  true  hypertrophy  rather  than  an  inflamma- 
tion, an  increase  due  to  surplus  of  nutritive  energy  or  pabulum,  or  both.  In 
one  case  of  Virchow's  the  pituitary  body  was  carefully  examined  and  found 
to  be  absolutely  normal. 

Diagnosis. — The  diagnosis  of  acromegaly  is  not  difficult  to  make,  once  on 
the  alert  for  its  occurrence.  Other  affections  in  children  simulate  it  to  some 
extent,  as,  for  example,  myxedema  and  cretinoid  disease :  true  cretinism  could 
not  be  mistaken  for  acromegaly.  In  myxoedema  the  swelling  is  not  particu- 
larly of  the  extremities,  but  of  the  subcutaneous  tissues;  and  the  differences  in 
the  color  and  appearance  of  the  skin,  and  in  the  condition  of  the  thyroid,  will 
serve  to  separate  it. 

What  is  sometimes  spoken  of  as  gigantism  might  be  confounded  with  acro- 
megaly, but  the  one  differential  point  is  that  in  gigantism  the  great  dispropor- 
tion between  the  extremities  and  the  main  portion  of  the  limb  is  not  present. 
In  gigantism  the  individual  may  be  unusually  tall,  in  accordance  with  the  gen- 
eral increase  in  all  directions,  while  patients  afflicted  with  acromegaly  are  as 
likely  to  be  under  as  over  the  average  size.  The  pulmonary  osteo-arthropathy 
described  by  Marie  would  be  distinguished  from  ordinary  acromegaly  by  the 
presence  of  the  pulmonary  lesions  and  the  peculiar  deformities  of  the  terminal 
phalanges.  Marie  has  described  these  deformities  as,  if  observed  sideways,  hav- 
ing some  resemblance  to  the  head  and  curved  beak  of  a  parrot.  In  acromegaly 
the  nails,  if  anything,  are  too  small  for  the  parts  they  cover,  while  the  nails  in 
pulmonary  osteo-arthropathy  are  deformed  as  well  as  the  fingers.  In  a  disease 
known  as  partial  acromegaly  a  considerable  hypertrophy  of  one  half  of  the  body, 
or  of  a  limb  on  one  side,  or  one  side  of  the  face,  may  be  present.  In  this  dis- 
ease, however,  true  deformity  is  always  present,  and  it  is  usually  unilateral 
and  congenital. 

Many  instances  of  hypertrophy  of  the  fingers  and  toes  have  been  reported  ; 
they  must  be  separated  from  true  acromegaly,  although  it  is  possible  that 
these  diseases  have  something  in  common,  and  such  cases  might  be  classed 
under  the  head  of  partial  acromegaly.  Recently  a  case  of  this  kind  was  seen 
by  me  in  consultation,  and  was  presented  at  the  meeting  of  the  Philadelphia 
Neurological  Society  by  Dr.  W.  J.  Taylor.  The  first  and  second  toes  of  the 
left  foot  Avere  enormously  enlarged,  and  the  third  toe  was  also  hypertrophied 
to  a  less  degree.  The  hypertrophy  was  much  the  greatest  in  the  second  toe. 
This  deformity  of  the  foot,  according  to  the  mother's  statement,  was  present  at 


ACROMEGALY.  693 

birth,  but  she  thought  that  the  left  leg  and  foot  had  been  growing  out  of  pro- 
portion to  the  right.  The  nails  were  thin  and  imperfect,  showing  evidences  of 
bad  nutrition.  Both  feet  and  hands  were  of  good  and  perhaps  of  unusual  size. 
Such  affections  probably  have  some  pathological  relationship  to  the  disease  here 
considered,  but  one  which  has  not  yet  been  clearly  determined.  Operations 
are  sometimes  resorted  to  for  their  relief,  but  the  question  of  the  central  nature 
of  the  affection  and  its  probable  progressiveness  deserves  consideration  by  the 
surgeon. 

Prognosis. — Acromegaly  is  essentially  an  incurable  disease,  but  may  make 
no  progress  for  years. 

Treatment. — Some  good  is  reported  to  have  been  obtained  by  the  use  of 
remedies  like  arsenic,  the  iodides,  the  alkalies,  and  special  diet.  The  headache, 
often  present,  may  be  relieved  by  some  of  the  remedies  ordinarily  used  for 
congestive  or  neurotic  headaches,  as  antipyrin,  antifebrin,  the  salicylates, 
and  phenacetin. 


ATHETOSIS  AND  ATHETOID  AFFECTIONS. 

By  CHARLES  K.  MILLS,  M.  D., 

Philadelphia. 


Athetosis,  a  word  meaning  "without  fixed  position,"  is  a  name  first  given 
by  Dr.  W.  A.  Hammond  to  a  peculiar  mobile  spasm  observed  chiefly  in  the 
finger  and  toes.  Strictly  speaking,  it  is  not  a  disease,  even  in  the  ordinary 
clinical  sense ;  it  is  usually  part  of  a  symptom-group  which  indicates  the  pres- 
ence of  some  lesion  of  the  cerebrum.  The  movements  of  athetosis  are  diffi- 
cult to  describe.  They  are  most  commonly  observed  in  the  upper  extremity 
of  one  side,  being  particularly  marked  in  the  fingers  and  hand,  but  occasion- 
ally they  are  bilateral.  Hughes  of  St.  Louis  ( Weekly  Med.  Revieic,  1887)  has 
reported  a  case  of  bilateral  athetosis  coming  on  in  a  boy  about  one  year  after  a 
railroad  accident  which  caused  injury  both  by  concussion  and  direct  violence, 
although  the  case  was  not  fully  developed  for  several  years.  This  boy  had  not 
complete  voluntary  control  over  the  movements  of  his  muscles;  he  could  not, 
by  direct  eflfort  of  the  will  along  the  regular  channels  of  nerve  conduction, 
restrain  either  the  rhythmical  movements  or  the  spasmodic  attitude  of  the 
fingers,  but  he  could,  by  strategy,  modify  both  attitude  and  movement  by 
bringing  one  limb  to  bear  upon  another  and  by  assuming  for  the  afi'ected  limbs 
flexed  positions ;  but,  no  matter  how  much  he  succeeded  in  managing  these 
movements,  grotesque  attitudes  would  always  recur  in  one  or  more  of  the 
fingers.  His  afiliction  unfitted  him  for  occupation  requiring  manual  dexterity. 
He  tried  a  number  of  things,  but  had  to  give  them  up  because  of  physical 
incompetency. 

Athetosis  is  most  frequently  congenital  or  an  affection  of  early  childhood, 
occurring  particularly  in  connection  with  some  of  the  fonns  of  cerebral  palsy 
in  children  which  have  been  described  in  this  work  by  Peterson.  Church 
{Review  of  Insanity  and  Nervous  Disease,  March,  1892),  has  recorded  an 
interesting  case  of  symmetrical  and  universally  distributed  athetosis  in  a  woman 
thirty  years  old,  who  had  suff"ered  from  the  aff"ection  since  birth.  She  was 
lacking  in  mental  development :  face  and  speech  were  both  aff"ected.  Many 
instances  of  what  might  be  termed  athetoid  aff'ections  are  to  be  found,  particu- 
larly among  idiotic  and  imbecile  children.  These  differ  from  typical  athe- 
tosis in  the  irregularity  and  wide  diff"usion  of  the  mobile  spasm.  Several 
cases  of  this  kind  are  nearly  always  present  in  the  nervous  wards  of  the  Phila- 
delphia Hospital.  One.  a  mentally  defective  deaf-mute  about  thirty  years  old, 
has  been  subject,  probably  from  early  childhood,  as  no  history  can  be  obtained, 
to  excessive  and  irregular  movements  and  distortions,  particularly  of  his  face 
and  upper  extremities. 

Symptoms. — Athetosis,  as  already  indicated,  is  a  word  descriptive  of  a 
series  of  grotesque,  irregular,  and  yet  monotonous,  involuntary  movements 
which  are  persistent,  but  subject  to  exacerbations,  and  are  usually  confined 
to  an  extremity  or  the  extremities  of  one  side.     The  movements  are  more  or 

694 


ATHETOSIS  AND    ATHETOID    AFFECTIONS.  6&5 

less  rhythmical,  and  do  not  seem  to  cause  the  patient  fatigue,  in  this  respect 
being  like  other  rhythmical  spastic  affections  of  functional  or  organic  origin. 
By  a  strong  effort  of  the  will  the  patient  can  usually  control  the  movement. 
As  a  rule,  sensation  is  not  impaired.  The  muscles  on  the  affected  side  are 
often  hypertrophied.  The  condition  of  the  reflexes  and  so-called  reflexes 
vary,  but  the  knee-jerks  and  other  allied  phenomena  may  be  increased  on  the 
affected  side.  As  the  disease  is  usually  cerebral  in  origin,  electrical  changes 
are  commonly  not  present. 

Etiolog-y. — The  etiology  of  athetosis  is  that  of  the  organic  affection  of 
which  it  is  a  symptom  or  with  which  it  is  associated.  It  may  be  caused  by 
accident,  as  in  Hughes's  case  of  bilateral  athetosis  to  which  reference  has  been 
made,  but  whether  or  not  athetosis  results  will  depend  upon  the  particular 
lesion  which  is  inflicted  on  the  nervous  system.  The  disease  has  been 
attributed  to  fright  or  undue  excitement  of  the  mother  during  pregnancy, 
and  fright  has  been  given  as  a  special  exciting  cause  in  a  few  instances, 
but  on  uncertain  grounds.  It  is  much  more  likely  to  cause  chorea  or  cho- 
reoid  affections.  Many  cases  of  athetosis  and  of  athetoid  affections  are  asso- 
ciated with  well-defined  idiocy  or  imbecility,  and  are  dependent  upon  the 
same  causes,  hereditary,  developmental,  or  accidental,  which  have  led  to  the 
latter.  According  to  Strlimpell,  athetosis  may  be  a  sequel  of  polioen- 
cephalitis ;  and  I  am  inclined  to  subscribe  to  this  opinion,  although  the  very 
existence  of  this  disease  in  children  has  been  denied  by  authors  of  ability. 
Toxic  agents  by  affecting  the  motor  cortex  or  subcortex  may  cause  this 
affection. 

Pathology. — The  lesions  in  reported  cases  of  athetosis  have  been  largely 
in  the  basal  ganglia  or  their  immediate  neighborhood.  In  one  case  a  sclerotic 
nodule  was  found  in  the  thalamus  very  near  its  central  upper  surface,  and  in 
several  other  instances  lesions  have  been  discerned  in  the  same  great  ganglion ; 
but  in  nearly  all  of  these  cases  neighboring  parts,  as  the  caudate  nucleus, 
internal  capsule,  or  corona  radiata,  have  also  been  involved.  Undoubtedly, 
mobile  spasm  may  depend  upon  lesions  either  of  the  thalamus,  the  striate 
bodies,  the  motor  cortex,  or  any  part  of  the  cerebral  motor  tract.  In  one 
interesting  case  of  athetoid  spasm  and  myotonia,  occurring  in  an  adult,  re- 
ported by  me,  and  in  which  an  autopsy  was  obtained,  some  light  was  thrown 
on  the  character  and  situation  of  the  lesions  which  may  in  some  instances 
produce  athetoid  spasm.  The  most  striking  features  were  brought  out  when 
the  patient  attempted  any  voluntary  movement,  and  among  other  manifestations 
his  fingers  were  twisted  and  thrown  into  a  position  which  illustrated  well  one 
of  the  forms  of  athetosis  of  the  upper  extremity.  Many  other  phenomena,  sen- 
sory and  motor,  were  present  in  the  case  and  are  detailed  in  the  report  (^Intern. 
Clinics,  April,  1891).  The  autopsy  showed  that  in  both  hemispheres,  chiefly 
over  the  superior  and  inferior  parietal  gyri,  the  dura  was  adherent  to  the  pia 
mater,  the  pia  was  deeply  injected,  thickened,  and  infiltrated  with  plastic 
lymph,  and  in  numerous  places  was  more  or  less  firmly  fixed  to  the  brain- 
substance;  but  the  injection,  infiltration,  exudation,  and  adhesions  were  much 
more  marked  in  the  postero-parietal  regions  than  elsewhere.  Beneath  the 
area  of  meningitis  both  the  cortex  and  the  subcortex  were  softened,  giving  the 
appearance  on  the  right  side  of  a  sunken,  subcortical,  or  subpial  cyst.  On  the 
left  side  of  the  brain,  in  a  nearly  corresponding  but  somewhat  smaller  area,  was 
a  similar  belt  of  inflammation  and  softening.  Subsequent  incisions  on  both 
sides  showed  that  the  softening  included  the  whole  of  the  gray  matter,  and 
involved  to  a  considerable  extent  the  white,  but  did  not  invade  the  ganglia  or 
capsules ;    it  was  confined  to  the  supraventricular  corona  radiata.     In  cases 


696    AMEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDMEN. 

unassociated  with  hemiplegia  or  diplegia,  irritative  foci  in  the  motor  areas  or 
tracts  may  give  rise  to  the  affection  ;  and  Gowers  believes  that  it  is  sometimes 
due  to  impaired  nutrition  of  the  growing  motor  cells. 

Diagnosis. — Typical  cases  of  athetosis  are  not  difficult  of  recognition. 
Occasionally  cases  of  hemichorea  and  hemiathetosis  in  children  might  be  tem- 
porarily confused.  The  movements  of  athetosis  are  said  to  continue  during 
sleep,  and  this  is  certainly  true  of  some  cases.  Post-hemiplegic  chorea  and 
athetosis  may  be  confused ;  and,  indeed,  chorea  secondary  to  a  paralytic 
attack  and  this  affection  differ  but  little  in  nature  and  characteristics.  In 
this  work  Peterson  has  described,  as  occurring  in  two  cases  of  congenital  hemi- 
plegia, an  affection  to  which  he  has  given  the  name  of  post-hemiplegic  poly- 
myoclonus,  in  which  the  movements  are  neither  choreiform  nor  athetoid,  but 
are  chronic,  constant  contractions  of  most  of  the  muscles  of  the  limbs  affected. 
The  face  is  seldom  affected  alone  in  a  disorder  which  may  properly  be  called 
athetosis.  In  athetosis,  as  contrasted  with  chorea,  the  movements,  although 
irregular  and  bizarre  in  themselves,  have  a  certain  regularity  and  monotony  in 
their  method  of  repetition,  which  is  not  the  case  with  choreic  movements. 

Prognosis. — The  prognosis  in  the  vast  majority  of  cases  is  bad,  as  the 
disease  is  due  to  an  incurable,  often  congenital,  organic  condition.  A  case  of 
primary  athetosis  which  is  quoted  by  Jacoby  from  Gnauck  {Keating  s  Cycl. 
Bis.  Children,  vol.  iv.)  resulted  in  complete  recovery,  and  many  cases  have 
been  reported  as  improved,  but  such  reports  are  always  of  uncertain  value. 
Usually  the  affection  goes  on  from  bad  to  worse  very  slowly.  Not  infrequently, 
athetosis  or  athetoid  movements  are  associated  with  general  convulsions,  and 
the  latter  may  be  much  improved  by  the  treatment  employed  for  epilepsy. 
Organic  athetosis  must,  of  course,  from  the  very  nature  of  the  affection,  have 
an  exceedingly  unfavorable  prognosis.  A  disease  which  is  due  to  atrophy, 
sclerosis,  neoplastic  formations,  meningo-encephalitis,  or  softening,  can  scarcely 
be  otherwise  than  incurable.  The  only  point  in  diagnosis  is  to  separate  a 
few  cases  of  pseudo-athetosis  of  hystei'ical  or  neurotic  origin  from  those  of  the 
common  type.  Hysterical  athetosis  is  possible,  has  been  observed,  and  has  a 
favorable  prognosis. 

Treatment. — It  follows  from  what  we  have  already  said  as  to  their  nature 
that  little  can  be  done  in  the  way  of  treatment  for  these  interesting  but  usually 
hopeless  cases.  Nerve  stretching  will  temporarily  stop  the  movements,  just 
as  it  will  in  cases  of  histrionic  or  facial  spasm  due  to  organic  lesion,  but 
as  soon  as  the  nerve  has  recovered  from  the  traumatism  the  movements  will 
begin  to  return,  and  will  soon  be  present  again  in  their  original  intensity. 
Galvanism  has  been  frequently  employed,  but  is  of  little  permanent  value. 
The  iodides,  bromides,  and  mercury  may  be  used  in  cases  in  Avhich  a  tumor  or 
meningitis  is  supposed  to  be  present.  Remedies  like  conium,  hyoscine,  opium, 
gelsemium,  may  be  tried,  but  from  the  very  nature  of  the  cases  can  only  be  of 
temporary  value. 


INSANITY  IN  CHILDREN 

By  CHARLES  K.  MILLS,  M.  D., 

Philadelphia. 


Although  juvenile  insanity  is  comparatively  rare,  it  is  sufficiently  important, 
both  clinically  and  medico-legally,  to  demand  systematic  consideration  in  a  trea- 
tise on  the  diseases  of  children.  It  is  important  not  only  in  itself,  but  also  in  its 
bearings  on  the  mental  and  physical  health  of  the  patient  after  he  has  reached 
adult  life.  The  varieties  of  insanity  which  occur  in  early  childhood  are  largely 
the  same  as  those  of  youth  and  manhood,  but  they  have  special  characteristics 
due  chiefly  to  age.  These  affections  are  distinct  from  idiocy,  imbecility,  and 
cretinism,  although  idiotic  and  imbecile  children  may  have  attacks  of  mental 
excitement  or  depression,  or  other  evidences  of  active  insanity.  The  two  con- 
ditions of  arrest  and  of  acquired  disorder  must  be  separately  regarded  and  dis- 
cussed. Morison,  in  his  Lectures  on  Insanity,  speaks  of  having  frequently  met 
with  violent  and  unmanageable  idiots  of  a  very  tender  age. 

The  mental  aifections  to  which  particular  attention  will  be  directed  are  those 
which  occur  in  children  presumably  born  with  at  least  an  average  degree  of 
intelligent  power  and  possibility.  Although  it  is  difficult  to  separate  moral 
insanity  and  moral  imbecility  in  children,  yet  such  a  distinction  can  sometimes 
be  made  with  advantage,  and  therefore  the  former  will  receive  brief  consider- 
ation in  this  section. 

The  difference  between  insanity  in  the  child  and  in  the  adult  is  in  harmony 
with  known  facts  and  physiological  principles  regarding  the  evolution  of  the 
mental  faculties.  "The  insanity  met  with  in  children,"  according  to  Maudsley 
{The  Physiology  and  Pathology  of  Mind),  "must  of  necessity  be  of  the  sim- 
plest kind ;  where  no  mental  faculty  has  been  organized  no  disorder  of  mind 
can  well  be  manifest."  The  forms  and  degrees  of  insanity  exhibited  by  chil- 
dren according  to  their  stages  of  mental  evolution  and  their  acquired  habits 
have  been  well  discussed  by  this  able  psychologist  and  alienist.  Violent  and 
convulsive  response  to  sensorial  impressions  gives  rise  to  mental  disorder  of  an 
epileptiform  character;  or,  once  the  power  of  definite  sensory  impression  has 
been  acquired,  and  hallucinations  are  possible,  these  may  lead  to  choreic  reac- 
tions. Some  forms  of  nightmare  in  children  are  the  result  of  vivid  hallucina- 
tions which  have  arisen  in  response  to  such  impressions.  Hallucinations  may 
occur  before  the  mind  is  sufficiently  organized  to  make  delusion  possible;  but 
later,  after  a  varying  time,  ideas  or  concepts  become  organized,  so  that  the 
child  is  able  to  think  about  absent  objects.  Ideas  which  are  at  first  simple 
and  isolated  become  elaborated  and  grouped,  and  as  soon  as  ideas  are  fully 
organized,  delusion,  which  is  an  insistent  baseless  belief,  becomes  possible. 

True  insanity  in  children  has  been  observed  at  a  very  early  age ;  indeed, 
Greding  has  reported  one  case,  cited  by  Crichton  and  Maudsley,  of  a  child  who 
is  said  to  have  been  raving;  mad  when  it  was  born.  The  mother  was  about 
forty  years  old,  was  of  full  plethoric  habit,  and  constantly  laughed  and  did 

697 


698  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

strange  things,  but  otherwise  was  in  the  best  of  health ;  she  was  delivered  of  a 
male  child  who  possessed  so  much  strength  in  his  arms  and  legs  that  four  women 
could  at  times  with  difficulty  restrain  him.  His  paroxysms  of  motor  excite- 
ment either  ended  in  uncontrollable  fits  of  laughter  or  else  he  tore  everything 
or  anything  near  him.  Mania  has  also  been  reported  by  Greding  as  beginning 
at  nine  months  in  a  child  who  died  at  eighteen  months  old ;  by  Rush  and  others 
at  the  age  of  two  years.  Sinkler  ( Univ.  3Iedical  Magazine,  Jan.,  1893),  has 
reported  two  interesting  cases  in  children  three  years  old.  Many  cases  have 
been  reported  as  occurring  between  the  ages  of  five  and  twelve  or  thirteen 
years. 

Varieties  of  Insanity  in  Children. — It  would  serve  no  useful  purpose 
to  attempt  a  formal  classification  of  the  insanities  of  childhood,  and  it  is 
best,  therefore,  simply  to  consider  the  subject  under  such  heads  as  experience 
and  published  records  indicate.  All  forms  of  insanity  may  occur  before 
puberty,  although  some  are  very  rare.  According  to  Cohn  {Arch.  f.  Kinder- 
heilk.,'^^.  iv.),  juvenile  insanity  should  be  divided  into  functional  and  organic, 
under  the  former  subdivision  placing  those  neuroses  which  may  be  in  part,  or 
may  develop  into,  psychoses,  as  the  insanities  of  chorea,  epilepsy,  and  hysteria, 
and  also  what  might  be  termed  idiopathic  psychoses,  such  as  hallucinatory 
confusional  insanity,  hypochondriacal  insanity,  melancholia,  mania,  and  moral 
insanity;  while  the  latter  are  comprised  under  such  forms  as  exhibit  clear 
manifestations  of  organic  cerebral  disease,  as,  for  example,  the  rare  cases  of 
paretic  dementia  and  mental  aifections  due  to  tumor,  abscess,  meningitis,  or 
other  determinable  lesions. 

It  Avill  be  convenient  for  practical  purposes  to  arrange  juvenile  insanities 
under  the  following  heads:  1,  Transitory  Psychoses;  2,  Mania;  3,  Melancho- 
lia; 4,  Circular  or  Alternating  Insanity;  5,  Choreic  Insanity;  6,  Hysterical 
Insanity :  7,  Cataleptic  or  Cataleptoid  Insanity ;  8,  Epileptic  Insanity ;  9,  Para- 
noia or  Primary  Delusional  Insanity ;  10,  Moral  Insanity ;  11,  Instinctive  Per- 
versions and  Morbid  Impulses;  12,  Morbid  Fears  or  Phobias;  13,  Paretic 
Dementia. 

A  favorite  method  of  classifying  insanity,  and  one  which  has  much  that  is 
practical  in  its  favor,  is  on  the  basis  of  etiology,  but  it  has  disadvantages,  and 
may  be  scientifically  misleading.  In  some  instances,  however,  both  in  adults 
and  in  children,  special  causes  are  so  prominent  in  the  production  of  certain 
types  of  insanity  that  it  serves  a  good  purpose  to  name  the  afiections  from  the 
point  of  view  of  causation.  Understanding  that  different  forms  of  insanity 
from  the  semiological  standard  may  be  produced  by  the  same  or  similar  causes, 
we  may  have  in  children  such  etiological  varieties  as  dementia  due  to  inherited 
syphilis,  febrile  and  post-febrile  insanities,  reflex  insaniti/,  masturbational 
insanity,  and  many  others,  according  to  the  views  of  the  alienist  discussing 
the  subject. 

Transitory  Psychoses. — Although  any  form  of  non-organic  insanity  in 
a  child  is  likely  to  be  transient,  because  it  has  not  the  soil  in  which  to  take  firm 
root,  still  certain  phases  or  varieties  of  mental  disturbance  in  the  very  young 
can  because  of  their  fleeting  character  be  conveniently  classed  as  transitory 
psychoses.  Under  this  head  would  be  placed  a  form  of  delirium  arising  in 
young  children  from  special  causes.  It  is  well  known  to  mothers  as  well  as  to 
physicians  that  some  children  have  a  greater  tendency  to  attacks  of  delirium 
than  others.  In  them  the  slightest  rise  in  temperature,  as  of  one  or  one  and  a 
half  degrees,  will  always  be  attended  with  more  or  less  delirium.  Sometimes 
this  delirium,  mild  in  type  and  Avithout  any  special  features,  constitutes  the 
entire  case  ;  but  an  attack  of  delirium  may  be  prolonged  and  take  the  form 


INSANITY  IN   CHILDREN.  699 

of  a  true  although  a  transient  and  non-tenacious  mania.  The  child  may  have 
frightful  hallucinations,  especially  of  sight  or  hearing. 

Speaking  of  the  insanity  of  young  children,  Maudsley  well  says  that  "  the 
precocious  imagination  of  a  child  which  sometimes  delights  foolish  parents  can- 
not possibly  be  anything  more  than  lying  fancy  ;  and  this  for  exactly  the  same 
reason  that  the  insanity  of  children  must  be  a  delirium,  and  cannot  be  a  mania 
— the  incomplete  formation  of  ideas  and  absence  of  definitely  organized  asso- 
ciations between  them." 

Pavor  nocturnus,  or  night-terrors,  might  be  classed  with  the  transitory 
psychoses  of  children,  but  this  affection  is  discussed  in  another  article. 

These  transient  psychoses  may  take  the  form  of  an  excited  or  agitated 
melancholia,  as  mentioned  by  Clouston  ( Clinical  Lectures  on  Mental  Diseases, 
1884),  the  patients  in  such  cases  screaming,  sobbing,  weeping,  and  giving  evi- 
dence of  great  mental  suffering  and  depression,  usually  without  being  able  to 
give  any  reasons  therefor,  although  they  will  sometimes  speak  of  seeing  or  hear- 
ing something,  or  more  or  less  vaguely  of  being  worried  or  frightened  by  appre- 
hensions of  evil  or  injury. 

The  affection  variously  known  as  transitory  frenzy,  mania  transitoria,  or 
ephemeral  mania,  which  in  the  adult  has  often  been  the  subject  of  medico- 
legal dispute,  occasionally  has  been  observed  in  children — an  abrupt,  rapid  dis- 
order, lasting  only  a  few  minutes  or  hours.  Morel  [Maladies  Mentales,  1853), 
speaks  of  a  little  girl  eleven  year  old  who  after  the  sudden  disappearance  of  a 
skin  eruption  exhibited  choreic  symptoms,  and  soon  after  those  of  a  true  mania- 
cal fury  in  which  she  became  homicidal ;  and  other  cases  of  transitory  fury, 
some  traceable  to  special  causes  and  some  not,  have  been  reported  by  various 
observers. 

Mania. — Mania  is  the  form  of  insanity  of  most  frequent  occurrence  in 
childhood.  It  usually  shows  itself  by  active  delirium,  great  motor  excitability, 
screaming  and  crying,  incoherence,  and  sometimes  by  hallucinations,  and  even 
delusions  of  slight  tenacity  in  children  old  enough  to  have  ideas.  Exacerba- 
tions of  extreme  fury  or  violence  come  on  in  the  course  of  the  general  excite- 
ment ;  convulsions  sometimes  occur,  and  speech  may  be  lost,  as  in  a  case 
reported  by  Morel  of  a  girl  ten  and  a  half  years  old.  It  was  necessary  to  send 
her  to  an  asylum,  and  she  never  seemed  to  be  happy  unless  she  was  destroying 
something  or  tormenting  somebody.  A  boy  five  years  old  was  suddenly  fright- 
ened, lost  the  power  of  speech,  was  turbulent,  and  had  frequent  maniacal 
paroxysms.  These  little  patients  sometimes  exhibit  great  anger  and  destruc- 
tive and  even  homicidal  impulses  and  propensities;  but  these  acute  morbid 
impulses  and  propensities  must  be  distinguished  from  those  which  are  due  to 
character,  and  will  be  referred  to  later  when  speaking  of  instinctive  insanitj^ 
and  morbid  impulses. 

Melancholia. — Melancholia  is  not  an  uncommon  form  of  insanity  in  chil- 
dren, but  it  is  not  likely  to  occur  before  the  age  of  five  or  six  years.  It  is 
always  necessary  to  distinguish  between  monomanias  or  paranoias  and  melan- 
cholias, but  genuine  uncomplicated  melancholia  is  sometimes  seen  in  children, 
and  has  been  reported  by  numerous  observers.  Hallucinations  may  or  may 
not  be.  present  Avith  the  mental  depression.  Melancholy  in  a  child  seldom 
assumes  the  extreme  form  which  is  observed  so  frequently  in  the  adult,  but  now 
and  then  a  true  agitated  melancholic  frenzy  is  observed.  Ordinarily  a  child 
suffering  from  melancholia  will  be  sad,  anxious,  weeping,  restless  by  day  and 
by  night,  wanting  in  the  liveliness  and  changeability  of  children — blue, 
depressed,  worried  and  worrisome,  knowing  not  why.  Delusions  so  common 
in  adults,  as  of  self-condemnation,  of  the  unpardonable  sin,  of  coming  to  want, 


700   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

or  of  fatal  organic  disease,  are  often  absent  in  the  melancholia  of  children. 
Children  brought  up  in  morbidly  religious  or  in  distressing  surroundings 
sometimes  exhibit  a  delusional  state  of  a  religious  or  painful  character,  but 
^this  does  not  obtain  the  same  depth  and  fixity  as  in  adults.  The  varieties  of 
melancholia  most  frequently  observed  in  children  are  the  simple,  the  hypochon- 
driacal, the  excited  or  agitated.  Suicide  in  children  is  not  commonly  due  to 
melancholia,  although  it  is  occasionally,  when  an  inherited  taint  will  often  be 
found  to  be  present.  Children,  like  adults,  are  now  and  then  driven  to  melan- 
cholia and  suicide  by  want  of  care  and  ill-treatment.  The  suicides  of  children 
are  sometimes  dependent  upon  the  most  trivial  causes  or  notions,  as  a  trifling 
chastisement. 

Circular  or  Alternating  Insanity. — A  well-known  and  most  interest- 
ing type  of  insanity  in  the  adult  is  that  which  is  characterized  by  alternating 
mental  states,  in  Avhich,  for  example,  the  patient  suffers  first  from  exaltation  or 
mania,  then  from  depression  or  melancholia,  then  has  a  sane  or  lucid  period, 
and  again  starts  on  the  vicious  circle  with  an  attack  of  exaltation.  Sometimes 
other  forms  of  alternation  appear,  or  simply  depression  and  exaltation  in  rota- 
tion. This  mental  disorder,  which  has  been  designated  folie  eirculaire,  or  cir- 
cular insanity,  and  also  alternating  insanity,  is  sometimes  observed  in  children. 

Choreic  Insanity. — Several  varieties  of  choreic  insanity  have  been 
described.  One  form  of  choreic  mania  usually  does  not  commence  until  the 
motor  disorder  has  lasted  two,  three,  or  four  weeks.  Before  the  onset  of  the 
mental  disorder  the  motor  disturbances  become  more  severe  and  irregular ;  the 
movements  never  cease,  even  in  some  cases  during  the  little  sleep  which  is 
obtained,  and  insomnia  becomes  almost  as  complete  as  in  delirious  mania.  As 
a  rule,  the  sufferers  preserve  more  knowledge  of  themselves  and  their  surround- 
ings than  would  seem  likely  from  the  apparent  mental  disturbance.  They  do 
many  things  which  appear  to  be  purposive  or  hysterical  in  character,  as  strug- 
gling, striking,  hurling  things,  breaking  furniture  or  dishes,  jumping,  rolling 
or  thumping  themselves  against  the  floor  and  walls.  These  cases  have  been 
well  described  by  Meyer  [Tukes  Diet,  of  Psychological  3Iedicine),  yiho  also 
briefly  details  the  symptoms  of  acute  choreic  delirium,  in  which  great  excitement 
with  anguish,  vivid  hallucinations  of  vision,  hearing,  smell,  taste,  and  also  with 
stupor,  are  reported.  Fever  and  evidences  of  endocarditis  are  usually  present. 
Idiots  not  infrequently  exhibit  choreic  disturbances  of  limbs  and  language. 
The  insanity  of  choreic  cases  is  not  to  be  regarded  so  much  as  caused  by  the 
disorder  as  an  essential  part  of  it,  the  peculiar  delirium,  irregular  and  inco- 
herent, being  comparable  to  the  choreic  movements  themselves. 

Hysterical  Insanity. — Occasionally  hysterical  mania  and  chronic  forms 
of  hysterical  insanity  are  observed  in  early  life.  Even  in  adults  it  may  be  difii- 
cult  to  distinguish  between  common  acute  mania  and  hysterical  mania,  and  it  is 
sometimes  even  more  difficult  in  children  ;  indeed,  these  two  affections  run  more 
together  in  childhood.  The  association  of  other  hysterical  phenomena,  such  as 
ecstasy,  catalepsy,  trance,  mutism,  aphonia,  fantastical  notions,  sensational 
deceptions,  or  pseudo-palsies,  will  be  aids  to  diagnosis.  Hysterical  mania  in 
childhood  usually  comes  and  goes,  the  attacks  being  short  and  showing  great 
emotional  excitement.  Some,  at  least,  of  the  acts  may  be  purposive,  although 
apparently  beyond  control.  Sometimes,  alternating  with  these  maniacal  attacks 
or  independently  of  them,  children  are  caught  in  sensational  deceptions  of  such 
outrageous  character,  and  repeated  so  often,  that  they  can  only  be  regarded  as 
due  to  mental  perversion.  "You  may  be  sure  that  a  young  girl  is  on  the 
premises,"  says  Wilks,  "when  you  read  of  loud  rappings  in  a  house  at  night, 


INSANITY  IN   CHILDREN  701 

of  a  room  being  constantly  set  on  fire,  of  sheets  torn  by  rats,  and  of  similar 
extraordinary  occurrences." 

Hammond  (^Treatise  on  Insanity  in  Its  Medical  Relations,  1883)  records 
the  case  of  a  girl  whose  disposition  was  always  sullen,  capricious,  and  eccentric, 
and  who  never  exhibited  the  least  feeling  of  tenderness  toward  her  parents — 
who  laughed  and  cried  without  cause,  and  committed  from  an  early  period  of 
her  life  all  kinds  of  singular  and  ridiculous  acts.  She  could  not  be  prevented 
from  using  obscene  and  ridiculous  language ;  and  soon  she  exhibited  a  series  of 
spontaneous  and  delirious  acts,  such  as  are  met  with  in  hysterical  mania.  One 
day  she  crowned  herself  with  flowers,  took  a  guitar,  and  announced  that  she 
was  going  to  travel  through  the  world.  She  got  up  in  the  night  and  washed 
her  clothes  in  the  chamber-pot.  She  had  convulsive  seizures,  mewed  like  a 
cat,  tried  to  climb  up  a  wall,  was  violent  in  her  acts  toward  others,  and  finally 
fell  into  a  state  of  stupor.  These  accessions  were  periodical,  and  it  became 
necessary  to  send  her  to  an  asylum. 

The  dancing  manias,  child-pilgrimages,  and  other  epidemic  and  endemic 
nervous  disorders  may  be  regarded  as  forms  of  hysterical  insanity  ;  at  least  they 
are  fundamentally  psychoses.  Occasionally  these  endemics  from  imitation  are 
observed  in  homes  and  schools.  Usually  convulsions,  speech  affections,  pseudo- 
paralyses,  contractures,  visual  hallucinations,  or  spells  of  great  emotional  excite- 
ment are  among  the  phenomena  exhibited. 

Cataleptic  or  Cataleptoid  Insanity. — Katatonia,  a  clinical  type  of 
insanity  first  described  by  Kahlbaum  in  1874,  has  in  rare  instances  been 
observed  in  children.  It  is  a  cyclical  or  alternating  insanity,  sometimes  hav- 
ing as  many  as  five  stages — beginning,  for  instance,  with  mania,  and  then 
melancholia,  stupor,  cataleptoid,  and  dramatic  periods  following.  The  different 
stages  may  vary  in  duration  and  continuation ;  thus,  depression  and  exaltation 
may  be  present  with  cataleptoid  and  histrionic  phenomena.  Some  cases  recover, 
and  others  pass  into  a  state  of  chronic  dementia.  It  has  been  claimed  that 
katatonia  cannot  be  regarded  as  a  distinct  clinical  entity,  as  various  cataleptoid 
and  convulsive  phenomena  and  histrionism  are  present  in  other  types  of 
insanity,  as  mania,  melancholia,  paranoia,  imbecility,  while  others,  again, 
hold  that  it  is  an  hj^sterical  disorder.  It  is  certain,  at  any  rate,  that  in  child- 
hood mental  disturbance  of  peculiar  character,  associated  with  catalepsy,  ecstasy, 
and  trance-like  states,  is  observed ;  and  transient  maniacal  attacks  may  be 
present  in  these  cases.  Occasionally  seizures  of  this  kind  have  been  observed 
in  undoubted  epileptics,  although  the  attacks  are  not  to  be  regarded  as  epileptic 
in  their  nature.  A  true  epilepsy  is  occasionally  developed  in  children  who  begin 
with  cataleptic,  hystero-epileptic,  and  hystero-maniacal  spells. 

Epileptic  Insanity. — Congenital  epileptics  are  not  infrequently  idiots  or 
imbeciles  or  sufferers  from  some  form  of  paralytic  or  atrophic  disease ;  in  other 
cases  epilepsy  appears  early  in  life  in  children  of  fair  mental  health,  some  of 
whom  develop  epileptic  insanity ;  sometimes  a  true  epileptic  dementia  comes 
on  even  before  the  period  of  childhood  has  passed,  showing  itself  by  loss  of 
memory,  judgment,  and  general  mental  enfeeblement.  Mania  may  occur 
before  or  after  an  epileptic  paroxysm,  or  may  take  the  place  of  such  a  par- 
oxysm, just  as  in  the  adult.  When  without  sufficient  apparent  cause  a  child 
has  transitory  fury  or  frenzy,  even  though  no  known  history  of  epilepsy 
be  present,  the  possibility  of  the  attack  being  epileptic  should  be  borne 
in  mind.  Sometimes  very  young  children  have  maniacal  outbreaks,  and 
subsequently  develop  regular  epilepsy ;  or  the  epileptic  seizures  may  be 
nocturnal,  and  thus  be  overlooked ;  or,  again,  attacks  of  petit  mal  may  be 
undemonstrative  in  character,  so  that  their  true  nature  may  not  be  recognized. 


702    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Attacks  of  fury  followed  by  epileptic  convulsions,  and  of  epileptic  convulsions 
followed  by  furious  excitement,  in  children  under  ten  years  of  age  are  recorded 
by  many,  and  have  been  observed  by  every  one  who  has  had  much  experience 
with  epileptic  children.  Epileptic  children  also  show  peculiar  perversions  of 
character  and  manners.  Post-epileptic  conditions  of  stupor,  delirium,  or  con- 
fusion are  sometimes  present,  and  a  chronic  maniacal  state  may  accompany  the 
epilepsy. 

Paranoia  or  Primary  Delusional  Insanity. — Paranoia,  a  Greek  word 
meaning  insanity,  has  been  reintroduced  into  the  literature  of  mental  disease. 
Primary  delusional  insanity,  suggested  by  Stearns  {Lectures  on  3Iental 
Diseases.,  1893),  is  a  better  term,  although  even  this  is  open  to  objection.  It 
is  a  chronic  insanity,  in  its  completest  type  characterized  by  recognizable  sys- 
tematized delusions,  but  showing  itself  also  by  general  mental  instability,  insist- 
ent ideas,  morbid  impulses,  and  perversions  of  character,  the  foundation  of 
these  being  in  reality  a  delusional  state.  The  delusions  of  paranoiacs  may  or 
may  not  be  accompanied  by  hallucinations.  While  paranoia  is  rare  under  the 
age  of  puberty,  the  children  who  subsequently  develop  primary  delusional  insan- 
ity have  often  such  marked  peculiarities  and  eccentricities  as  to  lead  physicians 
experienced  in  mental  diseases  to  forecast  the  probable  occurrence  of  this  affec- 
tion later  in  life.  They  show  oddities  of  dress  and  conversation,  excess  of  self- 
consciousness,  a  tendency  to  scheming  and  dreaming,  ambitious  and  egotistical 
notions,  conceits  and  misconceptions,  and  periods  of  moodiness,  depression, 
anger,  or  excitement.  Recently,  Moyer  and  Lyman  {Med.  and  Surg.  Ileijorter., 
March  25,  1893)  have  reported  paranoia  in  a  boy  between  tAvelve  and  thirteen 
years  old.  He  imagined  that  his  mother  was  going  to  poison  him  and  that  he 
had  yellow  fever  and  tape-worms.  In  a  strict  sense,  he  was  neither  exalted  nor 
depressed.  Two  maternal  grandaunts  died  insane.  This  case  might  be  regarded 
as  one  beginning  at  puberty,  but  now  and  then  a  case  with  definite  delusions 
of  a  systematized  character  is  seen  at  an  earlier  age.  According  to  Spitzka, 
imperative  conceptions,  morbid  fears,  and/o/ie  du  doute  are  frequent  in  infantile 
masturbators,  and  hypochondriacal  and  persecutional  paranoia  in  a  crude  form 
is  similarly  detected  at  this  period. 

Moral  Insanity. — It  is  difficult,  as  already  stated,  to  make  a  distinction 
between  moral  imbecility  and  moral  insanity  in  children,  and  sometimes  the  dis- 
tinction is  of  little  importance.  In  moral  insanity  the  perversion  of  the  moral 
or  affective  life  may  be  brought  about  by  injury,  disease,  or  vicious  habits  in  chil- 
dren who  to  all  appearances  have  been  of  healthy  moral  and  mental  tone.  The 
moral  imbecile  is  the  victim  of  heredity,  his  condition  being  manifested  as  soon 
after  birth  as  it  is  possible  to  recognize  deficiencies  in  the  moral  sense.  Extra- 
ordinary perversions  of  character  have  been  recorded  in  considerable  number 
due  to  acute  fevers  in  children.  Psychical  phenomena  approaching  attacks  of 
true  insanity  sometimes  occur  during  malarial  fevers,  and  sometimes  seem  to 
take  the  place  of  malarial  attacks. 

Instinctive  Perversions  and  Morbid  Impulses. — Instinctive  perver- 
sions and  morbid  impulses  flow  out  of  the  same  inherited  or  constitutional  con- 
ditions which  are  at  the  root  of  fully-developed  monomania  or  paranoia.  Chil- 
dren who  show  these  perversions  and  impulses  sometimes  later  in  life  become 
examples  of  paranoia.  Maudsley  prefers  to  consider  these  symptoms  or  con- 
ditions under  the  general  head  of  affective  insanity,  under  Avhich  he  would 
also  include  moral  insanity  proper.  With  regard  to  both  adults  and  children 
it  is  important  to  determine  whether  such  manifestations  are  symptoms  of  mania, 
melancholia,  or  epilepsy,  or  whether  they  are  constitutional  or  paranoiac  in 
type.     One  must  have  a  clear  idea  of  certain  terms  now  frequently  used  in 


INSANITY  IN   CHILDREN.  703 

considering  these  questions,  such  as  concepts,  imperative  concepts,  morbid 
concepts,  imperative  acts  or  movements,  insistent  ideas,  and  morbid  propen- 
sities. Concepts  are  distinct  or  isolated  thoughts,  the  elements  of  thought- 
processes  ;  they  become  imperative  when  they  dominate  or  tyrannize  the  mind. 
Imperative  acts  or  movements  or  morbid  impulses  are  the  results  of  these  im- 
perative conceptions.  The  term  insistent  idea,  suggested  by  Cowles,  describes 
a  habit  of  thought  resulting  from  the  repetition  and  multiplication  of  morbid 
concepts ;  after  a  time  these  insistent  ideas  hamper  and  manacle  the  individual's 
will  and  intellect.  Morbid  propensities,  like  insistent  ideas,  sometimes  steadily 
hold  possession  of  the  mind  ;  they  are  often  simply  exaggeration  of  the  normal 
propensities,  but  to  such  a  degree  as  to  become  a  true  insanity.  They  are  per- 
versions chiefly  of  the  desire  for  food  and  of  the  sexual  appetite. 

Under  morbid  impulses,  monomanias,  partial  ideational  insanity,  and 
partial  moral  mania  have  been  described  such  affections  as  moral  mania; 
homicidal  mania  or  the  impulse  or  propensity  to  kill ;  suicidal  monomania ; 
kleptomania  or  the  propensity  to  theft ;  erotomania  or  the  tendency  to  fall 
in  love  with  everybody  ;  nymphomania  which  may  be  distinct  from  eroto- 
mania and  exhibit  itself  in  sexual  precocity  and  salacity  ;  pyromania  or  the 
impulse  or  propensity  to  incendiarism ;  and  dipsomania  or  the  irresistible 
periodical  craving  for  drink.  It  is  perhaps  better  to  regard  these  as  desig- 
nations of  the  most  prominent  symptom  or  symptoms  in  a  case  of  insanity, 
rather  than  to  erect  them  into  a  special  variety  of  mental  disease,  although  the 
latter  procedure  sometimes  serves  a  good  practical  purpose. 

Almost  every  variety  of  monomania  or  morbid  impulse  has  been  observed 
in  young  children,  and  many  cases  might  be  given.  Esquirol  speaks  of  a  girl 
aged  five  years  who  repeatedly  attempted  to  kill  both  her  stepmother  and  her 
brother.  Not  a  few  cases  have  been  reported  like  that  of  the  boy  Pomeroy — 
children  who  have  shown  an  insane  inclination  to  cruelty  as  well  as  to  homicide, 
this  often  exhibiting  itself  in  a  tendency  to  give  pain,  to  mutilate,  to  harm  in 
various  ways  the  lower  animals  or  other  children.  Such  cases  usually  belong 
to  the  inherited  paranoiac  type,  but  in  others  the  inclination  to  injure  or  kill 
may  be  simply  one  of  the  violent  manifestations  of  a  curable  acute  mania. 

Both  thieving  and  lying  can  sometimes  only  be  regarded  as  true  mental 
perversions,  although  it  is  certainly  difficult  in  the  child  as  in  the  adult 
to  separate  such  forms  of  monomania  from  conscious  and  controllable  vicious- 
ness.  •  Girls  at  or  approaching  puberty  are  known  to  exhibit  such  tendencies 
to  a  morbid  degree,  in  many  cases  recovering  from  them  in  a  shorter  or  longer 
time,  but  occasionally  even  younger  children  show  the  same  monomaniacal 
inclinations.  Such  a  child  will  lie  without  rhyme  or  reason,  and  will  steal 
without  a  desire  to  gratify  appetite  or  passion. 

What  is  known  as  erotomania  is  more  frequently  exhibited  in  adults  than 
in  children,  but  rare  juvenile  cases  have  been  observed.  Erotomania  and 
nymphomania  are  not  the  same,  although  often  confounded.  In  erotomania, 
as  a  rule,  the  tendency  to  indecency  and  excess  is  not  present.  The  eroto- 
maniac boy  becomes  the  adorer  of  most  of  the  girls  he  meets,  or  the  girl  the 
admiring  slave  of  the  boys.  Nymphomania  or  satyriasis  exhibited  in  an  insane 
degree  is  by  no  means  uncommon  in  children,  and  even  occasionally  in  very 
small  children,  both  boys  and  girls.  Cases  have  been  reported  of  children 
two  and  three  years  old  who  have  exhibited  the  most  remarkable  sexual  pre- 
cocity, as  shown  by  indecency  of  attitude  and  act. 

Some  of  the  most  extraordinary  instances  of  morbid  impulses  and  propen- 
sities in  children  are  those  which  have  been  reported  as  cases  of  pyromania,  the 
child  persistently  and  perversely  striving  to  set  fire  to  anything  and  everything 


704   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

that  it  thinks  will  burn,  and  using  sometimes  great  cunning  and  skill  both  to 
succeed  and  to  conceal  the  act. 

Hammond  relates  the  case  of  a  girl  less  than  fifteen  years  of  age,  affected 
with  nostalgia,  who  twice  set  fire  to  the  house  in  Avhich  she  lived.  She  declared 
that  from  the  first  minute  of  entering  her  masters  house  she  had  been  seized  with 
the  desire  to  destroy  it  by  fire.  It  seemed  to  her  that  a  ghost  standing  before 
her  constantly  urged  her  on  to  the  act.  This  girl  had  sufiered  from  pain  in  the 
head  and  disordered  menstruation. 

Morbid  Fears  or  Phobias. — In  a  philosophical  sense,  sanity  and  insanity 
are  relative  terms  whether  applied  to  conditions  in  children  or  in  adults ; 
certainly,  not  a  few  cases  are  observed  which  may  be  properly  regarded  as 
on  the  borderland  between  mental  health  and  disease.  They  are  perhaps  best 
regarded  as  examples  of  partial  or  quasi-insanity  ;  that  is,  forms  of  mental 
disease  which  in  a  certain  manner  and  degree  have  the  attributes  of  insanity. 
They  are  abortive  or  imperfectly-developed  mental  disorders.  Sometimes  they 
are  as  transient  in  duration  as  they  are  limited  in  phenomena ;  but  in  other 
instances  the  few  elementary  deficiencies  or  disturbances  may  persist  without 
much  change  or  increase  through  life.  Many  of  these  cases,  like  the  morbid 
impulses  just  treated  of,  belong  under  the  head  of  paranoia.  They  have  been 
described  as  morbid  fears  or  phobias,  as  morbid  doubts,  as  emotional  mono- 
manias, and  even  as  forms  of  neurasthenia.  They  are  fundamentally  depend- 
ent upon  the  domination  of  the  mind  by  morbid  concepts  and  insistent  ideas. 
They  are  sometimes  observed  among  young  children,  although  more  common 
after  than  before  the  period  of  puberty.  Morbid  fear  may  be  the  result  of 
functional  disturbance  or  disease  in  a  normally  constituted  individual,  but  the 
cases  which  afford  the  most  striking  instances  of  morbid  fear  or  phobia  occur 
in  those  who  have  not  been  subjected  to  any  physical  or  mental  strain  sufficient 
to  break  down  a  healthy  organization.  Persistent  fear  of  the  monomaniacal 
type  occuring  in  children  is  rarely  due  to  overwork  or  fatigue,  as  at  school,  as 
is  frequently  supposed.  The  real  cause  is  generally  in  a  child's  progenitor  or 
progenitors.  They  are  cases  of  the  class  referred  to  by  Oliver  Wendell  Holmes, 
the  cure  of  which  should  have  been  begun  two  hundred  years  ago. 

These  quasi-insanities  or  phobias  have  been  much  divided  and  subdivided ; 
not  infrequently  several  of  the  so-called  varieties  are  present  at  the  same  time 
in  the  same  case.  Among  the  forms  of  morbid  fear  which  have  been  described 
by  particular  names  are  ijatlxoiyliohia^  or  fear  of  disease ;  mysophohia,  tlie  fear 
of  contamination,  defilement,  or  pollution;  agoraphobia,  the  fear  of  open 
squares  or  places ;  claustrophobia,  the  fear  of  closed  or  narrow  places ;  topo- 
phobia,  the  fear  of  places  in  general:  monophobia,  the  fear  of  being  alone; 
pyrophobia,  the  fear  of  fire ;  astrophobia,  the  fear  of  lightning  ;  and  hydropho- 
6ojoAo6ia,  or  fear  of  hydrophobia.  Some  cases  belong  to  a  class  which  may  be 
described  as  pantophobia,  or  fear  of  everythins:. 

A  few  cases  have  been  observed  in  comparatively  young  children.  Hurd 
(cited  by  Stearns),  reports  an  interesting  case  from  an  account  written  by  the 
patient  herself.  When  about  twelve  years  old  she  began  to  have  strange 
fancies,  as  fearing  the  blood  flowing  from  a  cut  finger  would  harm  those  who 
came  near  her.  Subsequently,  dressing,  walking  out  of  doors,  eating,  were  all 
greatly  interfered  with  through  the  same  morbid  ideas.  She  feared  contagious 
diseases  because  she  might  communicate  them  to  others.  The  insistent  idea 
changed  from  time  to  time,  but  seemed  to  spring  always  from  the  emotion  of 
fear.  She  eventually  recovered.  Hammond  cites  from  King,  of  Sedalia,  Mis- 
souri, an  interesting  case  of  pyrophobia  in  a  boy  of  ten  years.  Day  and  night 
he  was  infested  with  fear  of  this  kind.     On  one  occasion,  when  the  morninfr 


INSANITY  IN   CHILDREN  705 

was  cool,  he  succeeded,  after  a  contest  with  his  mother,  in  opening  the  stove- 
door  and  pouring  a  bucket  of  water  on  the  fire.  He  is  said  to  have  been 
cured  by  quinine,  the  bromides,  and  the  use  of  evaporating  applications  to 
the  head, 

A  few  cases  in  comparatively  young  children  have  been  reported  and  some 
have  come  under  my  notice.  A  boy  eleven  years  old,  developed  what  was  practi- 
cally a  pantophobia,  although  his  disorder  exhibited  itself  chiefly  as  a  patho- 
phobia, or  fear  of  disease.  He  was  kept  almost  constantly  under  the  care  of 
physicians.  Sometimes  his  morbid  ideas  revolved  round  real  affections  of  slight 
importance ;  sometimes  his  fears  and  suffering  were  due  purely  to  morbid  con- 
ceptions and  insistent  ideas.  Now  his  eyes  were  the  source  of  morbid  dread ; 
soon  his  limbs  were  the  seat  of  rheumatic  pain ;  he  narrowly  escaped  laparotomy 
for  typhlitis,  probably  of  psychical  origin ;  to  a  moderate  degree  he  suffered 
from  mysophobia,  spending  unusual  time  at  his  ablutions,  teeth  cleaning,  in 
dressing,  and  in  the  care  and  arrangement  of  his  clothes.  Anything  in  the 
nature  of  a  symptom  or  a  disease  mentioned  in  his  presence  was  likely  to  take 
possession  of  him.  His  morbid  notions  and  apprehensions  were  fed  and  encour- 
aged by  the  unceasing  attentions  of  members  of  his  family.  He  was  practically 
cured  by  taking  him  from  his  home-surroundings,  disregarding  his  complaints, 
forcing  him  to  do  things  on  time  and  after  the  manner  of  others,  at  the  same 
time  carefully  but  not  obtrusively  looking  after  his  general  health. 

Another  boy  at  the  age  of  ten  began  to  develop  the  scrupulous  and  myso- 
phobic  type  of  monomania;  in  fact,  he  was,  as  so  many  of  these  cases  are,  an 
illustration  of  the  admixture  of  several  of  the  so-called  classes  of  morbid  fears. 
He  was  constantly  worrying  about  many  things  he  said  and  did  in  his  inter- 
course with  others.  If  left  alone,  he  would  spend  hours  in  bathing  and  wash- 
ing himself,  and  often  imagined  he  had  been  polluted  or  would  contaminate 
others.  The  symptoms  were  in  many  respects  like  those  of  the  lady  described 
by  Hammond,  and  to  whose  case  he  first  applied  the  terra  mysophobia,  who 
could  touch  nothing  without  being  irresistibly  impelled  to  wash  her  hands,  and 
who  in  many  other  ways  was  tormented  by  the  fear  of  contamination.  This 
boy  improved  greatly  under  mental  discipline,  out-door  exercise,  and  careful 
tonic  medication. 

These  cases  of  morbid  fear,  particularly  when  they  assume  the  form  of  patho- 
phobia or  dread  of  disease,  are  sometimes  incorrectly  regarded  as  examples  of 
hypochondria  or  hypochondriacal  melancholia,  but  they  differ  from  the  latter 
as  monomania  or  paranoia  differs  from  mania  or  melancholia. 

Paretic  Dementia. — From  its  nature  and  pathology  paretic  dementia  is 
essentially  a  disease  of  adult  life.  It  usually  arises  in  patients  more  than  thirty 
years  of  age,  and  is  most  common  between  the  thirtieth  and  fortieth  years ;  but 
occasionally  it  is  observed  in  the  aged,  and  in  very  rare  instances  in  the  young. 
The  youngest  paretic  dement  observed  by  Spitzka  in  346  cases  was  eighteen 
years  old.  Other  cases,  however,  still  younger,  have  been  reported,  as  one  by 
Turnbull  {Jour.  Mental  Science,  October,  1881)  in  a  boy  of  twelve  years, 
who  was  first  observed  by  the  reporter  at  the  age  of  eighteen  years.  Up  to  the 
age  of  ten  he  had  been  healthy  and  apparently  like  other  boys,  but  at  this  age 
he  had  an  attack  of  hemiplegia,  which  passed  off  in  a  week  and  left  him  with  a 
certain  amount  of  stupidity.  He  continued  to  perform  his  duties  as  a  messenger- 
boy,  but  from  the  age  of  twelve  a  mental  weakness  increased  gradually  but  dis- 
tinctly. His  symptoms,  as  described,  were  certainly  those  of  general  paralysis, 
except  that  he  had  not  delusions  of  grandeur.  The  boy  died  in  less  than  a 
year  after  his  admission  to  an  asylum,  and  the  post-mortem  findings  were  those 
usually  seen  in  cases  of  paretic  dementia. 

45 


706   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Etiological  Varieties,  and  General  Btiolog-y. — A  form  of  juvenile 
dementia,  the  result  of  inherited  sr/i>hilis.  sometimes  occurs,  and  it  is  necessary 
to  separate  this  from  idiocy  and  imbecility,  whether  of  syphilitic  or  other  origin, 
which  may  be  done  by  remembering  that  the  dementia  usually  comes  on  after 
the  child  is  four  or  five  years  old,  and  therefore  when  the  mental  condition  has 
been  determined  not  to  be  that  of  idiocy.  In  rare  cases,  however,  it  happens 
that  a  juvenile  or  infantile  dementia  occurs  when  the  child  is  two  or  three 
years  old,  so  young  that  its  true  mental  status  has  not  been  fully  determined. 
With  this  word  of  caution  as  to  the  possibility  of  inherited  syphilis  showing 
itself  in  a  child  otherwise  healthy  in  the  first  year  or  two  of  life,  most  of 
the  cases  of  this  form  of  dementia  will  be  comparatively  easy  of  recognition. 
A  family  history  of  syphilis  will  often,  but  not  always,  be  obtained ;  often  the 
upper  incisors  will  be  pegged  and  notched,  while  cicatrices  at  the  angle  of  the 
mouth  and  the  characteristic  p»hysiognomy  will  be  present ;  and  sometimes  the 
child  will  have  attacks  of  keratitis,  choroiditis,  or  iritis,  or  a  history  of  snuffles 
or  of  a  rash,  and  sometimes  epilepsy  will  have  developed. 

Febrile  and  postfebrile  insanity  is,  on  the  whole,  not  rare  in  children. 
Many  cases  have  been  put  on  record.  They  have  been  arranged  byNasse  into 
three  classes — those  coinciding  Avith  the  fever,  those  which  are  apparent  con- 
tinuations of  tlie  fever,  and  those  developing  during  convalescence.  Accord- 
ing to  Spitzka  {Keating  s  Cyel.  Diseases  of  Children),  the  latter  group  is  more 
benign  in  character  and  prospect  than  the  other  two.  and  is  most  often  found 
in  adults,  the  first  two  groups  being  more  frequent  in  children.  Of  course 
delirium  is  an  accompaniment  of  most  fevers,  and  this  is  more  pronounced  and 
sometimes  of  a  peculiar  character  in  childhood  ;  but,  setting  aside  ordinary 
febrile  delirium,  mental  disorder  sufficiently  intense  and  persistent  to  be  classed 
as  insanity  is  of  comparatively  common  occurrence.  The  fevers  during  which 
or  after  which  insanity  is  most  likely  to  develop  are  typhoid,  scarlatina,  measles, 
rheumatism,  and  diphtheria.  Owing  to  the  intensity  of  the  psychical  pheno- 
mena, the  true  nature  of  typhoid  fever  in  the  child  or  adult  is  sometimes  over- 
looked. Most  cases  of  febrile  and  post-febrile  insanity  recover  in  periods 
varying  fi'om  a  few  days  to  a  few  weeks  or  months.  Rarely,  however,  a  true 
dementia  is  originated,  and  when  this  does  result  the  child  is  sometimes  left 
weaker  in  mind  and  less  capable  of  development  than  before  the  attack. 

Under  the  head  of  reflex  insanities  might  be  included  a  large  variety  of 
cases,  chiefly  illustrations  of  mania,  which  has  been  attributed,  and  apparently 
with  correctness,  to  splinters  in  the  great  toe,  to  a  carious  tooth,  to  ascarides 
and  other  varieties  of  intestinal  parasites,  to  rectal  and  preputial  irritation.  In 
one  case  seen  by  me  in  consultation  a  tape-worm  was  the  apparent  cause,  as 
the  symptoms  disappeared  when  the  parasite  was  discharged.  Affections  of 
the  nose  and  throat  and  digestive  disturbances  are  other  assigned  causes  of 
juvenile  insanity;  probably  such  causes  simply  act  as  excitants  in  children  who 
are  predisposed  by  heredity  to  mental  disease.  Some  of  the  conditions  which  are 
regarded  as  causes  are  really  due  to  the  mental  condition.  Spitzka  refers  in  this 
connection  to  the  functional  disturbances  of  the  digestive  apparatus  in  girls 
about  the  age  of  puberty,  who  go  on  from  slight  dyspeptic  symptoms  until  they 
get  an  aversion  to  food,  and  sometimes  even  delusions  about  eating,  so  that 
they  may  actually  starve  to  death,  forced  feeding  being  resorted  to  too  late. 
Masturbational  insanity .  as  occurring  both  in  children  and  adults,  has  been 
both  overrated  and  underrated,  but,  on  the  whole,  the  tendency  has  been  to  the 
former  rather  than  the  latter.  Some  alienists  deny  that  this  vice  is  ever  the 
true  cause  of  insanity,  holding  that  it  like  the  insanity  is  due  to  the  neuro- 
pathic state  of  the  individual,  or  that  at  the  most,  it  is  merely  a  concomitant  or 


INSANITY  IN   CHILDREN.  1^1 

My  experience  leads  me  to  believe  that  while,  as  is  known 
to  almost  every  one,  the  vice  is  extremely  common,  especially  among  boys,  it 
only  in  rare  instances  is  the  true  cause  of  mental  disease,  but  that  these  in- 
stances must  be  recognized.  Of  recent  writers,  Spitzka  has  laid  the  most  stress 
upon  the  existence  of  masturbational  insanity,  and  has  ably  described  it  from 
his  point  of  view.  According  to  this  writer,  the  typical  masturbational  psy- 
chosis occurs  between  the  thirteenth  and  twentieth  years,  and  therefore  at  a 
time  which  just  removes  the  subject  from  consideration  in  an  article  on  diseases 
of  childhood  proper ;  but  occasionally  the  same  symptoms  and  conditions  are 
observed  before  puberty,  although  before  this  period  Spitzka  believes  that  the 
dementia  is  more  like  a  true  imbecility,  and  that  infantile  insane  masturbators 
are  more  liable  to  epileptiform  attacks  than  to  outbursts  of  mania. 

Juvenile  insanity  may  be  directly  inherited,  but  far  more  frequently,  it  is 
the  tendency  rather  than  the  psychosis  which  is  inherited.  Besides  syphilis, 
which  has  already  been  considered,  alcoholism  exerts  its  sinister  influence  in 
this  as  in  so  many  other  directions.  Neurasthenia,  hysteria,  chorea,  epilepsy 
may  be  present  in  the  immediate  ancestors.  Other  causes  are  great  heat  or 
cold,  exposure  to  the  sun,  variations  in  temperature,  and  fright  which  acts 
unexpectedly,  especially  to  excite  the  maniacal  or  hysterical  forms.  Injuries  to 
the  head  are  of  so  much  importance  as  to  almost  warrant  the  creation  for  pur- 
poses of  convenience  of  a  class  of  traumatic  juvenile  insanities.  In  many  of 
these  traumatic  cases  the  mental  affection  is  of  the  maniacal  type,  and  is  often 
associated  with  epileptic  or  vertiginous  attacks.  Sometimes  insanity  originates 
in  connection  with  disease  of  the  heart  or  some  form  of  kidney  affection,  although 
these  causes,  and  particularly  the  latter,  act  much  more  frequently  in  adult  life. 
Poor  food,  bad  ventilation,  and  bad  hygiene  generally,  may  be  auxiliary  causes. 

Diagnosis. — Much  that  has  already  been  said  in  the  general  consideration 
of  the  subject,  and  also  in  connection  with  the  discussion  of  special  varieties  of 
insanity,  will  assist  in  the  diagnosis.  In  the  first  place,  insanity  in  childhood 
must  be  distinguished  from  idiocy  and  imbecility,  or  the  existence  of  both  in 
the  same  case  must  be  determined.  The  delirium  which  ushers  in  or  accom- 
panies a  continued  or  ephemeral  fever  must  not  be  set  down  as  insanity,  the 
febrile  disease  being  overlooked,  although,  as  has  been  considered,  the  occur- 
rence of  true  febrile  insanities  must  be  borne  in  mind.  The  distinction  between 
vice  and  insanity  is  not  always  easy  to  make  either  in  the  child  or  in  the  adult. 
I  agree  with  Tuke  {I)ict.  Psychol.  Med.),  that  it  is  difficult  to  lay  down  rules 
to  differentiate  moral  insanity  from  moral  depravity ;  each  case  must  be  decided 
in  relation  to  the  individual  himself,  his  antecedents,  education,  surroundings, 
and  social  status,  the  nature  of  certain  acts  and  the  mode  in  which  they  are 
performed.  Hysterical  excitement  or  mania  may  be  difficult  to  distinguish  from 
mania  of  either  toxic  or  unknown  origin,  but  the  past  history  of  the  child,  and 
the  presence  of  certain  hysterical  stigmata,  such  as  aphonia,  convulsions,  or 
paresis,  will  be  of  great  assistance  in  making  the  diagnosis.  The  existence  of 
epileptic  insanity  can  often  be  determined  by  a  close  investigation  of  the  history 
of  the  case,  which  will  sometimes  unexpectedly  reveal  the  fact  that  the  child 
has  had. at  least  serious  petit  mal  during  the  day  and  probably  spasms  during  the 
night.  Every  child  who  has  sudden  and  unaccountable  outbursts  of  extreme 
violence  should  be  watched  for  a  time  both  day  and  night  Avith  the  view  of  deter- 
mining as  to  the  existence  of  larvated  epilepsy.  It  is  sometimes  highly 
important  to  decide  as  to  the  type  of  insanity  from  which  a  child  is  suffering. 
If  the  symptoms  point  to  paranoia  or  primary  delusional  insanity,  even  if  of  an 
imperfectly  developed  form,  the  prognosis  will  not  be  as  favorable  as  if  the  child 
is  suffering  from  true  mania  or  melancholia.     The  mode  of  onset,  the  condition 


708    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  the  logical  faculties,  the  amount  of  emotional  manifestation,  will  aid  in  the 
diagnosis,  and  the  trained  observer  will  recognize  in  the  paranoic  child  that  the 
changes  are  fundamentally  those  of  temperament  and  character.  Transient 
morbid  fears  and  doubts  must  not  be  always  regarded  with  great  apprehen- 
sion. Children,  like  adults,  are  subject  when  neurasthenic  to  such  fears  and 
doubts,  but  these  only  arise  to  the  importance  of  mental  disease  when  persistent, 
progressive,  and  of  peculiar  character.  Their  importance  should  be  neither 
overrated  nor  misunderstood.  Paretic  dementia  is  so  rare  in  children  that  its 
diagnosis  has  not  much  practical  importance  ;  the  only  point  of  interest  would 
be,  in  a  case  which  simulated  general  paralysis,  to  decide  whether  it  might  not 
be  one  of  juvenile  dementia  due  to  inherited  syphilis,  rather  than  a  true  paretic 
dementia  of  unknown  origin.  Much  help  will  be  given  in  the  diagnosis  of  the 
latter  by  a  study  of  the  physical  evidences,  such  as  interstitial  keratitis,  cho- 
roiditis, acute  iritis,  and  optic  neuritis.  The  eye  should  always  be  carefully 
examined  in  suspected  cases.  The  occurrence  of  deafness  independently  of 
acute  aural  disease  is  important.  Notching  and  pegging  of  the  incisor  teeth, 
fissuration  of  the  corners  of  the  mouth,  flattening  of  the  bridge  of  the  nose, 
and  changes  of  the  knee-jerks  may  be  other  physical  evidences. 

Prognosis. — On  the  whole,  the  prognosis  of  insanity  in  childhood  is  good, 
but  differs  somewhat  with  the  varieties.  The  transitory  psychoses,  mania, 
melancholia,  circular,  choreic,  hysterical,  and  cataleptoid  insanities  generally 
recover  under  appropriate  treatment.  The  rare  cases  of  primary  delusional 
insanity,  and  the  more  numerous  instances  of  morbid  perversions,  impulses, 
and  propensities,  while  they  may  be  recovered  from  in  whole  or  in  part,  are 
likely  to  lay  the  foundation  or  to  be  the  precursors  of  serious  mental  affections 
later  in  life.  This,  however,  is  not  the  invariable  rule.  Young  patients  suffering 
from  morbid  fears  or  phobias,  worried  and  driven  by  insistent  ideas,  may  be 
much  benefited,  and  sometimes  permanently  relieved,  by  a  treatment  which  con- 
sists more  in  moral  management,  discipline,  and  general  hygiene  than  in  the  use 
of  medicines.  These  cases  also  sometimes  become  instances  of  life-long  mono- 
mania of  mild  or  severe  type.  Dementia  due  to  inherited  syphilis  may  be 
arrested  if  recognized  sufficiently  early.  True  paretic  dementia  is  practically 
hopeless  in  the  child  as  in  the  adult.  Some  cases  of  masturbational  insanity 
are  rescued  ;  others  pass  into  incurable  dementia,  or  at  least  to  a  lower  plane 
of  mental  life. 

Treatment. — "Great  care,"  says  Tuke  (Op.  cit.),  "  has  to  be  given  to  the 
surroundings  of  the  patients,  especially  in  acute  mania.  If  the  patients  have  to 
keep  in  bed,  the  quiet  of  being  in  a  room  without  noise  or  without  exciting  im- 
pressions is  to  be  preferred  to  isolation  in  a  cell,  but  one  scarcely  ever  can  do 
without  the  padded  room.  Lukewarm  baths,  with  cold  showers  on  the  head 
and  back  if  wanted,  are  very  useful,  because  of  the  good  they  do  to  the  skin, 
which  is  in  many  places  injured."  In  the  treatment  of  mania  at  home  every 
effort  should  be  made,  in  the  first  place,  to  remove  sources  of  irritation  and 
excitement.  The  child  should  be  kept  in  a  room  aw^ay  from  the  rest  of  the 
family,  and  noises  and  to  some  extent  even  light  should  be  excluded.  The 
bowels  should  be  thoroughly  opened  if  they  show  any  tendency  to  constipa- 
tion, but  sometimes  the  reverse  is  the  case.  Attention  should  be  given  to  the 
action  of  the  skin  and  the  kidneys,  using  diaphoretics  and  diuretics,  either 
alone  or  in  combination  with  some  of  the  I'emedies  to  be  presently  mentioned, 
for  the  more  striking  manifestations  which  are  present.  Food  should  be  sys- 
tematically urged  upon  the  patient,  although  in  some  cases  the  tendency  may 
be  to  eat  too  much  rather  than  too  little.  It  will  rarely  be  necessary  in 
mania,  or  even  in  melancholia,  in  children,  to  resort  to  feeding  either  with  the 


INSANITY  IN   CHILDREN  709 

nasal  or  the  stomacli  tube,  but  this  should  be  done  rather  than  to  let  the  child 
so  for  several  davs  "vvith  little  or  no  food.  The  food  should  be  of  a  dio-est- 
ible  character,  and  should  be  such  as  can  be  easily  taken  or  given  to  the 
patient,  as  milk,  broths,  milk  toast,  egg  custard,  soft  boiled  eggs,  or  tender 
meat. 

Sleeplessness  and  excitement  are  among  the  most  important  indications  to 
be  met  Avith  in  the  mania  of  children  by  such  remedies  as  chloral,  bromides, 
conium.  hyoscine,  or  other  preparations  of  hyoscyamus,  sulphonal,  opium,  can- 
nabis Indica,  acetanilid,  antipyrine,  chloralamid,  amylene  hydrate,  paraldehyde, 
somnal,  urethan.  Of  these  the  most  valuable  in  the  treatment  of  acute  mania 
in  children  are  the  bromides,  chloral,  hyoscine  hydrobromate,  conium,  sulpho- 
nal, and  opium.  The  doses  should  be  proportioned  to  the  age  of  the  child, 
bearing  in  mind,  however,  that  larger  doses  can  be  borne  than  in  children  not 
suffering  from  extreme  mental  excitement.  It  is  a  good  plan  to  combine  bro- 
mides and  fluid  extract  of  conium,  with  or  without  chloral,  in  one  preparation, 
to  be  given  four  or  five  times  daily,  and  in  addition  to  use  one  or  two  doses  of 
about  -^-g-Q  to  Yg-o  of  ^  grain  of  hyoscine  hydrobromate  twice  daily.  The  com- 
bination of  bromides  with  tincture  of  cannabis  Indica  will  be  sometimes  found 
very  serviceable. 

The  melancholia  of  children  is  generally  of  brief  duration.  It  should  be 
treated,  in  the  first  place,  by  rest  and  change :  a  trip  to  the  seashore  or  to  the 
country  or  mountains  will  sometimes  be  quickly  efiicacious.  All  the  secretory 
and  excretory  glands  and  organs  should  be  kept  in  good  condition.  Fruits, 
laxatives,  mineral  waters,  salines,  syrup  of  figs,  and  preparations  of  aloin, 
strychnine,  and  belladonna,  combined  with  cascara  or  podophyllin,  will  serve 
a  good  purpose  in  regulating  the  bowels.  Opium  is  of  more  service  in  melan- 
cholia than  in  mania,  and  may  be  used  in  small  doses  combined  with  bromides. 
Squibbs  deodorized  tincture  of  opium  is  excellent.  Food  should  be  regularly 
administered,  and  even  in  children  the  very  careful  use  of  stimulants  may  prove 
advantageous.  The  preparations  of  malt  will  be  found  preferable.  Various 
combinations  of  tonics  and  digestives  will  prove  of  service,  among  the  best 
being  nux  vomica  with  liquor  pepsin,  the  compounds  of  calisaya,  iron,  and 
strychnine,  and  arsenic  in  the  form  of  Fowler's  solution  administered  with  the 
compound  syrup  of  hypophosphites. 

The  treatment  of  choreic  insanity  is  practically  the  treatment  of  a  bad  case 
of  chorea,  plus  that  of  mania.  In  a  severe  case  seen  in  consultation,  a  girl 
eight  years  old  developed  chorea  shortly  after  an  attack  of  scarlet  fever,  and 
the  movements  were  incessant,  violent,  and  uncontrollable :  the  patient 
sleepless  and  at  times  semi-delirious.  Arsenic,  cimicifuga,  bromides,  and  mor- 
phine had  been  used  without  effect,  but  the  following  treatment  was  successfully 
adopted:  At  first  she  was  ordered  Squibb's  fluid  extract  of  conium  and  Fow- 
ler's arsenical  solution,  each  5  minims,  well  diluted,  every  two  hours;  and  also 
hydrobromate  of  hyoscine,  grain  -J^-,  every  two  hours  until  some  efiect  was 
produced.  Clysmic  water  was  ordered  to  be  taken  freely,  and  poultices  were 
used  over  the  kidneys.  The  choreic  movements  abated  somewhat,  but  after 
two  doses  of  hyoscine  had  been  administered  she  had  a  hysterical  convulsion, 
the  tongue  became  very  dry,  and  her  delirium  increased.  The  hyoscine  and  arsen- 
ical solution  were  discontinued  in  about  twelve  hours,  and  she  was  then  ordered 
Squibb's  fluid  extract  of  conium  and  tincture  of  digitalis,  each  5  minims,  every 
two  hours,  with  neutral  mixture.  This  treatment  was  kept  up  steadily  for 
forty-eight  hours.  One  dose  of  chloral.  30  grains,  and  bromide  of  potassium, 
60  grains,  was  given  by  rectal  injection.  The  poultices  and  clysmic  water  were 
continued,  and  a  purgative  was  also  administered.     The  chorea  showed  marked 


710    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

improvement  in  forty-eight  hours.  The  conium  and  digitalis  were  continued, 
but  with  gradually  decreasing  frequency,  for  a  week.  Two  or  three  doses  of 
chloral,  of  10  or  15  grains,  were  given  in  the  latter  part  of  the  day.  Great 
attention  was  paid  to  the  administration  of  nourishment,  chiefly  in  the  form  of 
milk. 

In  epileptic  insanity,  or  when  epilepsy  is  suspected,  bromides  should  be 
administered,  guarded  by  arsenic,  and  at  the  same  time  nutrients,  such  as  cod- 
liver  oil  and  the  preparations  of  malt,  and  also  tonics  in  small  doses,  should  be 
given. 

The  remarks  made  in  another  chapter  about  the  treatment  of  moral  imbecility 
will  apply  with  almost  equal  force,  at  least  in  most  cases,  to  the  treatment  of 
moral  insanity ;  but  the  cases  which  have  been  referred  to  as  arising  from  trau- 
matisms, toxic  diseases,  and  blood-poisoning  should  be  borne  in  mind  when 
considering  the  question  of  treatment.  Doubtless  some  of  these  may  be  amen- 
able to  surgical  or  medicinal  treatment.  When  children  are  found  to  suffer 
from  instinctive  perversions  and  morbid  impulses,  they  should  be  watched  with 
the  greatest  care ;  they  should  be  kept  as  far  as  possible  from  temptations ; 
their  moral  training  should  receive  particular  attention,  and  as  far  as  possible 
they  should  lead  healthful  out-door  lives,  great  care  being  observed  as  to  the 
choice  of  their  companions.  In  some  cases  these  perversions  and  impulses 
pass  away  at  puberty  or  adolescence.  The  treatment  of  children  who  are  the 
victims  of  morbid  fears  and  doubts,  of  pathophobias,  mysophobias,  pyropho- 
bias,  and  the  host  of  other  phobias,  is  worthy  of  careful  thought.  While 
the  tendency  which  has  led  to  these  disturbances  is  usually  inherited,  much 
may  be  done  to  prevent  their  full  development,  and  in  some  instances  the 
affections  may  pass  away  under  appropriate  treatment.  Such  children  often 
require  to  be  removed  from  their  home-surroundings,  as  almost  invariably  mis- 
takes are  made  by  their  parents  and  guardians  either  in  the  direction  of  too 
much  sympathy  and  coddling  or  of  too  much  harshness  or  want  of  appreciation 
of  the  disorder.  They  should  be  prevented  from  constantly  thinking  about 
themselves,  their  aches  and  ailments,  and  if  any  real  disease  be  present,  it 
should  receive  appropriate  but  not  too  anxious  consideration.  They  should  be 
disciplined  to  act  promptly  in  all  cases — to  act  tAvice  before  thinking  once. 

By  no  one  better  than  by  Clouston  has  the  treatment  of  masturbationai 
insanity  as  occurring  in  youths  been  discussed,  and  some  of  his  advice  and  rules 
are  applicable  to  the  disease  in  childhood.  The  paramount  indication  is  to 
brace  up  the  youth  mentally  and  morally.  As  soon  as  the  child  can  be  reached 
by  judicious  instruction,  efforts  should  be  made  to  strengthen  both  bodily  and 
mental  inhibition.  The  mistake  should  not  be  made  of  unnecessarily  calling 
the  attention  of  young  children  to  their  genital  organs  and  sexual  feelings; 
occasionally  parents  and  physicians  err  in  this  direction.  A  healthy  child 
should  be  let  alone,  and  too  much  anxiety  and  interference  should  not  be  shown 
because  of  some  physiological  sexual  manifestation.  Ordinary  attention  to 
health  will  often  suffice  to  keep  a  child  straight.  My  own  view,  as  already 
stated,  is  that  mental  disorder  in  children  from  masturbation  may  occur,  but  is 
not  common,  and  that  the  habit  sometimes  weakens  children  Avho  are  mentally 
and  physically  deficient  from  other  causes.  The  physician  or  parent  should 
not  take  for  granted,  as  is  done  so  often,  that  a  large  majority  of  the  nervous 
and  mental  symptoms  and  affections  of  children  are  attributable  to  this  vice. 
Some  mothers  and  fathers  seem  to  live  in  constant  worriment  about  this  matter, 
and  are  always  suspecting  their  children  of  self-abuse.  Clouston's  particular 
suggestions  with  reference  to  the  treatment  of  this  form  of  insanity  must  of 
course  be  qualified  by  considerations  of  age.     ''Avoid  flesh,"  he  says,  "  as  the 


INSANITY  IN  CHILDREN.  711 

incarnation  of  rampant,  uncontrollable  force,  sexual  and  otherwise.  Be  much 
in  the  open  air,  work  hard.  Finally,  so  fill  up  and  systematize  the  time  that 
none  is  left  for  day-dreaming." 

Spitzka  holds  that  painful  corporal  punishment  should  follow  every  attempt 
by  infants  at  touching  the  privates  or  executing  friction,  as  to  no  other  argu- 
ment is  so  young  a  child  accessible.  It  is  doubtful  whether  this  advice  is  of 
universal  application,  but  it  is  perhaps  best  follow;ed  in  some  cases.  As  soon 
as  children  are  old  enough  appeal  can  be  made  to  the  sense  of  shame  and  of 
self-respect.  Any  local  source  of  irritation,  such  as  adherent  prepuce,  irri- 
tative affections  of  the  genito-urinary  apparatus,  and  worms  in  the  alimentary 
canal,  should  of  course  be  removed,  although  this  last  source  of  trouble  is  likely 
to  be  overrated. 


IMPERATIVE  MOVEMENTS  IN  DEFECTIVE  CHIL- 
DREN: ALSO  HEAD-NODDING,  HEADSHAK- 
ING,  HEAD-ROTATING,  HEADBANGING,  AND 
NYSTAGMUS  IN  INFANTS. 


By  CHARLES  K.  MILLS,  M.  D., 

Philadelphia. 


Under  various  but  similar  names,  such  as  head-nodding,  head-jerking, 
head-rotating,  and  head-banging,  certain  acute  aflfections  in  inftmts  and  young 
children  have  been  described.  The  reports  of  these  cases  show  that  they  differ 
in  character,  and  to  such  an  extent  that  for  the  practical  purposes  of  prognosis 
and  treatment  distinctions  must  sometimes  be  made  between  different  varieties. 
Among  the  authors  who  have  contributed  to  our  knowledge  of  this  subject  are 
Henoch,  A.  Baginsky,  S.  Gee,  Stephen  Mackenzie,  and,  more  than  all,  W.  B. 
Hadden  [Lancet^  June  14,  1890,  and  >S'^.  Thomas'  Hospital  Reports,  1890) 
and  for  most  of  the  facts  contained  in  this  brief  sketch  I  am  indebted  to  the 
valuable  papers  of  the  last  named. 

Imperative  Movements  in  Defective  Children. — Before  considering 
the  affections  described  by  Hadden,  it  should  be  borne  in  mind  that  in  well- 
known  organic  affections  of  the  nervous  sj^stem,  so-called  imperative  move- 
ments, due  to  dominating  conceptions  and  insistent  ideas,  may  be  present  either 
in  children  or  adults.  These  may  take  the  form  of  the  salaam  or  bowing 
spasm,  of  snapping  the  eyes,  of  contortions  of  the  face,  of  shrugging  of  a 
shoulder  or  shoulders,  or  of  some  repeated  movements  of  the  arm,  trunk,  or 
leg  ;  or,  again,  they  may  be  some  peculiar  combination  of  movements  executed 
together  or  in  succession.  They  may  in  other  rare  instances  be  shown  as 
an  irresistible  tendency  to  touch  some  special  point  or  to  handle  an  object 
in  some  particular  way.  Occasionally  such  imperative  movements  are  asso- 
ciated with  explosive  expressions  which  may  be  of  profane  or  obscene 
character,  and  to  these  I  have  referred  in  discussing  speech-defects  and  ano- 
malies. Among  the  idiotic,  interesting  instances  of  imperative  and  automatic 
movements  are  observed.  At  the  New  Jersey  Home  for  Feeble-minded 
Children  at  Vineland  one  little  epileptic  patient  has  at  frequent  intervals 
attacks  of  head-shaking,  nodding,  and  jerking.  Another  girl  has  curious 
recurring  rhythmical  movements  Avhich  can  be  started  by  music  or  bv  beat- 
ing monotonously  some  object,  as  a  fan  or  desk.  Holding  one  hand  open 
with  the  little  finger  of  the  other,  she  rapidly  vibrates  the  fingers  of  the  open 
hand  or,  standing  squarely  on  her  feet,  she  continues  for  a  long  time  a  semi- 
rotary  movement  of  the  trunk,  at  the  same  time  tossing  the  head  from  right  to 
left  and  bending  the  body  from  side  to  side. 

At  the  Pennsylvania  Training  School  for  Feeble-minded  Children  at  Eli^n 
is,  or  was,  a  little  patient  familiarly  spoken  of  as   "The  Dervish,"      The 

712 


IMPERATIVE   MOVEMENTS,   HEAD-NODDING,  ETC.       713 

boy  was  of  small  stature  and  weiglit,  a  demi-microcephalic  epileptic  and 
mute  idiot.  At  all  times  he  Avas  subject  to  certain  automatic  tricks  with  his 
hands,  putting  them  and  twisting  them  into  various  positions.  Periodically, 
almost  every  day,  he  gave  exhibitions  of  the  habit  which  had  led  him  to  be 
called  The  Dervish.  He  commenced  by  tattooing  his  chin  with  his  left  hand ; 
next  he  deliberately  and  delicately  touched  the  fingers  of  his  left  hand  to  the 
wrist  of  his  right,  made  two  or  three  salaams,  and  then  impulsively  gyrated 
the  body  from  left  to  right. 

Sometimes  peculiar  movements  are  associated  with  ordinary  epilepsy  in 
children  not  imbecile  or  idiotic.  At  least  some  of  the  cases  particularly 
described  in  this  article  may  have  some  alliance  with  eclampsia  nutans  of  the 
salaam  convulsion  form,  to  which  affection  the  terms  nodding  spasm,  spasmus 
nutans,  and  eclampsia  rotans  have  also  been  applied. 

Head-nodding,  and  Head-jerking. — The  cases  particularly  described 
by  Hadden  in  his  series  of  papers  on  "Head-nodding  and  Head-jerking  in 
Children,  commonly  associated  with  Nystagmus,"  are,  in  his  own  words, 
"  characterized  by  nodding  or  lateral  movements  of  the  head,  either  singly 
or  associated  with  one  another  or  with  movements  of  rotation.  Further,  these 
movements  of  the  head  may  be  almost  constant,  or  may  occur  more  especially 
during  efforts  at  fixation  or  during  excitement,  always  ceasing  during  sleep 
or  when  lying  down.  In  most  cases  there  is  nystagmus  of  one  or  both  eyes, 
vertical,  horizontal,  or  rotary,  often  occurring  simultaneously  with  the  onset 
of  the  head  movements,  but  sometimes  preceding  or  following  them.  The 
nystagmus  is  much  more  rapid  than  the  head  movements,  and  has  an  inde- 
pendent rhythm  ;  it  is  aggravated  by  attempts  at  fixation  or  by  forcibly  restrain- 
ing the  head,  and  may  even  be  induced,  when  previously  absent,  by  these 
means." 

Hadden's  first  observations  were  based  on  an  analysis  of  twelve  cases.  His 
second  series  included  nine  cases  of  which  he  had  kept  notes,  although  in  all  he 
had  seen  fourteen  since  the  publication  of  his  first  series.  His  deductions  from 
an  analysis  of  twenty-one  cases  can  be  summarized  as  follows :  Pure  nodding, 
like  the  movements  of  a  mandarin  doll,  is  rare ;  in  others  the  movements  were 
lateral,  although  combined  or  alternated  nodding  or  rotation  was  common.  He 
sees  no  reason  for  subdividing  the' cases  into  nodding  and  shaking  as  separate 
classes,  as  one  of  these  movements  may  replace  the  other.  The  movements  are 
chiefly  seen  when  the  child's  attention  is  attracted  to  an  object,  and  are 
increased  each  time  it  makes  a  new  effort  at  fixation.  They  cease  during  sleep 
and  when  the  child  is  lying  down  and  when  the  eyes  are  covered.  The  asso- 
ciated nystagmus  is  rapid  and  of  short  range,  and  is  not  constantly  present,  the 
movements  of  the  eyeball  being  usually  horizontal  or  combined  with  some 
rotation.  In  one  case  the  head-nodding  and  nystagmus  were  vertical,  and  in 
another  the  nystagmus  was  confined  to  one  eye  and  associated  with  side-to-side 
movements  of  the  head. 

The  pupils  were  almost  always  normal.  Hippus  or  oscillation  of  the  pupil 
was  present  in  some  cases.  No  unhealthy  ophthalmoscopic  appearances  were 
found.  In  nearly  half  of  the  cases  the  children  had  a  tendency  to  cock  the 
head  on  one  side  or  to  hold  it  in  some  other  unusual  position  when  looking  at 
an  object.  In  a  large  percentage  of  cases  they  had  attacks  as  if  conscious- 
ness was  in  abeyance — seizures  much  resembling  in  character  the  descriptions 
given  of  petit  mal  or  epileptic  vertigo.  Convulsions  were  present  in  a  few 
cases,  and  attacks  of  convulsive  laughter  were  observed  in  one  child.  Rickets 
was  present  in  nine  out  of  the  twenty-one  patients. 

Head-banging. — An  affection  has  been  described  by  Gee  {St.  BartJio- 


714    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

lomew's  ffospital  Reports,  1886),  as  head-banging,  in  which  children  have  a 
habit  of  turning  on  their  faces  at  night  and  banging  their  heads  into  the 
pillow.  According  to  Gee,  the  affection  is  perhaps  a  habit.  As  few  of  these 
cases  have  been  recorded,  I  give  Gee's  brief  account  of  three  cases : 

"  I. — Gilbert  G ,  two  and  a  half  years  old  when  seen  with  Dr.  Donald  Hood, 

had  been  affected  thus  for  two  or  three  months  past.  At  night  in  bed,  both  when  awake 
(half  awake?  )  and  when  sound  asleep,  he  would  turn  over  on  his  face  and  bang  his  fore- 
head into  the  pillow.  In  this  way  he  sometimes  behaved  nearly  all  night  long ;  in 
which  case,  it  need  hardly  be  said,' he  awoke  very  weary.  He  never  had  convulsions 
of  any  kind;  indeed,  no  "disorder,  past  or  present,  other  than  head-banging.  A  year 
and  a  half  afterward  this  disorder  continued  when  he  was  not  tied  down  in  bed.  He 
had  never  suffered  from  nightmare  or  sleep-walking.  (Four  months  after  the  last  notes 
the  patient's  mother  told  me  that  he  continued  to  bang  his  head  at  night  when  not  tied 
down.  Even  when  tied  down  he  rolls  his  head  from  side  to  side,  being  asleep.  Put 
asleep  with  a  younger  brother,  the  latter  began  to  bang  his  head  also  ;  separated,  he,  the 
younger  child,  lost  the  habit.     The  first  boy  continued  healthy  and  cheerful.) 

"  II. — George  H ,  five  years  old,  a  patient  of  Mr.  Patten's,  was  backward  in  un- 
derstanding and  speaking,  but"  there  were  no  signs  of  cretinism.  He  was  a  first  child, 
born  at  full  time  after  a  long  labor  in  which  no  instruments  were  used.  He  had  knock- 
knees  and  splay-feet,  but  his  dentition  was  very  regular.  He  was  restless,  but  clean  in 
his  habits,  and  "never  wet  the  bed.  There  were  no  other  signs  of  disease.  He  never  had 
convulsions  of  any  kind.  Head-banging  began  when  he  was  two  and  a  half  years  old 
(that  is  to  say,  as  soon  as  he  could  hold  his  body  up),  and  it  had  continued  until  the  time 
when  he  wasseen.  He  used  to  turn  over  on  to  his  face  and  bang  his  forehead  into  the 
pillow  about  six  times  in  succession.  The  act  was  seldom  repeated  in  the  same  night, 
and  seldom  occurred  more  than  one  night  in  four.  He  was  fast  asleep  at  the  time,  but 
was  easily  roused. 

"  IIL — Francis  C ,  two  and  a  half  years  old.  had  been  subject  for  six  months  to 

banging  his  head  on  the  pillow  at  night  for  two  or  three  hours  at  a  time.  He  had  an 
inguinal  hernia ;  he  had  erections  of  the  penis  at  night ;  he  masturbated,  and  the  fore- 
skin was  adherent ;  otherwise  the  child  seemed  well.  A  year  afterward  Mr.  J.  Lucas 
Worship  wrote  this  about  him  :  '  While  he  was  staying  in  Sevenoaks,  about  a  month  ago, 
he  was  better  of  knocking  his  head  about,  but  the  nurse  said  that  whilst  at  home  it 
was  as  bad  as  ever.  He  was  a  great  deal  in  the  meadows,  and  slept  well  from  being 
in  the  open  air  so  much,  which  he  was  unable  to  get  while  living  at  home  in  the  town. 
He  was  operated  upon  for  his  phimosis,  which  is  all  right  now,  and  he  does  not  mastur- 
bate since  then.'  " 

At  the  meeting  of  the  Pennsylvania  State  Medical  Society  in  May,  1893, 
two  interesting  cases  of  head  movements  were  reported,  the  first  by  Dr.  J.  C. 
Gable  of  York,  Pa.,  to  whom  I  am  indebted  for  notes.  The  patient  was  a  girl 
ten  months  old,  well  developed  and  apparently  healthy  at  birth.  The  family  of 
the  child  was  of  more  than  ordinary  intelligence,  but  had  a  pronounced  neurotic 
and  tubercular  taint.  The  mother  suffered  from  chorea  when  a  young  girl. 
The  paternal  grandparents  died  of  pulmonary  tuberculosis,  and  an  aunt  suf- 
fered from  an  attack  of  tubercular  arthritis  of  the  right  knee,  which  eventually 
necessitated  a  thigh  amputation.  When  the  doctor  was  first  called  to  see  the 
little  patient  he  found  her  suffering  from  singular  and  seemingly  very  distressing 
semi-rotatory,  oscillatory  bowing  or  bobbing  movements  of  the  head.  These 
were  somewhat  varied  in  character  and  degree,  but  continued  with  a  monotonous, 
rhythmical  regularity,  as  long  as  the  child  remained  awake,  during  a  month, 
and  then  gradually  began  to  diminish,  and  ceased  entirely  in  about  eight  weeks. 
There  was  no  nystagmus,  nor  any  other  special  symptom  except  a  somewhat 
demented  expression  of  face,  which  caused  the  anxious  parents  to  fear  that  the 
child  was  suffei'ing  from  unsoundness  of  mind,  until  assured  that  its  complaint 
was  a  special  and  a  rare  form  of  chorea,  which  yielded  to  zinc  treatment  and 
proper  hygienic  mea.sures. 

The  second  case  was  reported  by  Dr.  J.  C.  McAllister  of  Driftwood,  Pa.,  who 
also  has  kindly  furnished  me  with  brief  notes.     The  child  was  born  in  April, 


IMPERATIVE   MOVEMENTS,   HEAD-NODDING,  ETC.       715 

1892,  with  forceps  delivery,  the  labor  being  the  first  and  quite  difficult ;  but  the 
baby  was,  however,  a  strong  and  well-nourished  boy,  and  no  history  of  nervous 
trouble  in  the  family  could  be  obtained.  In  February,  1893,  when  the  child 
was  about  ten  months  old,  the  doctor  was  consulted  for  the  relief  of  choreic 
movements  of  the  hands  and  arms,  and  also  for  certain  nodding  and  rotatory 
movements  of  the  head.  Aside  from  this,  constipation  was  the  only  symptom. 
Bromide  of  potassium  and  Fowler's  solution  were  prescribed  for  the  movements, 
and  the  constipation  was  also  treated.  After  a  few  weeks  the  bromide  was 
stopped,  but  the  arsenical  solution  was  increased  to  two  drops  four  times  a  day. 
The  infant  had  a  long  prepuce,  and  the  doctor  performed  circumcision,  April 
26,  1893.  The  movements  of  the  hands  ceased  under  the  use  of  the  arsenic 
before  the  operation,  but  the  other  movements  continued  until  after  the  cir- 
cumcision, when  they  gradually  disappeared. 

Nystagmus. — Nystagmus  may  be  described  as  a  constant  involuntary 
movement  of  the  eyeballs,  which  is  usually  horizontal,  but  sometimes  ver- 
tical, and  even  in  rare  cases  may  be  in  a  slightly  oblique  direction  ;  and 
rarely  also  the  vertical  and  horizontal  oscillations  may  alternate  regularly  or 
irregularly,  or  a  vertical  movement  may  be  present  in  one  eye  and  a  hori- 
zontal in  another.  The  commonest  form  of  nystagmus  is  that  in  which  the 
movement  is  bilateral,  horizontal,  and  consentaneous.  Nystagmus  is  present 
in  several  organic  affections  of  the  nervous  system,  as  in  disseminated  scle- 
rosis, and  to  a  less  degree  in  other  forms  of  sclerosis,  diseases  of  the  cere- 
bellum, and  hereditary  ataxia.  It  is  sometimes  due  to  local  affections  of  the 
eyes  which  interfere  with  sight,  as  opacities  of  the  cornea  or  of  the  lens  or 
humors  of  the  eye.  It  is  very  common  in  albinism,  and  is,  as  is  well  known, 
of  frequent  occurrence  among  miners.  As  an  affection  of  children  it  is  chiefly 
of  interest  as  it  occurs  either  in  rare  cases  of  cerebellar  or  other  form  of  brain 
tumor,  or  as  it  occurs  associated  with  head-jerking  and  head-nodding,  described 
in  this  article.  Nystagmus  seems  to  be  an  essential  element  in  a  majority 
of  these  cases,  and  Hadden  describes  and  discusses  these  movements  as  fol- 
lows: 

"This  is  very  rapid,  about  four  to  six  movements  persecond,  and  of  very  short 
range.  One  mother  said  it  was  'like  Perry's  pens  at  the  underground  stations,' 
and  this  homely  description  is  not  inapt.  Nystagmus  is  not  usually  constant ;  not 
infrequently  it  has  to  be  induced  by  making  the  child  fix  objects  here  and 
there,  by  forcibly  restraining  the  movements  of  the  head,  or  by  placing  the 
child  on  its  back.  On  two  occasions  it  was  especially  well  marked  when  the 
child  was  put  to  the  breast.     I  verified  this  by  personal  observation. 

"  The  movements  of  the  eyeballs  are  usually  horizontal,  combined  with 
some  rotation.  As  a  rule,  the  movements  of  the  head  and  eyes  are  in  the 
same  direction,  but  this  is  by  no  means  invariable.  In  my  solitary  case  of 
head-nodding  the  nystagmus  was  vertical,  whereas  in  another  patient  there 
was  vertical  nystagmus  limited  to  one  eye,  associated  with  side-to-side  move- 
ments of  the  head. 

"  There  is  occasionally  a  relation  between  nystagmus  and  the  position  of 
the  eyes  or  evident  ocular  state.  In  one  case  the  nystagmus  was  exaggerated 
on  extreme  conjugate  deviation  to  the  right.  In  two  instances  the  nystagmus 
was  chiefly  evident  when  the  eyes  were  directed  upward,  and  in  one  of  these  it 
was  generally  horizontal,  and  tended  to  become  vertical  when  the  eyes  were 
turned  upward.  The  nystagmus  may  vary  in  direction  apart  from  this  ;  in  two 
instances  the  nystagmus  was  sometimes  vertical,  sometimes  horizontal,  and 
sometimes  rotatory." 


716    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Nystagmus  may  be  the  only  form  of  movement  present  in  cases  exactly 
similar  in  nature  to  those  in  "svhich  the  head  movements  are  also  present ;  as  Had- 
den  put  it,  the  disorder  may  be  indicated  by  nystagmus  alone  just  as  there  may 
be  tabes  dorsalis  without  ataxia  or  paralysis  agitans  without  shaking.  He  gives 
one  instance  in  which  nystagmus  alone  was  present  for  a  year,  but  after  this  the 
patient  showed  occasional  slight  movements  of  the  head. 

Etiology. — In  some  of  the  reported  cases  a  decided  predisposition  to  neu- 
rotic disorder-was  present.  In  six  out  of  the  twenty-one  cases  a  history  of  con- 
vulsions in  other  children  of  the  same  family  was  obtained.  Rickets  was  pres- 
ent in  the  family  in  three  instances,  and  decided  evidences  of  rickets  were  shown 
in  nine  out  of  the  twenty-one  of  Haddens  patients.  The  affection  often 
appears  to  be  due  to  reflex  irritation  from  the  alimentary  canal  or  from  denti- 
tion. Henoch  attached  great  importance  to  dentition  as  a  cause,  but  on  it 
Hadden  does  not  lay  so  much  stress.  Head-jerking  occurs  sometimes  at  an  age 
before  the  process  of  teething  has  begun,  and  a  history  of  injury  to  the  head, 
usually  by  falls,  has  been  present  in  a  large  number  of  cases.  The  affection 
is  more  common  in  females  than  in  males.  In  the  majority  of  cases  it  begins 
between  the  ages  of  six  and  twelve  months.  Usually  the  head  movements  and 
nystagmus  occur  simultaneously  at  the  onset. 

Pathology. — The  pathology  of  the  cases  of  imperative  movements  described 
is  that  of  the  idiocy  or  imbecility  with  which  they  are  associated.  With  refer- 
ence to  the  nature  of  head-nodding  cases,  Hughlings  Jackson  has  suggested 
that  they  are  a  variety  of  spinal  chorea,  a  symptomatic  condition  allied  to  canine 
chorea;  but  Hadden  believes  that  the  seizures  point  to  instability  of  motor- 
centres  above  the  nuclei  in  the  spinal  cord  and  fourth  ventricle,  and  he  would 
therefore  attribute  the  disorder  to  a  functional  or  other  disturbance  of  the  cere- 
bral cortex.  The  child  has  acquired  certain  voluntary  or  purposive  movements 
of  the  head  and  eyeballs,  but  these  have  not  as  yet  become  thoroughly  organ- 
ized and  fixed  in  the  psycho-motor  aveas  of  the  brain ;  hence  a  dissolution 
takes  place  because  of  the  inability  of  the  strained  cortical  centres  to  stand  the 
work  to  which  they  have  been  too  early  subjected.  He  compares  these  head 
movements  to  the  tremors  in  the  head  which  often  occur  in  aged  people  and 
those  seen  sometimes  in  adults. 

Diagnosis. — The  chief  point  in  the  diagnosis  of  these  cases  is  to  distin- 
guish between  the  different  varieties  of  head  movements,  particularly  as  to 
their  occurrence  in  children  otherwise  healthy  or  diseased.  Imperative  or  auto- 
matic movements  suggest  the  presence  of  idiocy  or  imbecility,  and  should  lead 
to  a  study  for  these  affections.  Knowing  that  epilepsy  is  an  accompaniment  of 
some  forms  of  repeated  head  movements,  the  existence  of  this  disease  should 
be  determined  or  dismissed.  Bearing  in  mind  a  few  important  facts  of  this 
character,  the  explicit  and  careful  descriptions  afforded  by  Hadden  and  Gee 
will  serve  to  identify  these  curious  cases. 

Prognosis. — As  a  rule,  these  little  patients  recover,  the  disorder  lasting  for 
varying  periods.  Sometimes  the  movements  will  pass  away  in  a  few  weeks, 
and  at  others  several  months  or  even  one  to  two  years  may  elapse  before 
recovery  takes  place.  Nystagmus  is  said  to  persist  longer  than  the  head  move- 
ments, and  shows  a  greater  tendency  to  recurrence.  One  case  was  observed  by 
Hadden  for  two  years  and  a  half,  nystagmus  not  being  present.  In  making  a 
prognosis  a  distinction  must  be  made  betAveen  the  acute  and  curable  cases,  such 
as  have  been  reported  by  Hadden,  Gee,  and  others  mentioned  in  this  chapter, 
and  the  patients  suffering  from  idiocy,  imbecility,  epilepsy,  or  other  serious 


IMPERATIVE   MOVEMENTS,  HEAD-NODDING,  ETC.       717 

forms  of  mental  or  nervous  disorder,  who  are  the  victims  of  imperative  and 
automatic  movements  described  in  the  beginning  of  the  chapter. 

Treatment. — Any  sources  of  reflex  irritation  should  be  carefully  attended 
to,  but  in  this,  as  in  many  other  cases,  reflex  irritation  has  been  made  a 
scapegoat  for  ignorance  or  imperfect  knowledge.  The  general  health  of  the 
child  should  be  carefully  looked  after,  although  in  some  of  the  reported  cases 
this  seems  to  have  been  very  good.  The  somewhat  frequent  occurrence  of 
rachitis  should  give  this  constitutional  condition  an  importance  in  connection 
with  therapeutics.  Fatty  and  albuminous  foods  in  easily-digested  form  should 
be  given ;  cod-liver  oil  in  some  of  its  various  combinations,  as  with  lime  or 
malt ;  maltine  with  pepsin  and  pancreatin  ;  iron,  particularly  in  the  form  of  the 
powder  or  the  carbonate ;  glycerin,  cream,  peptonized  milk,  and  such  nutrients 
as  are  commonly  chosen  in  rachitic  cases,  may  prove  of  service  in  some  instances, 
as  are  also  such  medicinal  remedies  as  Lugol's  solution  of  iodine;  Donovan's 
solution  of  arsenic,  mercury,  and  iodine;  Fowler's  solution  of  arsenic,  the  syrup 
of  the  hypophosphites,  and  similar  strengtheners  and  builders.  Iodide  of  iron, 
tartrate  or  malate  of  iron,  and  phosphate  of  sodium  may  prove  useful.  Among 
the  remedies  which  are  supposed  to  have  some  influence  upon  the  disorder  bro- 
mides hold  the  first  place,  but  they  should  be  given  with  care,  and  not  in  the 
same  doses  as  in  undoubted  epilepsy.  Five  to  seven  grains  of  bromide  of 
potassium  or  sodium,  with  two  or  three  minims  of  tincture  of  belladonna,  or  one 
minim  of  the  fluid  extract  of  conium,  may  be  used  with  advantage,  and  at  times 
this  dose  may  be  increased  until  a  decided  impression  is  made.  Sulphonal  or 
chloralamid  in  small  doses  is  worthy  of  trial.  The  children  are  usually  not  old 
enough  to  have  their  eyes  refracted.  In  view  of  the  theory  that  the  condition 
is  allied  to  canine  chorea,  and  in  the  light  of  the  suggestion  of  H.  C.  Wood 
{Jour.  American  Med.  A%wc.,  February  25,  1893),  that  in  chorea,  and  par- 
ticularly canine  chorea,  the  inhibitory  apparatus  which  controls  motor  power  in 
the  spinal  cells  is  weakened  to  a  greater  extent  than  is  the  discharge  power, 
and  also  that  quinine  has  a  great  controlling  power  over  choreic  movements  in 
the  dog,  the  importance  of  at  least  trying  quinine  in  increasing  doses  in  the 
treatment  of  these  movements  is  suggested. 


HEADACHE. 

By  CHARLES  K.  MILLS,  M.  D., 
Philadelphia. 


The  term  "headache,"  \\hich  defines  itself,  is  used  to  describe  pain  due 
to  causes  either  outside  or  inside  of  the  cranial  cavity.  Its  general  synonyms 
are  cephalalgia  and  cephalsea,  and  for  one  of  its  most  common  varieties  the 
svnonyms  are  migraine,  megrim,  hemicrania.  or  sick  headache.  Headaches  in 
children  are  less  frequent  in  occurrence,  fewer  in  varieties,  and  less  severe  in 
type  than  in  adults.  Headache  is  most  frequently  a  symptom  of  some  recog- 
nizable functional  or  organic  disease,  and  its  occurrence  in  many  affections, 
such  as  infectious  fevers,  will  not,  of  course,  here  receive  consideration.  The 
wisdx)m  of  discussing  headache  separately  has  been  questioned,  and  with  good 
reason;  but  it  may  be  the  ruling  feature  of  a  case  which  is  presented  to  the 
doctor  for  diagnosis  and  treatment,  and  if  it  is  banished  from  the  picture  little 
is  left  except  to  the  most  critical  research,  although  even  in  such  a  case  care- 
ful study  will  generally  show  that  it  is  simply  a  symptom  of  some  rheumatic, 
dyspeptic,  hysterical,  inflammatory,  or  other  morbid  state. 

The  mechanism  of  pain  in  the  head  is  worthy  of  brief  attention.  It  is 
a  well-known  fact,  although  one  often  overlooked,  that  the  brain  substance  is 
practically  insensitive,  and  pain  in  the  head,  even  when  the  result  or  the 
accompaniment  of  disease  of  the  brain,  is  not  due  directly  to  lesion  of  its 
tissue.  The  brain  of  man  and  of  the  lower  animals  can  be  excised  without 
giving  rise  to  any  sensory  response,  although  the  gentlest  electrical  application 
to  a  motor  centre  may  excite  the  liveliest  movement.  Nerve  end-organs,  which 
are  an  essential  portion  of  the  apparatus  of  sensibility,  are  wanting  in  the 
brain  itself.  Disorders  of  sensibility  due  to  disease  of  the  brain  tissue  are 
referred  to  more  or  less  distant  parts  of  the  body.  The  membranes  of  the 
brain  play  an  important  role  in  intracranial  pain,  as  has  been  shown  by  Duret 
(Brain,  April,  1878),  Ferrier  (Brain,  January,  1879),  and  others.  The  dura 
is  highly  endowed  with  nerves  of  sensation  derived  from  the  trigeminus,  and 
in  rheumatic  or  neuritic  headaches  and  in  those  due  to  organic  disease  the  pain 
is  frequently  dependent  upon  direct  involvement  of  these  nerves.  The  pia  or 
pia-arachnoid  membrane  is  not  so  largely  supplied  Avith  sensory  nerves  as  the 
dura.  The  pia  is  largely  an  immense  network  of  vessels,  Avhose  supply  is  from 
the  gangliated  nervous  system,  and  is  concerned  in  head  pain  through  varia- 
tions in  pressure  and  tension  within  the  cranial  cavity,  as  well  as  to  a  less 
degree  by  direct  nerve  irritation.  Inflamed  arteries  and  veins  cause  pain,  prob- 
ably through  their  direct  or  indirect  influence  upon  nerves  of  sensation.  Blood 
charged  with  toxic  matter  also  causes  pain  both  by  direct  and  indirect  irritation 
of  nerves.  In  explaining  headaches  it  is  necessary,  then,  to  consider  neura] 
or  membranous  inflammation,  alterations  in  pressure  or  tension,  and  toxic  states 
of  the  blood. 


718 


HEADACHE.  719 

The  varieties  of  headache  which  best  deserve  to  be  ranked  as  special  types 
are  (1)  migraine,  and  (2)  the  headaches  of  organic  intracranial  disease.  Other 
so-called  varieties  are  usually  based  upon  etiological  considerations,  and  will  be 
considered  under  that  heading.  It  is  indeed  of  questionable  propriety  to  class 
mio-raine  as  a  headache,  and  this  is  only  done  because  it  seems  to  be  the  most 
practical  method  for  physicians  likely  to  use  a  general  treatise  on  diseases  of 
children.  The  disease  is  migraine,  and  headache  is  only  one  of  a  sei'ies  of 
important  phenomena — visual,  gastric,  motor,  and  mental ;  but  it  is  the  symp- 
tom which  causes  the  patient  the  greatest  suffering  and  for  which  he  appeals 
for  help. 

Migraine. 

Migraine,  megrim,  hemicrania,  or  sick  headache  is  by  no  means  uncommon 
in  children.  Sometimes  very  young  children  have  mild  attacks  of  sick  head- 
ache ;  these  at  first  come  very  seldom,  and  apparently  only  under  special  excit- 
ing causes,  as  over-eating,  excitement,  or  exhaustion  ;  and  at  first  the  intervals 
between  the  paroxysms  may  be  many  weeks  or  months,  but  gradually  they 
become  shorter.  At  first,  also,  the  attacks  can  be  scarcely  recognized  as  genuine 
sick  headaches,  pain  not  being  prominent,  but  as  years  progress  they  become 
more  prolonged  and  severe ;  still,  under  the  age  of  puberty,  however  clear  may 
be  the  type,  migraine  does  not  usually  assume  the  severity  and  intensity  which 
it  shows  after  this  period.  I  have  seen  a  few  instances  of  migraine  in  children 
under  six  years  of  age.  A  boy,  now  ten  years  of  age,  began  to  have  mild 
attacks  of  migraine  at  the  age  of  three,  at  first  having  only  two  or  three  attacks 
a  year,  but  these  gradually  became  more  and  more  frequent,  until  now  he  aver- 
ages a  spell  about  once  a  month.  A  history  of  migraine  is  present  in  four 
generations — in  the  mother,  and  in  the  maternal  grandfather  and  great-grand- 
father. Three  other  children  in  the  same  family  are  not  affected  in  the  same 
way.     The  child  in  other  respects  is  unusually  robust  and  free  from  disease. 

Symptoras. — Except  that  the  symptoms  are  less  pronounced  and  severe 
and  have  fewer  concomitants,  the  phenomena  of  migraine  in  children  are  prac- 
tically the  same  as  in  adults.  It  perhaps  shows  less  tendency  to  recur  at 
regular  periods.  The  child  may  suddenly  or  unexpectedly  exhibit  an  indis- 
position to  play,  may  look  pale  and  troubled,  may  complain  of  nausea  or  of 
being  chilly,  or  may  speak  of  disturbances  of  sight ;  then  the  pain  comes  on, 
and  at  first  is  often  confined  to  one  temple  or  at  least  to  one  side  of  the  head. 
Soon  it  becomes  more  and  more  severe,  and  the  little  patient,  without  urging, 
is  glad  to  go  to  bed  in  a  quiet  room.  The  pain  may  last  for  hours  or  the  better 
part  of  a  day,  or  in  some  instances  in  young  children  it  is  relieved  in  an  hour 
or  two,  usually  by  vomiting,  followed  by  sleep.  The  migraine  of  childhood  is 
not  so  likely  to  occur  early  in  the  morning  as  in  adult  life.  The  visual  pro- 
dromes are  comparatively  common  in  children,  although  they  may  be  absent. 
They  may  take  the  form  of  photopsia,  as  balls  or  rims  of  fire  or  zig-zag  colored 
lines,  or  hemianopsia,  or  general  obscurity  of  sight.  The  more  complicated  and 
profound  cerebral  phenomena  sometimes  seen  in  adults,  such  as  amnesic  aphasia, 
hemiparesis,  monoansesthesia,  and  hallucinations  of  sight  or  great  mental  per- 
turbation, may  be  present,  but  are  not  as  common  in  children  as  in  adults. 
Putnam  (cited  by  Sinkler,  St.  Louis  Med.  Revieiv,  October  29,  1887),  has 
recorded  a  case  of  a  patient  in  whom,  in  boyhood,  migraine  was  represented 
by  repeated  attacks  of  numbness  and  tingling  in  the  right  side  of  the  face  and 
right  half  of  the  body,  with  aphasia  and  hemianopsia,  followed  by  a  trifling 
headache  or  none  at  all ;  but  later  in  life  he  had  attacks  of  pain.  The  pain  of 
migraine  is  usually  one-sided,  and  may  be  confined  to  the  supra-orbital  or 


720    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

temporal  region.  The  attacks  are  usually  much  the  same,  except  that  they 
grow  in  severity  as  the  years  advance.  Nausea  and  vomiting  are  of  frequent 
occurrence,  but  not  invariable. 

Etiology. — Heredity  is  the  most  important  predisposing  cause  of  migraine, 
as  of  some  other  forms  of  headache.  Of  exciting  causes,  excessive  fatigue, 
mental  or  nervous  exhaustion,  and  indigestion  are  the  most  important.  Dis- 
orders of  digestion  are  often  placed  in  the  front  rank  of  exciting  causes,  but  it 
may  be  forgotten  that  the  nausea  and  vomiting  are  frequently  of  central  origin. 
Rheumatic  weather  seems  to  have  an  influence  in  precipitating  attacks  of 
migraine. 

Pathology. — The  pathology  of  migraine  is  practically  unknown,  as  no 
theory  which  has  been  advanced  has  well  withstood  the  attacks  made  upon  it. 
It  does  not  explain  its  true  pathology  to  show  that  attacks  may  be  induced  or 
excited  by  eye-strain,  or  disordered  digestion,  or  intestinal  putrefaction.  These 
attacks  are  certainly  sensory^  explosions,  analogous  in  their  methods  of  exhibi- 
tion to  the  spasms  which  result  from  discharges  of  the  cortical  motor  centres. 
Migraine,  as  has  been  claimed,  has  many  of  the  appearances  of  sensory  epi- 
lepsy. Cortical  discharges  of  the  visual  cerebral  centres  would  best  explain  the 
curious  and  frequent  visual  prodromes.  Whatever  may  be  its  pathology,  it  is,  as 
a  rule,  a  cerebral  affection.  Anstie  regarded  migraine  as  a  variety  of  neural- 
gia of  the  first  or  ophthalmic  division  of  the  trigeminus ;  and  in  favor  of  this 
theory  is  the  occurrence  of  certain  local  trophic  affections,  such  as  herpes  zos- 
ter, ulceration  of  the  cornea,  and  changes  in  the  color  of  the  hair  ;  but  cases  of 
neuralgia  or  neuritis  of  branches  of  the  fifth  nerve,  not  instances  of  true 
migraine,  are  sometimes  confounded  with  the  latter.  In  the  so-called  tic- 
douloureux  and  in  other  less  severe  forms  of  painful  disease  of  the  branches  of 
the  trigeminus,  trophic  disorders  are  frequent.  True  migraine  and  trigeminal 
neuralgia  or  neuritis  may  be  present  in  the  same  case ;  indeed,  the  affections 
sometimes  blend  in  the  same  person.  Migrainous  subjects  are  vulnerable  to  the 
same  influences  as  are  neuralgics  and  neuritics ;  but  these  and  similar  facts  do 
not  prove  that  the  disorders  are  identical.  Much  stress  has  been  laid  upon 
the  exact  state  of  the  vessels  of  the  brain  during  attacks  of  migraine.  Accord- 
ing to  one  view,  in  one  form  of  hemicrania  the  blood-vessels  of  one  side  of  the 
brain  or  of  a  limited  area  of  the  brain  are  in  a  spastic  state,  while  in  another 
variety  a  paretic  state  of  the  vessels  exists.  To  explain  the  pain  Du  Bois- 
Reymond  held  that  the  spasm  of  the  vessels  caused  pinching  of  the  nerves  in 
their  sheaths. 

Diagnosis. — A  clear  understanding  of  the  usual  prodromata  and  of  the 
method  of  progression  of  the  symptoms  is  the  best  key  to  the  diagnosis  of 
migraine.  It  is  perhaps  most  likely  to  be  confounded  with  headache  of  organic 
origin,  particularly  with  tumor  and  meningitis.  The  ophthalmoscope  and 
various  localizing  symptoms  which  will  be  spoken  of  hereafter  will  greatly  aid. 
Hysterical  or  imitative  headaches  in  children  may  occasionally  closely  simulate 
migraine,  particularly  in  children  whose  parents  are  victims  of  the  disease. 

Prognosis. — The  prognosis  of  migraine  as  to  cure  is  bad.  Usually  the 
attacks  become  more  frequent  as  the  child  groAvs  older. 

Treatment. — For  attacks  of  migraine  in  children  energetic  active  treat- 
ment does  not  seem  as  necessary  as  in  adults.  As  soon  as  the  prodromes 
appear  the  child  should  be  placed  in  a  quiet,  darkened  room,  away  from  sources 
of  irritation  and  depi'ession.  Phenacetin,  antipyrin,  antifebrin,  and  caffeine 
are  among  the  most  useful  remedies  for  the  abridgement  or  the  mitigation  of  the 
attacks.  Four  or  five  grains  of  antipyrin  or  antifebrin,  with  two  or  three 
minims  of  tincture  of  digitalis  or  tincture  of  strophanthus  to  protect  the  heart, 


HEADACHE.  721 

may  be  given  every  hour  or  two  until  three  or  four  doses  are  taken.  Caffeine, 
or  the  citrate  of  caffeine,  in  doses  of  one  to  two  grains  every  half  hour,  will 
sometimes  abort  an  attack  if  given  early.  Once  an  attack  has  fully  developed, 
it  is,  as  a  rule,  best  to  let  the  patient  alone  or  only  to  use  external  applications, 
as  of  hot  water  to  the  head  or  feet  or  menthol  or  chloral-camphor  or  mild  gal- 
vanization to  the  forehead  and  head.  An  emetic  of  ipecacuanha  is  sometimes 
efficient,  and  the  administration  of  a  large  dose  of  this  drug  may  afford  relief 
even  when  it  does  not  produce  emesis. 

The  treatment  of  migraine  during  the  intervals  of  the  attacks  is  of  con- 
siderable importance.  Everything  should  be  done  to  keep  the  child  in  the 
very  best  general  condition.  Cannabis  Indica  has  been  much  praised  for  adults, 
giving  it  in  increasing  doses,  beginning  with  one-tenth  or  one-twelfth  of  a 
grain  three  times  daily,  and  continuing  the  treatment  systematically  for  months ; 
but  its  use  for  children,  like  that  of  other  narcotics,  is  not  to  be  encouraged. 
Arsenic,  quinine,  iron,  hydriodic  acid,  and  the  hypophosphites  are  of  benefit, 
particularly  in  debilitated  cases  ;  but  it  is  not  my  experience,  as  it  seems  to  have 
been  of  others,  that  migraine  in  childhood  is  likely  to  occur  in  subjects  who 
are  weak,  ansemic,  and  sedentary.  The  most  robust  and  hearty  child  of  a 
family  may  be  the  sole  victim  of  the  disorder,  although  this  is  not  invariably 
true.  Great  attention  has  been  paid  in  recent  years  to  the  relief  of  eye-strain 
in  the  treatment  of  this  affection ;  and,  while  the  favorable  results  of  ocular 
treatment  have  been  overstated,  measures  directed  to  the  eyes  should  not  be 
neglected.  Hypermetropia,  myopia,  and  astigmatism  should  be  corrected  if 
sufficient  in  degree  to  clearly  cause  discomfort  or  annoyance.  The  eyes  should 
be  examined  under  atropine,  and  the  correction  should  be  as  complete  as  possi- 
ble. Tenotomy  or  partial  tenotomy  may  need  to  be  performed,  but  too  much 
in  a  curative  way  should  not  be  expected  from  these  measures.  In  particular, 
children  who  are  going  to  school  and  paying  close  attention  to  their  studies 
should  have  their  eyes  investigated.  Imperfectly  ventilated  and  badly-lighted 
school-rooms  and  house-rooms  probably  count  for  much  as  exciting  causes 
of  migraine. 

Some  children  suffer  from  forms  of  headache  which  have  many  of  the 
characteristics  of  migraine,  but  cannot  be  said  positively  to  belong  to  this  type. 
These  children,  most  commonly  young  girls  at  school,  have  attacks  of  head- 
pain,  accompanied  with  nausea  or  with  both  nausea  and  vomiting,  which  compel 
them  to  rest  and  cause  them  to  be  irritable  and  worrisome.  These  headaches 
are  often  associated  with  constipation.  They  are  sometimes  entirely  relieved 
by  a  change  from  a  sedentary  to  an  open-air  life.  They  recur  so  frequently 
that  the  term  "recurrent  headache "  has  been  used  in  describing  them, 
although  this  expression  has  been  applied  also  to  other  forms  of  headache. 
They  differ  from  typical  migraine  in  the  absence  of  prodromes  and  in  their 
lesser  severity.  They  might  perhaps  be  termed  migranoid  cases.  Like  typical 
migraine,  such  headaches  are  often  observed  in  children  of  neurotic  heredity. 

Headaches  due  to  Organic  Disease. 

Intracranial  tumor,  meningitis,  abscess,  and,  in  very  rare  instances,  aneu- 
rism, may  be  the  cause  of  headache  in  children.  Headache  is  rarely  absent  in 
brain  tumor,  and  sometimes  causes  extreme  suffering,  but  occasionally  a  growth 
may  be  present  without  this  symptom.  The  tumors  which  are  most  likely  not 
to  give  rise  to  pain  are  the  gliomata,  probably  because  these  neoplasms  are  not 
usually  connected  with  the  brain  membranes,  and  also  because  owing  to  their  soft 


722    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

structure,  they  exert  comparatively  little  pressure.  Much  of  the  horrible  pain 
commonly  present  in  intracranial  tumor  is  dependent  upon  irritation  of  branches 
of  the  fifth  nerve  in  the  dura,  and  this  does  not  always  occur  in  gliomata, 
because,  as  has.  been  stated,  they  may  be  unconnected  with  this  membrane.  In 
several  instances  I  have  observed  cases  of  gliomata  of  the  cerebellum  in  which 
pain  was  unimportant ;  but  it  remains  true  that  in  children,  as  in  adults,  head- 
ache is  a  very  common  symptom  of  an  intracranial  growtli.  In  infants  and 
very  young  children,  the  sutures  still  remaining  open,  the  pressure  within  the 
cranium  is  not  increased  to  the  same  extent  as  in  adults  by  a  developing  tumor. 
The  location  of  pain  in  the  head  is  sometimes,  although  rarely,  a  guide  to  the 
position  of  the  growth,  but  at  the  best  it  is  an  uncertain  guide.  A  constant 
occipital  pain  may  indicate  a  neoplasm  in  the  posterior  fossa,  but  often  this 
will  be  deceptive.  Patients  with  cerebellar  tumor  may  complain  of  severe 
frontal  pain.  In  tumors  pain  in  the  head  is  usually  increased  by  percus- 
sion, and  in  some  instances  this  pain  will  be  greatest  over  the  seat  of  the 
disease. 

Tuberculous  growths  or  conglomerations  are  common  in  tuberculosis  in  chil- 
dren, and  in  these  cases  more  or  less  tuberculous  meningitis  is  present,  so  that 
the  diagnosis  of  the  cause  of  the  headache,  as  between  an  isolated  growth  and 
a  meningitis,  becomes  difficult.  The  headache  of  tubercular  meningitis  is  often 
of  great  intensity,  and  this  disease  may  be  accompanied,  like  other  affec- 
tions of  the  cerebral  membranes,  and  particularly  of  the  dura,  with  vertigo, 
nausea,  vomiting,  and  screaming  or  crying ;  but,  while  this  is  true,  headache 
is  not  an  invariable  accompaniment  of  cerebral  meningitis,  and  particularly 
of  lepto-meningitis  of  slow  development. 

Occasionally  the  source  of  a  severe  headache  is  a  cerebral  or  cerebellar 
abscess,  which  is  usually  of  rapid  development,  as  long-latent  abscesses  are  not 
likely  to  occur  in  children.  Such  abscesses  are  commonly  found  in  association 
with  disease  of  the  middle  or  internal  ear,  and  the  pain  will  be  more  or  less 
referred  to  the  location  or  neighborhood  of  this  organ. 

The  diagnosis  of  tumor,  meningitis,  or  abscess  as  the  cause  of  a  head- 
ache will  be  made  by  a  careful  study  of  the  accompanying  conditions.  The 
most  common  of  these  will  be,  first,  such  general  symptoms  as  optic  neuritis, 
nausea,  vomiting,  vertigo,  monospasm,  or  convulsions,  mental  irritability,  or 
depression,  apoplectiform  attacks,  and  paralysis  of  cranial  nerves  or  of  the 
face  or  limbs,  liypersesthesia,  anaesthesia;  and,  according  to  the  seat  of  the 
growth,  special  phenomena,  such  as  hemianopsia,  or  cerebellar  titubation.  As 
tumors  of  the  cerebellum  are  somewhat  common  in  children,  the  particular 
symptomatology  of  growths  in  this  location  should  always  be  borne  in  mind. 
These  symptoms,  in  addition  to  the  headache,  vertigo,  vomiting,  hypergesthesia, 
optic  neuritis,  etc.,  just  described,  are,  or  may  be,  unsteadiness  in  station  or 
gait;  nystagmus;  sometimes  internal  squint;  frequent  blindness;  sometimes 
deafness ;  enlargement  of  the  head  from  acquired  hydrocephalus  ;  rigidity  of 
the  muscles  of  the  neck  with  retraction  of  the  head  ;  loss  of  knee-jerk,  or  occa- 
sionally striking  peculiarities  of  the  knee-jerk.  Sometimes  pain  is  marked  in 
the  neck  and  back.  These  symptoms  point  particularly  to  tumor  of  the  middle 
lobe  of  the  cerebellum. 

Among  organic  headaches  may  be  classed  those  which  are  due  to  inherited 
syphilitic  affections,  but  which  are  not  necessarily  eitlier  growths  or  meningitis. 
The  headache  which  accompanies  the  epileptic  paroxysm  also  must  not  be  over- 
looked in  considering  this  class.  As  is  well  known,  it  may  either  precede  or 
follow  the  epileptic  fit,  or  it  may  be  present  with  slight  attacks  of  petit  mal 
which   are  scarcely  observed.       Catarrhal   headache  of  inflammatory  origin, 


HEADACHE.  .      723 

according  to  Allen  {Med.  News,  March  13,  1886),  is  seen  occasionally  in  acute 
congestion  or  inflammation  of  the  frontal  sinuses.  The  pain,  which  is  severe, 
is  usually  confined  to  one  side,  but  it  is  rare  in  children. 

Etiological  Varieties  of  Headache. 

The  predisposing  causes  of  headache  in  children  are  few,  the  exciting  causes 
are  many,  and  numerous  classes  or  varieties  of  headaches  have  been  erected, 
based  chiefly  upon  etiological  considerations.  These  etiological  varieties  may  be 
indefinitely  extended,  and  it  is  chiefly  for  this  reason  that  authors  differ  so  much 
in  their  classifications  of  headache.  Even  the  headaches  of  children  have  been 
subdivided  into  numerous  classes,  as  into  the  so-called  school-headaches ;  the 
headaches  of  the  period  of  growth  ;  anaemic,  hypersemic,  and  neurasthenic  head- 
aches ;  headache  of  the  eye-strain  and  of  genital  irritation ;  and  so  on  through 
a  lono;  list,  accordino;  to  the  inclination  or  views  of  the  classifier.  The  causes 
of  organic  headaches  have  necessarily  been  given  in  the  course  of  their  general 
discussion.  The  great  predisposing  cause  of  migraine,  as  has  been  stated,  is 
heredity ;  the  exciting  causes  are  those  also  of  headache  of  any  type,  as  exces- 
sive fatigue,  mental  or  nervous  exhaustion,  disorders  of  digestion,  changes  in 
the  weather,  badly  heated  and  ventilated  rooms,  lack  of  exercise,  impoverished 
or  altered  blood  (anaemia,  hypersemia,  or  toxaemia),  overwork,  excitement, 
undue  exposure  to  heat  or  to  cold,  eye-strain,  gastro-intestinal  disorders,  genital 
irritation,  nasal  or  pharyngeal  catarrhs,  or  aching  teeth.  A  close  consider- 
ation of  the  causes  or  alleged  causes  of  headache  in  children  will  show  that  in 
addition  to  migraine  and  organic  headaches  we  might  conveniently  erect  the 
following  etiological  varieties:  1,  anaemic  headache;  2,  reflex  headache; 
3,  hysterical  headache  ;    4,  neuritic  headache. 

Anemic  Headache. — Angemic  headaches  sometimes  occur  in  children, 
although  with  not  nearly  the  same  frequency  as  in  adults,  and  especially  in 
women.  A  few  children  seem  to  inherit  an  anaemic  diathesis,  just  as  others 
are  congenitally  rachitic.  These  children  are  pale  in  skin  and  mucous  mem- 
branes, sometimes  to  the  extent  of  being  chlorotic ;  they  lack  in  strength 
and  in  nerve  energy ;  they  are  neurasthenic  as  well  as  anaemic.  It  is  rare,  in 
children,  to  see  a  neurasthenic  or  exhaustion  headache  not  associated  with 
impoverished  state  of  the  blood ;  and  therefore  the  distinction  between  a  neuras- 
thenic and  an  anaemic  headache  can  be  more  sharply  made  in  the  adult.  The 
diagnosis  of  an  anaemic  headache  is  to  be  made  by  a  careful  investigation  for 
the  evidences  of  anaemia,  even  to  the  extent,  if  necessary,  of  a  blood-count. 
It  is  well  to  remember  that  every  pale-faced  child  is  not  anaemic,  and  also  that 
some  children  who  are  well  supplied  with  fat  may  have  poor  blood. 

Reflex  Headaches. — While  too  much  stress  is  laid  upon  reflex  action 
as  the  source  of  innumerable  maladies,  it  plays  an  important  part  in  many 
cases  of  headache,  as  in  the  production  of  other  symptoms.  When  a  child 
complains  of  headache  after  study  or  use  of  the  eyes  at  close  work,  as  in 
drawing,  writing,  or  sewing,  the  eyes  should  be  investigated.  Serious  defects 
of  refraction  may  be  present,  particularly  hypermetropia  with  astigmatism,  and 
these,  if  sufficient  to  cause  strain,  should  be  at  once  corrected.  Children  who 
indulge  in  over-eating  or  careless  eating  sometimes  suffer  in  consequence 
from  headaches,  which  are  relieved  by  spontaneous  vomiting  or  by  the  use  of 
emetics  or  cathartics;  but  it  must  be  remembered  that  true  migraine  in  children 
is  associated  with  nausea  and  vomiting,  and  that  the  gastro-intestinal  disorder 
in  these  cases  is  a  concomitant  rather  than  a  cause  of  the  headache.  Perhaps 
too  much  stress  has  been  laid  on  sexual  irritation  as  a  cause  of  headaches  in 
children,  but  that  it  may  be  occasionally  causative  cannot  be  doubted.     Allen 


724    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

(loc.  cit.)  has  presented  some  points  of  practical  importance  in  connection  with 
reflex  headache,  in  association  with  chronic  nasal  catarrh,  which  have  a  bear- 
ing on  the  headaches  of  childhood.  These  reflex  headaches  are  said  by  him 
to  be  almost  entirely  restricted  to  the  temple  and  the  vertex.  Sometimes  nausea 
is  present,  and  sometimes  if  a  probe,  passed  into  the  nose,  is  made  to  touch  the 
middle  turbinated  bone,  vertex  pain  will  instantly  follow.  The  inner  wall  of  the 
orbit  is  often  peculiarly  sensitive,  and  the  nasal  mucous  membrane  is  in  a  state  of 
intense  inflammation.  The  reflex  headaches  of  chronic  nasal  catarrh  are  sharply 
separated  from  the  headaches  of  cerebral  disease  by  the  absence  of  any  symp- 
tom referable  to  cranial  sources,  the  lack  of  evidence,  as  furnished  by  a  history  of 
the  case,  that  the  complaint  is  of  central  origin,  and  the  complete  control  of  the 
pain  by  local  treatment.  Allen  distinguishes  reflex  catarrhal  headache  from 
sick  headache  of  gastric  origin  by  the  absence  of  furred  tongue,  and  from  the 
temple  pains  of  eye-strain  by  its  persistence  after  the  correction  of  errors  of 
refraction.  Such  headaches  may  be  the  cause  of  nervous  prostration.  Reflex 
headache  may  also  have  its  origin  in  the  pharynx  or  even  in  decayed  teeth. 

Hysterical  Headache. — A  frequent  form  of  headache,  even  in  children 
of  tender  years,  is  the  hysterical  headache,  or  what  might  perhaps  be  better 
termed,  in  most  instances,  the  imitative  headache.  Most  children,  and  particu- 
larly those  of  the  precocious  and  aff'ectionate  type,  are  fond  of  sympathy  and 
coddling.  They  are  very  close  observers  of  the  suff'erings  and  peculiarities  of 
others.  They  have  slight  pains  and  aches,  and  these  become  headaches  appar- 
ently of  very  great  severity.  Often  a  child  who  complains  of  vertical  head- 
ache, or  of  headache  associated  wuth  inability  to  stand  the  light,  or  of  great 
pain  over  the  eyes  or  in  the  back  of  the  head  or  neck,  will  be  found  on  close 
inquiry  to  have  a  father  or  mother,  and  especially  a  mother,  who  is  subject  to 
similar  aches  and  pains.  Just  as  hysterical  and  hystero-epileptic  convulsions, 
aphonia,  paresis  of  one  or  more  limbs,  and  even  hysterical  blindness,  may  be 
simulated  or  mimicked  by  the  child  of  a  neurotic  parent,  so  headache  and  other 
pains  and  aches  in  children  are  even  more  frequently  to  be  traced  to  the  same 
source. 

Neuritic  Headache. — Some  children,  usually  of  neurotic,  rheumatic,  or 
arthritic  heredity,  suff"er  from  pains  in  the  head  and  face  which  are  accompanied 
by  tenderness  and  pressure  over  exposed  nerve  ends  and  trunks,  and  also  are 
commonly  increased  by  pain  on  movement  of  the  scalp.  These  mild  but  annoy- 
ing head  pains  are  due  to  forms  of  subacute  or  chronic  neuritis,  which  may  or 
may  not  be  associated  with  slight  inflammation  of  other  tissues.  Head  pains 
and  headaches  of  this  kind  are  much  influenced  by  the  weather.  Even  Avhen 
external  tenderness  is  not  present,  pains  in  the  head  may  be  due  to  inflamma- 
tion of  the  branches  of  the  fifth  nerve  in  the  dura,  or  in  the  grooves  or  fora- 
mina of  the  skull,  or  in  the  scalp.  These  cases  usuall}^  yield  rapidly  to  anti- 
rheumatic or  antineuritic  treatment.  Since  the  occurrence  of  the  recent  pro- 
longed epidemic  of  influenza  many  cases  of  chronic  headache  or  of  chronic 
head  and  face  pains  have  been  observed,  chiefly  in  adults,  but  now  and  then  in 
children.  Most  of  these  have  been  due  to  a  lingering  neuritis  or  to  the  want 
of  tone  in  nerve  centres,  left  wounded  or  vulnerable  by  the  ravages  of  this 
disease. 

Diagnosis  and  Prognosis. — The  diagnosis  of  headache  in  general  relates 
chiefly  to  the  differential  diagnosis  of  its  varieties  already  considered.  When 
pain  in  the  head  is  present,  the  general  diagnosis  of  headache  is  made,  the  only 
point  of  importance  being  to  distinguish  as  to  Avhether  it  is  due  to  intracranial 
or  extracranial  causes.  The  points  already  given  under  the  general  varieties  of 
headache  will  serve  in  the  main  for  their  diff"erentiation.     I  would  simply  lay 


HEADACHE.  725 

stress  upon  the  necessity  of  separating  those  forms  due  to  pronounced  organic 
disease  from  migraine  and  from  functional  types,  such  as  the  hysterical,  the 
neurasthenic,  and  the  rheumatic.  Proper  but  not  undue  attention  should  be 
given  to  the  question  of  reflexes.  The  prognosis  of  headaches  has  already 
been  sufiiciently  considered  in  speaking  of  its  different  varieties. 

Treatment. — The  treatment  of  the  headaches  of  children  will  depend  largely 
upon  the  special  variety.  The  treatment  of  migraine  has  been  discussed  ;  that 
of  organic  headache  will  be  largely  of  the  underlying  disease.  For  the  relief 
of  these  headaches  two  classes  of  remedies  should  be  employed :  first,  those 
for  the  immediate  relief  of  pain ;  and,  secondly,  those  to  improve  the  state 
on  which  the  headache  depends.  For  the  immediate  relief  of  pain  the  best 
remedies  are  phenacetin,  antipyrin,  antifebrin,  bromides,  chloral,  sulpho- 
nal,  chloralamid,  codeine,  hyoscine,  ether,  chloroform,  and  preparations  of 
opium.  These  remedies  should  be  used  in  doses  proportioned  to  the  age  of  the 
child,  although  it  should  be  remembered  that  children  suffering  from  violent 
pain,  wherever  located,  will  stand  larger  doses  of  hypnotics  and  narcotics  than 
those  in  health  or  those  who  are  suffering  from  non-painful  diseases.  In  brain 
tumor  and  meningitis  phenacetin  and  antipyrin  in  combination  will  sometimes 
afford  great  relief. 

For  the  constitutional  or  the  acquired  organic  conditions  on  which  some 
headaches  depend,  mercury,  the  iodides,  hydriodic  acid,  arsenic,  and  similar 
constitutional  measures  will  be  found  most  beneficial.  In  most  cases  mercury 
is  best  used  in  the  form  of  minute  doses  of  the  bichloride. 

As  not  a  few  children  who  suffer  from  chronic  headache  are  both  anaemic 
and  neurasthenic,  it  is  of  great  importance  first,  to  pay  attention  to  these 
conditions,  and  the  best  treatment  for  adults  will  not  always  answer  in  these 
cases.  Preparations  of  iron  and  arsenic  should  be  given,  but  care  should  be 
taken  in  their  selection.  Among  the  most  useful  iron  preparations  are  the 
malate,  the  citrates  of  iron  and  quinine,  the  ammonio-citrate  of  iron,  the 
lactate  of  iron,  powdered  iron,  and  dialyzed  iron.  Palatable  preparations  can 
be  readily  chosen  with  a  little  care.  Arsenic  alone  or  in  some  combination  will 
often  be  found  extremely  useful.  I  prefer  small  doses  of  Fowler's  solution 
alone  or  in  combination  with  the  compound  syrup  of  the  hypophosphites.  In 
these  anasmic  children  most  careful  attention  should  be  paid  to  the  quality  of 
the  food  and  to  the  manner  of  giving  it.  Much  headache  in  American  chil- 
dren and  in  adults  is  associated  with  the  dyspeptic  troubles  which  are  so  com- 
mon in  this  country,  and  which  are  not  infrequently  due  to  the  use  of  the  fry- 
ing-pan and  to  other  evil  methods  of  preparing  food.  Children  with  their  fresh 
and  vigorous  digestive  organs  do  not  suffer  so  much  in  this  way  as  adults,  and 
particularly  those  who  have  reached  middle  age  or  who  have  passed  into  the 
decline  of  life ;  still,  the  matter  is  one  of  practical  importance  and  should  not 
be  overlooked.  The  diet  of  children  inclined  to  be  dyspeptic  and  to  suffer  from 
headache  should  be  plain,  wholesome,  nutritious,  and  easily  digested.  It  is  not 
well  to  train  children  to  depend  upon  digestives,  such  as  pepsin  and  pancreatin, 
although  occasionally  their  use  itiay  be  necessary.  The  stomachs  of  children 
are  greatly  helped  sometimes  by  the  administration  in  small  doses,  before  meals, 
of  bitter  tonics,  such  as  chamomile,  quassia,  columba,  gentian,  or  cascarilla, 
which  are  best  given  in  the  form  of  infusion  or  small  doses  of  the  fluid  extract. 

The  exciting  cause  of  a  reflex  headache  should  always  be  attacked.  Eyes, 
ears,  teeth,  nose,  pharynx,  stomach,  liver,  or  genital  organs  should  receive 
therapeutic  attention  if  necessary.  The  removal  of  adenoids  has  resulted  in 
great  benefit  to  children  suffering  from  headache  and  inability  to  study  or  fix 
their  attention.     Some  striking  instances  are  also  on  record  of  headaches  due 


726    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

to  decayed  teeth,  writers  even  going  so  far  as  to  declare  that  these  and  visual 
defects  are  the  most  common  causes  of  headache. 

For  hysterical  or  imitative  headaches  moral  treatment  and  the  improvement 
of  the  general  condition  of  the  patient  by  tonics,  nutrients,  good  food,  gym- 
nastics, bathing,  and  out-door  exercise  will  prove  most  beneficial. 

Neuritic  or  rheumatic  headaches  should  be  treated  with  the  salicylates, 
which  are  often  usefully  combined  with  small  doses  of  bromides  and  iodides. 

Of  local  applications  for  the  relief  of  headache  in  children,  the  most 
important  are  the  use  of  menthol,  chloral  and  camphor,  ointments  of  aconitia, 
hot,  cold,  or  ethereal  applications,  galvanism,  and  head  massage.  Sinapisms 
to  the  back  of  the  neck  and  hot  or  stimulating  foot-baths  are  good  old-fashioned 
remedies  which  may  prove  of  great  service. 


HYSTERIA. 


By  JAMES  HENDRIE  LLOYD,  A.M.,  M.  D., 

Philadelphia. 


Hysteria  in  children  has  probably  existed  always.  Peugniez  tells  us  that 
in  an  old  fresco  of  Dominicain  the  painter  represents  a  saint  curing  a  child 
possessed  of  an  evil  spirit.  The  patient  is  not  drawn  from  imagination,  but 
from  life,  for  he  is  in  one  of  the  classical  attitudes  of  the  grand  attack.  With 
arms  extended  in  the  position  of  the  cross,  eyes  rolled  upward,  and  trunk  con- 
vulsed in  opisthotonos,  he  exhibits  the  disease  in  one  of  its  most  common  forms. 
It  was  only  because  of  the  ancient  Hippocratic  definition  of  hysteria,  which 
attributed  the  great  neurosis  to  disorders  of  the  womb,  that  for  such  a  long 
period  it  was  not  recognized  or  acknowledged  before  puberty.  For  two  thou- 
sand years  this  error  ruled  the  medical  world,  and  had  for  a  kindred  error  the 
belief  that  hysteria  is  not  observed  in  men.  Lepois  was  undoubtedly  the  first 
writer  to  note  the  frequency  of  hysteria  in  children.  After  his  time  scattered 
references  to  the  subject  appeared,  but  still  the  old  pathology  prevailed  even 
to  the  time  (18-16)  of  Landouzy's  treatise.  Briquet's  statistics  in  his  classical 
monograph  on  hysteria  inaugurated  the  modern  epoch  of  scientific  investigation 
which  secured  the  recognition  of  this  form  of  the  disease.  It  is,  however,  to 
Charcot  and  the  contemporary  school  of  the  Salp^tri^re  that  we  owe  the  most 
light  upon  this  subject.  In  the  masterly  demonstration  of  hysteria  in  both 
sexes  and  at  all  ages  given  by  this  school  we  recognize  for  the  first  time  the 
unity  and  individuality  of  this  disease.  Hysteria  is  henceforth  no  longer  a 
vague  label,  of  indeterminate  value,  for  an  incongruous  mass  of  phenomena, 
seen  exclusively  in  women,  which  most  Avriters  have  by  tacit  agreement  united 
to  call  "  protean."  Far  from  being  changeable  and  indeterminable  these 
phenomena  are  shown  to  be  constant  and  subject  to  a  strict  arrangement:  far 
from  being  confined  to  one  sex  or  age  or  country,  they  are  shown  to  be  dis- 
tributed well-nigh  universally ;  and  far  from  being  typical  only  in  the  adult 
female  they  are  seen  probably  nowhere  to  more  advantage  than  in  children. 

In  addition  to  the  writings  of  Charcot,  we  may  make  special  mention  of  the 
thesis  of  Peugniez  and  the  treatise  of  Gilles  de  la  Tourette,  to  both  of  which 
we  are  indebted  for  invaluable  information.  Other  notable  theses  are  those  of 
Clopatt  d'Helsingfors  and  Mile.  H.  Goldspiegel,  quoted  by  Tourette,  The 
annual  contributions  of  Bourneville  on  hysteria,  epilepsy,  and  idiocy  are  of 
great  value.  In  the  English  language  the  most  complete  paper  on  hysteria  in 
children  is  by  Dr.  Mills  {Keating' s  Cyclopcedia  of  Diseases  of  Children,  vol. 
iv.).  All  these  papers  contain  copious  references  and  bibliographical  lists, 
which,  combined,  bring  the  whole  subject  easily  within  the  reach  of  the  student. 

It  is  our  design  in  this  paper  to  present  a  concise  arrangement  of  this  sub- 
ject somewhat  after  the  manner  of  the  French  school,  and  to  illustrate  it  with 
our  own  clinical  observations.  We  may  premise,  also,  that  while  we  hold 
hysteria  to  be  a  morbid  entity,  with  a  well-defined  etiology,  symptomatology, 

727 


728    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  prognosis,  we  recognize  that,  as  in  the  cases  of  so  many  other  diseases,  it 
is  modified  to  some  extent  in  childhood.  It  shall  be  our  especial  aim  to  empha- 
size this  fact. 

In  the  statistics  of  Briquet,  hysteria  in  children  occurred  as  follows  in  87 
cases  : 

In  childhood  (exact  age  not  given) 31  cases, 

At  5  years 3     " 

From  6  to  7  vears 6     " 

"    7  to  8  '  "      n    " 

"      8to9     "         a     " 

"      9  to  10  "        9     " 

"    10  to  11  "        4     " 

"    11  to  12  "        . 27     " 

Total,  87  cases. 

According  to  Briquet,  this  table  constitutes  one-fifth  of  his  own  observations 
in  patients  of  all  ages  ;  hence  20  per  cent,  of  his  cases  occurred  in  patients 
before  puberty.  This  proportion  is  probably  not  exceeded  in  any  other  gen- 
eral nervous  disease,  unless  it  be  in  chorea.  Briquet's  patients  seem  to  have 
been  girls. 

Cloplatt's  statistics  are  the  most  complete  up  to  date : 

Girls.  Boys.  Total. 

In  early  childhood  (exact  age  not  given) 19  1  20 

At  3  years   —  1  1 

4  "    1  1  2 

5  "    ....  4  2  6 

6  "    3  2  5 

7  "    15  4  19 

8  "    16  6  22 

9  "    15  7  22 

10  "  18  15  33 

11  "  24  17  41 

12  "  22  13  35 

13  "  27  16  43 

14  "  12  8  20 

15  "  .^^  _3  _^ 

176    96    272 

According  to  this  table,  the  disease  is  almost  twice  as  frequent  in  girls  as  in 
boys.  It  increases  almost  steadily  in  frequency  from  the  third  year  to  the 
thirteenth. 

Etiolog-y. — The  most  common  causes  of  hysteria  in  children  are  heredity, 
exhaustion  and  anaemia  from  acute  disease,  trauma,  disturbing  emotions,  imi- 
tation and  defective  education. 

The  subject  of  heredity  has  two  aspects  according  as  the  transmission  is 
between  similars  or  by  transformation.  By  the  first  is  meant  transmission  of 
the  disease  from  an  hysterical  parent  to  an  hysterical  child ;  by  the  latter, 
transmission  of  hysteria  from  a  parent  suffering  with  some  grave  nervous  dis- 
ease, as  epilepsy  or  insanity,  to  the  child.  The  latter  aspect,  although  not  the 
more  common,  is  far  the  more  important  of  the  two.  This  indirect  heredity 
illustrates  the  kinship  of  many  of  the  great  neuroses,  and  demonstrates  the 
necessity  for  a  scientific  investigation  of  remote  causes.  Briquet  was  the  first 
to  give  this  subject  exhaustive  treatment.  According  to  his  table,  351 
hysterical  patients  had  1103  near  relatives  whose  records  were  attainable ; 
among  these  relatives  were  found  214  cases  of  hysteria,  13  of  epilepsy,  16  of 
insanity,  1  of  delirium  tremens,  1  of  paraplegia,  3  of  somnambulism,  14  of 
convulsive  diseases,  and  10   of  apoplexy.      This  is  almost  25  per  cent,  of 


HYSTERIA.  729 

cases  of  grave  nervous  disease  in  the  immediate  families  of  the  patients.  A 
"control"  table  of  statistics  based  upon  the  cases  of  167  non-hysterical 
women  showed  less  than  3  per  cent,  of  such  nervous  affections  among  704 
near  relatives.  Hence  the  percentage  in  the  first  class  is  more  than  eight 
times  greater  than  in  the  latter. 

Bourneville  claims  that  alcoholism  in  the  father  is  a  not  uncommon  cause 
of  hysteria  in  young  children. 

Children  not  infrequently  present  hysterical  symptoms  during  the  prog- 
ress of,  or  convalescence  from,  acute  disease.  This  is  so  especially  in  cases 
of  the  infectious  diseases,  and  the  complication  may  obscure  the  diagnosis 
in  some  cases  not  a  little.  The  symptoms  then  observed  are  apt  to  be  inter- 
paroxysmal.  Other  toxaemias  also,  such  as  those  caused  by  lead,  mercury,  and 
alcohol,  may  produce  hysteria,  but  to  these  causes  children  usually  are  not 
exposed. 

Trauma,  next  to  heredity,  is  most  important  as  an  exciting  cause  of 
hysteria,  and  the  symptoms  of  the  grand  neuroses  which  it  is  especially  apt 
to  excite  are  among  the  most  intractable  and  simulate  most  closely  organic 
afiections.  These  symptoms  are  paralysis,  contracture,  tremor,  and  persistent 
localized  pain  or  tenderness.  This  cause  is  often  conspicuous  in  the  so-called 
neuroses  following  accidents  on  the  railroad  and  by  machinery  ;  but  in  children 
very  trifling  accidents  may  cause  hysterical  phenomena. 

Exciting  or  depressing  emotions  may  provoke  hysteria  in  children  who  are 
predisposed.  Fright  is  one  of  the  most  common  of  these.  Disappointment, 
chagrin,  loss  of  near  relatives  have  all  acted  thus.  Sometimes  vexations  of  a 
quite  trifling  character  are  sufiicient.  In  former  ages,  more  than  at  present, 
religious  excitement  claimed  many  victims  for  the  grand  neurosis.  The  chap- 
ters of  this  part  of  its  history  were  often  written  in  blood.  Demonology,  witch- 
craft, and  possession  were  often  but  phases  of  hysteria  complicated  with  super- 
stition and  fanaticism.  The  revolting  epidemic  of  Salem  witchcraft  in  this 
country  was  begun  by  some  hysterical  children  in  the  kitchen  of  a  New  England 
parson.  Imitation  and  suggestion  were,  and  are,  the  potent  factors  in  these  epi- 
demics. Somewhat  similar  but  harmless  epidemics,  due  to  these  causes,  are 
still  seen  occasionally  in  schools  and  convents. 

Finally,  a  defective  or  unwise  education  has  much  to  do  with  the  produc- 
tion of  hysteria.  The  child  that  is  constantly  indulged,  never  corrected  or 
controlled,  taught  to  regard  itself  and  its  own  wishes  as  ahvays  first,  allowed  to 
excite  the  emotions  and  imagination  with  fictitious  literature,  not  disciplined 
to  self-control,  to  self-denial,  to  duty  and  to  the  cultivation  of  the  higher  moral 
and  intellectual  faculties,  is  the  child  that  is  most  apt  to  display  the  symptoms 
of  hysteria.  It  must  not  be  inferred,  however,  that  hysteria  is  necessarily  per- 
verseness,  selfishness,  and  simulation.  This  is  a  too  common  error,  and  one 
which  unjustly  attaches  to  hysteria  a  certain  measure  of  opprobrium  and  con- 
tempt. It  is  true,  rather,  that  in  some  of  the  finest  minds  a  defective  educa- 
tion leaves  undeveloped  the  essential  qualities  of  self-knowledge  and  self-control. 
This  conduces  to  hysteria.  On  the  other  hand,  as  Briquet  has  pointed  out, 
excessive  severity  and  cruelty  to  children,  as  seen  especially  among  the  lower 
classes,  may  be  the  exciting  causes  of  the  disease. 

Symptoms. — The  symptoms  of  hysteria  divide  themselves  naturally  into 
two  groups — (1)  the  Paroxysmal,  and  (2)  the  Interparoxysmal.  We  shall  con- 
sider these  in  turn. 

(1)  Just  as  in  epilepsy,  so  in  hysteria,  the  convulsive  phenomena  too  often 
attract  the  attention  of  the  medical  observer  to  the  exclusion  of  even  more 
significant  symptoms.     The  hysterical  paroxysm  is  regarded  as  in  some  sort 


730    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  essential  element  of  the  disease,  the  acme  toward  which  all  the  other  elements 
tend.  Its  bizarre  character  is  no  doubt  the  cause  of  this.  As  we  shall  see, 
however,  the  more  permanent  but  less  conspicuous  symptoms  of  hysteria  are 
often  the  more  trustworthy,  and  sometimes  the  only,  signs  of  the  disease. 

The  hysteric  fit  has  several  grades,  but  as  the  less  are  included  in  the 
greater,  being  but  modifications  or  abortive  attacks,  it  is  best  to  limit  the 
description  to  the  typical  spell.  This  grand  attack  of  hysteria  has,  rather 
unfortunately,  been  called  hystero-epilepsy.  This  is  a  misnomer,  because  the 
fit  has  nothing  of  epilepsy  about  it.  The  term  seems  to  signify  a  union  of  the 
two  diseases,  but  such  is  not  its  true  meaning,  because  such  a  union  does  not 
exist  in  the  grand  attack  which  we  call  hystero-epilepsy.  It  is  hysteria — 
nothing  more  nor  less.  If  a  distinctive  term  were  required,  it  would  be  better 
to  speak  of  the  attack  as  hysteria  major,  just  as  in  epilepsy  we  distinguish  the 
grand  and  the  petit  mal.  The  term  hystero-epilepsy  is  unfortunate,  moreover, 
because  hotli  diseases  sometimes  occur  in  the  same  patient.  But  in  these  cases 
the  fits  are  always  distinct.  The  French  speak  of  these  as  cases  of  hystero- 
epilepsy  with  separate  crises. 

The  hysterical  paroxysm  usually  has  prodromes.  These  especially  are 
mental  symptoms,  and  are  noted  and  interpreted  rather  more  easily  in  children 
than  in  adults.  The  child  presents  a  change  in  disposition ;  this  change  is 
usually  from  gay  and  amiable  to  moody  and  choleric.  The  immediate  exciting 
cause  is  sometimes  evident,  but  not  always.  In  the  latter  case  the  origin  or 
point  of  departure  of  the  fit  may  be  in  some  mental  state,  some  auto-suggestion, 
which  we  shall  study  later.  In  this  mental  prodrome  the  child  shuns  society, 
appears  sad,  melancholy,  or  irritable,  and  cannot  be  drawn  readily  from  its 
self-absorption. 

The  paroxysm  is  preceded  immediately  by  an  aura.  These  aurse,  as  in 
epilepsy,  are  either  sensory  or  motor.  The  most  common  is  the  sense  of  a  ball 
rising  in  the  throat,  causing  a  feeling  of  suifocation.  This  may  be  quite 
alarming  to  the  child,  who  clutches  wildly  at  his  throat  in  evident  terror,  crying 
that  he  cannot  get  his  breath.  This  aura  is  called  the  globus  Itysterieus. 
Another,  equally  characteristic,  is  the  cephalic  aura.  This  consists  of  loud 
bruits,  or  beating,  throbbing,  and  hissing  sounds  in  the  ears ;  of  acute  pain, 
sometimes  as  of  a  nail  driven  into  the  head,  hence  called  clavus ;  and  of  dimness 
of  vision,  and  even  vertigo.  Other  common  aurge  are  the  ovarian  and  the 
testicular.  Ovarian  tenderness  not  uncommonly  precedes  the  fits.  This  may 
be  spontaneous  in  women  rather  than  in  little  girls.  We  have  observed  one 
case  in  which  the  patient  called  the  physician's  attention  to  ovarian  pain,  which 
proved  to  be  only  the  precursor  of  an  hysterical  fit.  Most  frequently  this 
ovarian  tenderness  may  be  elicited  by  pressure,  and  thus  in  confirmed  cases  the 
attack  may  be  elicited  by  simply  pressing  firmly  on  the  ovary.  The  aura,  once 
started,  seems  in  these  cases  to  set  going  the  whole  associated  mechanism  of 
the  fit.     Similar  results  are  claimed  in  boys  by  pressure  on  the  testicles. 

Immediately  after  the  aura  the  fit  proper  begins.  It  is  customary,  for  con- 
venience of  description,  to  divide  this  into  periods.  The  French  school  ob- 
serves four  of  these :  first,  the  epileptoid  period ;  second,  the  period  of  grand 
movements ;  third,  the  period  of  passionate  expression ;  fourth,  the  period  of 
delirium.  We  have  convinced  ourselves  in  our  own  clinical  observations  of  the 
general  accuracy  of  this  division,  but  think,  with  Peugniez,  that  the  third 
period  is  most  likely  to  be  wanting  in  the  cases  of  children. 

The  first  (or  epileptoid)  period  may  closely  simulate  true  epilepsy,  with 
which,  however,  it  has  no  identity  in  any  respect.  It  begins  with  a  tonic  stage, 
in  which  the  patient   usually  lies  supine  with  the  limbs  extended  and  rigid, 


HYSTERIA,  731 

but  with  fingers  and  toes  flexed.  Deviation  of  the  eyes  is  conspicuous;  usually 
there  is  lateral  conjugate  deviation,  the  eyes  heing  rolled  slowly  either  to  the 
richt  or  left;  in  some  cases,  however,  as  in  the  one  to  be  reported  later  in  this 
paper,  convei'gent  deviation  occurs.  The  teeth  are  held  forcibly  together,  the 
Isreath  is  heavy  and  slow,  then  rapid,  the  neck  is  swollen  (more  so  than  in  epi- 
lepsy), and  the  face  is  suffused.  The  heart's  action  is  already  becoming  rapid. 
Sensation  is  usually  blunted,  and  even  abolished  in  some  areas.  The  conjunc- 
tival reflex,  hoAvever,  is  usually  preserved  in  this  stage.  Consciousness  is 
obtunded,  and  even  lost  in  some  cases,  but  in  our  observation  consciousness  is 
not  afi"ected  so  profoundly  as  in  epilepsy.  The  tonic  phase  gives  place  rapidly 
to  the  clonic.  The  muscles  of  the  face,  trunk,  and  extremities  begin  to  tremble, 
and  then  to  be  agitated  with  a  succession  of  shocks.  During  this,  or  even 
during  the  preceding  stage,  the  patient  may  turn  over  on  his  side  or  even  pre- 
cipitate himself  from  the  bed.  This  clonic  stage  ends  usually  rather  abruptly 
with  a  long-drawn  breath,  and  is  succeeded  by  a  brief  period  of  repose,  during 
which  the  patient  lies  with  closed  eyes  as  if  asleep. 

The  second  and  third  periods  of  grand  and  passionate  movements  have  not 
been  observed  so  commonly  by  English  and  American  writers,  possibly  because 
they  have  not  studied  these  cases  so  methodically  as  the  French.  We  have  no 
doubt  of  the  importance  of  the  second  period,  especially  in  the  cases  of  boys 
and  girls.  It  explains  many  bizarre  co-ordinate  movements  in  children  which 
exist  sometimes  as  unsuspected  abortive  or  atypical  cases  of  hysteria.  This 
period  of  grand  movements  begins  abruptly.  The  patient  throws  himself  into 
many  and  curious  attitudes.  Among  the  most  common  of  these  is  the  position 
of  extreme  opisthotonos,  in  which  he  rests  upon  his  head  and  feet,  which  are 
at  the  ends  of  an  arc  of  a  circle.  Other  movements,  too  numerous  and  com- 
plicated to  describe  here,  occur.  Some  of  these  have  received  special  names, 
as  the  movement  of  salaam.  Some  of  these  movements  are  quite  complex 
and  apparently  purposive,  and  may  be  elaborately  automatic.  These  are  more 
common  in  confirmed  cases,  and  are  probably  the  product  of  suggestion  and 
auto-suggestion.  They  may  persist,  we  believe,  as  isolated  phenomena  some- 
times, or  as  a  kind  of  abortive  attack.  Charcot  calls  these  phenomena  ^'•clown- 
ism."     We  shall  narrate  a  case  briefly  in  this  paper. 

The  third,  or  period  of  passionate  movements,  is  the  least  common  in  chil- 
dren. We  do  not,  in  fact,  quite  see  the  necessity  for  this  subdivision,  because 
these  movements  naturally  grow  out  of  those  of  the  second  period,  with  which, 
in  fact,  they  are  sometimes  blended  and  confused.  They  are  still  more  com- 
plex movements,  or  rather  expressions  of  passions,  and  as  such  are  not  common 
in  children,  in  whom  passions  are  not  yet  elaborated,  and  such  as  do  exist 
receive  simple  expression.  In  these  passionate  moods  the  patients  betray  fear, 
anger,  resentment,  etc. ;  and  it  is  notable  that  if  they  attack  they  usually 
attack  some  one  whom  they  dislike.  We  recall  the  case  of  a  colored  girl  (in 
whose  race  hysteria  major  is  not  uncommon)  who  in  this  period  of  the  grand 
attack  struck  savagely  a  fellow  servant,  with  whom  she  had  had  a  quarrel  a 
short  time  before.  These  passionate  movements,  in  fact,  are  always  the  expres- 
sion of  some  pre-existent  mental  state,  which  persists  as  a  mental  picture — or 
"hallucination,"  as  the  French  say. 

The  fourth  and  closing  period  of  the  convulsive  attack  is  the  period  of 
delirium  so-called.  This  delirium,  well  portrayed  in  children  and  young  per- 
sons, is  also  the  expression  of  a  mental  state,  which  is  usually  reproduced  in 
every  succeeding  fit  in  the  same  patient.  This  mental  state  is  one  usually  of 
fear  and  sadness,  so  that  the  period  of  delirium  is  characterized  by  tears,  sobs, 


732    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cries,  incoherent  pleading,  and  appeal.  These  subside  gradually  and  the  attack 
is  finished. 

These  grand  attacks  may  be  complicated  with  somnambulism  and  cata- 
lepsy, and  they  may  present  various  atypical  and  abortive  forms,  such  as 
choreiform  movements. 

Somnambulism  has  several  traits  that  ally  it  to  the  hysterical  status.  In 
it  we  see  a  profound  unconsciousness  and  abolition  of  will-power,  leaving  the 
patient  under  the  influence  of  dreams  and  hallucinations,  and  extraordinarily 
susceptible  to  suggestions  from  without.  A  somnambulistic  state  has  been 
observed  sometimes  as  a  complication  of  the  hysterical  paroxysm  or  as  a  post- 
paroxysmal phenomenon.  Profound  lethargy  also  supervenes  sometimes  in  the 
fourth  period.  Catalepsy  is  another  psychosis,  which,  while  not  essentially 
hysterical,  has  yet  something  in  its  nature  that  affiliates  it  with  hysteria.  Cata- 
leptoid  symptoms  are  not  uncommonly  seen  in  various  periods  of  the  grand 
attack,  for  they  are  not  confined  to  any  one  period.  They  may  be  elicited 
sometimes  by  suggestion.  We  have  done  this  in  the  tonic  stage  of  the  epilep- 
toid  period  by  elevating  the  patient's  arms,  and  thereby  have  suspended  the 
fit  temporarily  or  even  suggested  a  new  turn  in  it. 

Among  the  most  interesting  products  of  hysteria  are  the  cases  of  so-called 
"  chorea  major."  This  is  another  misnomer,  for  which  the  Germans  especially 
are  responsible.  This  chorea  major  has  nothing  choreic  about  it ;  it  is  entirely 
hysterical.  To  understand  its  true  position  among  the  hysterical  symptoms  we 
may  recall  what  was  said  above — viz.  that  the  grand  attacks  may  present 
various  atypical  forms.  As  Peugniez  has  shown,  the  attacks  are  not  always 
complete.  One  period  alone  may  appear,  having  an  exaggerated  development 
and  leaving  the  other  periods  in  the  shade.  Sometimes  merely  an  aura,  as  the 
globus,  is  felt,  and  the  attack  aborts.  In  other  cases  the  period  of  delirium, 
with  tumultuous  emotions,  has  such  a  large  place  as  to  appear  to  constitute  the 
whole  attack.  Thus  we  believe  it  is  in  some  cases  with  the  period  of  grand 
movements.  These  movements  become  stereotyped  as  it  were  on  the  child's 
brain  at  the  moment  of  the  extreme  susceptibility  or  "  suggestibility  "  that 
characterizes  him  at  this  crisis.  They  become  further  developed,  in  successive 
fits  or  even  between  fits,  into  most  extraordinary  combinations  of  movements 
and  cries.  These  movements  are  sometimes  apparently  purposive,  sometimes 
of  the  nature  of  an  acquired  dexterity  or  trick,  or,  again,  they  may  be  most 
elaborately  automatic,  the  patient's  will  and  personality  seeming  to  have  noth- 
ing to  do  with  them.  These  complex  movements  may  be  propagated  readily 
to  others,  and  thus  they  may  give  rise  to  epidemics  in  schools  and  religious 
communities  which  resemble  the  dancing  manias  of  the  Middle  Ages.  The 
writer  saw  and  recorded  one  such  case  in  a  boy,  in  Avhom  there  was  an  elabo- 
rate syndrome  of  spasm,  rotation,  and  catalepsy,  undoubtedly  hysterical  in 
origin,  and  which  was  cured  by  a  slight  operation  on  the  foreskin.^ 

(2)  The  interparoxysmal  symptoms  of  hysteria,  which  form  the  second  main 
group,  are  even  more  important  than  those  of  the  paroxysm  itself,  for  upon 
them  must  often  depend  the  diagnosis  of  the  disease  from  grave  organic  affec- 
tions. Their  study  is  too  often  neglected.  They  are  the  permanent  markings 
of  hysteria,  and  hence  have  been  called  the  stigmata.  These  stigmata  are 
sensory,  motor,  visceral,  mental,  and  nutritional,  and  may  be  considered  here 
in  the  order  named. 

The  changes  in  sensation  are  varied  in  hysteria,  but  some  of  them  are 
almost  always  present.     Hypergesthesia  and  hyperalgesia  are  common.     The 

1  For  a  full  discussion  of  the  history  of  this  phase  of  the  subject  see  Richer's  Etudes  Cliniques 
mr  rHystero-Epilepsie,  Paris,  1881. 


HYSTERIA.  733 

former  is  usually  distributed  in  a  characteristic  way,  and  gives  origin  to  the 
well-known  hysterogenous  zones.  These  zones  are  points  or  areas  on  the  skin, 
pressure  on  which  is  usually  painful  and  may  excite  the  manifestation  of  other 
hysterical  symptoms,  especially  the  convulsion.  This  acute  sensitiveness,  how- 
ever, does  not  appear  to  be  confined  entirely  to  the  skin,  but  to  include  the 
subjacent  organs,  as  for  instance,  the  ovaries.  The  most  common  of  these 
hysterogenous  points  in  our  observation  are  over  the  ovaries  and  at  points 
along  the  spine.  Others  describe  them  as  in  the  testicles,  at  the  juncture 
of  the  ribs  to  the  sternum,  and  at  other  points  on  the  trunk.  Pressure 
on  a  hysterogenous  zone  is  a  common  means  of  exciting  the  convulsion  of 
hysteria  major,  and  when  at  its  height  pressure  on  the  same  region  will  often  stop 
it.  Hyperalgesia  exists  as  various  forms  of  neuralgia :  some  of  these  are  the 
accompaniments  especially  of  traumatic  hysteria.'  We  had  such  a  case  under 
observation  in  which  pain  at  a  circumscribed  area  in  the  dorsal  spine  in  a  girl, 
following  a  fall,  simulated  the  early  stage  of  spinal  caries.  This  case  occurred 
in  the  Home  for  Crippled  Children,  and  the  diagnosis  was  so  uncertain  for  a 
time  that  the  child  was  put  in  a  plaster  jacket.  This  seemed  to  make  a  bene- 
ficial mental  impression,  and  the  patient  recovered  rapidly.  Among  these 
traumatic  cases  that  simulate  organic  disease  are  those  in  which  the  hyperal- 
gesia becomes  fixed  in  one  of  the  joints,  as  the  hip  or  knee. 

Anaesthesia  is  one  of  the  most  important  stigmata  of  hysteria.  So  common 
is  it  that  it  is  doubtful  if  it  is  ever  entirely  absent  in  pronounced  cases,  and 
yet  so  little  observed  is  it  that  even  the  patient  himself  is  often  ignorant  of  its 
presence.  It  may  be  very  profound,  and  accompanied  with  coldness  and  vaso- 
motor changes  in  the  part.  During  the  dancing  manias  and  religious  crazes  of 
the  Middle  Ages  and  later,  it  was  observed  that  a  pin-stick  would  not  bleed. 
This  was  a  mark  of  especially  evil  augury  to  superstitious  minds  during  some 
of  the  witchcraft  plagues.  It  is  now  one  of  the  best-recognized  marks  of 
hysteria.  The  distribution  of  the  anaesthesia  varies.  One  of  the  most  com- 
mon types  is  hemiangesthesia.  This  extends  from  the  top  of  the  head  to  the 
sole  of  the  foot,  and  is  often  accompanied  with  anassthesia  of  the  special  senses 
— sight,  hearing,  taste  and  smell — and  of  the  mucous  membranes.  Another 
type  is  the  distribution  in  geometrical  figures,  in  which  case  the  patient  has 
areas  of  anaesthesia  of  various  shapes  and  sizes  scattered  over  the  body.  Still 
another  is  the  monoanaesthetic  type,  in  which  an  area  of  anaesthesia  covers  the 
arm  and  hand  like  a  gauntlet  or  the  leg  and  foot  like  a  stocking.  This  latter 
distribution  is  often  accompanied  with  paralysis  of  the  member.  This  asso- 
ciation with  paralysis  and  the  peculiar  sharp  demarcation  of  the  anaesthesia  at 
right  angles  to  the  long  diameter  of  the  limb  serve  to  characterize  this  form 
very  clearly.  The  hemiangesthesia  of  hysteria  sometimes  displays  a  peculiar 
phenomenon  called  transfer.  Under  the  influence  of  some  external  agent,  as 
electricity  or  a  magnet,  or  even  by  suggestion  or  auto-suggestion,  the  anaesthesia 
passes  from  one  side  to  the  other.  This  change,  however,  is  usually  of  short 
duration,  for,  as  a  rule,  the  aifection  soon  returns  to  its  first  seat. 

The  affection  of  the  special  senses  is  often  marked  in  hysterical  hemi- 
anaesthesia.  There  may  be  hemianopsia  toward  the  anaesthetic  side,  and  deaf- 
ness and  loss  of  taste  and  smell  on  the  same  side.  The  most  significant  changes 
are  in  the  eyes.  First  of  these  in  importance  is  the  concentric  narrowing  of 
the  visual  field.  In  the  normal  eye  the  visual  field  is  not  extended  equally  in 
all  directions,  being  widest  toward  the  temporal  side,  next  toward  the  lower 
segment,  next  toward  the  higher  segment,  and  least  extended  toward  the 
nasal  side.  In  the  hysterical  patient  these  relative  proportions  are  apt  to  be 
maintained,  the  centre  of  the  normal  field  being  the  centre  of  the  abnormal 


734    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

one,  but  the  field  itself  is  very  notably  contracted.  In  some  cases,  however, 
the  relative  proportions  are  not  maintained,  the  contracted  field  being  a  round 
or  oval  area  around  the  normal  centre.  This  contracted  field  may  be  very 
small  in  some  patients.  Another  significant  change  is  in  the  perception  of  colors. 
In  the  normal  eye  the  fields  for  colors  are  not  the  same.  The  widest  field  is 
for  blue,  then  come  the  fields  for  yelloAv,  red,  green,  and  violet  in  the  order 
named,  violet  having  the  smallest  field.  These  fields  for  color  are  practically 
concentric.  In  the  hysteric  eye  the  violet  field  disappears  first,  being  "  squeezed 
out  at  the  centre,"  as  some  one  has  expressed  it.  Then  the  other  fields  con- 
tract gradually  and  disappear  in  the  order  named,  Avith  the  important  exception 
that  the  red  usurps  the  place  of  the  blue  field — i.  e.  it  becomes  the  widest  and 
the  last  to  disappear.  In  fact,  red  is  a  very  persistent  color-perception  in  the 
hysteric,  and  is  supposed  by  some  French  observers  to  play  a  part  in  the  hal- 
lucinations and  mental  states  of  these  patients.  Other  affections  of  the  eye  are 
amblvopia  in  various  grades,  and  the  curious  phenomenon  known  as  monocular 
diplojpia  or  polyopia,  in  which  the  patient  sees  with  one  eye  two  or  more 
images  of  the  same  object. 

The  motor  symptoms  of  hysteria  are  of  two  orders :  those  that  depend 
upon  the  absence  of  function,  and  those  that  characterize  its  perversion. 
Paralysis  is  of  the  first  order,  and  contracture  and  tremor  of  the  second.  As 
RicheV  has  pointed  out,  these  disorders  of  motility  are  very  apt  to  appear  as 
isolated  phenomena  in  juvenile  hysteria,  and  sometimes  at  a  very  early  age. 

Hysterical  paralyses  present  a  variety  of  forms,  but  these  forms  are  not  as 
sic^nificant  as  their  mode  of  onset,  their  clinical  history,  and  their  termination. 
The  most  common  are  hemiplegia,  paraplegia,  and  monoplegia.  Very  fre- 
quently the  paralyzed  part  is  also  anaesthetic — a  very  uncommon  phenomenon 
in  similar  paralyses  due  to  central  nervous  disease.  In  some  cases  there  is  no 
anesthesia.  Paraplegia  is  more  common  in  children  and  young  persons  than 
hemiplegia.  In  hysterical  hemiplegia  the  face  often  escapes  ;  but  if  the  face 
be  invaded,  it  is  more  frequently  some  of  the  eye-muscles  that  are  involved, 
in  the  form  not  of  a  paresis  but  of  a  blepharospasm.  The  paralyzed  limbs 
may  be  flaccid  or  spastic.  The  onset  of  these  paralyses  usually  is  sudden. 
Their  most  common  causes  are  trauma,  emotion,  and  the  hysterical  fit.  In 
the  case  of  a  young  woman  observed  by  the  wn-iter  a  paraplegia  developed 
brusquely  during  a  highly  emotional  love  scene.  In  one  of  Bourneville's 
cases  a  paraplegia  followed  a  grand  attack  of  convulsions.  During  the  paralysis 
the  convulsions  ceased,  but  after  it  disappeared  they  returned.  The  duration 
of  these  paralyses  varies,  but  not  infrequently  they  disappear  as  suddenly  as 
they  come,  and  sometimes  as  a  result  of  mental  impression.  In  the  above 
case  observed  by  the  writer  the  faradic  current  cured  the  disease  promptly. 
Sometimes  a  paralysis  suddenly  quits  one  limb  or  group  of  muscles  and  appears 
in  another,  as  in  the  transfer  scene  in  hemianaesthesia. 

A  peculiar  form  of  hysterical  paralysis  is  loss  of  power  of  co-ordination — 
the  so-called  astasia-abasia. 

The  most  common  contractures  in  hysteria  in  children  are  as  follows  :  par- 
tial or  complete  contracture  of  a  limb,  intermittent  torticollis,  spasm  of  the 
orbicular  muscle,  and  paraplegic  contracture.  The  position  assumed  by  the 
contractured  limb  varies  according  as  the  contracture  occurs  in  the  armor  leg: 
in  the  case  of  the  arm  the  limb  is  usually  flexed,  while  in  the  case  of  the  para- 
plegic form  the  limb  is  extended,  the  foot  being  in  the  position  of  plantar 
flexion.  The  hysterical  contracture  may  be  very  persistent,  enduring  for  years. 
In  childhood,  as  Richer  observes,  the  contracture  may  appear,  disappear,  and 


HYSTERIA.  735 

reappear  with  a  sort  of  periodicity ;  in  other  cases  it  may  pass  from  one  seat 
to  another.     The  causes  of  contracture  are  the  same  as  those  of  paralysis. 

Tremor  is  a  rather  rare  motor  disorder  in  hysteria,  and  is  more  common  in 
adults  than  in  children.  It  may  he  caused  by  trauma,  but  it  occurs  sometimes 
spontaneously.  It  generally  presents  the  type  described  by  Rendu  of  a  rather 
fine  tremor  increased  by  voluntary  movement. 

The  visceral  and  internal  disorders  of  hysteria  are  numerous  and  quite 
important.  We  prefer  to  consider  them  here  as  a  separate  class,  although 
some  authorities  include  them  under  disorders  of  motility.  Among  the  most 
common  is  aphonia,  which  as  an  affection  of  the  larynx  may  be  included 
here.  It  is  caused  most  frequently  by  emotion,  and  is  sometimes  an  isolated 
symptom.  It  may  be  complete,  but  more  frequently  the  voice  is  not  entirely 
lost,  but  only  sinks  to  a  whisper.      It  may  appear  and  disappear  suddenly. 

Rapid  respiration  is  seen  sometimes  in  hysteria,  and  may  confuse  the  dia- 
gnosis, because  it  suggests  some  affection  of  the  lungs  or  heart.  It  is  a 
rather  rare  symptom,  and  is  probably  more  common  in  adults  than  in  children. 
It  presents  the  superior  costal  type  of  breathing,  and  the  respirations  may  be 
as  rapid  as  seventy  to  the  minute.  Dyspnoea  is  hot  present,  nor  any  accelera- 
tion of  the  heart,  as  a  rule.  The  only  typical  case  of  this  affection  seen  by  the 
writer  occurred  in  a  young  woman  during  a  long  convalescence  from  a  serious 
surgical  operation. 

Hysterical  anorexia  and  vomiting  are  occasionally  seen,  and  may  constitute 
the  most  serious  symptoms  of  the  disease.  They  may  bring  the  patient  to  the 
verge  of  the  grave ;  in  fact,  in  a  few  cases  they  have  actually  caused  death. 
The  vomiting  is  of  a  peculiar  type  which  may  serve  to  distinguish  it.  It  is 
caused  usually  by  a  spasmodic  movement  of  the  oesophagus,  by  which  the  food 
is  regurg-itated  without  having  entered  the  stomach.  This  has  been  called 
oesophagismus.  In  extreme  cases  this  spasm  continues  at  intervals  without 
the  ingestion  of  food,  as  in  a  case  seen  by  the  writer  and  reported  elsewhere, 
in  which  the  patient  regurgitated  only  a  frothy  saliva.  She  kept  a  napkin 
constantly  under  her  chin  as  she  lay  in  bed,  to  receive  the  ejecta.  She  was 
emaciated  to  an  extreme  degree.  In  her  case  the  symptom  was  caused  by  the 
shock  produced  by  swallowing  supposed  poison  accidentally. 

Paresis  of  the  intestine,  causing  immense  dilatation  of  the  tube  and  conse- 
quent distention  of  the  abdomen,  is  seen  occasionally  in  hysteria. 

Affections  of  the  bladder  are  not  uncommon.  Hysterical  ischuria  and 
painful  tenesmus  are  observed,  the  latter,  especially  in  women,  being  associated 
with  a  vaginismus.     In  young  girls  this  is  rare. 

The  consideration  of  the  mental  stigmata  of  hysteria  has  been  reserved  for 
this  place,  because,  while  these  stigmata  are  the  very  first  in  importance,  and 
constitute  really  the  essentials  of  the  disease,  they  can  best  be  described  after 
the  sensory,  motor,  and  visceral  disorders  which  they  serve  to  interpret.  Hys- 
teria is  a  psychosis.  Without  a  study  of  the  disease  from  this  standpoint  it  is 
futile  to  attempt  to  understand  it.  But  this  subject  is  deep,  complex,  and,  to 
some,  repellant.  Moreover,  we  have  space  here  only  to  indicate  its  outlines.^  It 
is  necessary  first  to  reject  the  idea  that  the  hysterical  child  is  a  simulator  and 
a  liar.  It  has  been  a  too  common  error,  due  to  the  writings  of  Legrand  du 
Saull  and  others,  to  confuse  the  mental  stigmata  of  hysteria  with  those  of 
imbecility,  degeneracy,  and  moral  perversity.  Hysteria  and  degeneracy  are 
distinct,  and,  while  the  two  may  coexist  in  the  same  patient,  just  as  may 
hysteria    and  epilepsy  or  hysteria    and    tabes,  it  is  inexcusable  to  confound 

^  An  early  paper  by  the  writer  on  "  Hysteria — A  Study  in  Psychology  "  was  an  attempt  to 
state  this  aspect  of  the  subject.     (See  Am.  Jour,  of  Nervous  and  Merit.  JDis.,  Oct.,  1883). 


736    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


them.  We  must  expect  and  search  for  distinct  and  characteristic  mental  stig- 
mata in  hysteria,  and  we  believe,  with  Gilles  de  la  Tourette,  that  such  exist 
and  may  be  recognized.  With  this  author  we  recognize  a  mental  impression- 
ability, a  proneness  to  take  and  act  upon  suggestions,  as  the  real  character- 
istic of  hysteria.  But  even  more  than  he,  Ave  would  insist  upon  the  hysterical 
automatism,  in  which  there  seems  to  be  a  dissociation  of  the  higher  mental 
faculties,  as  the  will  and  intellect,  from  the  lower  emotional  and  impulsive 
states.  This  dissociation  of  mental  faculties  is  more  apparent  than  real :  a 
more  exact  statement  would  be,  that  the  hysterical  child  reacts  to  a  morbid 
association  of  ideas,  which  permits  it  to  develop  the  various  physical  stigmata. 
It  is  of  first  importance  to  recognize  this,  because  by  the  proper  use  of  sug- 
gestion— i.  e.,  education — much  can  be  done  to  counteract  the  effects  of  this 
evil  "dislocation"  of  the  mental  faculties.  Suggestions  come  to  the  hysterical 
child  either  from  Avithout  or  from  Avithin ;  they  doubtless,  by  the  laAv  of  asso- 
ciation of  ideas,  tend  to  form  in  each  successive  grand  attack  a  more  complicated 
web.  Hence  it  is  that  many  of  the  physical  stigmata — paralysis,  anaesthesia, 
etc. — either  originate  in  or  are  aggravated  by  a  seizure.      Suggestions  from 

Fig.  1. 


Case  of  Hvsteria— (Harriet  B 


tage  under  Hyi)nijtism. 


without,  as  by  trauma,  moral  shock,  etc.,  act  often  between  or  independent  of 
the  paroxysms.  Sometimes  in  childi'en  the  paroxysm  aborts,  and  there  may 
be  a  true  "psychical  equivalent"  (as  in  epilepsy),  in  which  some  of  the  most 
astounding  of  the  hysterical  combinations  may  appear.  In  children,  too,  the 
attack  may  pass  off  in  some  of  the  psychical  prodromes,  but  these  prodromes 


HYSTERIA. 


737 


may  be  followed  by  the  dreamlike  or  delirious  states  of  the  fourth  period.  To 
these  dreamlike  states  and  states  of  reverie,  as  well  as  to  their  congeners,  the 
nightmares  and  night-terrors  not  uncommon  in  hysterical  children,  Tourette 
justly  attaches  great  importance.  They  influence  remarkably  the  mental  state 
between  the  attacks,  as  well  as  the  physical  stigmata.  The  auto-suggestion 
in  traumatic  cases  is  often  reinforced  by  these  dreams  and  nightmares. 

Changes  in  nutrition  are  not  marked  or  characteristic  in  hysteria.  It  is 
commonly  said  that  anaemia  is  observed,  but  this  is  not  in  any  sense  character- 
istic, but  only  a  result  of  the  anorexia  which  is  sometimes  present.  In  other 
words,  it  is  only  an  anaemia  from  malnutrition.  The  normal  hysterical  patient 
between  paroxysms,  unless  anremic,  does  not  present  changes  in  the  blood. 
The  observation  of  the  ancient  writers,  that  the  blood  would  not  flow  freely  from 
an  hysterical  patient,  was  correct,  but  the  fact  depended  upon  alteration  in  the 
vessels  of  an  anaesthetic  limb,  and  not  upon  any  alteration  in  the  blood.  Ac- 
cording to  the  table  prepared  by  Gilles  de  la  Tourette,  the  proportion  of  red 
blood-corpuscles,  of  haemoglobin,  and  of  urea  in  the  blood  of  hysterical  patients 
is  practically  normal.  During  and  after  the  paroxysm  it  is  probable  that  some 
transient  alteration  would  be  found. 

The  following  case,  from  the  writer's  clinic  in  the  Philadelphia  Hospital, 
illustrates  some  of  the  foregoing  descriptions  : 

Harriet  B ,  aged  seventeen,  English.  The  patient  has  a  history  from  early- 
childhood  of  headaches  and  fainting-spells.     At  twelve  years  she  was  severely  burned 


Fig.  2. 


Fig.  3. 


Ansesthesia  in  Geometrical  Fig^ures.    (From  author's  case  of  hysteria  in  a  girl,  drawn  by  Dr.  Riesman.) 
47 


738    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

about  her  body  and  limbs  by  her  dress  catching  fire.  She  had  her  first  fit  at  about 
fourteen  under  the  following  circumstances :  A  week  before  the  attack  she  had  slept 
with  a  very  sick  relative  who  was  raving  in  a  wild  delirium  all  night.  After  returning 
home  she  constantly  talked  of  this  experience,  which  had  evidently  made  a  deep  im- 
pression on  her  mind.  On  the  night  on  which  the  fit  occurred  her  father  had  stayed 
with  the  same  relative  until  a  very  late  hour,  and  then,  going  home,  knocked  on  his 
daughter's  door  and  awakened  her.  The  child  opened  the  door,  was  much  frightened, 
and  fell  to  the  floor  in  a  violent  fit.  Thereafter  for  a  while  she  had  as  many  as  from 
nine  to  fourteen  seizures  a  day.  A  physician  who  saw  her  in  one  of  these  said  she  was 
hysterical,  and  stopped  the  fit  by  slapping  her  in  the  face  with  a  wet  towel.  Some  of 
the  seizures  were  nocturnal. 

On  admission  the  patient  was  observed  to  be  a  tall,  well-developed  girl,  with  a 
marked  English  accent.'  She  had  many  scars  due  to  extensive  burns.  (These  happened 
some  years  before  her  first  convulsion).  On  the  fifth  day  after  admission  she  had  a 
grand  attack,  lasting  about  twenty  minutes ;  it  came  on  spontaneously.  She  uttered  a 
loud  wailing  cry  for  a  minute  or  two,  then  became  motionless  in  tonic  spasm,  with  the 
eyes  rolled  up  and  respiration  suspended.  Then  there  was  bilateral  squint  and  extreme 
dilatation  of  the  pupils.  The  period  of  tonic  spasm  was  succeeded  suddenly  by  one  of 
slight  clonic  movements,  complicated  with  spells  of  crying,  sobbing,  and  choking.  The 
patient  was  evidently  conscious  during  part  of  the  attack.  During  subsequent  attacks 
she  exhibited  grand  and  passionate  movements,  and  the  fit  was  sometimes  followed  by  a 
lethargic  state.  She  can  be  thrown  into  one  of  these  seizures  by  causing  her  to  gaze 
fixedly  at  an  object  held  before  her,  as,  for  instance,  a  lead-pencil. 

The  patient  was  found  to  have  hysterogenous  zones  over  the  ovaries  and  over  the 
upper  dorsal  spine.  Pressure  on  these  produces  an  attack  as  follows:  The  patient  be- 
comes rigid,  with  some  flexion  of  the  elbows  and  knees.  The  eyes  become  suflTused,  the  face 


Contraction  of  the  Visual  Fields  in  Hysteria.    Field  of  0.  S.  (From  author's  case ;  drawn  by  Dr.  Riesman.) 

^  This  case  furnishes  a  commentary  on  the  claims  of  some  English  writers  that  hysteria,  as 
described  in  France,  does  not  exist  in  England.  This  patient  is  a  typical  English  girl,  born  in 
Birmingham,  and  drops  her  A's  unmistakably.  Yet  she  exhibits  the  grand  attack  as  perfectly 
as  though  she  were  in  La  Salpetriere. 


HYSTERIA. 


739 


Contraction  of  the  Visual  Fields  in  Hysteria.     Field  of  O.  D.    (From  author's  case.) 

flushed,  and  a  rapt  expression  appears.  The  breathing  is  hurried  and  the  pulse  rapid. 
The  eyes  converge  in  internal  strabismus  and  the  pupils  dilate.  The  arms  maybe  placed 
in  any  position,  and  remain  fixed  in  true  cataleptoid  rigidity  (see  Fig.  1).  The  hysterical 
symptoms  are  seemingly  interrupted  at  times  by  the  catalepsy.  The  tonic  stage  lasts  for 
a  long  time.  The  clonic  stage  is  of  rather  short  duration,  and  is  marked  by  tremors  and 
clonic  movements  of  not  very  wide  range.  Grand  movements  are  observed  in  some 
attacks.     The  seizure  ends  in  a  paroxysm  of  tears  and  sobs.     A  lethargic  state  follows. 

Between  the  paroxysms  the  patient  has  marked  anaesthesia,  both  in  geometric  areas 
and  in  islets  (see  Figs.  2  and  3).  Sensation  is  blunted  in  the  buccal  and  lingual  mucous 
membranes.  There  is  no  thermo-ansesthesia.  There  is  some  vasomotor  weakness,  shown 
by  a  bright  erythematous  flush  extending  for  an  inch  or  two  around  the  mark  of  the 
gesthesiometre.  The  visual  fields  are  narrowed  concentrically  (see  Figs.  4  and  5),  but 
the  color  fields  are  not  modified  in  a  typical  way. 

It  is  to  be  noted  finally  that  this  patient  has  had  a  few  seizures  strikingly  like  true 
epilepsy,  in  which  she  is  unconscious,  froths  at  the  mouth,  and  bites  her  tongue.  These 
have  occurred  mostly  at  night,  and  their  exact  nature  therefore  is  difiicult  to  be  deter- 
mined. But  it  is  possible  that  the  patient  has  "  separate  crises,"  i.  e.,  both  hysteria  and 
epilepsy. 

Diagnosis. — In  general  terms  it  may  be  said  that  in  the  diagnosis  of  doubt- 
ful cases  of  hysteria  the  main  reliance  must  be  placed  upon  the  presence  of 
some  of  the  permanent  stigmata.  It  is  frequently  said  that  hysteria  simulates 
all  diseases,  but  the  truth  is  that  it  simulates  none  exactly.  The  stigmata  of 
the  disease,  if  it  is  present,  can  usually  be  found. 

Epilepsy  is  the  disease  most  closely  counterfeited  by  the  grand  attack.  But 
this  resemblance  is  seen  in  the  first  period  only,  the  periods  of  grand  move- 
ments and  passionate  attitudes  not  being  seen  in  epilepsy.  When  the  attack 
aborts  in  the  first  period,  the  likeness  to  epilepsy  may  be  striking,  and  it  may 
be  necessary  to  base  the  diagnosis  upon  the  stigmata.      The   possible   asso- 


740    A3LEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILD  BEN. 

elation  of  the  two  diseases  in  one  patient  ("separate  crises")  must    not  be 
forgotten. 

Paralysis  due  to  organic  disease  may  be  simulated  by  hysteria.  Para- 
plegia especially  may  be  so  simulated.  The  history  of  the  case  and  the  detec- 
tion of  other  hysterical  signs  can  usually  determine  the  diagnosis.  The  same 
may  be  said  of  hysterical  joint-disease. 

The  so-called  "  traumatic  neuroses  "  are  in  large  proportion  hysterical,  as  a 
proper  study  of  the  stigmata  will  usually  demonstrate. 

The  most  common  error  is  to  confuse  hysteria  with  degeneracy  and  moral 
perversity.  It  is  commonly  said  that  the  hysterical  patient  has  one  or  more 
of  such  syndromes  as  folic  du  doute,  morbid  scruples,  mysophobia,  agaro- 
phobia,  impulse  to  set  fire,  to  commit  suicide,  to  make  murderous  assault,  or 
that  he  is  guilty  of  sexual  perversions.  It  is  needless  to  say  that  these  are  the 
stigmata  of  degeneracy,  not  of  hysteria.  The  hysterical  child  is  not  a  moral 
imliecile.  While  hysteria  may  coexist  with  degeneracy,  as  with  numerous 
other  morbid  states,  it  is  not  part  of  it. 

The  various  internal  and  visceral  disorders,  as  hysterical  breathing,  anor- 
exia, vomiting,  phantom  tumors,  etc.,  may  usually  be  diagnosticated  by  a  pro- 
cess of  exclusion,  the  history  of  the  case,  and  the  presence  of  one  or  more 
hysterical  stigmata. 

Treatment. — The  treatment  of  hysteria  in  children  must  be  partly  moral 
and  partly  physical.  Among  the  first  we  include  especially  education,  and 
secondarily  isolation.  We  have  not  space  to  discuss  the  subject  of  education, 
but  after  what  we  have  said  already  of  defective  education  as  a  cause  of  hys- 
teria, and  of  the  peculiar  impressibility  of  the  hysterical  brain,  it  is  enough 
simply  to  indicate  the  sovereign  necessity  for  a  sound  moral  and  intellectual 
regime  for  these  cases.  Unfortunately,  it  is  often  difficult  to  procure  it.  In 
some  cases,  if  a  good  training  cannot  be  obtained  pei'manently,  the  influence 
of  an  evil  one  may  be  combated  temporarily  by  isolation.  To  remove  the 
patient  from  unwholesome  domestic  surroundings  is  the  first  requisite  for  a 
cure. 

Among  the  physical  agents  the  most  important  for  children  are  gymnas- 
tics, hydrotherap3%  and  vigorous  tonic  treatment.  Gj'mnastics  and  hydro- 
therapy are  much  used  by  French  practitioners,  and  with  signal  success. 
They  probably  act  partly  by  their  moral  eff"ects,  both  direct  and  indirect,  as,  for 
instance,  by  substituting  wholesome  impressions  for  morbid  ones,  and  by  divest- 
ing the  mind  of  the  unhealthy  complexus  of  ideas  which  undei'lies  the  hys- 
terical state.  This  vigorous  restorative  treatment,  unless  contraindicated  by 
special  conditions,  is  better  adapted  for  hysterical  children  than  is  treatment  by 
rest  and  by  measures  adapted  to  pamper  and  enervate  them. 

In  anaemic  states,  secondary  to  anorexia,  forced  feeding  and  iron  may  be 
indicated.  But  anaemia,  being  a  secondary  condition,  will  usualh^  improve, 
even  without  drugs,  on  the  hygienic  plan  above  suggested.  As  a  rule,  few  if 
any  drugs  are  indicated,  but  as  it  may  be  necessary  to  use  some  of  them  for 
their  moral  effect,  the  least  injurious  ought  to  be  carefully  selected.  Bromides 
and  sedatives  ought  to  be  avoided. 

To  abort  or  control  the  paroxysm  a  cold  douche,  pressure  on  a  hysterogen- 
ous  zone,  a  hypodermatic  injection  of  morphine,  or  an  emetic,  have  all  been 
recommended  and  tried.  Morphine,  however,  is  not  proper  for  these  cases.  In 
the  cases  of  children  suggestion  skilfully  used  will  sometimes  abort  paroxysms 
and  diminish  their  frequency.  The  suggestion  of  an  operation  will  sometimes 
act  thus.  Too  much  solicitude  and  too  persistent  holding  and  controlling  the 
patient  should  be  avoided. 


CONVULSIONS. 

By  FREDERICK  PETERSON,  M.  D., 
New  York. 


Eclampsia  is  a  term  often  used  synonymously  -with  convulsion.  Eclampsia 
is  a  series  of  violent  contractions  of  a  limited  number  or  of  many  muscles, 
clonic  generally,  sometimes  mingled  with  more  or  less  tonic  spasm,  paroxysmal 
in  character,  and  accompanied,  when  severe  and  general,  by  loss  of  consciousness. 
Convulsions  are  to  be  looked  upon  not  as  a  separate  and  distinct  disease,  but  as 
merely  a  symptom  of  a  great  variety  of  morbid  conditions  affecting  the  most 
divers  portions  of  the  animal  economy.  The  constant  repetition  of  convulsive 
seizures  at  irregular  intervals  is  often  considered  as  a  distinct  disease,  but,  in 
the  light  of  recent  research,  epilepsy  too  is  now  regarded  merely  as  sympto- 
matic of  many  pathological  states  which  give  rise  to  katabolic  discharges  in 
epileptogenetic  centres. 

But  while  eclampsia  is  only  a  symptom,  it  is  one  of  so  pronounced  a  char- 
acter that  it  merits,  and  indeed  requires,  special  consideration  as  regards  its 
point  of  origin,  etiology,  nature,  and  treatment. 

Convulsions  occur  at  all  periods  of  life,  but  are  so  common  in  infancy  and 
childhood  as  a  symptom  of  disturbance  in  nervous  centres  that,  as  West  says, 
convulsions  in  children  correspond  with  delirium  in  adults ;  and  Trousseau 
goes  even  farther  in  saying  that  there  are  some  children  who  have  convulsions 
as  easily  as  some  persons  have  delirium  or  dreams.  They  are  more  common 
under  the  age  of  two  years  than  at  any  other  period  of  early  life.  Males  are 
more  frequently  affected  than  females. 

Seat  of  Origin  of  Eclampsia. — Convulsions,  whether  local  or  general, 
have  their  origin  in  katabolic  discharges  of  nerve-cells,  either  in  the  cortex  or 
at  the  base  of  the  brain.  J.  Hughlings  Jackson  has  taught  that  there  are 
three  levels  from  which  such  discharges  may  occur  :  from  the  cells  of  the  ponto- 
bulbar region ;  from  the  Rolandic  area  ;  and  from  a  level  (purely  speculative 
on  his  part)  which  he  conceives  to  exist  in  the  frontal  lobes  and  to  represent 
the  highest  control  of  sensory-motor  functions.  Whatever  may  be  the  merits 
of  his  highest-level  theory,  I  believe  that  from  a  practical  point  of  view  we 
may  consider  eclampsia  as  originating  either  in  the  ponto-bullDar  region  or  the 
Rolandic  cortical  area,  and  generally  the  latter.  Jackson  thinks  laryngismus 
stridulus  is  a  convulsive  discharge  from  the  ponto-bulbar  region,  while  Semon 
believes  it  to  be  cortical.  The  former  would  also  classify  as  ponto-bulbar  con- 
vulsions the  respiratory  fits  induced  in  animals  by  asphyxia,  the  seizures  pro- 
duced by  convulsant  poisons  (such  as  nitrous  oxide,  curare,  absinthe,  camphor, 
and  uraemia),  and  those  resulting  from  injuries  to  the  cord  and  sciatic  nerve  in 
guinea-pigs.  Lately  he  has  been  modifying  his  earlier  views,  for  now  he  inti- 
mates that,  though  the  primary  discharge  in  these  cases  occurs  from  the  ponto- 
bulbar level,  the  higher  centres  may  also  at  the  same  time  be  implicated  by 
intermediation  of  the  ascending  sensory  fibres.     For  my  own  part,  I  see  no 

741 


742    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

reason  why  poisons,  for  instance,  circulating  in  the  blood  may  not  discharge 
cortical  centres  simultaneously  with  ponto- bulbar  centres.  Whatever  may  be 
the  ultimate  idea  attained  as  to  the  different  levels,  the  seat  of  the  discharge  in 
convulsions  is  undoubtedly  in  the  ganglion  cells  of  the  brain,  and  the  molecular 
disturbance  in  these  cells  necessary  to  the  discharge  is  determined  either  by 
direct  irritation  at  these  centres  (from  morbid  states  of  the  blood  or  vascular 
apparatus,  trauma,  neoplasms)  or  by  indirect  irritation  (reflex). 

Isubmit  a  diagram  of  the  two  chief  epileptogenetic  centres.    (Fig.  1).    There 
is  no  form  of  eclampsia  generated  from  the  ganglion  cells  in  the  spinal  cord. 


Fig.  1. 


Left  Hemisphere. 


Bight  Hemisphere. 


Muscles  of  trunk, 
arms  and  legs. 


Reflexes  from 
t^peripheral  nerves  and 


Showing,  schematically,  the  two  convulsive  centres— one  the  cortical,  the  other  the  ponto-bulbar,  and 
their  relations  and  connections.  They  may  be  acted  on  directly  by  lesions  of  the  centres  themselves, 
or  by  vascular  or  blood  states.  They  are  more  commonly  acted  upon  reflexly  by  irritations  conveyed 
along  sensory  fibres  from  remote  parts. 

Etiology. — Infants  are  always  particularly  liable  to  present  the  convulsive 
symptom,  because  of  the  incomplete  state  of  development  of  the  nervous  system. 
An  infant  is  a  bundle  of  nerves  and  nerve-centres  and  reflexes  in  a  state  of 
great  activity,  prepared  to  receive,  store  up,  and  re-energize  a  worldful  of  new 


CONVULSIONS.  743 

impressions  suddenly  thrust  upon  it.  While  the  nervous  system  of  the  adult 
has  acquired  the  steadiness  of  long  habit  and  has  but  to  repair  waste,  that  of 
the  infant  has  all  the  delicacy  and  instability  of  newly-formed  and  highly- 
impressionable  protoplasm,  and,  besides  having  to  preside  over  the  processes  of 
repair,  it  must  govern  the  growth  of  the  whole  organism.  The  lower  centres 
at  birth  are  more  developed  than  the  higher  ones,  and  control  is  therefore  much 
more  imperfect ;  yet  at  the  same  time  the  healthy  child  rarely  suffers  from 
eclamptic  seizures.  It  is  the  child  with  a  hereditary  neurotic  and  unstable 
nervous  system,  or  with  acquired  nervous  instability,  that  is  prone  to  fall  a 
victim  to  convulsions.  Most  authors  are  united  in  the  belief  that  there  is  an 
inherited  convulsive  tendency,  that  some  families  are  more  predisposed  to  the 
development  of  convulsions  in  infancy  than  others,  and  that  various  neurotic 
conditions  in  the  parents,  such  as  drunkenness  and  epilepsy,  may  give  origin 
to  this  tendency  in  their  offspring.  Rickets  is  one  of  the  strongest  predis- 
posing causes,  and  the  rickety  condition  is  exceedingly  common  in  children  that 
suffer  from  convulsions,  the  coincidence  occurring  in  30  to  40  per  cent.  (Gee, 
Morris  J.  Lewis,  and  others).  Anremic  conditions  and  exhaustion  or  general 
debility  from  any  cause  predispose  to  eclampsia. 

The  exciting  causes  are  chiefly  reflex,  either  from  irritation  in  the  fifth 
nerve  (dentition)  or  in  the  visceral  sensory  distribution  (gastro-intestinal  dis- 
orders). Many  of  the  exciting  causes  act  directly  upon  the  convulsive  centres 
(febrile  and  toxsemic  conditions).  These  are  given  as  typical  exciting  causes. 
Whether  the  purely  physiological  condition  of  dentition  is  the  sole  exciting 
cause  in  the  cases  usually  ascribed  to  that  period,  or  whether  there  may  not  be 
other  causes  operative  during  this  important  epoch  of  early  life,  cannot  always 
be  definitely  determined. 

Improper  feeding,  over-feeding,  and  disturbances  of  digestion  are  very 
frequent  causes  of  convulsions.  Instances  of  improper  feeding  are  not  often 
so  remarkable  as  one  that  came  under  my  observation  lately,  where  an  infant 
of  nine  months  was  given  a  dinner  of  corned  beef  and  cabbage.  This  was 
promptly  followed  by  convulsions  lasting  seven  hours,  and  these  by  a  hemi- 
plegia from  a  menmgeal  haemorrhage.  Gastro-intestinal  disorders  of  all  kinds 
are  frequent  precursors  of  convulsions.  Worms  no  doubt  often  give  rise  to 
eclamptic  symptoms,  but  not  so  commonly  as  is  popularly  believed.  Convul- 
sions complicate  many  of  the  acute  infectious  diseases,  and  are  probably  due  to 
toxines  of  bacterial  origin  circulating  in  the  blood.  In  the  intermittent  fever 
of  children  convulsions  usually  take  the  place  of  the  chill.  In  certain  districts 
it  is  common  to  speak  of  malarial  eclampsia  as  a  very  fatal  disorder.  Convul- 
sions complicate  pneumonia  occasionally,  but  rarely  after  the  age  of  two  years 
(Holt).  Fever  from  any  source  is  a  prolific  cause.  Infants  seem  to  be  very 
susceptible  to  the  influence  of  lead,  convulsions  sometimes  following  the  thera- 
peutic administration  of  this  metal  (Eustace  Smith).  The  so-called  "urgemic" 
conditions  frequently  give  rise  to  convulsions,  though  it  is  well  to  remember 
that  we  do  not  know  what  poison  in  the  blood  is  the  exciting  cause,  and  that 
we  do  know  that  urea  itself  is  innocuous.  In  3  to  5  per  cent,  of  cases  of 
whooping-cough  eclampsia  is  a  complication.  Fright,  terror,  anger,  burns, 
scalds,  morbus  cseruleus,  earache,  laryngeal  irritations,  and  organic  diseases  of 
the  brain  and  spinal  cord  are  to  be  borne  in  mind  as  more  or  less  frequent 
causes  of  infantile  convulsions. 

Pathology. — Often  after  death  from  convulsions  no  morbid  changes  are  to 
be  found  at  all  in  the  central  nervous  system.  Usually  there  are  signs  of  death 
by  asphyxia,  such  as  engorgement  of  the  meningeal  and  cerebral  veins  with  dark 
blood.     Sometimes  the  passive  hyperaemia  is  so  intense  that  effusion  of  blood 


744    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

takes  place,  or  oedema  may  be  present.  Some  authors  have  described  anaemic 
conditions  of  the  brain  after  death  from  convulsions.  The  pathology  is  of 
course  not  obscure  when  actual  organic  foci  of  disease  are  discovered. 

Outside  of  the  central  nervous  system  the  most  various  pathological  condi- 
tions are  found  at  times  in  the  heart,  lungs,  and  abdominal  viscera,  this  depend- 
ing naturally  upon  the  varying  nature  of  the  exciting  cause. 

Symptoms. — The  simplest  form  of  spasm  is  the  respiratory  spasm,  known 
by  several  names,  such  as  larA'ngismus  stridulus,  spasmodic  croup,  spasm  of  the 
glottis,  child-crowing,  and  inward  spasm.  It  is  a  local  spasm,  affecting  gener- 
ally the  glottis,  but  in  severe  cases  all  of  the  respiratory  muscles  may  take  part 
in  the  morbid  movement.  In  mild  cases  there  is  a  slight  stridulous  or  crowing 
sound  made  by  the  infant  during  inspiration  through  the  spasmodically  con- 
tracted glottis ;  in  severe  forms  this  sound  becomes  more  intense,  and  the  child 
may  become  pale  or  blue  before  the  obstruction  gives  way.  The  paroxysms 
may  appear  at  any  time  without  warning,  sleeping  or  waking,  when  being  fed, 
or  when  laughing  or  crving :  but  the  usual  onset  is  at  night.  The  attacks  last 
from  a  few  seconds  to  a  few  minutes,  and  terminate  in  a  coughing  or  crying 
spell.  Sometimes  rigidity  of  the  limbs,  opisthotonos,  or  even  general  convul- 
sions may  accompany  the  laryngeal  spasm.  These  seizures  may  occur  once 
or  several  times  in  one  night,  and  be  repeated  on  following  nights,  the  child 
being  apparently  well  in  the  intervals. 

In  general  convulsions  there  are  at  times  prodromal  symptoms,  but  more 
often  none.  The  prodromal  signs  are  restlessness,  starting  and  crying  in  sleep, 
grinding  of  the  teeth,  twitchings  of  the  face  or  extremities,  flexions  of  the 
thumbs,  and  the  like.  These  are  often,  however,  unimportant.  There  is  con- 
siderable variation  in  the  extent  and  severity  of  eclampsia  in  children,  from 
slight  jerky  movements  of  the  head  and  face  and  carpo-pedal  contractions,  to  a 
condition  not  differing  from  epileptic  fits.  Then  in  some  of  the  graver  cases  there 
may  be  a  cry  ;  consciousness  is  lost ;  there  is  at  first  a  tonic  contraction,  often 
not  so  long  as  in  epilepsy  ;  then  follow  vigorous  clonic  movements  of  the  face, 
eyes,  tongue,  jaw,  arms,  hands,  thighs,  and  legs,  which  gradually  diminish  in 
extent  as  the  nerve-storm  abates,  until  the  child  becomes  wholly  quiet,  and 
remains  dazed  or  in  a  deep  sleep  or  stupor  for  some  minutes  or  a  half  hour 
afterward.  There  may  be  frothing  at  the  mouth.  The  tongue  is  sometimes 
caught  between  the  teeth  and  bitten.  The  pupils  may  be  contracted  or  dilated, 
and  the  face  cyanosed  or  pale.  There  may  be  a  single  such  attack,  or  the 
seizures  may  be  repeated  daily  or  innumerable  times  during  a  day  or  two, 
resembling  the  status  epilepticus.  Sometimes  the  convulsions  may  be  limited  to 
one  side  or  one  extremity,  or  to  some  particular  part,  as  in  respiratory  spasm. 
The  repetition  of  convulsions  continuously  limited  to  one  side  or  one  extremity 
would  lead  one  to  suspect  a  localized  organic  lesion  in  or  about  the  motor  cor- 
tex. Consciousness  is  not  always  lost  in  the  milder  tj-pes  of  infantile  spasm. 
The  temperature  is  generally  normal  in  laryngismus  stridulus,  but  more  or  less 
fever  may  accompany  general  convulsions,  especially  when  prolonged  and  fre- 
quently repeated,  as  in  the  condition  resembling  status  epilepticus  (Morris  J. 
Lewis  suggests  the  term  status  eclamptieus  for  this  condition).  Death  may  occur 
during  a  paroxysm,  either  from  asphyxia  or  from  unknown  influences  on  cere- 
bral centres.  It  is  important,  too.  to  remember  that  hssmorrhage  may  take  place 
from  the  turgid  meningeal  vessels,  as  I  have  pointed  out  in  another  article  in 
connection  with  the  causation  of  the  cerebral  palsies  of  early  life. 

Prognosis. — Convulsions  in  children  are  always  a  symptom  of  great  gravity. 
Life  may  be  terminated  in  a  single  seizure.  Yet  many  children  become  robust 
and  healthy  after  passing  through  successive  series  of  attacks.     Naturally,  our 


CONVULSIONS.  745 

prognosis  must  be  governed  by  a  knowledge  of  the  exciting  causes,  and  these 
are  often  very  obscure.  In  children  afflicted  with  convulsions  during  the  first 
few  days  of  life  the  probability  of  meningeal  haemorrhage  from  instrumental 
delivery  or  tedious  labor  is  strong,  since  eclampsia  is  rare  from  other  causes  in 
infants  under  the  age  of  one  month.  Hyperpyrexia  is  a  very  grave  concomitant 
symptom.  General  convulsions  associated  with  respiratory  spasm,  whooping- 
cough,  and  toxaemia  of  any  kind  are  of  serious  import.  The  same  is  true  when 
they  follow  upon  wasting  diseases,  such  as  cholera  infantum  and  diarrhoea.  In 
the  exanthemata  convulsions  at  the  onset  are  not  so  ominous  as  in  the  later 
stages,  though  in  scarlatina  they  are  dangerous  indications  at  all  times.  The  pos- 
sibility of  the  recurrence  of  spasms  in  the  form  of  epilepsy  in  later  life  should  be 
borne  in  mind,  for  in  nearly  10  per  cent,  of  epileptics  a  history  of  infantile  convul- 
sions is  found.  It  is  probable  that  the  convulsions  are  a  symptom,  more  often 
than  is  generally  supposed,  of  organic  lesions  in  the  brain,  and  that  associated 
conditions,  such  as  hemiparesis,  hemiplegia,  and  mental  defects,  often  escape  rec- 
ognition until  later  development  of  the  child  brings  them  into  prominence.  It  is 
therefore  well  to  remember  that  eclampsia  may  be  associated  with  such  states,  as 
well  as  occasionally  produce  them,  as  noted  above.  When  convulsions  are 
ascertained  to  depend  upon  dyspepsia  or  other  mild  disorders  of  the  alimentary 
canal,  or  to  be  symptomatic  of  rachitis,  the  results  may  not  be  so  serious  as 
under  other  circumstances,  but  the  prognosis  should  always  be  guarded. 

Diag-nosis. — Convulsions  occurring  in  children  shortly  after  birth  are 
probably  due  to  injuries  received  during  labor  or  to  congenital  pathological 
conditions  (like  heart  disease  or  atelectasis),  though  reflex  digestive  disturbances 
are  to  be  considered  if  organic  causes  can  be  excluded.  In  infants  above  six 
months  of  age  gastro-intestinal  troubles  or  disorders  of  dentition  are  to  be 
regarded  as  most  commonly  the  exciting  cause,  particularly  in  such  cases  as  are 
predisposed  by  rickets  or  general  debility.  The  temperature  and  pulse  should 
be  taken,  for  these  often  furnish  indications  as  to  the  possible  onset  of  some  of 
the  exanthemata.  Symptoms  of  meningitis,  pneumonia,  and  bronchitis,  and 
eruptions  should  be  looked  for.  The  urine  should  be  examined  for  albumin. 
The  manner  of  origin  and  of  onset,  the  order  of  the  attack,  and  the  presence 
of  paresis  or  paralysis  should  be  carefully  inquired  into. 

Treatment. — The  treatment  of  the  convulsions  of  infancy  and  childhood 
depends,  of  course,  to  a  great  extent,  upon  the  cause.  But  this  cannot  always 
be  ascertained.  Where  there  is  reason  to  suspect  organic  brain  disease,  such 
as  haemorrhage,  the  treatment  is  much  the  same  as  in  the  adult — perfect  quiet, 
cold  applications  to  the  head,  relief  of  the  bowels  by  injection,  and  the  relief 
of  the  convulsions  by  chloroform  inhalation  and  later  by  small  doses  of  bromide 
of  potassium.  Should  there  be  fever,  the  tepid  half-bath,  with  cold  ablutions 
and  rubbing,  should  be  frequently  employed.  When  the  eclampsia  is  due  to 
some  reflex  disturbance,  the  warm  bath  is  useful  (96°-97°  F.),  and  if  there  be 
colic  or  abdominal  disorder  a  warm  bath  containing  mustard  should  be  employed. 
An  overloaded  stomach  or  an  alimentary  canal  containing  indigestible  food  may 
be  relieved  by  one  or  two  grains  of  calomel.  A  good  emetic  is  a  teaspoonful  of 
syrup  of  ipecacuanha  mixed  with  alum.  Tickling  the  fauces  should  not  be  for- 
gotten. If  the  child  be  at  the  age  of  dentition,  and  there  be  actual  evidence 
of  painful  and  swollen  gums,  these  should  be  incised. 

If  called  to  a  case  of  infantile  convulsions  where  the  cause  seems  to  be 
wholly  obscure,  it  may  be  laid  down  as  a  safe  rule  to  give  a  warm  (not  a  hot) 
bath,  if,  indeed,  this  has  not  already  been  done  by  the  family,  and  to  give  an 
enema  of  five  grains  of  chloral  in  a  little  warm  starch-water,  using  a  few  drops 
of  chloroform  for  inhalation  while  the  chloral  injection  is  being  prepared  and 


746    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

while  awaiting  its  effects.  In  recurrent  convulsions  medicines  may  be  given  in 
the  intervals,  and  among  these  the  bromide  of  potassium  in  doses  of  3  to  5 
grains  for  an  infant  six  months  old,  and  chloral  2  to  3  grains,  stand  pre- 
eminent as  antispasmodics.  The  bromide  should  be  continued  for  a  few  days 
after  the  convulsions  have  ceased,  in  order  to  prevent  their  repetition. 

In  laryngismus  stridulus  chloroform  inhalation  will  always  stop  the  par- 
oxysm, though  simpler  means  should  be  resorted  to  at  first — viz.,  ammonia  to 
the  nose,  slapping  with  a  cold  wet  towel,  tickling  the  fauces,  and  the  like.  In 
the  interim  between  attacks  the  treatment  of  special  exciting  conditions  should 
be  carried  out,  as  in  infants  suffering  from  general  convulsions. 

In  all  cases  the  diet  should  be  regulated,  and  morbid  states,  such  as  rickets, 
diarrhoea,  worms,  dyspepsia,  earache,  and  the  like,  be  given  appropriate  treat- 
ment. 


EPILEPSY. 


By  JAMES  HENDRIE  LLOYD,  A.  M.,  M.  D., 

Philadelphia. 


Epilepsy  is  not  a  disease  ;  it  is  a  syndrome.  By  this  is  meant  that  it  is  a 
collection  of  symptoms  or  a  comprehensive  symptom-group.  It  was  among  the 
earliest  recognized  so-called  diseases,  because  of  its  abrupt  onset  and  dramatic 
features.  Like  many  other  symptom-groups  of  which  the  morbid  anatomy  was 
unknown,  this  one  was  made  to  include  phenomena  of  a  variety  of  distinct 
affections  due  to  widely  varying  causes.  With  the  growth  of  modern  pathology 
these  various  disease-processes  have  been  more  and  more  carefully  studied  and 
differentiated.  Hence  one  by  one  independent  classes  of  epileptic,  or  ejnlejytoid, 
affections  have  been  separated  from  the  main  group.  Thus  the  convulsions  of 
hysteria  major  were  first  set  aside.  Later  puerperal  convulsions,  or  eclampsia, 
were  defined.  So,  too,  the  convulsions  of  urgemia,  of  certain  toxaemias,  of 
infectious  diseases,  of  degenerative  processes  such  as  general  paresis,  and  those 
occurring  in  infancy,  were  demarcated.  No  one  now  would  think  of  speaking 
of  these  fits  as  epileptic,  and  yet,  except  in  hysteria,  the  convulsive  crises,  as 
well  as  some  of  the  attendant  sensory  and  psychic  phenomena,  are  practically 
identical  with  those  of  epilepsy.  Later  still  it  was  observed  that  in  some  cases 
the  fits  began  always  in  one  particular  muscle  or  muscle-group,  whence  they 
radiated  to  a  variable  extent,  sometimes  persisting  in  only  a  few  muscles  or 
spreading  to  one  limb  or  to  one  side,  but  in  some  cases  extending  to  the  whole 
body,  involving  consciousness  only  partially  in  the  milder  cases.  These  local 
fits  were  found  to  be  due  to  a  "  discharge  "  from  a  limited  area  in  the  brain- 
cortex,  determinable  now  by  the  principles  of  cerebral  localization.  This  area 
of  discharge  is  oftenest  in  the  motor  zone,  but  not  always,  because  sometimes 
the  first  or  "signal"  symptom  is  sensory.  This  species  of  epilepsy  is  called 
"focal,"  or,  after  the  writer  who  first  described  it,  Jacksonian  epilepsy.  Not 
unfrequently  such  focal  epilepsy  is  found  to  be  due  to  a  distinct  local  lesion, 
such  as  may  be  caused  by  trauma,  by  a  neoplasm,  or  by  some  point  of  irritation 
or  inflammation.  Again,  a  large  class  of  epileptics  is  associated  with  idiocy, 
arrest  of  development,  or  atrophy  of  the  brain.  The  pathological  processes 
underlying  these  are  numerous,  and  some  of  them  have  not  yet  been  clearly 
demonstrated. 

Thus  it  is  seen  that  the  tendency  of  modern  research  is  to  demonstrate  dis- 
tinct pathological  processes  for  the  various  diseases  or  conditions  which  have 
among  their  symptoms  an  occasional  epileptic  spasm.  Hence  there  is  left  only 
a  constantly  narrowing  group  of  epilepsies,  of  which  the  pathology  is  as  yet 
unknown,  and  to  which  some  writers  illogically  apply  the  terms  "true"  or 
"essential  "  epilepsy,  or,  still  worse,  idiopathic  epilepsy.  The  author  does  not 
believe  that  epilepsy  or  any  other  disease  is  truly  idiopathic,  but  he  thinks, 
with  Fdre,  that  this  group  of  essential  epilepsies  is  one,  not  in  which  there  is 
no  pathology,  but  in  which  the  pathology  is  unknown.     But  so  long  as  this 

747 


748    AM£:IiICA^^  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

group  stands  he  recognizes  that  it  will  be  desirable,  even  necessary,  to  give  a 
clinical  description  of  it  in  a  text-book  on  practice,  to  state  briefly  the  advances 
that  have  been  made  in  its  pathology,  and  especially  to  describe  its  proper 
treatment. 

Etiology. — It  follows  from  what  has  been  said  that  the  causes  of  the 
various  forms  of  epilepsy  differ.  Focal  epilepsy  is  usually  dependent  upon  a 
local  lesion,  such  as  a  trauma,  a  tumor,  or  a  syphilitic  or  tubercular  process. 
The  causes  of  "  essential "  or  vulgar  epilepsy  are  often  very  problematical.  It 
is  the  custom  now  to  regard  it  as  a  manifestation  of  a  degenerative  process  in 
the  brain,  dependent  largely  upon  heredity  or  congenital  imperfection.  In  this 
aspect  it  has  its  alliances  Avith  insanity  on  the  one  hand  and  with  idiocy  on  the 
other.  It  is  possible  that  some  cases  are  the  results  of  intra-uterine  mishaps  or 
diseases,  or  of  injury,  unobserved  and  unsuspected,  at  the  time  of  birth. 
Others,  again,  may  date  from  the  insidious  process  of  some  infectious  disease.^ 
Alcoholism  is  an  occasional,  not  a  common,  cause  of  confirmed  epilepsy.  It  may 
act  in  the  parents,  however,  to  contribute  to  degenerative  processes  in  the  chil- 
dren, among  the  symptoms  of  which  may  be  epilepsy. 

Pathology. — Epilepsy,  in  its  motor  aspect,  is  an  explosion  of  nerve-force 
from  the  brain-centres.  But  this  is  a  crude  and  inadequate  explanation  of  the 
disease-process.  It  does  not  explain  all  the  phenomena,  especially  the  loss  of 
consciousness  and  the  various  psychical  disorders.  Bevan  Lewis  believes  that 
the  cells  of  the  second  layer  of  the  brain-cortex  undergo  degeneration  or  "vacu- 
olation" — that  these  cells  are  the  sensory  pole  of  a  true  sensori-motor  arc,  the 
motor  pole  being  the  large  cells  of  the  deeper  layers.  Hence  the  normal  inhi- 
bition exerted  by  the  sensory  cells  being  destroyed,  a  periodical  explosion  of 
the  motor  cells  occurs.     It  is  needless  to  say  that  this  is  a  mere  theory. 

Morbid  Anatomy. — The  gross  lesions  of  focal  epilepsy  are  usually  easily 
recognized.  Among  the  most  common  are  tumors,  especially  in  the  motor 
region  of  the  cortex.  Next  are  wounds,  causing  either  depressed  fractures  of 
the  skull  or  localized  inflammatory  products,  or  both.  Such  wounds  may  be 
caused  by  blows  on  the  head  and  by  gun-  and  pistol-shots.  Syphilitic  lesions, 
as  a  localized  pachymeningitis,  may  cause  a  focus  of  discharge.  So  may  a 
tubercular  deposit,  often  called  massive  tubercle.  Focal  discharges  are  some- 
times, as  the  author  has  seen,  among  the  earliest  symptoms  of  tubercular  men- 
ingitis. The  gross  deformities,  such  as  porencephalon,  and  diffused  processes, 
such  as  lobar  sclerosis,  which  manifest  themselves  by  idiocy  and  arrest  of 
development,  and  are  not  unfrequently  provocative  of  epileptic  seizures,  are 
not  properly  to  be  described  here. 

A  number  of  diffused  lesions  have  been  reported  as  found  in  cases  of  chronic 
epilepsy.  These  are,  as  a  rule,  scleroses  of  different  parts  of  the  brain  or  bulb. 
Sclerosis  of  the  Ammon's  horn  has  attracted  much  attention  and  caused  much 
debate.  According  to  some,  it  is  found  in  only  G  per  cent,  of  brains  examined, 
but,  according  to  others,  it  is  much  more  frequent.  The  facts  of  motor  local- 
ization, as  Fere  says,  do  not  lend  countenance  to  the  theory,  and  experiment 
shows  that  lesions  of  this  part  do  not  cause  epilepsy  ;  nevertheless,  the  obser- 
vations are  rather  too  frequent  to  be  mere  coincidents.  With  this  author  we 
may  suppose  that  the  induration  of  the  cornu  Ammonis  is  only  a  predominant 
localization  of  a  more  diffused  lesion.  Fere  reports  also  plates  of  induration  in 
various  parts  of  the  cortex  and  induration  of  the  olivary  bodies  similar  to  that 
of  the  Ammon's  horn.     Chaslin  claims  to  have  found  in  brains  of  some  of  F^r^'s 

'  The  infectious  origin  of  epilepsy  lias  lately  been  claimed  by  Marie  (Prog.  Med.,  1887,  No. 
44),  Lemoine  (Ibid.,  1888,  No.  16),  and  by  Veysset  (Thesis,  1889,  De  ^influence  des  maladies  infecr 
tieuses  sur  le  developpement  de  I'epUepsie). 


EPILEPSY.  749 

patients  a  diffused  neurogliar  sclerosis,  a  real  gliosis — in  other  words,  a  pro- 
liferation of  the  neurogliar  tissue  of  the  brain,  as  distinct  from  a  sclerosis  of 
connective  tissue.^  The  claim  of  Bevan  Lewis  that  the  distinctive  lesion  of 
epilepsy  is  a  vacuolation  of  the  cells  of  the  second  layer  of  the  cortex  has  already 
been  referred  to.  It  still  remains  a  vital  point  to  be  decided  whether  these 
various  lesions  are  the  causes  or  the  effects  of  confirmed  epilepsy. 

Symptoms. — Adopting  Fern's  plan,  we  may  divide  the  symptoms  of  epi- 
lepsy into  four  groups :  (1)  Sensory,  (2)  Motor,  (3)  Psychie,  (4)  Visceral. 
These  blend  in  various  ways  in  different  cases  ;  in  fact,  it  may  be  said  that  no 
two  cases  of  epilepsy  are  alike. 

Sensory  symptoms  may  precede  or  follow  the  fit,  or  both.  The  sensory 
aura  is  a  very  common  signal  or  initial  symptom.  It  may  be  a  sense  of  numb- 
ness or  tingling  in  one  of  the  extremities,  as  in  a  finger  or  toe,  or  it  may  be  a 
peculiar,  indescribable  sensation  starting  from  the  epigastrium  and  mounting 
to  the  head.  This  epigastric  aura  is  perhaps  the  most  common.  When  it 
reaches  the  head  or  neck,  the  patient  usually  loses  consciousness  and  falls  in 
the  fit.  Sometimes  the  aura  is  in  one  of  the  special  senses,  as  flashes  of  light 
in  the  eyes  or  rumbling  or  other  sounds  in  the  ears.  Auras  of  taste  and  smell 
are  more  rare.  Occasionally  hallucinations  of  sight  are  described,  as  an  image 
of  some  person  or  thing,  either  agreeable  or  terrifying,  appearing  and  advancing 
to  the  patient.  The  aura,  whatever  it  is,  is  usually  unvarying ;  that  is,  the 
same  patient  always  experiences  the  same  aura  in  succeeding  fits.  The  sensory 
symptoms  following  the  attack  are  less  striking  and  variable.  The  most  fre- 
quent is  headache,  which  may  persist  for  some  hours  or  even  a  day.  Some- 
times the  sensory  symptoms  constitute  the  whole  of  the  attack,  and  may  consist 
in  a  crisis  resembling  migraine.  In  fact,  some  authors  teach  that  all  migraine 
is  an  epileptoid  affection,  but  of  this  there  is  not  satisfactory  proof.  Certainly, 
ordinary  migraine  does  not  show  a  tendency  to  pass  into  motor  epilepsy. 

The  motor  symptoms  of  epilepsy  are  by  far  the  most  conspicuous,  and  so 
dominate  the  scene  that  they  are  apt  to  be  regarded  as  the  most  important;  but 
this  is  an  error.  They  present  great  variety,  and,  for  the  sake  of  brevity,  can 
best  be  described  in  some  of  their  typical  forms.  The  first  visible  motor 
symptom  may  be  in  the  form  of  an  aura;  that  is,  a  signal  symptom  recognized 
by  the  patient.  This  may  coexist  with  or  immediately  follow  a  sensory  aura, 
such  as  has  already  been  described.  It  is  usually  a  tonic  or  clonic  movement 
of  the  muscles  of  one  of  the  fingers  or  toes,  or  of  the  external  muscles  of  the 
eyes,  or  of  the  muscles  of  the  face  or  neck.  This  motor  aura  is  especially 
likely  to  occur  in  the  focal  epilepsy  referred  to  above.  This  slight  initial 
spasm  soon  radiates  to  other  muscles,  then  to  the  proximal  parts  if  in  a  limb, 
then  to  the  whole  limb,  then  to  the  limbs  of  one  side,  and  then,  in  severe  cases, 
to  the  whole  body.  The  first  movement  of  the  convulsed  muscles  is  nearly 
always  tonic  or  spastic,  rapidly  giving  way  to  vibratory  and  clonic  movements. 
In  some  milder  cases  or  attacks  of  this  focal  epilepsy  the  movement  may  consist 
of  merely  a  slight  spastic,  followed  by  a  jerky,  clonic  convulsion  in  a  very 
limited  muscle-group.  In  the  most  severe  of  all  forms  of  epilepsy,  known  as 
vulgar  epilepsy  or  grand  mal,  the  motor  phenomena  are  about  as  follows : 
Almost  instantly,  with  a  very  brief  aura,  or  even  without  any  warning  whatever, 
the  patient  utters  a  peculiar  startling  cry  and  falls  convulsed.  This  cry  is 
probably  part  of  the  motor  symptom-group,  being  rather  the  result  of  the 
forcible  expulsion  of  air  from  the  chest  by  the  vice-like  spasm  of  the  respiratory 
muscles  than  the  expression  of  emotion  or  other  psychic  states.     When  he  falls 

^  For  an  exhaustive  discussion  of  this  whole  subject  see  Fern's  treatise,  Les  Epilepsies  et  les 
epiJeptiques,  Paris,  1890,  chap,  xxx,  p.  437. 


750    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  patient  is  in  a  general  tonic  or  spastic  stage.  The  pupils  are  dilated.  The 
face,  at  first  pale,  rapidly  becomes  congested  and  cyanosed.  The  teeth  are 
firmly  set,  the  tongue  probably  caught  between  them.  The  fists  are  clenched, 
the  limbs  extended,  the  head  often  drawn  forcibly  to  one  side.  In  a  few  mo- 
ments vibratory  movements  begin  in  the  muscles  of  the  eyes,  face,  and  extrem- 
ities. These  vibrations  soon  increase  in  range,  and  they  pass  into  clonic  spasms, 
which  gradually  diminish  and  usually  terminate  in  wider  shock-like  movements. 
While  they  endure  bloody  or  unstained  froth  escapes  from  the  mouth ;  the  urine, 
and  rarely  the  faeces,  may  be  expelled.  The  patient  often  injures  himself  in 
his  fall,  besides  biting  his  tongue.  He  is  unconscious  from  the  first  moment, 
and  sleeps  heavily  for  many  hours  afterward.  Exhaustion,  even  paralysis,  of 
the  convulsed  muscles  may  follow  the  fit.  Exhaustion  and  abolished  knee- 
jerks  are  seen  after  these  severe  attacks  especially.  Paralysis  in  the  previously 
convulsed  muscles  is  more  apt  to  occur  after  focal  epilepsy,  especially  when 
this  depends  upon  a  destructive  focus,  such  as  trauma  or  tumor,  in  the  brain. 

The  psychic  symptoms  of  epilepsy  are  of  the  very  first  importance.  It  is 
too  often  the  custom,  unfortunately,  to  regard  epilepsy  as  a  mere  motor  dis- 
order characterized  only  by  a  fit.  There  is  nothing  Avider  from  the  truth  than 
this.  Epilepsy,  or  that  for  Avhich  it  stands,  is  much  more  than  a  fit.  Its  essen- 
tial factor  is  probably  a  Avidespread  degenerative  process  which  involves  not 
only  the  motor  and  sensory  cortex,  but  also  the  higher  intellectual  spheres  of 
the  brain.  Hence,  as  was  recognized  long  ago,  epilepsy  has  important  rela- 
tions to  the  mental  health.  The  transient  psychic  disorders  usually  attending 
the  convulsion,  or  following  it,  have  already  been  noted.  They  consist  of  very 
fleeting  mental  states,  which  accompany  the  aura,  such  as  confusion,  possibly 
in  some  cases  terror,  or  even  rage,  and  which  soon  pass  into  unconsciousness. 
This  unconsciousness  lasts  for  a  variable  time,  usually  persisting  as  a  deep  sleep 
for  some  hours  after  the  fit.  But  there  are  other  and  more  important  psychic 
phenomena.  Not  only  loss  of  consciousness,  but  also  stuporous  and  confusional 
states,  as  well  as  various  forms  of  mental  derangement,  attests  how  comprehen- 
sive may  be  this  degeneration.  Among  the  most  common  of  these  derange- 
ments are  episodes  of  fury  with  forgetfulness,  mania,  substituting  or  following 
the  paroxysm,  delusional  ideas,  moral  perversions,  coma,  and  chronic  deteriora- 
tion of  the  brain-faculties.  Many  years  ago  Morel,  a  French  Avriter,  described 
masked  epilepsy  {epilepsie  larvee),  in  which  the  motor  crisis  is  not  apparent, 
but  is  replaced  by  an  explosion  of  maniacal  fury.  This  is  perhaps  an  extreme 
doctrine  if  applied  to  the  cases  of  persons  avIio  have  never  been  known  to  have 
any  of  the  motor  disorders  of  epilepsy.  But  this  variety  is  very  similar  to  the 
noAv  Avell-recognized  substitutional  attacks.  These  are  episodes  of  confusion, 
forgetfulness,  automatism,  and  even  violence,  taking  the  place  of  a  motor  seizure 
in  a  confirmed  epileptic.  They  are  called  also  psychical  equivalents.  Another 
mental  disorder  is  mania,  a  dangerous  complication.  It  may  appear  as  a  sub- 
stitute for,  or  as  a  sequel  of,  a  paroxysm.  Delusions  sometimes  persist  in  the 
epileptic,  which  appear  to  have  had  their  birth  in  the  disordered  brain  just 
before  or  after  a  convulsion.  Homicidal  and  suicidal  impulses  are  sometimes 
displayed.  The  terminal  dementia  of  epilepsy  is  a  state  of  degeneration  of  the 
mental  faculties.  As  was  said  above,  no  two  epileptics  are  alike.  Hence  it  is 
futile  to  attempt  to  classify  this  great  array  of  psychoses  into  "prodromal," 
"post-paroxysmal,"  etc.,  as  some  have  done.  Each  case  must  be  studied  by 
itself.  Commonly,  mental  symptoms  appear  just  before  or  after  or  substituting 
a  paroxysm;  in  other  words,  they  are  part  of  the  epileptic  discharge.  Where 
they  seem  to  come  independently  of  a  fit,  it  is  well  to  recollect  that  the  motor 
discharge  may  have  been  so  slight  as  to  have  been  overlooked. 


EPILEPSY.  751 

The  great  viscera  are  variously  affected  in  epilepsy.  Death  has  resulted 
from  asphyxia  due  to  the  spasm  of  the  chest-muscles,  or  even  from  rupture  of 
the  heart  occurring  during  the  tonic  stage.  Crises  resembling  angina  pectoris, 
also  peculiar  spasmodic  affections  of  the  larynx,  are  sometimes  epileptic  in 
character.  Nocturnal  incontinence  of  urine,  especially  if  persisting  after  early 
childhood,  may  excite  a  reasonable  suspicion.  Disorders  of  digestion  not  unfre- 
quently  persist  for  some  days  after  a  convulsion ;  these  are  chiefly  nausea,  vom- 
iting, anorexia,  constipation,  or  diarrhoea.  Jaundice  even  has  been  seen. 
Post-paroxysmal  albuminuria  has  been  observed,  but  not  constantly,  as  some 
have  claimed.  Glycosuria  is  exceptional.  A'isceral  symptoms  are  quite  prom- 
inent in  some  cases  of  petit  mal;  thus  with  slight  dizziness  and  confusion  there 
may  be  nausea  or  palpitation  of  the  heart.  In  a  very  few  cases  hjemorrhage 
into  the  brain  has  been  found  as  a  result  of  a  fit. 

The  nutrition  is  variously  affected  by  the  epileptic  seizure.  Loss  of  weight 
and  alterations  in  the  blood,  such  as  diminution  in  the  quantity  of  oxyh^emo- 
globin.  have  been  observed  and  studied  by  Fere,  Henocque,  and  others. 

Epilepsy  leaves  its  marks  or  stigmata  upon  the  body  of  the  patient.  These 
are  most  conspicuous  in  chronic  cases  that  have  begun  early  in  life,  and  hence 
in  cases  that  are  most  distinctly  degenerative  in  origin  and  course.  Some  of 
these  somatic  sicrns,  in  fact,  are  identical  with  those  that  are  now  well  recog-- 
nized  in  constitutional  or  hereditary  types  of  insanity,  or  even  in  arrest  of 
development.  Among  them  are  cranial  and  facial  asymmetry ;  also  other  cra- 
nial and  skeletal  deformities.  Such  epileptics,  on  the  whole,  are  of  poor  or 
even  stunted  development,  although  many  exceptions  to  this  rule  occur.  Defec- 
tive development  of  teeth,  external  ears,  and  genital  organs  is  sometimes 
noted.  The  epileptic  facies  has  been  described,  but  it  is  too  often  the  evidence 
of  bromidism  rather  than  of  disease. 

Varieties. — There  are  many  varieties  of  epilepsy.  Focal  epilepsy  has 
'already  been  described.  Petit  mal  is  often  only  a  minor  form  of  this  :  it  consists 
in  a  momentary  dazed  or  confusional  state,  with  or  without  localized  muscular 
movements.  G-rand  mal  also  has  been  described.  Xocturnal  epilepsy  is  not 
distinct,  except  for  the  fact  that  the  attacks  occur  during  sleep :  somnial  epi- 
lepsy would  be  a  better  term,  because  the  attacks  occur  really  dtuing  sleep, 
whether  this  be  ditring  the  day  or  night.  Cases  have  preserved  this  type  for 
many  years.  Procursive  ejjilepsy  derives  its  name  from  the  fact  that  the 
patient  runs  for  some  distance  before  falling  in  the  fit.  JIasked  epilepsy, 
already  referred  to,  is  the  type  in  which  the  sensory  and  motor  symptoms  are 
replaced  by  a  psychosis.  A  very  grave  complication  is  the  epileptic  status. 
In  this  the  patient  passes  rapidly  from  one  convulsion  into  another.  He  is 
comatose,  with  high  temperature,  a  weak  pulse,  and  a  stertorous  respiration. 
In  this  condition  he  may  die. 

Diagnosis. — ^Epilepsy  is  to  be  distinguished  especially  from  hysteria,  from 
the  convulsions  of  uraemia,  and  from  those  due  to  gross  organic  brain  disease. 
It  can  be  distinguished  successfully  from  hysteria  by  the  absence  of  the  hys- 
terical stigmata,  which  cannot  be  described  here ;  by  the  history  of  the  case, 
and  by  a  careful  comparison  with  a  typical  grand  attack  as  described  elsewhere. 
It  can  be  distinguished  from  urgemia  by  the  history  of  the  case  and  by  the 
absence  of  evidence  of  organic  kidney  changes.  In  gross  brain  disease  the 
symptomatic  epilepsy  is  often  focal,  although  not  always,  and  other  symptoms, 
such  as  various  forms  of  paralysis  of  motion  and  sensation,  changes  in  the  optic 
disks,  vomiting,  vertigo,  and  acute  mental  symptoms,  together  with  the  history  of 
the  case,  assist  in  the  diagnosis.  In  children  a  grave  question  sometimes  arises 
as  to  the  exact  nature  of  a  convulsion,  especially  if  it  has  been  repeated  after 


752    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

a  comparatively  long  interval  without  apparent  cause.  Reflex  epilepsies  ia 
children  from  teething,  worms,  constipation,  etc.,  are  not  nearly  so  frequent  as 
has  been  supposed.  The  great  majority  of  infantile  convulsions  are  caused  by 
some  infection  of  the  blood,  such  as  the  poisons  of  scarlatina,  measles,  whooping- 
cough,  etc.,  or  the  products  of  indigestion.  Where  no  such  cause  exists,  and 
especially  when  the  convulsions  are  repeated  at  comparatively  long  intervals, 
the  case  ought  to  be  recognized  as  serious,  as  threatening  the  formation  of  the 
epileptic  habit,  and  it  ought  to  be  treated  accordingly. 

Prognosis. — In  early  exceptional  cases,  not  caused  by  gross  brain  disease, 
it  is  possible  that  a  cure  may  be  obtained.  For  chronic  epilepsy  there  is  no 
cure.  The  more  inveterate  and  severe  the  fits,  the  greater  is  the  chance  of 
mental  complications  and  ultimate  deterioration.  This  rule  is  not  universal, 
however,  because  mental  symptoms  are  due  to  obscure  causes  and  may  appear 
in  mild  cases.  Patients  with  severe,  if  infrequent,  attacks  often  lead  a  long 
and  even  useful  life.  The  epileptic  status  is  always  dangerous  to  life.  Brain- 
surgery  has  relieved  focal  cases  due  to  gross  lesions,  but  even  in  these  cases 
relapses  have  occurred. 

Treatment. — The  treatment  of  epilepsy  must  be  both  hygienic  and  spe- 
cific. It  has  long  been  observed  that  over-eating,  over-sleeping,  and  a  slothful 
life  are  especially  injurious  to  epileptics.  In  young  patients,  Avho  do  not  yet 
show  the  marks  of  chronicity  and  deterioration,  it  is  important  to  regulate  the 
habits  and  the  daily  life.  Attention  ought  to  be  paid  to  the  gastro-intestinal 
tract ;  over-eating  and  constipation  must  be  guarded  against.  Radcliife  of 
England  also  cautions  against  over-sleeping  as  provocative  of  more  frequent 
seizures.  An  overloaded  bowel  will  undoubtedly  act  injuriously  upon  the 
epileptic.  This  is  a  matter  of  common  observation  in  the  Philadelphia  Hospital 
among  the  epileptics  and  the  epileptic  insane.  An  idle  life  is,  unfortunately, 
often  forced  upon  the  epileptic ;  he  both  shuns  and  is  shunned  because  of  his 
affliction.  It  were  far  better  if  he  could  be  kept  busy  at  some  light  and  agree- 
able task.  In  private  patients  this  need  can  and  ought  to  be  met.  Finally, 
the  well-recognized  rules  of  personal  hygiene,  which  cannot  be  given  here  in 
detail,  ouo-ht  never  to  be  relaxed. 

The  indications  for  treatment  supplied  by  the  advanced  pathology  of  epi- 
lepsy, given  above,  are  several.  Drugs  which  have,  or  are  supposed  to  have, 
a  restraining  eff'ect  upon  connective  tissue  or  neurogliar  proliferation  ought  to 
have  a  thorough  trial.  Iodide  of  potassium  is  the  first  of  these  in  importance. 
The  mercurial  drugs  may  have  a  somewhat  similar  eff'ect,  as  may  also  nitrate 
of  silver.  Arsenic  and  zinc  salts  are  of  doubtful  utility.  It  is  but  reasonable 
to  suppose  that  the  peculiar  action  of  these  medicines  will  be  exerted  best  in 
recent  cases  and  in  young  persons.  Certainly,  every  such  case  ought  to  have  a 
thorough  trial  of  the  iodide  of  potassium.  If  time  shall  prove  that  this  latter 
drug  exerts  a  true  alterative  action  upon  the  sclerotic  processes  seen  in  epilepsy, 
it  will  deserve,  rather  than  the  bromides,  the  title  of  a  specific. 

The  bromides  are  undoubtedly  the  surest  remedy  for  epilepsy,  especially 
for  controlling  the  fits  in  confirmed  cases.  That  they  are  ever  curative,  even 
when  given  early  in  young  patients,  is  at  least  doubtful.  The  writer  has  never 
seen  them  eff'ect  a  cure.  Some  authorities  advise  heroic  doses  given  until  the 
patient  is  "  bromidized."  It  is  well  to  try  this  plan  in  early  cases  in  the  hope 
of  eradicating  the  disease.  In  chronic  cases  bromide  in  any  doses  cannot  cure, 
but  it  can  reduce  the  number  of  seizures.  It  does  this,  however,  at  the  cost 
of  much  depression,  and  in  advanced  cases,  if  given  in  large  doses  for  a  long 
time,  it  probably  promotes  some  deterioration  of  the  brain.  Children  bear 
large  doses  of  the  bromides  well.     Of  the  various  salts,  the  potassium  is  rather 


EPILEPSY.  753 

the  most  reliable,  the  sodium  is  least  likely  to  disturb  the  stomach,  and  the 
ammonium  is  stimulating  to  an  insignificant  degree.  The  iodide  of  potassium 
can  be  given  with  any  bromide  salt. 

Antipyrin  has  been  tried  with  apparently  good  eiFect  in  epilepsy.  It 
belongs  strictly  to  the  same  class  as  the  bromides — i.  e.  it  is  palliative  rather 
than  curative.  Chloral  hydrate  may  assist  the  bromides,  especially  in  urgent 
cases  like  epileptic  status. 

Of  other  drugs,  none  deserve  special  mention  except  belladonna  and  nitrite 
of  amyl.  The  former  has  value,  but  its  unpleasant  physiological  action  is  much 
against  it.  The  nitrite  of  amyl  is  of  use  in  some  case  of  petit  mal  to  abort  the 
crisis. 

Surgery  offers  relief  in  many  cases  of  focal  epilepsy  due  to  gross  lesion  of 
the  brain  or  skull,  such  as  tumor  and  fracture.  The  seat  of  an  old  fracture,  or 
even  suspected  fracture,  ought  to  be  trephined  if  epilepsy  supervenes.  The 
principles  of  cerebral  localization  may  indicate  the  seat  of  a  lesion  in  obscure 
cases.  Even  in  cases  where  no  organic  lesion  has  been  discovered,  excision  of 
that  part  of  the  cortex  which  contains  the  focus  of  discharge  has  done  good.^ 
Trephining  in  cases  of  epileptic  idiocy  caused  by  brain  atrophy,  porencephalon, 
and  other  gross  defects,  should  be  condemned.  It  is  not  based  upon  scientific 
principles,  and  the  results  in  the  cases  in  which  it  has  been  done  are  disap- 
pointing, and  they  have  often  been  fatal. 

'  See  cases  by  Lloyd  and  Deaver,  Am.  Jour.  Med.  Sd.,  Nov.  1888,  and  Intern.  Clinics,  voL 
iii.,  2d  Ser.  1892. 
48 


CHOREA. 


By  M.  ALLEN  STARR,  M.  D.,  Ph.  D., 

New  York. 


Chorea  mixor,  Chorea  of  Sydenham,  or  St.  Vitus'  Dance,  is  a  functional 
nen^ous  disease  characterized  bv  sudden  rapid  twitchings  of  any  or  all  of  the 
muscles  of  the  body,  by  slight  deficiency  in  the  control  of  the  muscles  which 
twitch,  and  by  mental  irritability. 

Description. — The  movements  produced  by  chorea  are  spasmodic,  unex- 
pected, and  inimitable.  They  cannot  be  arrested  by  will  for  any  length  of  time, 
but  are  much  increased  by  attention,  by  excitement,  or  by  any  effort  either  to 
restrain  them  or  to  exercise  the  muscles  involved.  In  the  majority  of  the  cases 
the  movements  are  momentary  and  slight,  and  do  not  exhaust  the  patient.  In  a 
few  most  severe  cases  they  are  extended,  violent,  and  continuous,  endangering  the 
patient's  safety  and  even  his  life.  These  movements  interfere  greatly  with 
voluntary  acts,  rendering  them  imperfect,  awkward,  excessive,  or  even  impos- 
sible. When  chorea  is  slight,  such  acts  as  dressing,  writing,  or  playing  the 
piano  may  reveal  irregular  motions  not  noticeable  in  a  state  of  rest ;  and  often 
it  is  this  unusual  awkwardness  in  the  performance  of  these  acts  or  nervousness 
which  first  attracts  attention  to  the  condition.  When  the  disease  is  fully  devel- 
oped any  movement  involving  fine  co-ordination  is  impossible.  While  any  muscle 
of  the  body  may  be  involved  in  the  choreic  movements,  it  is  more  common  to 
notice  them  in  the  extremities  and  face  than  in  the  muscles  of  the  trunk.  The 
facial  muscles  are  frequently  aff"ected,  and  the  child  makes  queer  faces,  espe- 
cially while  talking.  The  eyes  are  suddenly  closed  or  opened  ;  the  mouth 
pouts  ;  the  tongue  if  protruded  is  seen  to  be  affected,  and  may  be  suddenly 
withdrawn,  or  even  be  cut  by  an  unexpected  snapping  together  of  the  jaws; 
occasionally  the  laryngeal  and  respiratory  muscles  are  affected,  and  noises  are 
made  in  the  throat.  The  neck  is  not  as  frequently  affected  as  the  shoulders, 
but  the  arms  below  the  elbow  are  almost  always  involved,  and  irregular, 
awkward  motions  of  the  fingers  are  always  seen  or  felt  if  the  hands  are  held. 
While  the  trunk-muscles  do  not  often  appear  to  swell  out  in  contraction,  yet 
the  entire  body  is  uneasy,  and  frequent  changes  of  posture  are  always  to  be 
seen.  The  legs  below  the  knees  are  affected  as  often  as  the  arms,  but  the 
thighs  do  not  often  twitch,  and  the  patient  is  rarely  seen  to  fall,  though  he  may 
stagger  in  walking.     These  motions  cease  during  sleep. 

The  tveakness  in  the  muscles  affected  may  occasionally  amount  to  paralysis, 
but  this  is  rare.  The  awkwardness  or  ataxia  is  always  noticeable.  The  disease 
might  be  supposed  to  be  entirely  muscular  in  its  origin,  were  it  not  for  the  facts 
that  it  is  very  often  unilateral  and  almost  always  associated  with  mental  irri- 
tability. Hemichorea  is  about  one-third  as  common  as  general  chorea.  In  474 
cases  of  my  own  169  were  unilateral.  It  occurs  on  either  side,  and  if  the 
disease  begins  as  a  hemichorea  it  rarely  becomes  general.  If  it  has  once 
occurred  as  a  hemichorea,  it  usually  recurs  as  such. 

The  mental  irritability  is  usually  noticeable  early  in  the  disease.     It  may 

754 


CHOREA.  755 

be  accompanied  by  mability  to  exert  the  mind  continuously  and  by  enfeebled 
ability  and  depression  of  spirits.  The  child  frets  and  is  easily  irritated,  is 
quarrelsome  when  previously  of  good  temper,  cannot  be  amused,  and  is  said  to 
be  naughty  when  in  reality  it  is  unable  to  exercise  self-control  in  a  normal 
manner.  It  may  act  in  a  semi-imbecile  manner,  laughing  too  easily.  It  is 
always  incapacitated  for  study.  This  mental  excitement  may  interfere  with 
sleep. 

A  child  wlio  is  suffering  from  chorea  is  unusually  pale,  badly  nourished,  has 
little  appetite,  is  constipated,  passes  but  little  urine,  and  that  of  high  specific 
gravity,  loaded  with  phosphates  and  urates.  Very  frequently,  if  examined,  it  will 
be  found  to  have  a  loud  systolic  heart-murmur,  which  may  be  either  functional 
and  due  to  anaemia  or  organic  and  due  to  endocarditis.  There  is  often  obtained 
a  history  of  muscular  pains  or  of  an  attack  of  rheumatism  preceding  or  coincident 
with  the  appearance  of  the  chorea,  and  also  of  headache.  There  is  usually 
diminution  of  the  tendon  reflexes  and  a  hyperexcitability  of  the  muscles  to 
electrical  stimulation.     Temperature,  pulse,  and  respiration  are  normal. 

The  disease  appears  suddenly  sometimes  after  a  fright,  increases  during  the 
first  two  weeks,  lasts  for  several  weeks  (ten  is  the  average),  and  gradually  sub- 
sides, but  will  probably  recur  after  a  year  at  the  same  season  at  which  it  first 
appeared. 

This  description  applies  to  the  majority  of  cases  of  chorea.  There  are 
exceptional  cases  which  require  mention. 

In  a  few  instances  the  motions  are  constant,  excessive,  and  violent,  so  that 
the  patient  will  be  thrown  off  a  chair  or  out  of  bed,  and  is  liable  to  injure 
his  limbs  by  their  violent  contact  with  objects.  Unless  these  patients  are 
kept  asleep,  they  are  soon  worn  out  and  may  die  of  exhaustion. 

In  a  few  cases  the  mental  irritation  rises  to  the  pitch  of  mania,  and 
active  delirium  occasionally  occurs  in  this  form  of  the  disease. 

In  some  the  weakness  is  so  much  more  apparent  than  the  twitching  that 
the  case  impresses  the  observer  as  one  of  paralysis :  this  has  been  named  the 
paralytic  form.  I  have  known  a  case  of  chorea  to  be  mistaken  for  infantile 
spinal  paralysis.  Occasionally  the  twitching  is  less  noticeable  than  the  awk- 
wardness, and  were  it  not  for  the  age  of  the  patient  and  the  absence  of  other 
symptoms  the  case  might  be  thought  to  be  one  of  locomotor  ataxia. 

In  a  few  instances  speech  becomes  affected  early,  and  may  be  so  indistinct 
that  it  cannot  be  understood :  it  is  in  these  cases  that  grunting  noises  may  be 
made.  Sometimes  nervous  patients  affected  with  twitching  motions  give  vent 
to  loud  words  unexpectedly,  usually  of  a  profane  or  obscene  kind.  This  con- 
dition, known  as  coprolalia,  is  not  choreic,  but  hysterical.  So,  too,  is  echolalia, 
in  which  the  patient  repeats  the  last  word  heard.  Such  patients  often  mimic 
motions  and  show  other  signs  of  hysteria. 

Subcutaneous  nodes,  which  are  small,  round,  hard  nodules  appearing  in 
many  parts  of  the  body,  notably  on  the  back  and  along  the  flexor  surfaces  of 
the  extremities,  are  occasionally  seen  in  choreic  patients.  They  are  to  be 
regarded  as  evidence  of  rheumatism,  and  have  no  special  relation  to  the 
chorea. 

Duration  of  the  Disease. — The  duration  of  an  attack  of  chorea  is  very 
variable  in  different  cases.  Sometimes  the  disease  runs  a  rapid  course,  and 
terminates  in  recovery  within  a  month ;  again  it  may  continue  for  a  year  or 
more  with  varying  degree  of  severity;  occasionally  it  becomes  chronic  and 
lasts  for  years. 

The  large  majority  of  cases  of  chorea  last  from  six  to  ten  weeks,  and  ter- 
minate in  recovery ;  but  there  is  always  danger  of  a  relapse,  and  the  greater 


756    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

number  of  the  patients  suffer  from  a  second  or  third  attack,  which  attack  usu- 
ally occurs  at  the  same  period  of  the  year  at  which  the  first  seizure  occurred. 
I  have  treated  a  patient  for  seven  successive  years  every  spring,  and  have  many 
cases  on  my  books  of  fourth  and  fifth  recurrences. 

Death  only  occurs  as  an  exception  in  children,  though  fatal  cases  in  adults, 
especially  when  chorea  complicates  pregnancy,  are  not  very  rare.  When  a  child 
dies  of  chorea  it  is  because  of  exhaustion  on  account  of  the  severity  of  the 
motions. 

Etiology. — *SV.r. — ^lales  are  less  liable  to  the  development  of  chorea  than 
females,  the  proportion  being  about  1  to  3.  Of  466  cases  of  my  own,  136 
were  males  and  330  were  females;  of  436  cases  collected  by  the  Collective 
Investigation  Committee  of  the  British  Medical  Association  in  1887,'  114  were 
males  and  322  were  females. 

Age. — While  chorea  may  occur  at  any  age  of  life,  instances  having  been 
reported  both  at  birth  and  at  the  age  of  eighty-six.  yet  the  large  majority  of 
cases  appear  between  the  fifth  and  fifteenth  years  of  life.  Table  I.  shows  the 
age  of  onset  in  467  cases  under  my  own  observation  and  in  436  cases  tabulated 
in  the  report  of  the  B.  C.  C. : 

Table  I. — Age  of  Incidence  of  Chorea. 


Cases. 

u 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

11. 

12. 

13. 

14. 

15. 

16 
to 
20. 

21 
to 
25. 

26 
to 
30. 

31 
to 
35. 

36 
to 
40. 

S  1 

5 

B.  C.  C.  cases  .  . 
Personal  cases  . 

2 
3 

1 

7 

3 
19 

15 
22 

37 

25 
34 

59 

20 
55 

75 

43 
44 

87 

46 
43 

89 

49 
35 

84 

42 
42 

84 

41 
42 

83 

39 
35 

74 

20 
22 

42 

71 
56 

127 

10 
10 

20 

2 
0 

2 

1 
2 

3 

1 

1 

2 

6 
5 

n 

5 

8 

22 

Glasses. — While  children  in  all  classes  of  the  community  may  be  attacked 
by  chorea,  a  large  majority  of  the  cases  are  found  to  develop  among  the  lower 
classes,  especially  among  children  living  in  tenement-houses  under  bad  hygienic 
surroundings  and  subsisting  upon  poor  and  badly  cooked  food. 

Season. — Several  interesting  investigations  have  been  made  with  regard  to 
the  relation  between  atmospheric  and  climatic  conditions  and  the  development 
of  chorea.  An  attempt  has  been  made  by  Lewis  to  trace  some  relation  between 
the  occurrence  of  storms,  between  barometric  changes,  between  changes  in 
humidity  of  the  atmosphere,  and  the  occurrence  of  the  onset  of  chorea.  While 
it  appears  from  the  tracings  upon  his  table  (see  Table  II.)  that  there  is  some 
connection  between  the  conditions  of  the  weather  and  the  development  of  rheu- 
matism, and  while  there  is  undoubtedly  a  distinct  tendency  for  chorea  to  pre- 
vail in  certain  climates  at  certain  seasons  of  the  year,  yet  no  precise  statements 
in  regard  to  the  influence  of  climatic  changes  upon  the  production  of  chorea 
can  be  made. 

Weir  Mitchell  and  Sinkler  have  called  attention  to  the  fact  that  chorea 
appears  with  greater  frequency  at  certain  periods  of  the  year,  notably  during  the 
spring.  Table  III.,  which  compares  the  months  of  onset  of  170  cases  of  Weir 
Mitchell  and  409  of  the  author's,  clearly  shows  that  the  largest  number  of  cases 
begins  in  the  spring. 

Relation  of  Mheumatism    and    Chorea. — For   many    years    it    has    been 

admitted  that  there  is  an  intimate  relation  between  chorea  and  rheumatism. 

.  Many  cases  of  chorea  develop  immediately  after  an  attack  of  acute  rheumatism, 

with  or  without  accompanying  endocardial  complications.     In  many  instances 

^  The  results  of  this  investigation  are  valuable,  and  will  be  referred  to  in  the  course  of  this 
article  as  the  B.  C.  C,  British  Chorea  Committee.    (See  British  Medical  Journal,  Feb.  20, 1887.) 


CHOREA. 


1^1 


rheumatism  and  chorea  appear  alternately,  one  succeeding  the  other  in  some 
patients;  in  many  cases  they  appear  simultaneously.  In  Table  IV.  the  relation- 
ship or  coincidence  of  these  diseases  is  displayed,  and  the  large  percentage 
of  cases  of  chorea  in  which  rheumatism  has  existed  (26  per  cent.)  can  not  be 
ignored.  The  statement  may  be  made  that  a  certain  poison  in  the  blood,  either 
of  extraneous  origin  or  internal  development,  under  certain  conditions,  produces 
rheumatism  or  chorea  or  endocarditis.  This  poison  may  affect  the  joints  or  the 
nervous  system  or  the  heart,  probably  in  accordance  with  the  varying  suscepti- 
bility of  these  organs  in  different  individuals,  and  in  many  subjects  it  produces 
all  three  diseases  at  once. 

Some  authors  regard  the  existence  of  "growing  pains"  of  an  indefinite 
muscular  character  as  sufficient  evidence  of  rheumatism,  and  in  the  statistics 
here  collected  it  has  not  always  been  possible  to  determine  vfhether  the  pains 
called  rheumatic  were  of  this  character.  In  my  own  cases  I  only  consider 
those  rheumatic  in  which  a  history  of  acute  articular  rheumatism  occurring 
within  three  months  of  the  onset  of  the  chorea  has  been  obtained. 


PHILBDELPHIP. 


Table  II. 
/37-0  -  /eso 


Tff.BK.'S.  -T. 


2 

°  tt'  ?■  ^  s'  ^ 
^  i  ^  i  ^  ^ 

o    q:    i^   :^    o    z 

3      lU      O     O      Ul      K 

K    w    o    e    Q    -7 

o    g    a    >•    i 

111     K      £     tt     § 
"•    E     K    g    ^ 

H: 

1 ""ajr"" 

:H:|::j:iniiiill: 

E;EEEi:E::;EEiEE:a| 

11== 

y/o. 

liili 

=  ,; 

m^}kmm\ 

:::::::::   |:::i::::: 

100. --~ 

lli 



::::-]|3::*:::E;E:E;:: 

:::::::::::::::  :::S::: 

90. 

:   :      1       ::::::::::::: 

::.: ::.. :::: :..: : ;;: :s: 

ii:  mm 

"i: 

;:^   :-^K-'--T:---:-: 

::::::-::::::::::::;:: 

WffM\\M\\\] 

-5''^ 

.::: :::: ;::: ::::   ::  —  S 

so, 

BIB 

i---E|i;-Ej:EEEEEi 

5:::  :: 

i™ 

-Z2:E:| 

^m 

:.'.t  : 

:l:|:J:l::::: 

11 

S3§M 

■iSI 

^\m^ 

mil 

>ff»;-/i- 

::::::::|::=;::^=    -i; 

°T\--' 

[-A V-  A —  — 

1 1   1  i  w 

40. 

jpj 

\\M\M\i\\lmm 

:;:::: 

:      t          :::  3.: 

llE^ElEEi 

-.-=t 

MM! 

EEEE  EEEEEEEE: 

2ft8j        ao.'----^ 

{■\\nii:;::\U,l':'::zl 

\\i\^\':l':yzl-:':~zz-zll': 

99,90                   ----- 

Mh^iMiinlniiEEJE; 

|:5;;eee|=;?ee 

99.95  eO^S» 

\\\\hmm:\\\y:\ 

EEiEi^^EEEElhiEEEEEE 

N 

frmfi 

S0.0O    6S^       

lllllllillllli 

EEEEEEEE  ?;.i;i;;;EEEEE 

;eee;ee;::::eee::e^^;E: 

=  ::::::;i=::E:::-|:::: 

0. 

' 

::±::::::::::::::::::: 

1.  717  separate  attacks  of  chorea ;  2.  Storm-centres  passing  within  400  miles  of  Philadelphia ;  3.  Mean 
barometer ;  4.  Mean  relative  humidity ;  5.  674  separate  attacks  of  acute  inflammatory  rheumartism.— (Lewis, 
Trans.  Assoc.  Amer.  Phys.,  1892). 


758    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Table  111.— Showing  Month  of  Onset  of  Chorea.     (409  cases  of  author,  black  line;  110  ernes  of 

Weir  Mitchell,  dotted  line.) 


65 
60 
56 
60 
45 
40 
35 
30 
^5 
20 
15 
10 
5 

Jan. 

M. 

Mar. 

Apr. 

May. 

June. 

July. 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

p 

A 

A 

/    \ 

y 

\ 

\ 

V 

—A 

\ 

/ 

A 
1  < 

\ 

V 

/     * 

\ 

; 

/ 

\ 

V 

^ 

r 

/ 

->• — 

-- -- 

-N 

^ 

•-^^ 

/ 

^>^,^ 

~-— - 

.♦- — 

"-- • 

Relation  of  Chorea  to  Endocarditis. — In  a  large  percentage  of  patients  suf- 
fering from  chorea  examination  of  the  heart  reveals  the  existence  of  a  murmur. 

Table  IV. — Showing  the  Relationship  of  Chorea^  Bheumatisnij  and  Endocarditis. 


Author. 

Reference. 

No. 
Cases    Chorea. 

Rheumatism. 

Cardiac. 

Groendal 

Meyer 

Koch 

Peiper    

See 

Wien.  nied.  Woch.,  Mar.  26, 

1891 

Berl.  klin.  Woch.,  July  14, 

1890 

Arch.  klin..  Med.,  1886     .    . 
Deut.  med.  Woch.,  July,  1888 
La  Med.  moderne,  Oct.,  1891 
Eev.  Mens,  des  Mai.  de  I'Enf., 

June,  1890 

Lancet,  Oct.  31,  1891  .    .    . 
Lancet,  Jan.  12,  1889     .    . 
Lancet,  Jan.  12,  1889      .    . 
Lancet,  May  4,  1889   .    .    . 
Brit.  Med.   Jour.,  Feb.  26, 

1887 

Dis,    Nerv.  System,  vol.  ii. 

p.  550    

Keatinffs  Cyclo.  Child.  Dis., 

vol.  iv.  p.  843      .... 
Arch,    of  Pediatrics,    Apr., 

1888      

Peiypei-'s  System  of  Med.,  vol. 

iv.  p.   442 

52 

121 

267 

30 

196 

80 
20 
80 
80 
84 

439 

100 

70 

130 

279 
448 

37 

11 

48 

14 

134 

5 

3 

37 

36 

62 

116 

24 

8 

7 

37 

83 

Majority. 

15 

37 

6 

Leroux 

Dale 

Herringham 

Garrod 

Cheadle 

Brit.  Col.  Invest.  Com. 

Gowers 

Sachs  

Dana 

Sinkler 

Starr 

5 

8 
20 
45 

141 

40 

12 

8 

82 
83 

2476 

662 
26  per  cent. 

502  + 

CHOREA.  759 

This  murmur  is  usually  a  mitral  systolic  murmur,  heard  at  the  apex,  only  occa- 
sionally being  aortic  or  double.  In  many  of  the  cases  the  murmur  heard 
appears  with  the  beginning  of  the  attack  of  chorea,  and  ceases  after  the  attack 
is  over.  Such  murmurs  are  usually  considered  as  blood-murmurs,  owing  to 
their  association  with  anaemia,  and  are  not  thought  to  indicate  any  actual  disease 
of  the  valves.  A  certain  proportion,  however,  of  patients  who  have  chorea  con- 
tinue to  have  a  cardiac  murmur  after  the  chorea  has  passed  away,  and  just  as 
rheumatism  may  leave  a  diseased  heart,  so  chorea  may  leave  a  diseased  heart ; 
and  this  is  true  whether  the  chorea  has  been  associated  with  rheumatism  or  not. 
It  is  true  that  the  rheumatic  cases  of  chorea  are  more  liable  to  develop  endo- 
cardial murmurs  than  the  non-rheumatic  cases,  but  it  is  not  true  that  the 
development  of  a  true  endocardial  murmur  is  evidence  of  the  existence  of 
rheumatism  in  a  given  case  of  chorea. 

In  my  own  records  I  have  distinguished  between  cases  in  which  a  murmur 
has  been  present  and  has  passed  away  after  the  chorea  has  ceased  (65  cases),  and 
cases  in  which  the  murmur  has  remained  for  a  period  exceeding  six  months 
after  recovery  from  the  chorea  (83  cases).  There  were  300  cases  in  which  the 
heart  was  carefully  watched,  and  in  which  no  murmurs,  either  functional  or 
organic,  appeared.  Osier  has  shown  that  in  a  considerable  proportion  of  cases 
of  chorea  the  complicating  endocarditis  is  independent  of  rheumatism,  but 
lays  the  foundation  of  organic  heart  disease — an  opinion  which  my  experience 
confirms. 

Other  Etiological  Facts. — It  is  well  known  that  chorea  occurs  as  a  sequel 
of  scarlet  fever  and  measles,  whooping-cough  and  varicella.  It  is  possible  that 
the  original  infectious  agent  producing  these  diseases  acts  as  an  irritant  to  the 
nervous  system.  The  chorea  which  occurs  during  pregnancy  need  not  be  con- 
sidered here  as  it  is  not  a  disease  of  childhood. 

A  large  majority  of  the  patients  suffering  from  chorea  present  evidences  of 
anaemia  in  greater  or  less  degree.  It  cannot  be  stated,  however,  that  anaemia 
is  a  cause  of  chorea.  It  is  probable  that  the  same  conditions  which  give  rise 
to  anaemia  conduce  to  the  development  of  chorea.  The  anaemia  is  frequently 
so  severe  as  to  require  treatment  simultaneously  with  the  chorea. 

While  it  is  possible  that  local  twitchings  of  the  muscles  of  the  eyes  or  face 
or  neck  may  be  produced  by  eye-strain  or  by  irritation  in  the  naso-pharynx, 
true  chorea  is  never,  in  my  opinion,  produced  by  these  causes,  and  treatment 
directed  to  the  relief  of  so-called  muscular  insufiiciencies  in  the  eye-muscles  is 
useless. 

The  exciting  causes  of  chorea  are  not  fully  determined,  but  a  certain  pro- 
portion of  the  cases  develops  after  sudden  mental  excitement,  such  as  fright  or 
grief.  Thus  in  87  cases  out  of  490  of  which  I  have  records,  a  fright  was 
assigned  as  the  exciting  cause,  and  in  the  B.  C.  C.  report  it  is  assigned  as  a 
cause  in  96  cases  out  of  222.  In  order  to  be  considered  as  an  actual  cause  of 
chorea  the  mental  shock  must  precede  the  development  of  chorea  by  not  more 
than  a  week,  for  it  is  hardly  to  be  supposed  that  the  effects  of  any  mental 
shock  can  appear  after  a  longer  interval. 

Certain  authors  have  called  attention  to  hereditary  influences  acting  as  pre- 
disposing causes  to  chorea,  and  it  is  a  fact  that  if  the  family  history  be  carefully 
investigated,  rheumatism,  various  nervous  disorders,  alcoholism,  and  tubercu- 
losis are  frequently  discovered. 

Pathology. — According  to  our  definition,  chorea  is  a  functional  disease. 
This  implies  that  there  are  no  organic  changes  constantly  present  as  its  patho- 
logical cause.  That  all  functional  diseases  are  undoubtedly  due  to  disturbance 
in  the  nutrition  or  in  the  molecular  structure  of  tissues  is  admitted,  and  that 


760    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

in  chorea  such  changes  are  present  in  the  nerve-cells  of  motor  function  is  highly 
probable;  but  inasmuch  as  the  very  large  majority  of  patients  suffering  from 
chorea  recover  entirely,  and  inasmuch  as  in  many  cases  of  chorea  there  are  no 
permanent  objective  symptoms  which  indicate  a  loss  of  any  function,  it  must 
be  admitted  that  a  constant  pathological  condition  visible  by  the  microscope  is 
not  to  be  expected. 

Nevertheless,  numerous  cases  of  chorea  have  been  examined  post-mortem, 
and  many  changes  have  been  described  in  the  nerve-cells,  in  the  neuroglia,  and 
in  the  blood-vessels  as  characteristic  lesions  of  chorea.  The  statements  made 
by  some  authors  regarding  hyperemia  of  the  nervous  system  as  a  cause  of 
chorea  may  be  dismissed  without  consideration,  for,  aside  from  the  question 
whether  hyperemia  or  antemia  during  life  leaves  any  evidences  in  the  nervous 
system  after  death — an  open  question — these  appearances  are  described  in 
other  diseases  besides  chorea. 

Some  authorities  have  described  minute  haemorrhages  and  capillary  emboli 
as  the  lesions  of  chorea,  but  other  equally  good  observers  have  failed  to  find 
these  conditions. 

Vacuolization  of  the  nervous  tissue  and  of  the  nerve-cells  has  been  assigned 
as  the  lesion  of  chorea,  as  have  also  dilatations  of  the  spaces  around  the  blood- 
vessels ;  but  this  condition  has  also  been  described  as  the  lesion  of  diabetes  and 
of  various  functional  nervous  diseases,  and  cannot  be  accepted  as  characteristic 
of  chorea  alone. 

Hyaline  degeneration  in  the  nervous  cells  of  motor  function  in  the  cortex 
and  in  the  basal  ganglia  has  been  described,  but  this  is  known  to  be  present 
in  epilepsy  and  in  many  organic  lesions  not  attended  by  the  twitchings  of 
chorea. 

Hyperplasia  of  the  neuroglia  has  been  seen,  but  this,  too,  cannot  be  con- 
sidered as  a  necessary  accompaniment  of  chorea,  inasmuch  as  it  is  permanent, 
while  the  disease  is  temporary. 

It  is  to  be  remembered  that  in  the  majority  of  cases  which  have  come  to 
autopsy  other  diseases  than  chorea  have  caused  the  death  of  the  patient,  or  else 
the  patient  has  succumbed  to  a  condition  of  exhaustion  which  in  itself  might 
be  suflficient  to  produce  many  of  the  changes  described;  therefore  I  do  not 
believe  that  the  pathological  anatomy  of  chorea  can  be  said  to  be  known. 

It  is  not  positively  determined  Avhether  the  portion  of  the  motor  nervous 
system  affected  in  chorea  is  the  spinal  cord,  basal  ganglia,  or  cortex.  Probably 
various  cases  present  various  conditions.  In  the  cases  in  which  the  mental 
symptoms  are  prominent  the  cortex  is  undoubtedly  involved,  and  in  the  unilat- 
eral cases  the  lesion  is  undoubtedly  cerebral.  There  is  little  ground  for  posi- 
tive statement  regarding  the  situation  of  the  lesion  in  chorea,  and  writers  too 
often  indulge  in  theoretical  argument. 

Diag-nosis. — There  are  many  diseases  in  which  the  chief  and  most  promi- 
nent symptom  is  a  twitching  of  the  muscles.  These  should  not,  however,  be 
mistaken  for  chorea.  Tic  convulsif.  which  is  a  unilateral  twitching  of  the  mus- 
cles of  the  face,  is  usually  a  reflex  spasm  due  to  some  irritation  in  the  domain 
of  the  trigeminal  nerve ;  Avhich  irritation,  being  conveyed  inward  to  the  pons, 
gives  rise  to  a  sudden  impulse  outward  through  the  facial  nerve,  just  as  a  bit 
of  dust  in  the  eye  gives  rise  to  a  wink.  The  limitation  of  this  spasm  to  the 
face,  and  the  fact  that  in  the  majority  of  cases  it  can  be  arrested  by  pressure 
exerted  upon  some  branch  of  the  trigeminal  nerve  upon  the  face,  will  prevent 
its  being  mistaken  for  chorea. 

There  is  a  similar  disease,  called  general  convulsive  tic  or  maladie  des 
tics  conviilsifs,  fii'st  described  by  Gilles  de  la  Tourette,  consisting  of  a  sudden 


CHOREA.  761 

twitching  of  any  or  all  of  the  muscles  of  the  body.  This  resembles  chorea 
closely,  but  should  not  be  mistaken  for  it.  It  is  not  attended  by  any  weakness 
of  the"^  muscles  or  by  any  awkwardness  of  voluntary  movement ;  the  twitchings 
do  not  occur  during  voluntary  movements,  but  only  appear  during  rest.  The 
disease  is  a  chronic  one,  appearing  as  a  rule  about  the  fifteenth  year  and  remain- 
ing during  life.  The  twitchings  are  more  sudden  than  those  of  chorea,  and 
there  is  no  mental  irritability.  The  disease  does  not  appear  as  early  in  life  as 
chorea,  and  it  does  not  yield  to  arsenic. 

Habit-spasm  has  been  mistaken  for  chorea,  but  should  not  be  confounded 
with  it.  All  children  have  a  tendency  toward  mimicry,  and  a  child  who  is 
afflicted  by  habit-spasm  makes  movements  which  have  the  character  of  volun- 
tary movements,  such  as  winking,  pouting  the  lips,  turning  the  head,  shrugging 
the  shoulders,  or  moving  the  extremities :  such  habit-spasms  are  not  as  quick 
and  sudden  as  the  spasms  of  chorea;  after  a  time- they  are  not  easily  controlled 
voluntarily,  as  they  are  in  the  early  stage  of  the-  affection.  Voluntary  control 
can,  however,  be  increased  by  forcing' the  child's  attention  to  the  necessity  of 
it,  and  in  this  condition  moral  treatment  and  general  hygienic  measures,  such 
as  baths  and  proper  exercise,  are  of  more  service  than  medicines. 

Paramyoclonus  multiplex  is  a  spasmodic  affection  of  the  muscular  system 
which  resembles  chorea.  In  this  disease  it  is  the  muscles  of  the  body  and  of 
the  proximal  portions  of  the  limbs  Avhich  are  affected ;  the  face  and  arms  and 
hands  and  legs  do  not  participate  in  the  spasm.  The  spasms  are  bilateral  and 
symmetrical ;  they  occur  at  intervals,  and  are  rapidly  repeated,  as  many  as 
ninety  contractions  of  the  muscles  occurring  in  a  minute.  The  movements 
during  the  attack  of  spasm  are  very  violent,  so  as  to  throw  the  patient  down 
if  walking  or  to  hurl  him  off  a  chair  if  seated.  The  spasm  can  be  brought 
on  by  tapping  the  patellar  tendon.  During  the  interval  between  the  spasms 
fibrillary  tremor  of  the  affected  muscles  may  be  seen.  The  disease  may 
occur  at  any  age ;  it  usually  develops  after  some  mental  or  physical  strain  in 
patients  of  an  hysterical  temperament,  and  recovery  generally  takes  place  after 
a  time.  It  will  be  seen  from  this  description  that  the  disease  should  not  be 
mistaken  for  chorea. 

The  hemichorea  which  follows  hemiplegia  is  characterized  by  slow,  irregu- 
lar ataxic  movements  on  voluntary  motion,  and  does  not  consist  of  twitchings 
in  individual  muscles.  It  should  be  regarded  as  hemiathetosis  rather  than  as 
a  species  of  chorea. 

Multiple  sclerosis  may  be  the  cause  of  irregular  movements,  but  these  never 
occur  when  the  patient  is  at  rest,  and  this  is  not  a  disease  of  childhood. 

Prog-nosis. — In  view  of  the  facts  stated  it  is  evident  that  the  prognosis 
given  to  the  parents  in  any  case  of  chorea  should  be  a  hopeful  but  also  a 
guarded  one.  For  while  the  chances  are  all  in  favor  of  a  speedy  recovery 
within  three  months,  they  are  also  in  favor  of  a  recurrence  of  the  disease,  and 
in  no  case  is  it  possible  to  promise  a  cure,  because  of  the  fact  that  a  few  of  the 
cases  which  cannot  at  the  outset  be  distinguished  from  the  ordinary  cases 
become  chronic  and  do  not  recover  at  all. 

Another  fact  should  be  mentioned  which  should  lead  to  a  guarded  prog- 
nosis— namely,  that  certain  children  are  exceedingly  susceptible  to  the  effects 
of  arsenic,  which,  as  we  shall  see  in  the  section  upon  Treatment,-  is  the  only 
remedy  of  value.  These  children  either  cannot  take  arsenic  in  sufficient  doses, 
or  if  they  take  it  develop  arsenical  poisoning  or  even  arsenical  multiple  neuri- 
tis, both  of  which  conditions  hamper  the  treatment  exceedingly. 

The  development  of  rheumatism  during  the  disease  does  not  necessarily 
make  the  prognosis  very  grave,  for  few  children  die  of  rheumatism.     Nor  does 


762    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

the  development  of  endocarditis  with  organic  murmurs  in  the  heart  lead 
to  any  great  anxiety  as  to  the  life  of  the  patient :  such  murmurs  may  remain 
through  life,  and  in  later  years  the  heart  disease  may  give  rise  to  much  trouble ; 
but  it  is  very  rare  to  find  in  children  suffering  from  chorea  and  endocarditis 
any  evidence  of  insufficiency  of  the  heart's  action,  as  demonstrated  by  oedema 
of  the  extremities  or  cedema  of  the  lungs.  Nor  have  I  ever  seen  hemiplegia 
develop  in  the  course  of  chorea  as  an  evidence  of  cerebral  embolism. 

Treatment. — The  first  endeavor  of  the  physician  who  is  called  upon  to 
treat  a  case  of  chorea  should  be  to  direct  such  an  arrangement  of  the  patient's 
life  and  surroundings  as  will  remove  him  from  the  bad  hygienic  influences 
which  have  conduced  to  the  development  of  the  disease.  If  the  patient 
remains  in  a  damp  or  ill- ventilated  room,  if  he  be  not  properly  bathed  and  fed, 
and  if  he  cannot  be  kept  quiet  and  without  excitement,  the  prospect  of  success 
in  treatment  is  not  good.  The  child  should  always  be  removed  from  school. 
Nutritious  diet  of  varied  character,  the  digestion  of  which  should  be  aided,  if 
necessary,  by  the  use  of  digestants  and  of  laxatives,  is  important.  Long-con- 
tinued baths  are  to  be  recommended,  the  child  being  allowed  to  play  in  the 
the  water  for  half  an  hour  twice  a  day.  The  bath  should  be  tepid,  between 
95°  and  100°  F.,  and  no  sudden  shock  of  cold  is  to  be  used.  The  object  of 
the  bath  is  to  have  a  soothing  influence  as  well  as  to  dilate  the  vessels  of  the 
surface,  and  the  sharp  contraction  of  the  vessels  produced  by  cold  applications 
is  to  be  avoided.  Rest  in  bed  or  upon  a  bed  or  couch  is  very  essential  during 
the  first  two  weeks  of  the  disease.  It  is  difficult  to  keep  a  child  who  is  irri- 
table in  bed ;  therefore  it  is  best  for  the  child  to  be  warmly  clad  in  merino 
underclothing,  but  not  fulh^  dressed,  and  to  be  allowed  to  play  about  upon  a 
large  bed,  but  not  allowed  to  run  about  upon  the  floor.  Gentle  massage  to  the 
entire  body  for  an  hour  daily  or  for  half  an  hour  twice  a  day,  the  body  being 
anointed  with  cocoa  butter,  is  of  decided  benefit.  It  is  better  for  a  child  with 
chorea  to  see  but  one  or  two  members  of  the  family,  so  as  to  be  kept  free  from 
all  mental  excitement.  After  the  child  is  kept  at  rest  in  this  manner,  being 
amused  in  every  possible  way,  being  fed  frequently,  bathed  and  massaged,  a 
very  marked  improvement  will  be  noticeable  within  two  weeks. 

The  improvement  can  be  hastened  materially  by  the  use  of  medicines.  The 
treatment  of  a  case  of  chorea  will  depend  somewhat  upon  the  mode  of  its  onset. 
If  the  child  has  had  an  attack  of  acute  articular  rheumatism  just  preceding 
the  chorea  or  associated  with  it,  and  if  he  has  pains  in  the  limbs  and  a  rise  of 
temperature  in  the  evening,  it  is  much  more  important  to  treat  him  with  salicyl- 
ate of  sodium  or  salicin  or  salophen  than  with  arsenic.  These  remedies  may 
be  used  in  connection  with  antipyrine,  phenacetin,  or  exalgin,  the  latter  drug 
being  of  considerable  service  in  the  early  stage  of  an  acute  attack.  In  the 
use  of  these  remedies  the  condition  of  the  heart  must  always  be  taken  into 
account,  and  heart  stimulants  added  if  necessary.  I  prefer  camphor  and  caf- 
feine to  other  heart  stimulants  in  this  condition.  The  dosage  of  these  remedies 
must  depend  entirely  upon  the  severity  of  the  symptoms  and  upon  the  age  of 
the  child.  It  may  be  necessary  to  give  to  a  child  of  eight  years  ten  grains  of 
the  salicylate  of  sodium  every  two  hours  for  several  days ;  it  may  not  be  neces- 
sary to  give  more  than  ten  grains  three  times  a  day.  Exalgin  is  to  be  given 
in  three-grain  doses  every  four  hours  in  a  severe  case,  and  three  times  a  day  in 
a  mild  case.  With  children  I  prefer  to  use  these  remedies  in  capsules,  as  the 
disagreeable  taste  is  then  avoided. 

If  there  be  no  history  of  rheumatism,  it  is  well  to  think  of  the  possibility 
of  malarial  infection  as  a  cause  of  chorea.  If  there  be  a  daily  periodical  rise 
of  temperature,  with  or  without  a  chill,  or  if  an  examination  of  the  blood 


CHOREA.  763 

reveals  the  presence  of  the  malarial  plasmodium,  a  dose  of  calomel,  followed 
by  Warburg's  extract  in  capsules,  or  quinine  in  capsules,  kept  up  for  a  week, 
will  be  efficacious  in  cutting  short  an  attack  of  chorea. 

Arsenic  is  the  chief  remedy  for  chorea  not  complicated  by  rheumatism  or  by 
malaria.  Fowler's  solution  is  the  best  preparation  to  use,  being  tasteless.  It  is 
to  be  begun  in  three-drop  doses  three  times  a  day,  the  number  of  drops  being 
increased  daily  one  drop  until  physiological  effects  are  produced.  These  are  a 
puffiness  of  the  eyelids  noticeable  on  waking  in  the  morning,  and  slight  nausea 
or  griping  pains  with  diarrhoea.  It  is  possible  in  some  children  to  reach  a  dose 
of  fifteen  drops  of  Fowler's  solution  three  times  a  day  without  the  production 
of  these  effects;  many  children  take  ten  drops  three  times  a  day  without  dis- 
comfort. It  is  my  rule  to  keep  on  increasing  the  dose  until  the  physiological 
effects  appear.  When  this  occurs  the  medicine  is  to  be  stopped  for  twenty-four 
hours,  and  then  resumed  at  the  dose  just  below  that  which  produced  poison- 
ing ;  and  this  dose  is  to  be  kept  up  regularly  so  long  as  treatment  is  needed. 
Arsenic  should  always  be  given  after  eating  and  well  diluted  with  water.  There 
are  some  children  who  cannot  take  it  in  efficient  doses  without  producing 
poisonous  effects.  In  these  reliance  must  be  placed  upon  the  hygienic  rules 
already  laid  down,  and  if  the  chorea  is  very  severe  chloral  may  be  given,  the 
condition  of  the  heart  being  carefully  regarded  during  its  administration.  In 
some  cases  which  do  not  yield  readily  to  arsenic  it  is  well  to  employ  chloral  in 
combination  with  it,  giving  from  five  to  ten  grains  three  times  a  day.  In  some 
cases  tincture  of  cimicifuga  is  of  service. 

A  few  cases  of  chorea  present  very  severe  symptoms,  the  spasms  being  so 
extensive  and  violent  as  to  throw  the  patient  about  in  bed  and  even  to  prevent 
sleep.  In  these  the  use  of  a  combination  of  bromide  of  potassium  and  chloral 
(bromide  30  grains,  chloral  15  grains),  given  two,  three,  or  even  four  times  a 
day  by  the  rectum,  is  advisable,  while  at  the  same  time  arsenic  is  used  by  the 
mouth,  being  given  in  eight-drop  dose  in  milk.  A  few  patients  are  kept 
awake  by  the  movements  and  rapidly  become  exhausted:  in  these  cautious 
administration  of  chloroform  by  inhalation  may  be  necessary  in  order  to  secure 
the  needed  sleep.  The  hypodermatic  use  of  hydrobromate  of  hyoscine  in 
dose  of  2^  grain  for  a  child  of  eight  years,  once  in  twelve  hours,  may  be 
tried  in  very  violent  cases.  Sulphonal  and  chloralamide  are  valuable  hyp- 
notics in   such  cases. 

In  addition  to  the  foregoing  treatment  of  the  disease,  it  is  usually  necessary 
to  remove  the  condition  of  ansemia  which  is  present  in  the  majority  of  cases, 
and  therefore  iron  must  be  given  in  any  form  which  may  be  preferred.  The 
solution  of  the  albuminate  of  iron  is  perhaps  the  best  form  to  use  for  children, 
although  the  chocolate  lozenges  containing  iron  may  also  be  given  freely. 
Every  form  of  nutritious  food,  especially  milk  and  cream,  and  cod-liver  oil,  if 
the  child  can  be  made  to  take  it,  is  also  indicated. 

When  medicinal  treatment  appears  to  be  of  little  service,  a  change  of  air, 
especially  a  change  to  the  sea-shore,  is  often  of  very  great  benefit.  The  sea 
air  is  much  more  conducive  to  recovery  than  mountain  air,  though  sea-bathing 
is  not  to  be  recommended.  In  any  case  a  certain  amount  of  open-air  life  should 
be  enforced  during  the  treatment. 


TETANY. 


By  henry  M.    LYMAN,   A.  M.,   M.  D. 

Chicago. 


Tetany  is  a  functional  disease  of  the  nervo-muscular  apparatus,  charac- 
terized by  the  occurrence  of  paroxysmal  tonic  spasms  that  involve  certain 
groups  of  muscles,  and  that  in  severe  cases  may  extend  to  nearly  all  of  the 
voluntary  muscles  of  the  limbs  and  body.  The  nerves  that  are  concerned  in 
the  production  of  these  contractions  exhibit  a  considerable  increase  of  elec- 
trical and  mechanical  excitability. 

The  functional  character  of  the  disease  has  led  many  observers  to  doubt 
the  propriety  of  dividing  it  from  other  functional  spasmodic  disorders.  The 
infrequency  with  which  it  is  encountered  in  certain  localities  and  among  cer- 
tain races  has  also  ci'eated  a  degree  of  scepticism  regarding  the  disorder  as 
a  separate  entity.  But  this  lack  of  unanimity  is  principally  due  to  the  fact 
that  tetany  prevails  chiefly  among  women  and  children  who  belong  to  neurotic 
families  and  are  subject  to  unfavorable  conditions  of  living.  It  will  be  observed 
more  frequently  by  physicians  in  general  practice  than  by  those  whose  expe- 
rience is  limited  to  ofiice  and  consultation  practice. 

Etiology. — Tetany  occurs  most  frequently  among  children  during  the 
period  of  first  dentition ;  it  is  especially  connected  with  gastro-intestinal  dis- 
orders which  interfere  with  nutrition,  and  is  associated  with  an  exaggerated 
excitability  of  the  nervous  system  at  the  period  of  life  when  those  tissues  are 
naturally  more  unstable  than  during  later  years.  For  somewhat  similar 
reasons  it  is  not  infrequent  among  young  people  near  the  age  of  puberty. 
The  influence  of  sex  is  not  very  decided ;  it  is  less  conspicuous  than  are  the 
influences  that  are  derived  from  ancestral  sources.  The  children  of  nervous, 
weakly  parents  are  particularly  liable  to  the  disease.  Constitutional  causes 
and  diathetic  influences  which  favor  the  development  of  scrofula,  arthritism, 
and  rickets  are  powerful  predisposing  causes  of  tetany.  The  disease  is,  in 
fact,  closely  allied  to  those  spasmodic  tendencies  that  are  so  commonly  wit- 
nessed among  rachitic  children.  It  is  undoubtedly  due  to  insufiicient  diet  and 
to  the  other  predisposing  causes  of  rickets  that  the  disease  is  so  often  encoun- 
tered among  children  in  orphan  asylums,  foundlings'  homes,  and  similar  con- 
gregations of  ill-conditioned  infants. 

Among  the  exciting  causes  of  tetany,  exposure  to  cold  exhibits  great 
prominence.  The  disease  is  more  often  experienced  during  cold  weather  than 
in  summer.  Exposure  to  cold  and  wet  has  been  noticed  as  an  antecedent  of 
the  disease,  and  its  manifestation  is  sometimes  accompanied  by  articular  swell- 
ings that  are  highly  suggestive  of  rheumatism. 

When  a  predisposition  to  tetany  exists,  almost  any  irritation  of  the  cuta- 
neous or  mucous  surfaces  of  the  body  may  excite  an  attack  of  the  disease. 
It  is  therefore  frequently  observed  during  the  course  of  infantile  diarrhoea 

764 


TETANY.  765 

and  other  irritative  disorders  of  the  alimentary  canal.  Among  female  patients 
its  occurrence  is  closely  connected  with  menstrual  disorders,  pregnancy,  and 
lactation.  It  has  been  observed  as  a  sequel  of  various  infective  diseases,  but 
it  is  probable  that  in  such  cases  the  infection  merely  lowers  the  resistance  of 
the  nervous  system,  so  that  morbid  manifestations  of  various  character  are 
more  easily  excited.  When  a  predisposition  has  been  established,  almost  any 
active  disturbance  of  a  peripheral  character,  or  even  of  a  psychical  origin, 
may  suffice  to  arouse  a  paroxysm. 

Symptoms. — The  occurrence  of  an  attack  of  tetany  is  usually  preceded 
by  certain  premonitory  symptoms  of  nervous  disturbance.  Occasionally  the 
patient  complains  of  dizziness,  determination  of  blood  to  the  head,  humming 
sounds  in  the  ears,  and  flashes  of  light  before  the  eyes.  Various  perversions 
of  sensation  in  the  limbs  may  be  also  experienced.  When,  finally,  the  attack 
is  matured,  it  is  upon  the  fingers  and  toes  that  the  force  of  the  paroxysm  is 
usually  expended.  The  muscular  spasms  are  generally  bilateral,  and  in  ordi- 
nary cases  they  are  limited  to  the  flexor  muscles  of  the  fingers,  wrists,  and 
toes  ;  the  extensor  muscles  escape  more  frequently  than  the  flexors  ;  sometimes 
the  muscular  groups  of  the  forearm,  upper  arm,  leg,  and  thigh  are  involved. 
In  certain  rare  instances  the  muscles  of  the  abdomen,  thorax,  neck,  face,  eyes, 
tongue,  pharynx,  diaphragm,  and  bladder  may  participate  in  the  tonic  spasm. 
The  tips  of  the  fingers  and  thumbs  are  frequently  drawn  together  into  the 
conical  position  assumed  by  the  accoucheur  when  about  to  introduce  the  whole 
hand  into  the  vagina.  The  great  toe  is  flexed  and  bent  laterally  under  the 
other  toes,  which  are  also  drawn  down  into  the  position  of  plantar  flexion. 
Occasionally  the  toes  and  fingers  ai^  spread  apart,  instead  of  being  tightly 
drawn  together.  The  upper  arm  is  drawn  against  the  side  of  the  thorax, 
while  the  forearm  is  partially  flexed  and  crossed  over  the  front  of  the  body. 
The  legs  are  usually  extended,  but  the  thighs  are  adducted,  and  are  sometimes 
flexed  upon  the  body.  When  the  muscles  of  the  trunk  and  of  the  neck  are 
invaded  respiration  becomes  difficult,  and  suffocation  sometimes  appears  immi- 
nent. When  the  paroxysms  succeed  one  another  intermittently,  the  phenomena 
of  tetanus  are  closely  counterfeited,  though,  fortunately,  the  comparative  brevity 
of  the  attack  and  the  rarity  of  a  fatal  termination  mark  a  decided  difierence 
between  the  two  diseases. 

During  the  course  of  the  paroxysm  the  peripheral  nerves  of  sensation 
exhibit  various  disorders.  Sensations  of  cold,  heat,  numbness,  and  formica- 
tion are  not  uncommon.  Neuralgic  pains  and  a  feeling  of  soreness  in  the  con- 
tracted muscles  are  often  experienced,  together  with  headache,  dizziness,  and 
other  cerebral  symptoms  of  sensory  disorder. 

Three  cardinal  symptoms  deserve  notice:  Trousseau  many  years  ago 
remarked  that  pressure  exerted  upon  the  large  arteries  and  nerves  of  the 
limbs  of  a  patient  would  be  often  followed  by  the  development  of  a  paroxysm 
of  tetany.  In  this  way  a  latent  predisposition  may  be  aroused  to  active  mani- 
festation of  the  disease.  This  phenomenon  is  more  easily  produced  in  the 
upper  extremity  than  in  the  lower.  Occasionally  the  paroxysm  may  be 
excited  by  pressure  upon  the  carotid  artery  and  the  sympathetic  ganglia  in 
the  neck. 

A  second  characteristic  depends  upon  the  increase  of  electrical  excitability 
in  the  motor  nerves  of  the  body  and  limbs.  When  applied  to  the  nerves, 
very  weak  faradic  currents  are  sufficient  to  excite  muscular  contractions.  The 
application  of  galvanic  currents  also  indicates  great  increase  of  excitability, 
so  that  tetaniform  contractions  of  the  muscles  can  be  aroused  by  currents 
which  ordinarily  would  scarcely  be  noticed.     This  inordinate  sensitiveness  to 


766    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

electrical  excitation  is  frequently  manifested  in  latent  cases  where  the  fully- 
developed  paroxysDi  has   never  been  experienced. 

The  increased  excitability  of  the  motor  nerves  is  further  indicated  by  their 
behavior  under  the  influence  of  mechanical  stimulation.  A  slight  tap  upon 
the  trunk  of  a  nerve  is  often  sufficient  to  arouse  a  paroxysm,  even  though  the 
muscles  themselves  cannot  be  thus  thrown  into  contraction  by  direct  percus- 
sion. When  the  facial  nerves  are  involved  the  muscles  of  the  face  may  be 
easily  brought  into  a  state  of  spasmodic  contraction  by  tapping  upon  the 
trunk  of  the  nerve  at  its  point  of  emergence  from  the  bony  canal,  or  by  draw- 
ing the  point  of  the  fingers  across  the  face  from  the  external  angle  of  the 
orbit  to  the  styloid  foramen. 

Besides  the  various  disturbances  of  sensation  that  have  been  already 
noted,  painful  pressure-points  are  sometimes  discovered  over  the  spinous  pro- 
cesses of  the  vertebrae. 

The  duration  of  a  paroxysm  may  vary  from  a  few  minutes  to  many  hours, 
or  even  two  or  three  days.  In  cases  of  such  long  duration  muscular  spasm 
persists  even  during  sleep,  though  its  intensity  is  considerably  diminished. 
The  number  of  paroxysms  during  the  course  of  an  attack  is  also  subject  to 
great  variation.  A  single  paroxysm  sometimes  terminates  the  attack,  while 
in  other  cases  the  spasms  follow  one  another  at  brief  intervals,  almost  like  the 
paroxysms  of  genuine  tetanus. 

Pathological  Anatomy. — Since  tetany  rarely  proves  fatal,  the  oppor- 
tunity for  investigation  of  its  pathological  anatomy  is  seldom  offered.  It  is 
probably  a  functional  disease  of  the  whole  nervous  system,  but  many  of  the 
morbid  processes  that  have  been  described  are  the  results  of  predisposing  dis- 
eases, or  of  the  convulsive  paroxysms  to  which  the  patient  has  been  subjected, 
rather  than  causes  of  its  phenomena.  Among  these,  undoubtedly,  are  the 
slio;ht  haemorrhages  that  have  been  noted  in  the  membranes  of  the  cord  and 
in  the  cord  itself.  The  various  conditions  of  hypergemia  and  actual  inflamma- 
tion that  have  been  sometimes  remarked  are  also  of  the  same  accidental  or 
complicating  character.  The  reflex  nature  of  the  symptoms  and  their  pi'oduc- 
tion  by  irritation  of  the  peripheral  nerves  render  it  probable  that  the  disease 
has  its  principal  seat  in  the  spinal  cord,  though  the  reflex  arcs  in  which  the 
cranial  nerves  are  included  sometimes  display  evidence  of  disturbance  in  a 
way  that  indicates  an  extension  of  disorder  throughout  the  entire  length  of  the 
nervous  axis.  The  occurrence  of  the  disease  after  diarrhoea  and  other  wasting 
discharges  suggests  the  idea  that  this  inordinate  excitability  of  the  nervous 
centres  is  in  some  way  connected  with  malnutrition  and  with  the  exaggerated 
irritability  that  is  thus  induced.  It  is  not  impossible  that  these  conditions 
are  dependent  upon  an  infection  that  has  invaded  the  tissues  of  the  spinal 
cord.  The  occurrence  of  the  disease  after  extirpation  of  the  thyroid  gland 
has  aroused  a  suspicion  that  tetany,  like  myxoedema,  may  be  due  to  an  auto- 
intoxication with  mucin.  But  these  speculations  have  not  yet  emerged  from 
the  realm  of  hypothesis. 

Diagnosis. — Tetany  may  be  easily  recognized  by  the  occurrence  of 
paroxysmal  tonic  contraction  in  particular  groups  of  muscles,  usually  the  flex- 
ors of  the  extremities,  and  by  the  increased  reaction  that  takes  place  after 
electrical  or  mechanical  excitation  of  the  peripheral  nerves.  By  attention  to 
these  phenomena  the  disease  may  be  readily  distinguished  from  tetanus,  a  dis- 
order which,  moreover,  usually  commences  with  trismus — a  symptom  that  is 
rarely  observed  in  tetany.  Similar  facts  of  dissimilarity  serve  to  distinguish 
tetany  from  the  convulsive  paroxysms  of  hysteria,  and  from  the  spasmodic 
movements  that  are  sometimes  witnessed  in  writer's  cramp  and  the  allied  pro- 


TETANY.  .  767 

fessional  neuroses.  The  spasmodic  attacks  that  sometimes  occur  as  a  conse- 
quence of  ergotism  very  closely  resemble  tetany,  and  should  probably  be 
considered  as  belonging  to  the  same  class  of  toxic  disturbances  of  the  nervous 
system. 

Prognosis. — The  disease  is  seldom  fatal,  but  sometimes  it  persists  for 
a  considerable  period  of  time.  In  such  lingering  cases  a  certain  degree  of 
muscular  contracture  and  weakness  is  occasionally  evident  on  careful  examina- 
tion, even  after  the  cessation  of  spasmodic  attacks.  Mechanical  or  electrical 
excitation  of  the  nerves  may  then  suffice  to  arouse  a  more  or  less  complete 
paroxysm. 

Treatment. — In  the  management  of  tetany  special  reference  must  be  made 
to  the  underlying  causes  of  the  disease  in  each  individual  case.  Disorders  of 
the  alimentary  canal  require  appropriate  treatment ;  all  exhausting  discharges, 
such  as  haemorrhage,  diarrhoea,  excessive  menstruation  or  the  opposite  condi- 
tion, prolonged  lactation,  inordinate  perspiration,  etc.,  demand  attention. 
Rheumatic  and  tuberculous  patients  require  the  treatment  that  is  appropriate 
to  such  diathetic  conditions. 

Electricity  has  been  employed  with  but  indifferent  success.  Counter-irri- 
tants of  all  kinds  have  been  applied  to  the  spine,  and  hydropathic  treatment 
has  also  been  prescribed  with  varying  degrees  of  benefit.  For  the  relief  of 
the  paroxysm  the  various  narcotics  are  generally  recommended.  Bromide  of 
sodium,  cannabis  Indica,  hyoscyamus,  belladonna,  chloral,  ether,  chloroform, 
valerian,  oxide  of  zinc,  and  the  opiates  have  been  exhibited  with  temporary 
advantage.  In  severe  attacks  it  is  advisable  to  administer  ether  by  inhalation 
and  to  employ  non- volatile  remedies  by  hypodermatic  injection.  Calabar  bean 
and  curare  are  too  powerful  and  uncertain  for  administration  in  this  disease. 
The  principal  object  of  treatment  should  be  the  improvement  of  the  general 
health  of  the  patient  and  the  removal  of  all  unfavorable  conditions  that  inter- 
fere with  nutrition.  For  this  reason  hygienic  measures  and  dietetic  manage- 
ment are  more  important  than  specific  medication  for  the  palliation  of  symp- 
toms. 


PSEUDOHYPERTROPHIC  MUSCULAR 
PARALYSIS. 

By  FRANCIS  T.  MILES,  M.  D., 

Baltimore. 


The  essential  feature  of  this  disease  is  a  progressive  loss  of  power  in  certain 
definite  muscles  and  groups  of  muscles,  and  its  most  characteristic  and  distin- 
guishing symptom  (from  which  it  has  received  its  name)  is  the  increase  of 
volume  and  apparent  hypertrophy  in  some  of  the  weakened  muscles. 

Symptoms. — It  is  a  disease  of  early  childhood,  the  great  majority  of  cases 
occurring  before  the  tenth  year.  It  is  but  seldom  that  its  invasion  appears  to 
begin  about  or  after  the  time  of  puberty,  and  it  is  probable  that  the  eye  of  one 
accustomed  to  the  disease  would  have  discovered  indications  of  it  long  before 
that  time.  As  a  rule,  the  first  symptom  that  arrests  the  attention  of  the 
parents  or  nurse  is  the  seeming  clumsiness  manifested  by  the  child  in 
using  his  legs.  A  slight  trip  or  jostle  causes  him  to  fall,  and  then  he  gets  up 
slowly.  He  walks  with  a  straddling,  inelastic  gait,  ascends  steps  laboriously, 
clinging  to  the  banisters  and  pulling  himself  up.  Sooner  or  later  (in  some 
cases  it  is  the  first  thing  to  attract  attention)  certain  muscles  begin  to  develop 
out  of  proportion  to  the  rest,  and  are  hard  and  elastic  to  the  touch.  Usually 
the  first  muscles  to  show  this  increase  of  volume  are  those  of  the  calves  of  the 
legs,  with  which  are  generally  associated  the  glutei,  one  or  more  of  the  divisions 
of  the  quadriceps  extensor,  and  the  erector  spinse  in  the  lumbar  region.  But 
the  hypertrophy  aflFects  other  muscles  than  those  of  the  lower  limbs.  Thus  the 
infraspinatus  is  very  commonly  much  enlarged,  frequently  the  deltoid,  and  even 
the  biceps  and  triceps  are  sometimes  involved.  The  escape  of  the  muscles  of  the 
hand  and  forearm,  which  have  been  but  very  rarely  described  as  implicated  in 
this  affection,  gives  a  distinctive  peculiarity  to  this  form  of  muscular  paralysis. 
The  neck  and  face  do  not  show  an  absolute  immunity,  and  cases  of  hypertrophy 
of  the  sterno-mastoids,  temporals,  masseters,  and  even  of  the  tongue,  have 
been  recorded.  In  a  case  of  Bergeron's  all  the  muscles  except  the  pectorals 
and  sterno-mastoids  were  increased  in  volume,  thus  giving  to  the  child  an 
appearance  of  great  athletic  development. 

In  marked  contrast  to  the  Herculean  proportions  of  the  muscles  is  their 
strength,  which  is  almost  always  so  greatly  diminished  that  they  are  incapable 
of  performing  their  required  functions.  After  a  time  these  muscles  cease  to 
increase  in  size,  and  then  begins  a  diminution  of  their  volume,  which  may  go 
on  to  complete  atrophy,  with  corresponding  absolute  loss  of  power.  But  by  the 
side  of  these  enlarged  and  feeble  muscles  we  observe  others  whose  power  is 
diminished  more  or  less  while  they  retain  their  normal  size,  or  are  from  the 
first  involved  in  a  process  of  atrophy.  In  the  lower  extremity  this  loss  of 
power  is  manifested  in  the  flexors  of  the  hip,  which,  though  out  of  reach  of 
direct  observation,  are  thus  evidently  invaded  by  the  disease.     The  extensors 

768 


P8EUD0-HYPEBTB0PHIC  PABALYSIS. 


769 


Fig.  1. 


of  the  hip  and  knee  may  be  under-sized  or  atrophied,  and  always  much 
weakened.  The  flexors  of  the  knee  are  but  rarely  afi'ected.  Of  the  muscles 
of  the  upper  extremity,  those  of  the  shoulder-girdle  are  generally  more  or 
less  atrophic,  especially  (indeed,  almost  without  exception)  the  costal  portion 
of  the  great  pectoral  and  the  latissimus  dorsi.  Less 
frequently,  but  not  uncommonly,  the  biceps  and  triceps 
are  small  and  weak.  If  we  attempt  to  lift  the  child 
by  placing  the  hands  under  its  arms,  we  find  that  the 
shoulders  yield  against  the  weight  of  the  body,  and 
are  dragged  almost  to  the  back  of  the  head. 

This  mixed  and  variable  picture  of  hypervolumi- 
nous  and  atrophied  muscles  would  seem  to  indicate 
that  the  pseudo-hypertrophy  is,  as  it  were,  an  acci- 
dental factor,  and  that  the  intrinsic  nature  of  this 
disease  is  the  progressive  loss  of  power  in  certain 
muscular  groups.  Indeed,  cases  have  occurred  in 
which  all  the  motor  symptoms  of  pseudo-muscular 
hypertrophy  were  present,  but  in  which  the  diseased 
muscles  that  caused  these  symptoms  presented  no  alter- 
ation of  volume.  In  the  words  of  Charcot :  "  The 
hypertrophy  is  not,  all  things  considered,  an  essential 
element  in  the  constitution  of  the  aff"ection  called 
pseudo-hypertrophic  paralysis."  We  will  return  to 
this  point  farther  on. 

On  account  of  the  weakness  of  the  muscles  involved, 
the  attitude  in  standing  and  the  manner  of  walking 
in  this  disease  are  peculiar  and  characteristic.  In  a 
state  of  health,  while  standing  erect  the  centre  of 
gravity  of  the  body  falls  slightly  in  front  of  the  point 
of  support,  and  the  hip-  and  knee-joints  are  not  in 
a  position  of  complete  extension;  so  that  to  maintain 
the  equilibrium  and  to  prevent  the  flexion  of  those 
joints  a  sustained  action  of  the  erector  spinge  and 
the  extensors  of  the  hip  and  of  the  knee  is  demanded.  In  the  disease 
under  consideration  an  involuntary  efibrt  is  made  to  relieve  these  en- 
feebled muscles  by  throwing  the  centre  of  gravity  very  far  back.  To  do 
this  the  lumbar  concavity  is  increased  as  much  as  possible,  so  as  to  throw  the 
weight  of  the  head  and  shoulders  behind  the  hip-joint,  thus  producing  a  marked 
lordosis,  with  a  corresponding  protrusion  of  the  chest  and  belly.  The  knee- 
joints  are  fully  extended  (locked),  so  that  the  weak  quadriceps  extensors  are 
at  rest,  while  the  base  of  support  is  broadened  by  the  wide  separation  of  the 
feet.  The  lordosis  disappears  when  the  child  is  seated ;  but  in  an  advanced 
stage  of  the  disease,  when  the  erectors  of  the  spine  are  greatly  weakened,  a 
kyphosis  may  for  the  time  take  its  place.  When  standing  the  patient 
may  be  able  to  raise  himself  on  his  toes,  but  cannot  spring  from  the  floor.  In 
ordinary  natural  walking,  while  one  foot  is  off"  the  ground  and  is  being  pro- 
pelled forward  the  centre  of  gravity  of  the  body  falls  much  nearer  the  median 
line  than  the  supporting  foot,  and,  indeed,  it  continues  to  move  toward  the 
opposite  side  until  the  advancing  foot  reaches  the  ground  and  receives  the 
weight  of  the  body. '  During  this  time  the  weight  of  the  body  is  sustained 
upon  the  head  of  the  fixed  femur,  principally  by  the  glutei  muscles.  In  pseudo- 
hypertrophic paralysis,  these  muscles  being  too  weak  to  perform  their  task,  the 
patient  relieves  them  by  throwing  the  body  far  over  to  the  side  of  the  sustain- 

49 


Pseudo  hypertrophic  Muscu- 
lar Paralysis. 


770    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ing  foot,  thus  bringing  the  weight  over  the  point  of  support,  while  the  other 
leg  swings  forward.  This  manoeuvre,  being  repeated  alternately  for  the  two 
limbs,  gives  a  peculiar  and  characteristic  swaying  motion  of  the  body  from  side 
to  side  in  walking.  This  false  position  of  the  trunk  and  the  weakness  of  the 
extensors  of  the  knee  hinder  the  foot  being  projected  forward  to  the  length  of 
a  full  step,  and,  instead  of  the  heel  touching  the  ground  first,  as  is  usual  in 
walking,  the  ball  of  the  foot  or  the  toes  first  descend,  giving  the  appearance  of 
an  attempt  to  step  softly.  This  stepping  on  the  toes  is  sometimes  caused  by  a 
contraction  of  the  muscles  of  the  calf,  which  may  occur  early  in  the  disease. 

Very  characteristic  and  almost  pathognomonic  of  this  disease  are  the 
manoeuvres  executed  by  the  child  in  getting  into  the  erect  from  the  recumbent 
position.  They  were  first  and  with  great  clearness  described  and  explained  by 
Gowers.  The  weak  extensors  of  the  hip  and  knee  are  not  equal  to  the  Avork 
of  extending  these  joints  and  giving  the  erect  position  to  the  body  against  the 


Fig.  2. 


Postures  in  rising  to  the  Erect  Position  (Gowers^ 


weight  of  the  head  and  shoulders.  The  child,  therefore,  unable  to  assume  the 
sitting  position,  takes  that  of  "all  fours,"  thus  throwing  the  weight  upon  the 
hands  and  arms,  while  the  legs  are  being  straightened.  He  then  Avorks  his 
hands  backward  along  the  floor  until  he  gets  to  a  position  from  which  with  an 
effort  he  can  grasp  the  legs  above  the  knee,  and  then,  by  alternately  clasping 
them  at  a  higher  level,  he  thrusts  the  trunk  into  a  more  and  more  erect  posi- 
tion, until  by  a  final  push  he  jerks  the  spine  into  the  position  of  lordosis  already 
described.  To  use  the  common  and  appropriate  phrase,  he  "  climbs  up  his 
legs." 

We  have  already  said  that  the  hypertrophied  muscles  after  a  time  lose  their 
volume  and  become  atrophied.  This  may  not  take  place  until  after  many  (ten 
to  fourteen)  years,  and  does  not  aff"ect  all  of  the  hypertrophied  muscles  at  the 
same  time.  Those  of  the  upper  extremity  are  generally  the  first  to  undergo 
the  change,  the  muscles  of  the  calf  being  the  last  to  lose  their  volume.  In- 
creasing weakness  more  and  more  circumscribes  the  movements  of  the  patient, 
until  at  last  he  can  no  longer  walk  or  stand,  although  the  movements  of  the 
arms  and  hands  may  still,  in  a  measure,  be  retained.  Now  contractions  of  the 
wasted  muscles  set  in,  and  joints,  as  the  knee  and  elbow,  are  fixed  in  the  posi- 
tion in  which  they  are  usually  maintained.     The  ankle-joint  takes  the  position 


PSEUDO-HYPEBTBOPHIC  PABALYSI8.  Til 

of  pronounced  talipes  equinus,  partly  from  fixation  in  the  position  in  which  un- 
supported it  hangs,  and  partly  from  contraction  of  the  muscles  of  the  calf. 
From  loss  of  power  in  the  spinal  muscles  there  may  result  lateral  curvature. 

The  tendon  reflexes,  as  a  rule,  show  no  change,  except  that  they  grow  more 
feeble  as  the  muscles  become  weaker,  until  they  are  finally  lost.^  The  sphinc- 
ters are  unaffected. 

Fibrillary  contractions  have  been  observed  so  rarely  as  to  make  it  presum- 
able that  they  are  caused  by  some  intercurrent  trouble,  such  as  neuritis.  While 
the  electric  reactions  are  gradually  diminished  and  lost,  they  are  qualitatively 
normal,  and  in  the  very  few  cases  in  which  degenerative  reaction  has  been 
described  it  is  probably  due  to  some  secondary  cause  similar  to  that  which 
causes  the  fibrillary  contractions  in  certain  reported  cases.  Sensation  is  nor- 
mal, and  mental  impairment,  although  occurring  in  some  instances,  does  not 
seem  to  be  a  consequence  of  the  disease.  A  symptom  which  might  be  referred 
to  an  affection  of  the  vaso-motor  nerves  is  the  bluish  mottling  or  marbling 
of  the  skin  of  the  lower  limbs  which  is  sometimes  seen.  There  is  no  evidence 
of  any  disturbance  of  the  sympathetic  nerves. 

The  disease  runs  a  chronic  course,  it  may  be  of  ten  or  twenty  years'  dura- 
tion, and  does  not  itself  directly  cause  the  death  of  the  patient.  This  termina- 
tion is  usually  the  result  of  some  intercurrent  respiratory  trouble,  to  which  the 
enfeebled  condition  of  the  patient  gives  force. 

Etiology. — Hereditary  influence  can  be  traced  in  a  large  majority  of  cases, 
and  exclusively  through  the  mother,  who,  without  being  herself  a  subject  of 
the  disease,  may  nevertheless  transmit  this  developmental  defect  to  her  off- 
spring. Males  are  much  more  frequently  affected  than  females,  and  in  the 
latter  it  tends  to  develop  later  in  life  and  progress  more  slowly.  The  disease 
may  be  considered  as  a  congenital  affection,  for  even  when  it  develops  after  the 
period  of  childhood,  as  it  sometimes,  though  rarely,  does,  there  is  reason  to 
assume  that  the  defect  of  muscular  development  has  merely  lain  dormant 
during  the  earlier  years  of  life.  No  other  etiological  factors,  as  syphilis  or  alco- 
holism, have  been  recognized  in  the  causation  of  the  disease.  For  a  long  time 
after  pseudo-muscular  hypertrophy  had  been  observed  and  fully  described  clin- 
ically, it  was  considered  a  disease  of  spinal  origin,  a  myelopathy.  But  more 
recently  the  opinion  that  it  is  a  primary  disease  of  the  muscles,  an  idio- 
pathic myopathy,  has  received  a  very  general  sanction  from  pathologists.  It 
is  recognized  as  one  (and  the  most  frequent)  form  or  type  of  a  group  of  myo- 
pathic atrophies,  or  muscular  dystrophies,  of  which  Erb's  juvenile  type,  the 
facio-scapulo-humeral  or  infantile  type,  and  it  may  be  Leyden's  hereditary  type, 
are  the  most  distinctively  marked  forms  :  "  The  infantile  type  is  characterized 
by  the  early  facial  paralysis,  the  juvenile  type  by  the  time  of  its  development 
(early  youth)  and  localization  of  the  atrophy  (in  the  muscles  of  the  shoulder- 
girdle)  ;  the  pseudo-hypertrophic  type  by  its  development  in  early  childhood 
and  the  predominance  of  the  lipomatous  condition  of  the  muscles ;  the  heredit- 
ary type  (Leyden's)  by  its  heredity." 

While  these  forms  of  muscular  atrophy  are  fairly  separable  clinically  when 
well  marked,  there  are  numerous  transition  forms  which  cannot  be  easily  clas- 
sified. Not  infrequently  the  different  types  occur  in  members  of  the  same 
family,  and  arise  presumably  from  the  same  inherited  defect. 

As  Erb  has  shown,  there  are  no  greater  differences  amongst  these  varie- 

^  The  writer  has  recently  seen  a  case  of  pseudo-muscular  hypertrophy  in  a  boy  nine  years 
old,  in  which  the  knee-jerk  was  abolished,  although  he  could  still  walk,  and  the  partly  hyper- 
trophied  quadriceps  extensor  could  extend  the  knee  almost  completely  when  the  patient  was 
seated. 


772   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ties  than  there  are  amongst  the  individual  cases  of  any  one  variety.  Thus 
in  the  pseudo-hypertrophic  form  we  have  fairly  constant  atrophy  of  the 
muscles  of  the  shoulder-girdle  and  arm — i.  e.  those  characteristically  affected 
in  the  juvenile  type;  and  in  some  cases  described  by  Erb  there  was  atrophy 
of  the  muscles  of  the  face,  the  mark  of  the  infantile  type.  Indeed,  Erb  sug- 
gests that  many  cases  having  the  clinical  aspect  of  the  pseudo-hypertrophic 
form,  afterward,  as  the  adipose  matter  is  absorbed,  take  on  the  appearance  of 
the  juvenile  type  of  muscular  atrophy. 

Pathological  Anatomy. — The  essential  feature  of  the  pathological  anat- 
omy in  this  disease  is  a  degenerative  change  in  the  muscular  tissue  itself;  and 
this  change  is  probably  the  first  which  takes  place.  Pieces  cut  from  the  living 
muscles  (which  are  much  to  be  preferred  to  morsels  extracted  by  the  "  har- 
poon"), and  properly  prepared,  present  the  following  microscopic  appearances: 
The  muscular  fibres  in  cross-section  are  seen  to  have  lost  their  polygonal  out- 
line, to  have  become  rounded  in  contour,  even  to  be  complete  circles.  Amongst 
fibres  of  normal  size  there  are  those  which  are  hypertrophied,  and  others  which 
show  atrophy  in  varying  degree,  even  to  the  point  of  complete  disappearance. 
The  abnormal  increase  in  volume  of  the  muscular  fibres  would,  from  recent 
observations  (Erb),  appear  to  be  an  essential  feature  in  the  muscular  atrophies, 
and  it  may  be  that  it  is  a  condition  of  the  fibres  which  very  generally  precedes 
their  atrophy.  At  any  rate,  such  hypertrophied  fibres  are  rarely,  if  ever, 
wanting  in  preparations  of  muscular  tissue  taken  from  these  diseases.  This 
increased  volume  of  the  fibres  cannot  be  explained  by  their  contraction  after 
excision,  since  it  is  seen  when  precautions  are  taken  to  counteract  this.  In 
addition,  the  fibres  show  a  splitting  in  the  longitudinal  direction  and  the  for- 
mation of  vacuoles  in  their  interior.  The  muscle-nuclei  are  sometimes  more, 
sometimes  less,  but  ahvays  considerably,  increased. 

The  alteration  of  the  connective  tissue  must  follow  very  closely,  if  it  is  not 
coincident  with,  that  of  the  muscular  fibres.  A  proliferation  with  increase  of 
its  nuclei  goes  on  joar«  passu  with  the  muscular  atrophy,  until  finally  it  becomes 
excessively  developed.  In  pseudo-hypertrophic  muscles  the  connective  tissue 
is  not  only  increased,  but  is  crowded  with  fat-cells.  It  is  this  condition,  in- 
deed, to  which  they  owe  their  increased  volume  and  hardness.  In  muscles 
primarily  atrophied,  and  in  the  pseudo-hypertrophic  muscles  after  they  have 
undergone  atrophy,  there  is  little  or  no  adipose  matter,  only  a  greater  or  less 
amount  of  connective  tissue  (connective-tissue  cirrhosis  of  Erb).  In  muscle 
preparations  from  the  dead  body  the  microscopic  appearances  are  practically 
the  same  as  those  seen  in  pieces  from  living  muscles.  It  is  of  great  importance 
to  observe  that  the  microscopic  appearances  in  muscles  taken  from  the  different 
types  of  muscular  dystrophy  do  not  differ  more  from  each  other  than  do  those 
in  preparations  obtained  from  different  cases  of  the  same  type,  nor,  indeed, 
than  those  in  different  specimens  from  the  same  individual.  Not  only  do  the 
pathological  changes  in  the  muscles  bear  a  very  close  resemblance  in  all  the 
types  of  muscular  dystrophy,  but  these  changes  as  closely  resemble  those  found 
in  other  forms  of  muscular  atrophy,  as,  for  instance,  the  spinal  atrophies  and 
those  attending  arthritic  disease.  "  The  proof  for  or  against  the  pure  myopathic 
nature  of  the  progressive  muscular  atrophies  cannot  at  present  be  furnished  by 
histological  research." 

Investigations  of  the  nervous  system,  both  central  and  peripheral,  have  in 
such  a  large  majority  of  cases  given  a  negative  result  that  the  reports  of  lesions 
of  the  spinal  cord,  though  made  by  competent  observers  in  recent  cases,  will 
scarcely  change  the  generally  accepted  opinion  that  the  muscular  dystrophies 
do  not  depend  on  discoverable  nerve  lesions.     The  question,  however,  has 


PSEUDO-HYPEBTBOPHIC  PABALYSIS.  773 

arisen,  and  still  awaits  its  answer,  as  to  whether  the  muscular  dystrophies  are 
absolutely  myopathia,  or  whether  functional  disturbances  ("dynamische 
Storung  ")  in  the  trophic  mechanism  of  the  cord,  too  subtle  to  be  ascertained 
by  our  present  methods  of  investigation,  may  not  set  up  at  first  hand  nutritive 
changes  in  the  muscles.  Some  considerations  certainly  point  in  the  direc- 
tion of  classing  these  diseased  conditions  of  the  muscles  with  the  tropho- 
neuroses. 

Diagnosis. — When  the  disease  has  advanced  to  a  point  where  the  athletic 
proportions  of  the  hypertrophied  muscles  stand  in  strong  contrast  to  their 
weakness,  and  where,  moreover,  along  with  these  over-developed  muscles,  we 
have  others  which  are  atrophied,  there  can  be  little  difficulty  in  making  the 
diagnosis.  Gowers  claims  diagnostic  importance  for  the  "condition,  which  is 
seldom  absent,"  "of  enlargement  of  the  infraspinatus,  with  a  wasting  of  the 
latissimus  and  lower  part  of  the  pectoralis."  In  cases  where  the  enlargement  of 
the  muscles  is  slight,  or,  as  in  some  instances,  where  they  retain  their  normal 
size,  the  difficulty  may  be  greater.  The  peculiar  position  in  standing,  and, 
still  more,  the  makeshift  movements  of  the  patient  in  rising  from  the  recumbent 
position,  are  almost  positive  evidence  of  the  disease,  whose  main  characteristics 
depend  on  the  invasion  and  weakening  of  the  muscles  employed  in  these  acts. 

From  a  progressive  chronic  neuritis,  which  might  cripple  these  muscles,  the 
diagnosis  would  most  likely  be  made  by  the  absence  of  fibrillary  contractions 
and  of  degenerative  reactions,  both  of  Avhich  symptoms  belong  to  neuritis.  A 
history  of  other  members  of  the  family  having  sufiered  with  atrophy  of  the 
muscles  would  be  strong  confirmation.  Congenital  spastic  paraplegia,  in  which 
the  muscles  sometimes  exhibit  a  considerable  volume,  is  distinguished  from 
pseudo-muscular  hypertrophy  by  the  muscular  spasms  and  the  increased  myo- 
tonus,  which  shows  itself  in  an  exaggerated  knee-jerk,  and  often  in  ankle-clonus. 
The  different  types  of  muscular  dystrophies  may  be  distinguished  among  them- 
selves by  marks  already  given. 

Prognosis. — In  this  disease  no  hope  can  be  entertained  of  recovery,  and 
very  little  of  delay  in  its  progress,  which  in  children  is  infallibly  to  utter  help- 
lessness, with  all  the  intercurrent  risks  incidental  to  that  state.  The  best 
cared-for  will  generally  live  longest,  but  the  great  majority  never  attain  adult 
years.  In  girls  the  outlook  is  somewhat  more  favorable  as  to  length  of  life. 
Cases  where  the  disease  has  not  developed  till  later  years  have  been  seen  to 
progress  more  slowly,  and  even  to  come  to  a  standstill  before  the  power  of 
standing  and  walking  was  lost. 

Treatment. — It  is  in  vain  that  we  look  for  any  drug  which  will  exert 
direct  influence  on  the  diseased  processes  in  the  muscles.  Tonics,  arsenic,  cod- 
liver  oil,  etc.,  can  only  benefit  indirectly  by  improving  the  general  nutrition. 
In  children,  as  soon  as  the  disease  is  suspected,  or,  indeed,  in  all  the  children 
of  a  family  in  which  any  one  of  the  muscular  dystrophies  has  shown  itself,  a 
scrupulous  and  untiring  enforcement  of  all  the  rules  of  health  with  regard  to 
diet,  fresh  air,  and  exercise  should  be  observed.  Gowers  argues  with  con- 
vincing force  on  the  probable  benefit  of  judicious  exercise  of  the  affected 
muscles.  The  cold  mottled  limbs  would  indicate  the  employment  of  massage. 
Electricity,  so  far,  seems  to  have  exerted  no  beneficial  influence.  For  the  con- 
tractures so  marked  in  the  last  stage  of  the  disease,  tenotomy  is  unhesitatingly 
to  be  employed.  This  is  especially  demanded  in  the  contractures  of  the  calf- 
muscles,  which  sometimes  occur  early  in  the  disease  and  render  walking  or 
standing  impossible. 


FACIAL  PARALYSIS  AND  PROGRESSIVE  FACIAL 

HEMIATROPHY. 


By  CHARLES  W.  BURR,  M.  D., 

Philadelphia. 


I.  Facial  Paralysis. 


Facial  Paralysis,  Bell's  palsy,  or  mimetic  paralysis,  is  due  to  injury  or 
disease  of  the  motor  portion  of  the  seventh  cranial  nerve  or  its  nucleus. 

Etiology. — Cases  occurring  at  birth  are  due  frequently  to  pressure  of  the 
forceps  upon  the  nerve  at  its  point  of  exit  from  the  skull ;  or  even  if  forceps 
are  not  used  and  the  labor  is  normal,  though  much  prolonged,  paralysis  may 
ensue.  In  the  latter  case  it  is  due  to  pressure  exerted  either  by  the  promontory 
of  the  sacrum  or  by  the  ischiatic  spines.  A  few  cases  have  been  reported  which 
were  caused  by  the  pressure  of  intrapelvic  tumors. 

The  causes  acting  after  birth  are  the  same  as  those  which  occur  in  adult 
life,  but  the  aflFection  is  not  nearly  so  common  in  infants  as  in  older  people. 
The  most  common  cause  is  cold,  which  acts  by  setting  up  a  neuritis — the  so- 
called  rheumatic  palsy.  Ear  disease,  especially  if  caries  of  the  bone  and  sup- 
puration be  present,  is  a  common  causative  factor.  It  is  undoubtedly  true, 
however,  that  the  affection  may  develop  when  only  the  lining  membrane  of  the 
tympanum  is  inflamed,  without  accompanying  bone  disease.  Tumors,  meningi- 
tis, or  fracture  of  the  base  of  the  skull  are  occasional  causes.  Surgical  opera- 
tions in  the  region  of  the  ramus  of  the  jaw  are  quite  frequently  followed  by 
palsy  due  to  division  of  the  nerve.  A  blow  in  the  same  region  may  have  a 
like  effect.  Certain  acute  infectious  diseases — as,  for  example,  diphtheria — may 
be  causative.  Very  rarely  it  occurs  in  acute  infantile  spinal  palsy.  Non-trau- 
matic cases,  in  which  the  onset  is  sudden  and  the  palsy  complete,  and  in  which 
there  is  no  evidence  of  cerebral  disease,  must  be  due  to  hgemorrhage  in  the 
nerve-sheath  or  Fallopian  canal.  Gowers  has  seen  two  cases,  and  Wilks  and 
Moxon  have  found  the  haemorrhage  after  death. 

Symptoms. — Often  there  is  preceding  pain  in  the  ear  or  over  the  entire 
side  of  the  head,  and  a  slight  swelling  may  be  present  in  the  region  of  the 
parotid  gland.  The  onset  is  rapid — rarely,  as  stated  above,  sudden.  The 
child  may  be  put  to  bed  well  and  wake  up  affected.  Usually  in  from  a  few 
hours  to  a  few  days  the  palsy  reaches  its  height.  There  is  ordinarily  little  or 
no  constitutional  disturbance. 

In  very  young  children  the  signs  of  palsy  may  be  very  slight,  on  account 
of  the  greater  quantity  of  adipose  tissue,  the  greater  elasticity  of  the  skin,  and 
the  smaller  muscular  development.  There  may  be  when  at  rest  only  a  slight 
drooping  of  the  angle  of  the  mouth.  When,  however,  the  infant  cries  or 
laughs,  the  deformity  becomes  marked.  The  affected  side  remains  motionless, 
the  eye  cannot  be  closed,  the  cheek  and  ala  of  the  nose  fall  in  and  out  with 
inspiration  and  expiration,  and  the  mouth  is  drawn  strongly  toward  the  sound 

774 


FACIAL    PARALYSIS  ANB    HEMIATROPHY.  lib 

side.  Most  often  the  tongue  and  soft  palate  are  unaffected,  and  the  child 
experiences  no  diiEculty  in  nursing.  Taste  may  be  lost  in  the  anterior  half  of 
the  tongue  on  the  affected  side.  The  reaction  to  electricity  depends  upon  the 
severity  of  the  attack  and  the  time  which  has  elapsed  since  the  onset.  In  a 
typical  case  reaction  of  degeneration  appears  after  a  time.  After  some  months 
in  severe  cases,  but  not  in  those  in  which  the  palsy  remains  complete,  contrac- 
tures develop  on  the  affected  side,  making  it  on  first  view  appear  to  be  the 
sound  side.  Examination  during  movement,  however,  reveals  that  the  diseased 
side  moves  much  less.  The  contracture  causes,  furthermore,  a  wrinkle  which 
has  no  analogue  on  the  sound  side.  It  must  be  remembered  that  in  some  cases 
only  a  part  of  the  nerve  may  be  palsied — only  the  mouth  or  only  the  orbicularis 
palpebrarum — and  also  that  both  nerves  may  be  affected. 

Diagnosis. — The  palsy  is  unmistakable,  and  the  only  question  is  whether 
the  lesion  is  central  or  peripheral.  If  the  lesion  be  situated  above  the  nucleus, 
there  is  never  lasting,  but  sometimes  transient,  palsy  of  the  eyelid.  Emotional 
movement  is  less  impaired  by  central  disease  than  voluntary  movement.  Re- 
action of  degeneration  is  never  present  in  central  disease,  and  is  never  absent 
in  peripheral  disease  unless  the  palsy  be  very  slight.  In  the  former  the  reflexes 
are  present,  in  the  latter  they  are  lost.  If  taste  be  lost,  the  lesion  is  within 
the  Fallopian  canal.  In  disease  of  the  nucleus  the  orbicularis  oris  is  not 
affected. 

Prognosis  is  excellent  in  the  cases  due  to  pressure  at  birth  and  in  those 
from  diphtheria.  Gowers  justly  lays  great  stress  on  the  prognostic  value  of  the 
electric  excitability  of  the  nerve.  If,  he  says,  it  is  not  below  normal  at  the 
end  of  ten  days,  recovery  will  probably  follow  in  a  few  weeks.  If  at  the  end 
of  a  fortnight  it  is  absolutely  lost,  the  palsy  will  certainly  last  several  months. 

Treatment. — The  first  indication  is.  of  course,  to  remove  the  cause  if  pos- 
sible. In  recent  cases,  due  to  cold,  hot  fomentations  should  be  placed  in  front 
of  and  below  the  ear.  Blisters  should  be  applied  over  the  mastoid  process  or 
occiput.     Hot  baths  and  free  purgation  are  very  useful. 

Galvanism  is  useful  when  the  condition  has  become  chronic.  The  positive 
electrode  should  be  placed  below  the  zygoma,  and  the  negative  moved  gently 
over  the  muscles.  The  least  amount  of  current  sufficient  to  produce  muscular 
response  should  be  used.  But  little  can  be  done  to  influence  contracture. 
Daily  gentle  massage  of  the  face  is  at  least  harmless. 

n.  Progressive  Facial  Hemiatrophy. 

Progeessiye  Facial  Hemiatrophy — also  called  Neurotic  facial  atrophy, 
Facial  trophoneurosis,  Prosopodysmorphia — is  a  chronic  progressive  disease 
characterized  by  wasting  of  the  skin,  fat,  connective  tissue,  bone,  and  some- 
times, but  to  a  less  degree,  the  muscles  of  one  or  very  rarely  both  sides  of  the 
face. 

Etiology. — The  disease,  while  absolutely  rare,  is  far  more  frequent  in 
females  than  in  males.  Of  92  cases  collected  by  Hermann  Steinert,  60  occurred 
in  the  former,  30  in  the  latter,  and  in  2  the  sex  was  not  mentioned.  It 
is  most  apt  to  occur  in  early  life.  In  29  cases  the  onset  was  before  the  tenth 
year,  24  began  between  the  tenth  and  twentieth  years,  while  only  22  occurred 
between  the  twentieth  and  fiftieth  years ;  in  1  the  onset  was  at  sixty  years. 
Traumatism  seems  to  exert  a  positive  causal  influence,  as  in  quite  a  number 
of  cases  injuries  to  the  face,  the  jaw,  or  the  head  preceded  but  a  little  while  the 
first  symptoms.     It  sometimes  follows  an  acute  infectious  disease. 

Symptoms. — The  major  symptom,  wasting,  may  begin  either  diffusely  or 


776  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

in  one  spot,  spreading  thence  slowly,  and  involving  skin,  subcutaneous  tissue, 
the  muscles  mayhap,  and  the  bone.  The  atrophy  is  most  marked  in  the  bone 
if  the  disease  begins  during  the  period  of  active  growth.  Usually  the  process 
stops  abruptly  at  the  middle  line,  making  the  face  look  as  if  it  were  made  up 
of  halves  from  different  people,  but  it  may  involve  both  sides,  and  even  extend, 
it  is  alleged,  to  the  shoulder  and  arm.  The  skin  on  the  wasted  side  is  thinner 
and  paler.  The  hair  may  become  simply  gray,  finer,  and  smoother,  or  it  may 
fall  out.  The  alveolar  processes  waste  and  the  teeth  are  shed.  The  lower  jaw 
becomes  both  thinner  and  shorter.  The  orbital  fat  disappears  and  enophthal- 
mos  develops,  but  the  eyeball  is  not  aifected.  There  is  sometimes  an  associated 
hemiatrophy  of  the  tongue.  Pain  and  numbness  are  not  uncommon,  but  anaes- 
thesia is  rarely  present.  Anidrosis,  weakness  of  the  carotid  pulse,  and  loss  of 
the  power  to  blush  are  occasional  symptoms.  There  is  never  marked  difference 
of  the  surface  temperature  of  the  two  sides  of  the  face.  The  special  senses  are 
never  affected.  There  are  no  changes  in  the  electrical  reactions  of  nerves  or 
muscles.  The  diseased  side  in  well-advanced  cases  may  produce  an  expression 
mimicking  the  drawn  features  of  old  age. 

The  disease  follows  a  slowly  progressive  course,  sometimes  extending  over 
many  years,  or  it  may,  after  reaching  a  certain  stage,  cease  to  progress. 

Pathology. — The  pathology  of  the  condition  remains  as  yet  almost  entirely 
theoretical.  Mendel  has  made  one  autopsy  in  which  he  found  an  interstitial 
neuritis  of  the  trifacial  from  its  origin  to  the  periphery.  In  an  atypical  case 
of  Horner  a  tumor  was  found  pressing  on  the  Gasserian  ganglion  and  the 
trifacial  nerve.  Taking  all  things  into  consideration,  it  is  probable  that  the 
future  will  show  that  disease  of  this  nerve  stands  in  close  causative  relation  to 
the  affection. 

Diagnosis  in  a  well-developed  case  is  easy.  The  only  conditions  with 
which  it  can  be  confounded  are  congenital  facial  asymmetry  due  to  torticollis, 
facial  paralysis,  and  facial  hemihypertrophy.  These  need  only  be  named  to 
avoid  error. 

Treatment  has  so  far  been  absolutely  valueless.  On  theoretic  grounds 
Dercum  in  1891  recommended  section  of  the  various  branches  of  the  trifacial. 
He  holds  that  the  condition  depends  not  upon  failure  of  trophic  nerve  stimulus, 
but  upon  a  radical  perversion  of  that  stimulus. 


INFLAMMATORY  DISEASES  OF  THE  SPINAL 
MENINGES  AND  SPINAL  CORD. 

By  AECHIBALD  CHUBpH,  M.  D., 

Chicago. 


I.  SPINAL  MENINGITIS. 

Spinal  Meningitis  is  an  inflammation  of  the  covering  membranes  of  the 
spinal  cord. 

The  varieties  of  meningitis  ordinarily  described  have  been  somevrhat  arbi- 
trarily based  upon  anatomical  considerations.  As  the  dura  or  the  softer  mem- 
branes are  principally  involved,  the  terms  pachymeningitis  and  leptomeningitis 
are  respectively  employed,  but  a  sharp  division  is  impossible  clinically,  and  is 
not  found  post-mortem. 

For  purposes  of  description  we  may  consider — 1st,  Pachymeningitis,  or 
external  and  internal  inflammation  of  the  dura;  and  2d,  Leptomeningitis, 
or  inflammation  of  the  pia.  But  inflammation  of  the  inner  surface  of  the  dura 
must  from  contiguity  involve  the  leptomeninges  more  or  less,  so  that  the  con- 
ditions are  usually  associated,  and  meningitis  originally  external  may  finally 
invade  the  pia.  Association  with  myelitis  is  hardly  less  frequent ;  mixed 
forms,  therefore,  or  meningo-myelitis,  are  common,  and  are  to  be  classed  as 
the  thecal  or  cord  symptoms  may  predominate. 

Pachymeningitis  Externa. 

Pachymeningitis  externa,  or  external  dural  meningitis,  is  due  to  chronic 
irritation  and  inflammatory  conditions  invading  the  spinal  canal,  and  is  there- 
fore secondary  to  other  morbid  states.  Thus,  vertebral  tuberculosis.  Pott's  dis- 
ease, abscesses  and  new  growths  near  the  spine,  inflammation  and  purulent  col- 
lections in  the  pleurae,  mediastinum,  peritoneum,  and  pelvis,  may  be  the  source 
of  the  meningeal  thickening,  which  gives  rise  to  symptoms  mainly  by  irritation 
of  the  sensory  and  motor  nerve-roots  which  pass  through  the  area  of  disease. 
When  the  thickening  becomes  extreme,  as  it  rarely  does,  it  may  be  sufficient 
to  compress  the  cord  itself  and  give  rise  to  pressure  symptoms  and  the  spastic 
paraplegia  of  a  cross-myelitis.  There  is  local  tenderness  over  the  spine,  shoot- 
ing or  constant  pains  in  the  distribution  of  the  irritated  nerves,  twitching  of 
their  muscles,  hypereesthesia  in  their  cutaneous  areas,  which  may  go  on  to  anaes- 
thesia and  muscular  palsy  if  the  nerves  be  sufficiently  compressed  or  inflamed 
to  cause  their  complete  degeneration. 

Anatomically,  the  dura  is  found  hyperplastically  thickened,  with  much 
adventitious  fibrous  tissue,  and  is  frequently  covered  by  a  caseous  or  purulent 
deposit  or  involved  in  a  new  growth.  The  various  findings,  of  course,  depend 
upon  the  nature  of  the  primary  disease.  When  the  thickening  is  extreme,  the 
soft  membranes  are  adherent  to  the  dural  tumescence  and  may  be  indistinguish- 
able.    The  cord  then  shows  a  constriction,  and  may,  in  severe  cases  of  long 

777 


778  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

standing,  be  very  considerably  reduced  in  size  at  the  place  of  disease,  with 
inflammation  and  degeneration. 

The  diagnosis  is  usually  not  difficult  if  the  primary  disease  is  recognized. 
It  may  be  confounded  with  a  myelitis,  with  which  late  in  the  case  it  is  often 
associated;  but  the  clinical  history  shows  a  preponderance  of  pain,  spasm,  and 
irritation,  a  chronic  course,  and  an  early  absence  of  paralysis;  while  in  myelitis 
the  rapid  onset,  the  absence  of  pain  aside  from  the  girdling  sensation,  and  the 
promptly  developed  paralytic  state  with  early  bladder  and  bowel  symptoms,  are 
distinctive. 

Owing  to  the  serious  nature  of  the  causal  conditions,  the  prognosis  is  bad 
and  treatment  is  practically  surgical.  The  pachymeningitis  externa  associated 
with  Pott's  disease  is  perhaps  the  least  grave,  as  the  proper  orthopaedic  and 
surgical  management  of  such  cases  frequently,  in  very  marked  instances,  is 
followed  by  practical  recovery,  even  when  the  cord  has  been  notably  com- 
pressed. 

Pachymeningitis  Interna. 

Pachymeningitis  interna,  or  internal  inflammation  of  the  dura,  is  described 
as  hypertrophic  and  hsemorrhagic.  In  reality,  these  forms  are  but  stages  of 
one  and  the  same  process,  the  thickening  and  hypertrophy  following  upon  the 
organization  of  the  hemorrhagic  exudate;  and  the  term  hematoma  of  the 
spinal  dura  mater  has  been  sometimes  used.  The  condition  is  a  rare  one,  and 
usually  the  cerebral  meninges  are  similarly  afi'ected.  It  is  most  commonly 
found  in  general  paralysis  of  the  insane,  and  consequently  is  practically 
unknown  in  childhood. 

The  portion  of  afi'ected  dura  presents  on  its  inner  surface  a  very  consider- 
able thickening,  which  may  be  a  layer  of  reddish-brown  exudate  or  consist  of 
a  lamination  of  fibrous  tissue,  the  apparent  result  of  the  organization  of  suc- 
cessive hemorrhagic  exudations,  and  may  attain  sufficient  size  to  constrict  the 
cord.  The  softer,  more  recent,  and  reddish  or  brownish  layers  consist  of  fibrin 
and  blood.  Its  distribution  is  frequently  extensive,  but  in  some  instances  it  is 
confined  to  a  comparatively  short  vertical  extent  of  the  spinal  envelope,  and  is 
then  more  frequently  situated  in  the  cervical  region.  This  circumscribed  cer- 
vical form  was  first  described  by  Charcot  and  Jofl"roy. 

Syphilis,  trauma,  alcoholism,  and  exposure  are  regarded  as  competent 
causes,  and  hence  it  occurs,  as  a  rule,  in  adult  males,  though  some  cases  in 
children  are  recorded. 

The  condition  is  essentially  chronic  and  of  slow  onset.  At  first,  irritation 
of  nerve-roots  gives  rise  to  local  pain  and  hyperesthesia  over  the  spine  and  in 
the  peripheral  distribution  of  the  spinal  nerves  of  corresponding  origin.  This 
is  followed,  months  or  years  later,  by  gradual  loss  of  poAver,  atrophy,  and  anes- 
thesia in  the  corresponding  parts,  and,  as  compression  upon  the  cord  is  pro- 
duced, spastic  symptoms  appear  below,  with  increased  reflexes,  rigidity,  and 
paraplegia  leading  to  exhaustion  and  death.  Some  cases  present  stationary 
periods,  and  a  few  recoveries  are  claimed. 

The  diagnosis  is  difficult  when  a  general  distribution  and  cerebral  symptoms 
are  wanting.  Diseases  of  the  spine,  progressive  muscular  atrophy,  cross-mye- 
litis, tumor,  and  external  pachymeningitis  must  be  excluded.  An  operation 
may  be  required  to  do  this,  and  as  it  presents,  except  in  syphilitic  cases,  the 
best  chances  of  favorably  influencing  the  condition  and  preventing  destruction 
of  the  cord,  in  the  desperate  situation  that  is  presented  and  with  the  courage 
given  by  asepsis,  it  may  the  more  reasonably  be  resorted  to  early.  Where 
syphilis  is  strongly  suspected  specific  treatment  should  be  persistently  tried. 


INFLAMMATION   OF  SPINAL   MENINGES  AND    COBB.    779 


Acute  Leptomeningitis. 

Acute  leptomeningitis,  or  inflammation  of  the  spinal  pia  mater,  is  due  to 
infection,  usually  involves  the  inner  surface  of  the  dura,  and  extends  to  the 
substance  of  the  cord. 

Etiology. — The  infection  of  cerebro-spinal  meningitis  in  epidemics  of  the 
disease  falls  sometimes  only  on  the  cord,  and  the  infective  nature  of  the  attack 
is  obvious.  In  those  cases,  however,  that  are  attributed  to  exposure,  "  insola- 
tion," rheumatism,  and  other  occult  conditions,  the  infection  is  less  readily 
comprehended,  but  in  all  probability  is  equally  in  operation,  being  favored  by 
the  physical  conditions  mentioned.  The  association  of  cases  with  septicaemia, 
pygemia,  and  other  infectious  blood-states  points  to  the  same  conclusion,  and  in 
the  lymph  and  spinal  fluid  of  these  cases  abundant  pathogenic  organisms  have 
been  observed.  In  some  instances  the  spinal  trouble  is  an  extension  from  the 
cerebral  meninges,  the  cervical  portion  of  the  cord  being  usually  the  only  part 
involved.  Injuries  resulting  in  traumatism  of  the  membranes  by  vertebral 
dislocations,  strains,  and  severe  concussions  may  incite  a  leptomeningitis  over  a 
limited  area,  from  which  it  may  extend  or  in  which  an  infection  may  find  a  suit- 
able field  for  development.  Surgical  operations  upon  the  spine  and  penetrating 
wounds  may  afford  access  to  and  furnish  the  infection.  Tuberculosis  is  a  com- 
mon cause,  but  the  resulting  meningitis  is  rather  less  acute,  as  is  the  case  to 
a  greater  degree  in  syphilitic  inflammation,  which  has  a  marked  tendency  also 
to  remain  localized. 

Pathology. — The  disease  is  usually  of  Avide  extent,  the  infection  travelling 
rapidly  through  the  arachnoid  spaces,  and  finding  in  the  spinal  fluid  an  excellent 
medium  for  its  propagation  and  extension.  Congestion  of  the  pia,  of  the  adj  oining 
inner  surface  of  the  dura,  and  of  the  cord,  marked  by  increased  vascularization 
and  an  increase  of  spinal  fluid,  passes  into  inflammation,  with  dulness  of  the  mem- 
branes, opacity,  thickening,  and  an  exudation  of  large  quantity,  varying  in 
color  from  an  opalescent  to  a  puriform,  and  of  corresponding  consistency.  The 
microscope  shows  the  diapedic  elements  of  inflammation  and  often  numerous 
bacteria,  including  at  times  those  closely  resembling  the  pneumococcus  of  Fried- 
lander.  Tubercles  here  correspond  to  their  histological  and  bacterial  characters 
on  other  serous  surfaces.  For  a  time  the  somewhat  resistent  pial  covering  of  the 
cord  and  nerve-roots  protects  these  structures,  and  especially  in  the  purulent 
form  of  the  disease ;  but  usually  the  periphery  of  the  cord  and  the  roots  show 
the  inflammatory  invasion,  with  corresponding  changes  in  the  nerve-fibrils,  neu- 
roglial framework,  and  vessels.  In  cases  reaching  a  convalescent  or  chronic 
stage  adhesions  form  between  the  cord  and  the  dura,  obliterating  the  arachnoid 
space  over  more  or  less  extensive  areas,  distorting  the  nerve-roots,  and  some- 
times changing  the  outlines  of  the  cord  itself,  which,  if  softening  in  its  substance 
has  taken  place  as  a  result  of  the  meningo-myelitis,  presents  degenerations  of 
its  conduction  tracts  and  localized  destruction  of  its  gray  matter.  Large  quan- 
tities of  spinal  fluid  usually  mark  these  late  cases,  causing,  Avith  the  irregular 
adhesions,  a  sacculated  condition  of  the  dura. 

Symptoms. — The  abrupt  onset  of  the  disease  may  be  preceded  by  a  day 
or  two  of  malaise  and  slight  anorexia ;  but  sometimes  no  invasive  period  is 
present,  and  a  sharp  chill  is  followed  or  attended  by  great  pain  in  the  back  and 
darting  pains  around  the  body  or  down  the  limbs.  In  children,  vomiting  or 
convulsions  may  be  present,  and  the  former  is  a  common  symptom.  Tenderness 
is  at  once  developed  over  the  spine,  easily  detectable,  when  not  prominent,  by 
the  use  of  a  sponge  dipped  in  hot  water  or  by  sharp  percussion  with  the  finger. 
Spasm  and  rigidity  of  the  muscles  appear  at  once,  causing  stiffness  of  the  neck 


780  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  back,  sometimes  notable  retraction  of  the  head  ;  fixation  of  the  limbs  upon 
the  body  more  or  less  marked,  with  a  tendency  to  flexed  attitudes  ;  retraction 
of  the  belly  from  implication  of  the  abdominal  muscles;  and  sometimes  difficulty 
of  breathing,  by  involvement  of  the  chest  musculature  aside  from  the  dyspnoea, 
Cheyne-Stokes'  respiration,  and  cardiac  symptoms  of  medullary  implication. 
The  cramps  in  the  muscles  are  painful,  and  yet  tenderness  and  hj^peraesthesia 
in  the  limbs  prevent  manipulations  and  passive  movements.  The  rectum  and 
bladder  are  the  seat  of  similar  spasms  which  may  cause  constipation  and  reten- 
tion of  urine,  with  frequent  annoying  and  ineffectual  expulsive  contractions  of 
these  viscera. 

Pulse  and  temperature  are  fickle,  sometimes  being  subnormal,  sometimes  in- 
creased, and  more  often  divergent ;  for  instance,  a  subnormal  temperature  with 
an  accelerated  pulse.  The  lack  of  uniformity  in  their  range  is  especially  valu- 
able in  diagnosis,  even  when  the  cerebrum  is  apparently  not  involved.  A  tem- 
Dcrature  of  103°  F.  is  not  uncommon.  Vaso-motor  paralysis  is  usually  shown  by 
the  vivid,  persistent,  but  slowly-developed  line  which  follows  every  stroke  of 
the  finger-nail  or  similar  object  upon  the  skin,  and  from  the  same  cause  the 
limbs  may  be  congested  and  even  slightly  oedematous.  At  first,  for  a  day 
or  two,  reflexes  are  inclined  to  be  increased,  and  later  may  be  wanting. 

Cases  which  outlast  the  acute  symptoms  develop  paralysis,  anaesthesia, 
atrophy,  and  contractures  in  proportion  as  the  cord  and  nerve-roots  are  aff"ected. 
Paraplegia  may  result,  presenting  the  features  of  a  cross-myelitis  with  bladder 
paresis,  bed-sores,  increased  reflexes,  and  spasticity.  Symptoms  vary  with  the 
location  of  the  disease,  but  its  tendency  to  involve  the  entire  spinal  apparatus 
is  marked,  and  indications  of  its  eff'ect  upon  all  spinal  segments  are  to  a  greater 
or  less  degree  present  in  a  majority  of  instances.  Some  regions  situated  in  the 
focus  of  the  inflammatory  action  show  early  and  emphatic  involvement ;  those 
at  a  distance  may  be  disturbed  very  little;  and  yet  in  some  purulent  cases, 
where  the  dural  sheath  is  greatly  distended  through  its  entire  length  with  the 
large  accumulation,  the  pia  protects  the  cord  and  nerve-roots  from  infection,  so 
that  pi'essure  symptoms  alone  may  be  present. 

Course. — Some  cases  terminate  fatally  within  a  day  or  two  ;  others  last  a 
fortnight,  and  may  then  end  fatally  or  recover.  The  nature  and  virulence  of 
the  infection  are  a  determining  factor,  as  is  the  location  of  the  disease — exten- 
sion upward  or  early  involvement  of  the  high  levels  of  the  cord  tending  to  an 
early  fatal  issue.  Complete  recovery  is  rare,  and  the  conditions  resulting  from 
myelitis  are  of  long  duration,  and  may  even  last  a  lifetime.  The  tubercular 
and  syphilitic  varieties,  as  already  indicated,  less  rapidly  run  their  course,  and 
the  latter  is  capable  of  material  modification  by  treatment. 

Diag-nosis. —  The  diagnosis  depends  upon  the  rapid  onset,  the  pain  in  the 
back,  the  radiating  pains,  the  rigidity,  the  increase  of  pain  on  voluntary  move- 
ment, the  hyperaesthesia,  and  the  fickle  temperature  and  pulse.  From  myelitis 
it  is  distinguished  by  the  paralysis  and  lack  of  pain  Avhich  characterize  the  cord 
lesion,  but  the  frequent  association  of  the  two  is  to  be  always  kept  in  mind. 
Haemorrhage  into  the  subdural  space,  from  the  irritation  of  the  nerve-roots,  pre- 
sents very  similar  symptoms,  but  is  extremely  rapid  in  the  onset,  usually  follow- 
ing traumatism  or  a  strain,  and  develops  meningitis  in  a  short  time  thereafter. 
Haemorrhage  into  the  spinal  cord  gives  instantaneous  symptoms  and  immediate 
paralysis,  and  is  practically  devoid  of  pain.  The  rigid  form  of  tetany  may 
present  a  very  close  counterfeit,  but  its  long  duration,  remissions,  and  amen- 
ability to  spinal  sedatives,  with  absence  of  spinal  tenderness  and  shooting 
pains,  and  with  the  possible  history  of  previous  attacks  and  the  usual  irritability 
from  pressure  upon  nerve-trunks  and  arteries,  should  differentiate  it.     Tetanus 


INFLAMMATION   OF  SPINAL   MENINGES  AND    CORD.    781 

may  be  mistaken  for  spinal  meningitis.  The  early  trismus,  the  excessive 
hypersesthesia,  the  fever  of  onset,  the  paroxysms  of  spasm,  and  the  frequent 
history  of  traumatism  point  the  way  to  diagnosis.  Muscular  rheumatism  and 
strain  present  a  very  superficial  resemblance. 

Prognosis. — The  outlook  as  to  life  is  always  serious  and  grave  in  propor- 
tion to  the  acuteness  of  the  onset,  to  the  virulence  of  the  infection,  to  the 
implication  of  the  upper  portion  of  the  cord,  and  to  the  height  of  temperature. 
The  estimate  is  also  to  be  guided  by  the  previous  condition  of  health  and  the 
age  of  the  patient,  children  and  the  aged  quickly  yielding  to  the  disease. 
Traumatic  and  surgical  infection  is  less  serious  than  auto-infection  by  leuco- 
maines.  The  possibility  of  the  removal  of  sources  of  infection  cuts  some 
figure  as  to  ultimate  results,  providing  the  patient  survives  the  acute  stage. 
The  late  results,  due,  for  the  most  part,  to  permanent  changes  in  the  cord,  are 
usually  beyond  the  hope  of  marked  improvement. 

Treatment. — Complete  and  absolute  quiet  is  to  be  insisted  upon,  and  the 
patient  maintained  upon  the  side  or  face,  if  possible  to  do  so  without  increasing 
the  cramps.  The  partial  knee-elbow  position  over  a  mound  of  firm  pillows 
will  often  be  found  very  comfortable,  and  at  the  same  time  will  aiford  the 
best  opportunity  for  local  applications.  These  at  first  should  be  strongly 
counter-irritant,  as  the  thermo-cautery,  blisters,  or  detergents  like  leeches, 
vigorous  dry-cupping,  or  wet-cups  in  robust  or  plethoric  individuals.  Should 
myelitis  be  associated,  less  active  measures  are  indicated,  and  the  skin  must  not 
be  broken  or  highly  irritated,  owing  to  the  tendency  to  bed-sores.  A  hot  bath 
and  pack  at  the  onset  with  active  catharsis  have  seemed  to  do  good.  Seda- 
tives, especially  spinal  sedatives,  are  frequently  required  to  control  the  spasms, 
and  anodynes  to  relieve  the  pains.  A  thorough  course  of  mercurial  inunc- 
tions over  the  spine  has  strong  advocates,  the  quantity  used  being  sufficient  to 
produce  slight  ptyalism.  Owing  to  the  reflex  irritability,  these  rubbings  must 
often  be  impossible,  and  the  therapeutic  value  of  mercury  in  the  acute  stage 
of  non-luetic  cases  is  open  to  question.  Iodide  of  potassium  and  ergot  are 
also  at  this  time  of  little  or  no  value.  The  ice-bag  to  the  spine  is  one  of  the 
most  serviceable  measures,  but  is  rarely  tolerated  long  by  the  patient,  and  its 
intermittent  application  is  useless.  It  should  always  be  tried.  As  the  active 
stage  subsides,  light  cauterizations  with  the  Paquelin  apparatus,  mild  sinapisms 
applied  for  six  or  eight  hours,  and  the  hot  spray  douche  seem  to  assist  the 
reparative  efforts  of  nature.  Cerebral  symptoms  usually  mean  the  implication 
of  the  brain  coverings,  the  spinal  features  become  of  secondary  importance, 
and  the  treatment  is  that  of  cerebro-spinal  meningitis.  The  paralysis,  con- 
tractures, and  other  late  results  of  the  myelitis  are  to  be  managed  in  accord- 
ance Avith  the  rules  of  practice  in  that  disease. 

Chronic  Leptomeningitis. 

The  chronic  form  of  inflammation  of  the  soft  membranes  is  usually  the 
sequential  stage  of  an  acute  attack,  but  may  follow  alcoholism,  syphilis,  or 
tuberculosis.  Its  origin  as  a  primary  affection  is  open  to  some  doubt,  but  a 
very  slowly-developed  leptomeningitis  may  follow  concussion,  though  it  is 
impossible  in  such  a  case  to  exclude  immediate  slight  histological  injuries  of 
which  the  later  inflammation  is  a  natural  development.  The  formerly  much- 
used  term  "chronic  meningitis,"  which  was  given  to  every  group  of  obscure 
subjective  symptoms  referable,  however  remotely,  to  the  spine,  only  needs 
mention  to  be  condemned. 

The  symptoms  are  practically  those  of  the  acute  form  much  reduced  in  in- 


782  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tensity,  and  are  dependent  upon  similar  causes.  Pain  in  the  back  predomi- 
nates, and  spasm  is  insignificant  or  absent.  The  radiating  neuralgic  pains  are 
especially  pronounced,  and  partesthesite  are  prominent.  Their  distribution  de- 
pends upon  the  nerve-roots  involved  and  the  location  of  the  inflammation, 
which  is  much  more  circumscribed  than  in  the  acute  form.  The  late  manifes- 
tations are  those  due  to  neuritis  originating  in  the  roots,  and  myelitic  symptoms 
are  comparatively  infrequent. 

The  anatomy  of  the  disease  is  very  little  known,  as  opportunity  for  post- 
mortem examination  rarely  occurs,  but  a  more  or  less  extensive  fibrous  thick- 
ening may  be  found,  and  adhesions  between  pia  and  dura  which  constrict  the 
nerve-roots  and  may  girdle  the  cord.  Degeneration  of  the  spinal  nerves  travers- 
ing the  lesion  is  not  rare,  and  this  accounts  for  the  herpetic  and  other  cuta- 
neous symptoms  of  neuritis  which  are  occasionally  noted. 

The  prognosis  will  be  guided  mainly  by  the  effect  of  treatment,  but  a  com- 
plete recovery  is  very  rare.     Each  case  must  be  carefully  estimated  by  itself. 

The  treatment  in  syphilitic  cases  consists  in  the  heroic  management  of  that 
disease,  and  iodides  and  mercury  are  also  the  most  efficient  drugs  in  non-luetic 
cases.  General  measures  are  of  avail,  and  persistent  counter-irritation  over 
the  spine  is  the  most  valuable  local  measure.  Sometimes  rest  in  bed  and  the 
ice-bag  to  the  spine  are  of  distinct  value.  Sedatives  and  analgesics  are  often 
required. 


n.  MYELITIS. 


Myelitis,  or  inflammation  of  the  spinal  cord,  is  a  generic  term  covering  a  con- 
dition presenting  many  varieties  of  a  more  or  less  arbitrary  character,  depend- 
ing upon  the  mode  of  onset,  the  portion  of  the  cord  involved,  the  duration  of 
the  disease,  and  the  exciting  cause.  Thus  it  is  acute,  subacute,  or  chronic ; 
transverse,  diffuse,  focal,  disseminated,  central,  or  annular ;  parenchymatous  or 
interstitial ;  and  compressive,  traumatic,  secondary,  syphilitic,  infectious,  etc., 
the  adjectives  sufficiently  describing  the  modifications.  The  forms  of  myelitis 
constituting  the  so-called  system  lesions,  poliomyelitis,  locomotor  ataxia,  and 
other  circumscribed  scleroses,  are  described  under  separate  headings.  The 
clinical  variations  of  the  disease  are  multiform.  So  widely  do  the  several 
tracts  and  segments  of  the  cord  vary  in  function  that  their  implication  gives 
rise  to  the  most  diversified  symptomatology,  for  the  comprehension  of  which  a 
fair  knowledge  of  the  anatomy  and  physiology  of  the  cord  is  requisite. 

Acute  Myelitis. 

Acute  Myelitis,  acute  softening  of  the  cord  or  transverse  myelitis,  is  the 
most  ordinary  foi'm,  and  not  a  rare  disease. 

Etiology. — While  the  disease  may  appear  at  any  age,  it  is  very  rare  in 
children  ;  males  from  eighteen  to  forty  years  furnish  the  large  majority  of  cases, 
syphilis,  exposure,  and  muscular  effort  playing  an  important  part  in  precipitating 
the  malady.  Next  to  trauma,  syphilis  is  the  most  frequent  cause.  Benedict 
and  Erb,  indeed,  are  disposed  to  assign  to  the  syphilitic  cases  a  clinical  entity  ; 
but  the  only  variations  are  those  attributable  to  the  infection,  the  nature  of 
the  syphilitic  process,  and  its  partial  response  to  treatment  in  some  cases. 
Lead,  mercury,  and  other  chemical  poisonings  are  at  times  provocative  of 
myelitis.  Acute  infections,  saprgemic  and  pyogenic  conditions,  may  lead  to  it, 
the  last  sometimes  producing  an  abscess  of  the  cord.     Pressure  from  hsemor- 


INFLAMMATION   OF  SPINAL    MENINGES  AND    CORD.    783 

rhage,  pachymeningitis,  tumors,  fractures,  dislocations,  and  from  Pott's  disease, 
very  rarely  from  a  thoracic  aneurism,  may  incite  it,  and  it  has  been  attributed 
to  sexual  excesses.  Wounds  of  the  cord  or  in  the  neighborhood  leading  to 
infection,  minute  haemorrhages  in  the  cord  from  strains,  violence,  concussion,  and 
arterial  disease,  thrombosis  or  embolism,  may  originate  the  softening.  Whether 
concussion  unattended  by  immediate  histological  injury  to  the  cord  is  capable 
of  producing  myelitis  or  not  is  a  mooted  question,  but  the  growing  tendency  is 
to  look-  upon  the  material  and  anatomical  factors  as  requisite  to  its  develop- 
ment. The  annular  form,  and  sometimes  other  varieties,  are  due  to  extension 
from  a  meningeal  inflammation. 

Pathology. — The  inflammatory  process  may  be  very  slight  or  absolutely 
destructive  in  intensity.  If  the  lesion  be  examined  early,  there  will  be  found 
hypergemia  and  swelling  of  the  adjacent  pia  mater  and  of  the  affected  portion 
of  the  cord.  Later,  the  condition  depends  largely  upon  the  amount  of  blood 
effused ;  in  some  instances  the  disintegration  of  the  cord  is  such,  and  the  ex- 
travasation of  blood  so  considerable,  that  the  gross  characters  of  a  clot  only 
are  found.  In  other  cases  softening  is  so  pronounced  that  the  cord  is  diffluent 
and  of  a  creamy  consistence  and  appearance.  From  the  hsemorrhagic  element 
"red  softening,"  comparable  to  that  in  the  brain,  may  be  found,  and  this,  by 
the  resorption  and  change  of  the  coloring  matter,  later  becomes  yellowish.  In 
time  the  affected  area,  through  the  removal  of  the  fat  and  the  deposition  of 
adventitious  fibroid  elements,  looks  grayish  and  translucent  and  is  shrunken 
in  outline.  Thus,  after  some  lapse  of  time,  the  cord  may  be  reduced  to  a 
narrow  filament.  In  these  prolonged  cases  upward  and  downward,  secondary, 
sclerotic  degenerations  in  the  white  columns  ensue. 

Peripherally,  the  muscles  innervated  by  the  involved  cord-segments  rapidly 
waste  and  degenerate,  and  dystrophic  bed-sores  are  common  even  at  an  early 
stage.  Implication  of  the  nerves  controlling  the  bladder  frequently  results  in 
cystitis,  leading  to  nephritis  and  uraemia. 

Microscopically,  the  findings  vary  greatly  with  the  intensity,  form,  and  dura- 
tion of  the  disease.  When  the  cord  has  become  entirely  disintegrated  and  dif- 
fluent such  examinations  are  of  little  value.  In  the  mildest  forms  the  vascular 
changes  are  the  most  noticeable,  the  blood-vessels  being  widened,  crowded  with 
the  formed  elements  of  the  blood,  and  the  perivascular  spaces  greatly  distended 
Avith  leucocytes.  Minute  extravasations  are  common.  The  gray  substance 
of  the  cord  is  more  granular  than  in  health,  its  cells  distorted,  swollen,  and 
devoid  of  processes  when  the  condition  is  marked.  Corpora  amylacea  and 
globules  of  myelin  are  common.  In  the  white  portions  increase  and  alteration 
in  the  neuroglia  are  found.  Spider-cells  are  frequent.  The  fibres  show  swell- 
ing of  the  axis-cylinder,  and  the  myelin  has  a  tendency  to  break  up.  At 
points  of  pressure  the  fibres  are  shrunken  and  may  entirely  disappear.  In  the 
parenchymatous  forms  the  nerve-cells  present  the  principal  changes,  the  inter- 
cellular substance  and  interstitial  material  showing  practically  no  change,  and 
the  vascular  condition  is  less  marked. 

In  cases  of  long  duration  both  fibres  and  cells  give  place,  in  large  part  or 
completely,  to  an  actual  increase  in  the  fibrous  elements  of  the  interstitial 
structure,  and  new  fibroid  tissue  is  deposited.  The  resulting  ascending  and 
descending  degenerations  show  sclerotic  features  similar  to  those  in  the  system 
lesions,  and  sometimes  a  more  active  inflammatory  process  extends  a  short  dis- 
tance up  or  down  the  cord,  occasionally  following  the  central  canal,  which  may 
show  dilatation,  proliferation  of  the  epithelial  lining,  and  more  or  less  dis- 
tortion. 

The  distribution  of  the  inflammation  in  the  cross-section  of  the  cord  is 


784   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

subject  to  no  rule.  In  some  cases  it  is  scattered  in  random  foci,  in  others 
confined  to  a  few  principal  points  ;  or  the  entire  cross-section  may  be  involved, 
and  the  gray  matter  does  not,  relative  to  its  proportions,  seem  to  be  especially 
selected. 

Symptoms.  — The  onset,  except  in  traumatic  cases,  is  gradual,  but  in  the 
course  of  a  few  hours  or  days  or  weeks  paraplegia  may  become  complete. 
Very  rarely,  and  usually  only  in  syphilitic  forms  and  those  due  to  slowly-devel- 
oped pressure,  there  are  prodromata  for  weeks  or  months  before  the  attack,  con- 
sisting in  temporary  weakness,  tingling  and  radiating  pains  ;  but  ordinarily  a 
feeling  of  numbness  and  weakness  in  the  legs  is  experienced,  the  lower  extrem- 
ities feel  heavy  and  unmanageable :  in  a  few  hours  they  refuse  to  bear  the 
weight  of  the  body,  and  in  a  few  days  may  become  completely  paralyzed. 
During  the  first  week  the  temperature  may  be  elevated  a  degree  or  two,  but  very 
rarely  attains  a  height  of  104°  F.  Delirium  and  convulsions  have  been  seen 
occasionally  in  children,  and  more  rarely  in  adults.  The  reflexes,  where  directly 
related  anatomically  to  the  affected  segments,  are  lost  early  and  permanently, 
and  below  that  level  are  increased  after  a  few  days,  unless  the  cord  has  been 
entirely  destroyed  at  the  inflammatory  focus,  when  they  are  abolished.  Pro- 
vided the  posterior  roots  and  meninges  are  involved,  pain  in  the  back  and  limbs 
is  a  prominent  symptom,  but  rarely  is  of  an  excruciating  character  at  the 
onset.  At  the  upper  level  of  the  inflammation  some  pain  is  the  rule,  which  gives 
rise  to  a  band  or  girdle  sensation  and  a  zone  of  hypergesthesia  about  the  abdo- 
men or  chest.  This  sign,  with  the  paralysis,  definitely  localizes  the  upper  limit 
of  the  lesion,  but  if  it  be  in  the  lower  cervical  region  this  sensation  passes  down 
the  arms  and  is  not  so  sharply  defined.  Lesions  in  the  cervical  region  are  also 
marked  by  implication  of  the  cilio-spinal  centre,  with  consequent  dilatation  of 
the  pupil.  Continuous  priapism  is  then,  too,  a  usual  occurrence,  and  the  inter- 
costal muscles  and  heart  may  be  aff"ected.  Below  the  lesion,  and  depend- 
ing upon  its  intensity,  there  are  variations  in  sensibility  to  all  forms  of  stimu- 
lation, from  slight  blunting  to  the  usually  complete  anaesthesia.  Sensations  of 
drowsiness  and  aching  in  the  paralyzed  and  anaesthetic  limbs  are  sometimes 
mentioned ;  and  cramps  and  drawing  up  of  the  limbs  frequently  occur  early,  and 
later  are  the  rule.     Distinct  muscular  atrophy  related  to  the  portion  of  the  cord 

Fig.  1. 


r^^^::\ti\n%;;^f>;^,nl 


Showing  Flexion,  Cross-leg  from  Adduction,  Coutractious  causing  Drop-foot 
and  Bed-sores. 

affected  takes  place,  but  in  the  trunk  is  not  readily  discernible.  The  paralyzed 
limbs  during  the  first  few  days  are  abnormally  warm,  but  soon  present  a  sub- 
normal temperature :  sluggish  circulation  and  emaciation  ensue,  with  oedema 
of  the  feet  and  legs  if  the  limbs  are  left  any  length  of  time  in  a  pendent  posi- 
tion.    If  the  lesion  is  low  down,  the  atrophy  is  a  marked  feature  and  the  re- 


INFLAMMATION  OF  SPINAL   MENINGES  AND    COBB,    785 


action  of  degeneration  is  present.  Under  the  influence  of  pressure  bed-sores 
form  on  prominent  portions  of  the  body  and  limbs,  and  this  very  early.  In 
some  cases  within  the  first  week  immense  sphacelization  may  take  place  over 
the  sacrum,  which  cannot  be  explained  by  pressure  and  the  moisture  from  the 
urine,  but  implies  a  dystrophic  condition  of  cord  origin.  Bed-sores  of  this 
nature  are  especially  liable  to  form  when  the  lumbar  cord  is  the  seat  of 
the  disease. 

Course. — The  onset,  as  already  indicated,  is  moderately  rapid,  as  a  rule, 
and  in  the  course  of  a  few  days  the  complete  picture  of  paraplegia  is  presented. 
Although  the  case  may  stop  short  of  this  at  any  point,  it  may,  on  the  other 
hand,  rapidly  progress  to  the  formation  of  bed-sores,  the  development  of 
cystitis,  and  rapidly  progressive  exhaustion,  often  terminating  in  a  fatal  issue. 
Non-fatal  cases  come  to  a  standstill  after  two  or  three  weeks,  and  if  nutrition 
and  strength  are  maintained  improvement  slowly  takes  place,  sensation  and 
motion  gradually  reappearing  and  increasing  for  a  year  or  two.  A  complete, 
or  apparently  complete,  recovery  is  rarely  seen.  For  the  most  part,  secondary 
degenerations,  upward  in  the  posterior  columns  of  the  cord  and  downward  in 
the  lateral  tracts,  cause  inco-ordination  on  the  one  hand  and  spastic  symptoms 
on  the  other — a  combination  suggestive  of  ataxic  paraplegia,  and  no  doubt 
sometimes  confused  with  that  disease.  The  implication  of  the  pyramidal  tracts 
leads  to  the  spasms,  tremors,  and  cramps  which  form  such  prominent  features 
of  these  late  cases,  and  gives  rise  to  th-e  spastic  gait  when  walking  is  pos- 


Fig.  2. 


Fig.  3. 


Chronic  Myelitis,  showing  station  and  rigidity,  with  partial  flexion  and 
adduction  of  thighs. 

sible,  and  to  the  flexed  limbs,  adducted  thiojhs,  and  crossed  leors  of  the  bed- 
ridden  cases,  as  shown  in  Figs.  1,  2,  and  3.  In  these  later  stages  the  condi- 
tion is  often  spoken  of  as  chronic  myelitis. 


786    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Diagnosis. — Regarding  the  location  of  the  lesion,  the  best  guide  will  be 
the  upper  level  of  anaesthesia  and  the  hyperaesthetic  girdle.  After  a  few 
weeks  increased  superficial  and  deep  reflexes  occur  below  the  disease,  while 
those  reflexes  whose  arcs  are  involved  in  the  softening  disappear.  Thus,  if 
the  umbilical  or  mid-abdominal  reflex  is  absent,  those  below  being  present 
and  exaggerated,  and  a  girdle  sensation  is  present  just  above  the  navel  with 
anaesthesia  below,  the  lesion  is  at  the  tenth  dorsal  segment  and  opposite  the 
body  of  the  ninth  dorsal  vertebra,  the  guide  to  which  is  the  eighth  dorsal 
spine.     With  this  the  distribution  of  paralysis  should  also  agree. 

The  intimate  and  usual  association  with  myelitis  of  some  more  or  less  local- 
ized meningitis  is  to  be  constantly  in  mind,  as  the  obtrusive  symptoms  arising 
therefrom  may  serve  to  very  much  embarrass  the  diagnosis,  especially  in  the 
beginning,  and  mislead  the  judgment  as  to  the  future  of  the  case.  The  nature 
of  the  lesion  must  be  determined  by  a  careful  study  of  the  clinical  history  and 
a  careful  clinical  examination  of  the  patient  for  spine  disease,  for  neoplasmata 
in  other  locations,  for  tuberculosis,  for  syphilis,  and  for  injuries. 

Prognosis. — While  the  prognosis  is  always  grave  as  to  ultimate  recovery, 
and  early  in  a  given  case  must  be  carefully  guarded  as  to  the  probability  of 
a  fatal  termination,  there  are  certain  facts  which  modify  the  estimate.  A 
dorsal  myelitis  is  less  serious  than  a  lumbar,  and  very  much  less  than  a 
cervical  involvement.  The  more  sudden  and  complete  the  onset,  the  greater 
the  probable  damage  to  the  cord.  High  temperature  and  early  bed-sores  are 
extremely  ominous.  Serious  involvement  of  the  bladder  and  bowel,  implying 
lumbar  cord  lesions,  are  distinctly  unfavorable.  The  reappearance  of  sensa- 
tion in  the  anaesthetic  area  is  hopeful,  and  usually  followed  by  some  return  of 
voluntary  motion.  When  improvement  has  distinctly  commenced,  it  may  be 
expected  to  continue  for  a  year,  and  progresses  even  two  years  or  more  in 
some  instances.  Secondary  degenerations  mean  an  ataxic  paraplegic  condition. 
Myelitis  depending  upon  Pott' s  disease  or  upon  pressure  may  reasonably  be 
expected  to  make  a  fair  recovery  if  the  causal  condition  can  be  removed. 
Indeed,  it  is  marvellous  to  what  an  extent  the  cord  may  be  slowly  compressed, 
and  eventually  regain  functional  activity  with  disappearance  of  all  the  para- 
plegic symptoms.  When  the  myelitis  is  due  to  active  syphilis  or  to  pressure 
by  a  syphilitic  neoplasm,  some  considerable  improvement  under  treatment  is 
the  rule,  but  an  absolute  recovery  the  extreme  exception.  This  is  especially 
true  when  the  luetic  lesion  is  confined  to  the  cord  itself. 

Treatment. — The  patient  should  be  put  at  once  to  bed,  and  kept  on  the 
side,  or,  better,  Avhen  possible,  upon  the  face.  This  can  usually  be  accom- 
plished by  building  up  a  mound  of  pillows  under  the  thorax  and  abdomen.  In 
this  position  the  bowels  and  bladder  can  be  readily  evacuated  and  the  patient 
easily  managed.  A  brisk  cathartic  should  be  administered  and  the  bladder 
carefully  watched,  the  catheter  being  avoided  as  long  as  possible,  and  used 
under  the  strictest  rules  of  cleanliness  when  finally  it  is  necessary.  The 
tendency  to  retention  of  urine,  with  cystitis,  and  its  unfavorable  significance, 
cannot  be  too  much  insisted  upon.  To  the  spine  counter-irritation  with  mild 
sinapisms  is  desirable.  Here  the  dystrophic  tendency  must  be  borne  in  mind, 
and  blistering  or  severe  irritation  below  the  line  of  inflammation  absolutely 
avoided.  A  mustard  plaster  four  inches  wide  and  two  feet  long,  made  of  one 
part  mustard  to  ten  of  flour  and  thoroughly  mixed,  can  be  applied  for  hours 
and  with  benefit.  The  use  of  ergot  and  other  drugs  to  control  the  circulation 
is  of  doubtful  value,  but  may  be  tried  if  the  stomach  is  tolerant.  The  mechan- 
ical causes  of  the  disease  must  be  met  surgically.  When  present,  except  in 
syphilitic  cases  and  Pott's  disease,  nothing  but  operation  promises  any  reason- 


INFLAMMATION   OF  SPINAL   MENINGES  AND    COBD.    787 

able  relief,  and  operation  under  strict  aseptic  methods  adds  practically  nothing 
to  the  gravity  of  the  situation.  When  bed-sores  appear  or  the  tendency  to 
their  formation  is  marked,  a  water-  or  air-bed  kept  at  a  proper  temperature  is 
useful,  but,  unfortunately,  is  rarely  available.  Great  care  to  protect  the  skin 
from  discharges  and  uncleanliness  of  all  sorts,  with  frequent  applications  of 
alcohol  and  unirritating  dusting  powders,  and  repeated  changes  of  position,  will 
do  very  much  to  obviate  these  dangerous  complications.  After  ten  days  or 
two  weeks  systematic  passive  movements,  massage,  and  the  use  of  faradic  elec- 
tricity should  be  adopted  to  prevent  the  wasting  and  tendency  to  contracture. 
When,  later,  the  contractures  may  be  very  prominent,  splints  should  be  em- 
ployed. As  sensation  and  slight  voluntary  motion  return,  a  carefully  guarded 
system  of  mild  exercises  should  be  instituted.  The  intelligent  use  of  the  fara- 
dic wire  brush  to  the  anaesthetic  parts  sometimes  is  of  distinct  benefit  in  hasten- 
ing sensory  improvement,  which  in  turn  is  usually  followed  by  more  or  less 
volitional  activity. 

Some  syphilitic  cases  yield  promptly  to  large  doses  of  iodide  of  potassium 
and  mercury,  and  nearly  regain  the  condition  of  health.  A  certain  residuum 
of  impairment  is  always  left,  however,  when  the  cord  has  been  actually  invaded. 
Other  cases  fail  to  respond  to  this  line  of  treatment  even  when  heroic  doses  are 
employed.  One  should  not  be  satisfied  in  an  adult  to  stop  short  of  an  ounce 
of  iodide  a  day  if  smaller  doses  fail  to  make  an  impression,  and  by  guarding 
the  stomach  with  Vichy  and  the  bowels  with  bismuth  this  can  usually  be  accom- 
plished without  much  difficulty.  In  children  the  dose  must  be  proportioned  to 
their  age. 

The  bladder  and  bowel,  except  when  the  lumbar  centres  are  destroyed,  tend 
to  regain  some  power  and  control,  which  can  be  assisted  by  rendering  their 
contents  unirritating  and  by  encouraging  regular  habits  regarding  their  evacu- 
ation, with  the  use  of  faradization  to  strengthen  the  sphincters.  Everything 
conducing  to  the  general  healthy  tone  of  the  individual  assists  directly  and 
indirectly  the  local  disability. 

Chronic  Myelitis. 

Chronic  myelitis  is  usually  the  terminal  stage  of  an  acute  softening,  and  but 
very  rarely,  if  ever,  is  a  primary  condition.  Its  separate  consideration  is  only 
warranted  by  the  fact  that  it  is  often  mistaken  for  primary  spastic  paraplegia, 
for  ataxic  paraplegia,  rarely  for  locomotor  ataxia,  and  that  its  treatment  requires 
description.  Its  diagnosis  depends  on  its  long  duration  and  the  history  of  an 
acute,  or  at  least  tolerably  rapid,  onset,  on  the  involvement  of  bladder  and 
bowels,  on  the  paraplegic  distribution  of  sensory  and  motor  deficiency  and 
wasting,  on  the  absence  of  pupillary  symptoms,  lightning  pains  and  inco-ordi- 
nation,  on  the  presence  of  rigidity,  increased  reflexes  and  contractures,  and  on 
the  evidence  of  old  bed-sores. 

The  treatment  consists  practically  in  the  use  of  everything  that  will  elevate 
the  general  tone;  in  guarding  against  bed-sores,  cystitis,  contractures,  and 
wasting;  in  the  use  of  massage,  electricity,  hot  and  cold  spinal  douches,  and 
counter-irritation  in  the  form  of  flying  blisters  and  the  thermo-cautery ;  in 
operation  for  pressure  conditions  from  tumor  or  bone ;  in  appropriate  suspen- 
sion and  fixation  in  Pott's  disease;  in  the  persistent  use  of  antisyphilitics  in 
luetic  cases,  and  in  operation  when  these  do  not  succeed  or  a  gummy  tumor  is 
reasonably  suspected.  Exercises  to  develop  the  impaired  muscular  power,  pas- 
sive movements,  and  volitional  efi"orts  against  resistance  are  valuable.  The 
sphincteric  paresis  can  also  be  improved  by  the  passive  and  active  movements 


788  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

recommended  by  Brandt  in  prolapsus  uteri,  which  serve  to  strengthen  the 
pelvic  floor,  and  consist  for  the  most  part  in  having  the  patient  adduct  and 
abduct  the  flexed  thighs  while  lying  on  the  back  and  raising  the  pelvis  from 
the  bed,  the  motions  being  resisted  by  the  attendant.  Continued  and  often- 
repeated  voluntary  attempts  to  contract  the  sphincters,  as  in  restraining  faeces, 
should  be  encouraged.  Late  in  the  disease,  when  it  has  become  stationary, 
tenotomies  and  appropriate  apparatus  may  enable  an  otherwise  bed-ridden 
patient  to  get  about.  The  tendency  toward  some  improvement  during  the  first 
two  or  three  years  should  be  kept  in  mind,  and  everything  done  at  this  time  to 
assist  the  reparative  efforts  of  nature. 


ACUTE  ANTERIOR  POLIOMYELITIS. 

By  ARCHIBALD  CHURCH,  M.  D., 

Chicago. 


Acute  Anterior  Poliomyelitis,  also  known  as  myelitis  of  the  anterior 
horns,  atrophic  spinal  paralysis,  infantile  paralysis,  or  the  essential  paralysis 
of  children,  is  a  febrile  disease  the  activity  of  which  falls  upon  the  anterior 
horns  of  the  gray  matter  of  the  spinal  cord  ;  it  is  marked  by  rapidly  developed 
and  extensive  paralysis,  a  portion  of  Avhich  remains  permanently,  and  is  usually 
followed  by  atrophy  of  muscle  and  often  by  non-development  of  bone,  and  by 
deformity. 

Btiolog-y. — It  is  a  disease  almost  peculiar  to  childhood,  and,  though  cases 
occurring  in  adult  life  have  been  recorded,  it  is  probable  that  many  of  these 
late  instances  have  been  cases  of  peripheral  neuritis,  the  diagnosis  of  which  has 
only  of  late  years  been  generally  made.  The  great  majority  of  cases  occur 
before  the  tenth  year  of  age,  and  three-fifths  are  encountered  before  the 
fourth  year,  being  equally  divided  for  the  first  three  years  of  life.  As  it 
is  comparatively  rare  during  the  first  six  months,  the  latter  half  of  the  first 
year  of  life  is  therefore  the  most  susceptible  period.  The  coincidence  of  the 
first  dentition  at  this  time  has  given  an  altogether  undue  importance  to  the 
role  played  by  the  eruption  of  teeth  as  a  probable  cause.  At  one  time  ex- 
posure to  cold  wos  considered  an  active  etiological  factor,  but  Sinkler  of  Phila- 
delphia found  that  over  four-fifths  of  all  cases  occurred  during  the  hot  months 
from  May  to  September  inclusive,  with  a  heightened  frequency  during  the 
hottest  months,  July  and  August.  Heat  may  therefore  be  considered  as  a 
predisposing  or  favorable  condition  for  the  evolution  of  the  malady.  It  is  to 
be  remembered,  however,  that  slight  colds  among  children  are  as  frequent  in 
warm  weather,  from  draughts  when  lightly  clad,  as  in  winter.  In  nearly  every 
case  the  history  of  a  fall  or  blow  of  some  sort  is  brought  forward  by  the  parents, 
too  frequently  resulting  in  casting  unmerited  blame  upon  the  nurse  or  others 
in  charge  of  the  child.  It  must,  of  course,  be  admitted  that  a  concussing  force 
applied  to  the  spine  might  lower  resistance  to  the  disease,  but  there  is  no  good 
reason  for  attaching  great  weight  to  slight  traumatism.  In  a  numerous  list  of 
instances  the  disease  is  said  to  have  followed  acute  diseases,  such  as  the  exanthe- 
mata, but  in  many  such  cases  the  initial  fever  of  the  poliomyelitis  was  probably 
mistaken  for  some  other  complaint,  and  a  careful  study  of  these  reports  reveals 
such  a  lack  of  detail  that  they  must,  as  a  rule,  be  accepted  with  caution.  In 
others  the  original  ailment  is  stated  to  have  been  obscure  or  atypical,  and  as  a 
matter  of  fact  the  diagnosis  of  anterior  poliomyelitis  is  very  difficult  during 
the  initial  fever,  and,  until  paralysis  is  apparent,  difiers  but  little  from  the  febric- 
ula  of  indigestion  or  other  slight  ailments. 

Patholog-ical  Anatomy. — It  is  only  since  1865  that  the  lesion  in  this 
disease  has  been  known.  In  that  year  Provost  thoroughly  described  it,  and 
his  findings  have  been  invariably  confirmed  by  workers  in  this  field.     Owing 

789 


790  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

to  the  fact  that  only  rarely  does  death  occur  in  the  very  early  stages  of  the 
disease,  or  is  then  attributed  to  other  causes,  the  initial  appearances  and  con- 
ditions are  practically  unknown,  but  can  from  later  observations  be  fairly  well 
indicated.  As  a  rule,  the  anatomical  changes  are  limited  to  the  anterior  horns 
of  gray  matter,  only  involving  the  neighboring  white  tracts  of  the  anterior  and 
lateral  columns  by  the  extension  of  the  inflammatory  or  hgemorrhagic  processes 
which  take  place  in  the  cornua,  and  which  result  in  a  softening  and  disintegra- 
tion of  their  elements.  The  large  motor  and  trophic  cells  either  completely 
disappear  or  only  a  few  shrunken  representatives  are  left ;  in  milder  cases 
slight  alterations  in  the  cells  alone  are  found.  Later,  from  the  shrinkage  of 
the  neuroglial  tissue  and  from  the  deposition  of  other  fibrous  elements,  a  de- 
pression is  found  in  the  implicated  part  of  the  cord,  and  granular  disintegration 
of  the  involved  nerve-elements  is  present.  When  the  pyramidal  tract  is  in- 
volved, descending  degeneration  may  take  place,  though  this  is  uncommon,  and 
when  present  is  usually  slight  in  transverse  extent.  The  muscles  depending 
for  innervation  upon  the  affected  cornual  cells  rapidly  waste,  and  the  sarcode  ele- 
ments in  extensive  cases  entirely  disappear,  nothing  but  the  fibrous  tissue  being 
left.  In  less-pronounced  cases  individual  fibres  or  groups  of  muscle-bundles 
are  destroyed,  or  sometimes  merely  a  diminution  in  size  is  found  ;  and  rarely 
isolated  muscular  fibres  are  encountered  which  show  a  true  hypertrophy,  prob- 
ably of  a  compensatory  character.  Where  the  bones  are  affected,  they  are 
smaller,  smoother,  less  well  marked  by  muscle  insertions,  more  compact,  showing 
less  cancellated  structure,  and  are  consequently  more  fragile. 

The  peripheral  nerves  arising  from  the  affected  anterior  horns  show  de- 
generative changes  of  a  corresponding  degree.  Sometimes  in  extensive  cases 
nothing  but  fibrous  cords  are  left,  but  usually  all  the  fibrils  are  not  destroyed, 
the  cross-section  of  the  nerve-trunk  showing  many  normal  elements.  This,  of 
course,  is  to  be  expected,  as  the  sensory  fibres  which  enter  the  cord  by  the 
posterior  root  are  not  implicated  in  the  central  lesion  ;  but  the  same  is  true  of 
sections  of  the  anterior  roots  close  to  the  cord,  and  the  sympathetic  fibres  in  the 
anterior  roots  also  escape.  Examinations  of  the  brain  are  usually  negative. 
In  some  extreme  cases  of  extensive  peripheral  distribution  of  long  standing  the 
corresponding  cortical  motor  area  has  been  found  smaller  or  undeveloped. 

A  number  of  cases  are  on  record  in  which  an  acute  polyneuritis  has  ap- 
parently coincided  with  the  spinal  attack,  but  these  cases  require  more  study, 
and  the  presumption  is  that  the  tenderness  in  the  nerve-trunks  in  such  cases 
is  due  to  the  degenerative  process  in  the  motor-fibres  and  the  attending  irri- 
tation of  the  adjoining  sensory  bundles  which  furnish  the  nervi  nervorum. 

Pathology. — The  acute  onset,  the  short  duration  of  the  fever,  its  com- 
paratively uniform  range,  and  the  immediate  paralysis  point  to  a  systemic 
infection,  or,  to  adopt  the  expression  of  GoAvers,  "a  blood-state,"  Avhich  finds 
its  local  expression  and  its  anatomical  manifestation  in  the  anterior  spinal  gray 
matter.  The  elective  action  of  certain  drugs  upon  the  spinal  centres  leads 
naturally  enough  to  the  supposition  that  a  ptomaine  or  leucomaine  might  have 
a  similar  selective  tendency,  as,  for  instance,  that  of  diphtheria  is  known  to 
have  for  the  peripheral  nerves,  or  of  hydrophobia  for  the  central  apparatus. 
This  idea  receives  some  support  from  instances  in  which  more  than  one  case 
occurred  at  the  same  time  in  a  given  family  ;  and  several  practical  endemics  of 
the  disease  are  on  record.  The  whole  question  is  yet  undecided,  but  the  in<. 
fection  theory  would  seem  to  be  the  best  working  hypothesis. 

Symptoms. — Usually  without  apparent  provocation  the  child  is  found  to 
be  feverish  and  ill.  A  temperature  of  100°  to  102°  F.  has  been  frequently 
noted,  and  this  febrile  invasion-stage  lasts  from  a  few  hours  to  a  few  days,  when 


ACUTE  ANTERIOR   POLIOMYELITIS, 


791 


Fig.  1. 


Leg  Type,  with  Marked  Cal- 
caneus. 


Fig.  2. 


paralysis  and  flaccidity  of  one  or  more  limbs  are  detected.  It  is  not  rare,  how- 
ever, for  the  child  to  go  to  bed  apparently  well  and  to  awake  paralyzed  in  the 
morning.  The  febrile  movement  may  be  attended  by 
vomiting  and  diarrhoea,  by  convulsions  of  a  generalized 
character,  or  by  delirium  and  diffuse  cerebral  manifes- 
tations. As  soon  as  the  paralysis  is  noted  the  case  is 
usually  recognized.  Most  writers  state  that  rarely  there 
is  a  complaint  of  pain  in  the  afflicted  members,  but  the 
rule  is  that  sensation  in  all  its  phases  is  entirely  normal. 
It  is  probable,  however,  that  early  dysesthesia,  owing 
to  the  age  of  the  patient  and  a  lack  of  careful  search  for 
such  difficulty,  has  been  many  times  overlooked.  In 
some  considerable  number  of  cases  during  the  initial 
fever  handling  of  the  affected  limbs  provoked  outcries, 
which  were  not  elicited  by  similar  manipulation  of  the 
other  members ;  and  it  is  likely  that  more  attention  in 
this  direction  will  show  localized  hypergesthesia  or  some 
kindred  state  to  be  usually  present  and  of  diagnostic 
importance.  Indeed,  complaints  of  pain  and  formica- 
tion have  been  generally  noted  in  cases  of  a  comparatively  advanced  age, 

lending  perhaps  undue  weight  to  the  supposi- 
tion that  such  cases  are  not  of  a  true  spinal 
type.  The  sphincters  are  almost  never  relaxed, 
so  that  control  of  the  bladder  and  bowel  re- 
mains unimpaired,  but  in  the  rare  cases  in  which 
these  sphincters  are  relaxed  there  is  more  or 
less  apparent  loss  of  sensation,  the  extent  of  the 
lesion  is  greater,  and  the  prognosis  is  extremely 
unfavorable. 

Even  in  fat  children  the  implicated  muscles 
can  be  seen,  after  a  few  weeks,  to  have  wasted, 
and,  if  tested  with  the  faradic  current,  either  do 
not  respond  at  all  or  show  a  remarkable  diminu- 
tion in  their  excitability.  At  this  time  the 
patient  will  have  begun  to  show  considerable 
improvement,  the  motor  paralysis  remaining 
complete  only  in  the  parts  that  are  to  per- 
manently suffer,  and  a  gradual  improvement 
may  be  reasonably  expected  to  extend  over 
several  months.  In  the  muscles  showing  less- 
ened faradic  excitability  galvanism  produces 
exaggerated  responses  as  compared  Avith  the 
sound  limbs ;  and  the  complete  reaction  of  de- 
generation or  any  modification  of  it  may  be 
encountered.  In  a  well-marked  case  faradism 
fails  by  the  tenth  day,  and  the  galvanic  in- 
creased response  appears,  lasting  for  about  six  months,"^  when  it  gradually  fails. 
At  this  point  faradic  excitability  returns,  and  the  muscle  regains  something  of 
its  size  and  strength ;  or,  if  too  seriously  impaired,  faradic  response  does  not 
reappear,  galvanic  response  disappears,  and  the  muscle  is  irretrievably  lost. 

The  reflexes  are  lessened  or  abolished  in  proportion  as  the  muscles  which 
are  anatomically  associated  with  them  are  involved  ;  or  perhaps  it  would  be 
better  to  say  that  their  alteration  depends  upon  the  implication  of  the  cornual 


Anterior  Leg  Type,  with  Drop-foot. 


792  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


cells  making  up  a  part  of  their  arc.  Bones  which  have  not  attained  their  full 
growth  are  retarded  or  fail  entirely  to  develop  if  their  trophic  centres  are 
implicated. 

The  seriously  atrophied  muscles  become  unyielding  fibrous  bands  ;  and  since 
they  offer  to  the  synergic  and  antergic  muscles  neither  assistance  nor  opposition, 


Fig.  3. 


Shoulder  and  Arm  Type  (Kindness  of  Drs.  Ridlon  and  Jones). 

distortions  soon  develop  with  joint-changes  and  sometimes  subluxations.  Joints 
which  depend  upon  muscular  support,  as  the  shoulder,  may  allow  of  so  much 
deformity  by  the  relaxation  of  the  muscles  which  have  lost  their  tonicity  that 
the  articular  surfaces  widely  separate.  The  skin  is  inactive,  often  cold,  and 
sometimes  dry  and  scaly,  but  the  atrophic  conditions  so  usual  in  neuritis  are 
practically  absent,  and  bed-sores  are  almost  unknown. 

The  distribution  of  the  permanent  paralysis  and  wasting  is  characterized  by 
non-conformity  to  any  type,  and  the  resulting  deformities  are  therefore  of  all 
grades  and  descriptions.  The  lower  extremities  are  affected  about  three  times 
as  frequently  as  the  upper,  and  the  left  leg  twice  as  often  as  the  right.  A 
crossed  form,  in  which  the  upper  extremity  on  one  side  is  involved  with  the 
opposite  lower  limb,  is  not  rare ;  but  involvement  of  both  limbs  on  the  same 


ACUTE  ANTERIOR   POLIOMYELITIS.  793 

side  is  extremely  uncommon.  In  the  lovrer  extremity  the  extensors  seem  more 
susceptible  than  the  flexors  ;  hence  drop-foot,  with  equine  talipes,  flexed  knee, 
and  flexed  thigh  are  common.  When  the  paralysis  is  below  the  knee  the  sural 
muscles  usually  escape.  In  the  upper  extremity  the  most  frequently  encoun- 
tered wasting  is  in  the  small  muscles  of  the  hands,  the  deltoid,  and  the  exten- 
sors of  the  wrist — the  biceps  and  supinators  generally  escaping.  For  the  most 
part,  the  central  lesion  is  confined  to  the  cervical  and  lumbar  enlargements; 
consequently  the  body  muscles  usually  are  spared,  and  involvement  of  the  cranial 
nerves  is  so  rare  as  to  always  raise  a  doubt  regarding  the  diagnosis. 

CoTirse. — The  course  of  the  disease  may  be  clinically  divided  into  (1) 
a  stage  of  febrile  invasion,  lasting  from  a  few  hours  to  a  few  days,  with  local 
tenderness  and  rapidly  developing  and  increasing  paralysis ;  (2)  a  stationary 
stage,  lasting  for  several  weeks ;  (3)  a  period  of  improvement,  lasting  to  the 
end  of  the  year;  and  (4)  a  stage  of  permanent  disability  for  the  remainder  of 
life.  Relapses  during  the  early  weeks  have  been  recorded  in  very  rare 
instances,  and  second  attacks  are  still  rarer.  Among  the  sequelae  the  spastic 
contractions,  dislocations,  and  deformities  have  been  already  mentioned.  The 
fragility  of  the  bones  makes  them  liable  to  fracture,  but  union  takes  place  with 
ordinary  promptness  under  proper  fixation. 

Diagnosis. — In  the  early  stages  of  fever,  before  paralysis  has  appeared, 
the  diagnosis  is  usually  missed  except  under  rare  epidemic  conditions,  and  the 
termination  of  an  apparently  trivial  ailment  in  extensive  paralysis  is  frequently 
the  cause  of  much  chagrin  on  the  part  of  the  medical  attendant,  who  may  have 
expressed,  naturally  enough,  a  favorable  prognosis.  As  already  indicated,  the 
initial  fever  may  be  readily  mistaken  for  that  of  general  disorders,  and  some- 
times, though  rarely,  the  pain  in  the  limbs  leads  to  the  idea  of  rheumatism. 
If,  however,  the  possibility  of  anterior  poliomyelitis  be  in  mind,  and  examina- 
tion discloses  some  slight  local  tenderness  or  diminished  muscular  activity,  or 
both,  a  guarded  opinion  will  naturally  follow.  It  is  only  when  the  paralysis  is 
developed  or  is  developing  that  the  nature  of  the  disease  becomes  certain,  and 
even  now,  if  there  have  been  cerebral  symptoms,  such  as  delirium  or  con- 
vulsions, difficulties  are  not  at  an  end.  The  cerebral  palsy  of  children  is 
almost  invariably  ushered  in  by  convulsions,  but  these  have  a  definite  distribu- 
tion involving  one  side  or  one  limb,  or  only  the  face,  while  the  convulsions  of 
the  disease  under  consideration  are  generalized.  Localized  pain  from  traumat- 
ism or  inflammation  may  cause  immobility  of  a  limb,  and  when  preceded  by  a 
fever  gives  rise  to  doubt;  but  the  usual,  indeed,  almost  invariable,  absence 
of  extreme  sensory  troubles  in  disease  of  the  anterior  horns  is  a  distinguishing 
feature,  while  the  local  conditions  can  be  otherwise  made  out.  After  a  few 
days  the  electrical  test  gives  absolute  data.  Faradic  response  is  abolished 
in  no  other  disease  so  early ;  even  in  severe  neuritis  it  is  longer  maintained, 
and  is  then  attended  by  a  very  marked  sensory  disturbance,  which  also  usually 
precedes  it  for  a  long  time.  A  few  careful  applications  of  the  induced  current 
at  this  period  can  do  no  harm.  Diphtheritic  palsy  presents  the  history  of  the 
throat  affection,  and  the  involvement  of  the  palate  and  muscles  of  visual  accom- 
modation is  distinctive. 

Prognosis. — As  far  as  life  is  concerned,  this  disease  terminates  fatally  very 
exceptionally,  and  if  the  patient  survives  but  a  short  time  the  onset  of  the 
paralysis,  life  may  be  considered  out  of  danger.  Further,  one  can  say  with  a 
reasonable  degree  of  certainty  that  the  paralysis  at  first  developed  will  notably 
recede,  but.  unfortunately,  it  is  equally  certain  that  a  portion  of  it  will  per- 
manently remain.  At  the  end  of  a  fortnight  a  cai'efully  conducted  faradic 
examination  of  the  muscles  enables  the  physician  to  speak  more  specifically 


794  A2IERICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

regarding  the  amount  of  permanent  disability.  At  that  time  any  muscle  which 
responds,  however  feebly,  may  be  expected  to  regain  a  fair  degree  of  its  former 
tone  and  strength,  while  those  that  do  not  respond  even  to  strong  currents  are 
not  necessarily  beyond  hope  of  slight  improvement.  Even  after  several  months 
faradic  stimulation,  at  repeated  intervals,  of  a,  at  first,  perfectly  inactive  muscle 
may  develop  some  contractility,  and  this  is  of  favorable  import  for  the  given 
muscle.  The  extent  of  permanent  paralysis  governs  the  amount  of  resulting 
contracture  and  deformity;  and  likewise  the  retardation  of  development  of  the 
limb  and  of  the  bones  is'in  similar  relation.  The  anticipated  amount  of  these 
deforming  conditions  will  have  a  bearing  on  the  probable  general  activity 
of  the  individual,  his  prospective  physical  health,  and  liability  to  fractures. 
Finally,  the  outlook  is  modified  by  any  cachectic  state,  as  tuberculosis,  rickets, 
or  syphilis. 

Treatment. — Owing  to  the  irregularities  of  the  course  of  this  disease  in 
various  cases,  and  its  natural  tendency  to  improve  up  to  a  certain  point,  it 
becomes  a  matter  of  great  difiiculty  to  estimate  the  value  of  any  therapeutic 
agent  or  mode  of  treatment.     In  the  early  stage,  as  soon  as  the  diagnosis  is 
made — and  that  is  usually  as  soon  as  the  palsy  is  recognized — if  fever  still 
continues  there  is  good  reason  to  suppose  that  antipyretic  antiseptics  like  the 
salicvlates.  or  even  bichloride  of  mercury,  would  do  good.     To  the  spine  hot 
applications  can  be  made  if  the  circumstances  of  the  patient  will  assure  their 
intelligent  and  faithful  employment :  otherwise  they  are  worse  than  useless,  and 
very  mild  sinapisms  can  be  more  properly  used.     The  child  should  be  kept  on 
theside  or  face,  and  the  aflfected  limbs  should  be  thoroughly  enveloped  in  cotton- 
wool to  maintain  the  circulation  and  the  nourishment  of  the  muscles  in  the 
parts  laboring  under  diminished  trophic  influence.     The  use  of  stimulants  like 
strvchnia  or  electricity  while  the  lesion  is  active  is  to  be  strictly  avoided ;  but 
when  the  active  process  has  come  to  a  standstill — that  is.  ordinarily  at  the  end 
of  a  fortnif^ht — the  systematic  use  of  electricity  is  one  of  the  most  important 
measures.  Its  object,  however,  should  be  thoroughly  understood,  and  some  occult 
influence  on  the  central  lesion  or  the  peripheral  nerves  should  not  be  expected 
of  it.     Its  usefulness  consists  in  maintaining  the  nourishment  and  nonnal  con- 
tractilitv  of  the  muscles  which  are  temporarily  deprived  of  their  natural  trophic 
and  motor  control,  so  that,  as  the  inflammation  subsides  and  the  widespread 
inhibitory  effect  of  the  local  lesion  recedes,  the  central  apparatus  may  find  the 
muscula/  periphery  in  the  most  favorable   state  to  respond  to  its  enfeebled 
influence.     For  this  purpose,  as  faradism  is  early  abolished,  the  interrupted 
galvanic  current  must  be  used,  the  slightest  intensity  being  employed  that  will 
cause  a  contraction,  and  care  must  be  exercised  not  to  unduly  fatigue  the  mus- 
cles.   A  dozen  contractions  at  most  should  be  elicited  at  one  seance,  and  often 
onlv  one  or  two  can  be  provoked  by  a  strength  of  current  that  is  bearable. 
Care  not  to  alarm  the  child  is  imperative,  as  a  daily  struggle  will  probably  do 
more  harm  than  the  electricity  will  do  good.     It  is  well  to  commence  with  dry 
or  wet  sponges  alone  until  the  young  patient  is  accustomed  to  the  manipula- 
tion.    As  the  muscles  often  react  better  and  with  less  pain  to  the  positive  pole 
than  to  the  negative,  it  is  well  to  have  for  the  negative  electrode  a  broad  sponge 
which  can  be  placed  on  the  sacrum  or  breast,  and  with  a  smaller  positive  sponge 
the  muscles  can  be  exercised.    Applications  of  galvanism  through  the  cord  are 
quite  useless,  and  even  if  such  currents  reached  the  lesion,  which  is  doubtful, 
their  effect  for  good  is  questionable. 

Later  on.  as  faradic  response  returns  in  the  muscles  only  slightly  affected  or 
temporarily  inhibited,  this  form  of  electricity  is  efficacious  for  the  purpose  of 
local  stimulation,  and  the  presence  of  this  reaction  in  any  muscle  is  always,  as 


ACUTE  ANTERIOR   POLIOMYELITIS.  795 

already  indicated,  a  gratifying  circumstance.  To  entrust  electrical  treatment 
to  the  parents,  however  intelligent  they  may  be,  is  a  mistake. 

In  the  same  way,  local  frictions  and  salt  baths,  warm  wrappings,  and  mas- 
sage are  valuable  measures  which  can  be  more  rationally  entrusted  to  parents 
or  nurses  who  take  an  intelligent  interest  in  the  work.  The  moment  a  group 
of  muscles  weaken,  the  limb  tends  to  assume  an  abnormal  position,  and  it  is 
very  highly  important  to  meet  this  tendency  from  the  very  first  moment,  even 
in  cases  where  there  is  every  probability  that  the  paresis  will  recede.  It  can 
be  easily  accomplished  by  means  of  the  warm  wrappings,  or  even  by  the  appli- 
cation of  light  apparatus.  There  can  be  no  question  that  recovering  muscles 
will  find  their  task  much  easier  if  their  proper  relations  have  been  maintained, 
and  unbalanced  muscles  will  be  much  less  liable  to  contractures  if  an  artificial 
balance  has  been  provided  and  joint  surfaces  have  not  been  altered  by  vicious 
positions  long  maintained. 

As  soon  as  the  permanent  paralysis  can  be  fairly  well  foretold,  massage 
should  be  especially  directed  to  obviate  the  contractures  and  deformities  that 
ordinarily  result,  as  indicated  by  the  anatomical  knowledge  of  the  physician. 
Stretching  of  the  unopposed  muscles  by  passive  movements  of  the  joints  will 
accomplish  much,  and  the  moment  a  tendency  to  contracture  is  perceived  the 
case  becomes  one  for  permanent  mechanical  appliances.  The  tendency  to 
equine  talipes,  for  instance,  can  be  met  by  a  slight  elastic  cord  from  the  toe  of 
a  shoe  to  a  band  at  the  knee  ;  and  more  elaborate  orthopaedic  apparatus  should 
be  employed  at  the  knee  and  hip  if  required.  These  cases  are,  therefore,  prac- 
tically orthopaedic  troubles  from  the  very  first. 

Nearly  all  the  improvement  that  is  to  take  place  in  the  muscles  will  have 
developed  by  the  end  of  the  first  year,  and  what  is  slowly  gained  subsequently 
in  this  direction  is  quite  independent  of  any  treatment  whatsoever. 

The  treatment  of  a  late  or  neglected  case  is  practically  surgical.  Short- 
ened tendons  may  be  cut  and  joints  straightened.  A  resection  at  the  knee  is 
sometimes  of  advantage  to  secure  a  straight  limb  instead  of  a  useless  contor- 
tion or  a  dangle  leg ;  by  using  a  high  shoe  or  other  appliance  crutches  may 
often  be  laid  aside.  In  some  of  these  cases  electricity  also  does  good. 
Though  the  first  few  applications  to  the  paralyzed  muscles  may  show  no 
response,  slight  contractions  not  infrequently  appear  later,  and  voluntary  con- 
trol soon  follows — weak,  to  be  sure,  but  in  proportion  to  the  amount  of  muscular 
tissue  undestroyed,  and  better  by  far  than  no  motion  whatever. 

The  local  hypodermatic  use  of  strychnia  has  had  many  advocates,  not  only 
in  these  late  cases,  but  also  in  the  early  treatment.  As  any  results  to  follow 
its  use  depend  upon  its  stimulating  action  on  the  spinal  centres  and  upon  its 
general  tonic  value,  the  hypodermatic  method  is,  in  the  case  of  timid  children, 
the  cause  of  useless  pain  and  often  of  harmful  mental  excitement. 

The  arrangement  of  exercises  to  increase  the  strength  of  the  involved 
muscles  which  retain  some  fraction  of  their  muscular  elements  is  of  distinct 
advantage,  and  must  be  devised  to  meet  the  requirements  of  each  case,  but  no 
elaborate  apparatus  is  necessary.  By  passive  and  active  movements  and  efibrt 
against  resistance  everything  of  this  sort  can  be  accomplished,  Underlying 
systemic  conditions  like  rickets,  rheumatism,  syphilis,  tuberculosis,  and  bad 
hygenic  surroundings  of  course  require  early  and  suitable  attention.  A  fatty 
dietary,  and  particularly  cod-liver  oil,  is  often  distinctly  valuable. 

Subacute  and  Chronic  Anterior  Poliomyelitis. 

Analogy  to  other  febrile  and  inflammatory  conditions  would  lead  one  to  the 
expectation  of  encountering  subacute  and  chronic  forms  of  poliomyelitis,  but 


796  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Fig.  4. 


there  are  many  who  apparently  doubt  their  entity  or  classify  such  instances  under 
other  headings.  Though  Gowers  devotes  several  pages  to  these  forms  in  the 
latest  edition  of  his  Diseases  of  the  Nervous  System,  the  impression  conveyed 
is  one  of  uncertainty  as  to  their  existence  and  discredit  as  to  the  cases  reported 
under  this  caption.  Other  recent  systematic  treatises  make  no  mention  of  the 
subject,  except  the  description  of  the  classic  form  of  progressive  muscular 
atrophy  of  the  spinal  variety.  Cases,  however,  are  encountered  presenting 
every  gradation  between  the  sudden  acute  form  and  the  pre-eminently  chronic 
variety  which  produces  our  dime-museum  "living  skeletons." 

In  some  instances  there  is  a  gradually  developed  weakness  in  one  or  more 
limbs,   without  or  with   an   initial  fever,   and  the  palsy  increases  slowly  for 

several  weeks.  After  a  stationary 
period  of  considerable  duration  it 
recedes,  and  only  a  trace  is  perma- 
nently left.  In  others  the  paralysis, 
insidious  in  its  onset,  goes  progres- 
sively forward,  involving  limb  after 
limb  and  producing  conditions  in- 
distinguishable, as  regards  gross  ap- 
pearances, from  those  of  progressive 
muscular  atrophy. 

Of  the  milder  forms  the  follow- 
ing case  is  an  example :  A  child 
of  three,  of  healthy  parentage  and 
living  in  fairly  good  surroundings, 
active,  bright,  and  lively  in  disposi- 
tion, Avas  noticed  to  have  difficulty 
in  getting  up  and  down  the  stairs. 
Two  weeks  later  she  was  unable  to 
rise  from  the  floor  except  by  draw- 
ing herself  up  with  the  aid  of  her 
hands  ;  she  could  not  Avalk,  and  the 
lower  extremities  would  quickly  give 
Avay  under  her.  The  hands  and  arms 
then  became  slightly  affected,  A 
month  later  the  symptoms  commenced  to  recede,  and,  a  year  after,  nothing  was 
left  but  a  little  wasting  of  the  anterior  tibial  muscles  with  slight  quantitative 
electrical  changes.  There  has  been  no  absolute  loss  of  faradic  excitability  at 
any  time,  no  pain  and  no  tenderness. 

Of  the  chronic  forms,  the  case  figured  in  Fig.  4,  from  a  photograph,  is  an 
instance :  A  boy  of  fourteen  yeai's,  with  no  family  or  personal  history  of  sig- 
nificance, at  the  age  of  six  had  an  attack  of  "malarial  fever"  (?)  lasting 
several  weeks,  and  then  could  not  use  his  legs  or  even  stand.  He  gradually 
improved  and  after  a  year  was  quite  active,  when  his  muscular  power  again 
became  impaired  in  the  legs.  Atrophy  and  weakness  have  steadily  progressed 
to  the  trunk,  neck,  and  upper  extremities,  with  numerous  contractures.  He 
is  able,  hoAvever,  to  use  a  bicycle  and  get  about  on  crutches.  Many  muscles 
fail  to  respond  to  all  currents,  some  show  only  quantitative  changes,  and  some 
comparatively  recently  affected  show  the  reaction  of  degeneration. 

Perhaps  some  cases  of  pseudo-hypertrophic  paralysis  should  be  classed  in 
this  place. 

Diagnosis. — From  neuritis  the  distinction  is  confessedly  difficult,  especially 
from  that  variety  of  neuritis  which  involves  mainly  the  motor  filaments,  and 


Chronic  Anterior  Poliomyelitis. 


.ACUTE  ANTEBIOB   POLIOMYELITIS.  797 

is  not  marked  by  the  dyssesthesia  and  sensory  difficulties,  usually  of  importance 
and  prominence  in  the  history  and  differentiation  of  the  peripheral  disease.  It 
is  not  unlikely  that  many  reported  cases  of  subacute  poliomyelitis  have  been 
mistaken  in  this  way. 

Treatment  is  practically  futile  in  the  progressive  form,  but  those  measures 
which  commend  themselves  in  chronic  myelitis  should  be  faithfully  tried,  and 
local  measures,  such  as  vigorous  massage  and  electricity,  have  produced  tem- 
porary improvement.  In  the  subacute  variety  these  measures  seem  to  be 
distinctly  productive  of  good,  and  what  has  been  said  of  the  prevention  of 
contractures  and  deformity  in  the  acute  form  of  cornual  disease  may  be 
reiterated. 


LANDRY'S  PARALYSIS. 

By  ARCHIBALD  CHURCH,  M.  D., 

Chicago. 


The  obscure  paralysis  known,  since  Landry's  description  of  it  in  1859,  by 
his  name,  and  designated  "acute  ascending  paralysis"  by  English  writers, 
while  presenting  a  striking  clinical  entity  in  typical  cases,  shades  oif  materially 
from  early  descriptions  in  many  instances  more  lately  observed.  It  may  be 
roughly  described  as  an  acute  disease  marked  by  paralysis  commencing  in  the 
lower  extremities,  usually  in  the  feet,  which  progresses  steadily  upward,  involv- 
ing the  trunk,  upper  extremities,  the  neck,  until  finally,  deglutition,  respiration, 
and  the  heart  are  implicated.  There  is  slight  or  no  modification  of  sensation ; 
the  muscles  do  not  rapidly  waste  nor  usually  lose  their  electrical  excitability  and 
myotatic  response;  the  sphincters  are  exempt;  bed-sores  do  not  occur;  and 
the  temperature  is  frequently  normal  throughout  the  attack.  In  cases  that 
recover  the  parts  last  and  least  affected  soonest  regain  power,  and  improve- 
ment, therefore,  extends  from  above  downward.  Fatal  cases  terminate  by 
respiratory  or  cardiac  failure  in  from  one  to  two  weeks. 

Etiology. — The  causation  of  Landry's  paralysis  is  practically  unknown. 
It  occurs  in  men  more  frequently  than  in  women,  and  most  frequently  be- 
tween the  ages  of  twenty  and  forty.  In  children  it  has  been  recognized  very 
rarely.  It  is  known  to  follow  infectious  diseases  which  are  provocative  of  neur- 
itis. Exposure  to  cold,  and  very  rarely  trauma,  alcoholism,  and  syphilis, 
have  preceded  it. 

Pathology. — In  some  well-marked  cases  the  most  thorough  examination 
of  the  cerebro-spinal  apparatus  by  competent  pathologists  has  failed  to  discover 
the  slightest  abnormality.  Several  cases  have  presented  a  diffuse  myelitis; 
one  or  two,  a  cross-myelitis;  a  few,  well-marked  neuritis,  and  some  have  shown 
changes  both  in  the  spinal  cord  and  in  the  peripheral  nerves.  No  constant 
lesion  is  present.  In  some  instances  there  has  been  pronounced  swelling  of  the 
spleen,  pancreas,  and  mesenteric  glands. 

The  frequent  lack  of  anatomical  findings,  the  onset  and  course  of  the  dis- 
ease, its  relations  to  antecedent  infectious  maladies,  such  as  typhoid,  small-pox, 
influenza,  etc.,  and  its  close  resemblance  to  multiple  peripheral  neuritis,  with 
which,  indeed,  a  large  number  of  observers  consider  it  identical,  lead  to  the 
almost  positive  conviction  that  it  is  the  result  of  some  infection  or  toxine. 
Bacteriological  investigation  has  thus  far  been  inconclusive,  though  highly 
suggestive. 

Symptoms. — Generally  without  malaise,  fever,  or  premonitory  symptoms, 
usually  without  tingling,  numbness,  or  other  sensory  disturbance,  a  feeling  of 
weakness  begins  in  the  feet  and  legs,  and  slowly  creeps  upward,  becoming  more 
and  more  pronounced  in  the  lower  levels  as  the  disease  mounts.  At  the  end  of 
two  or  three  days  or  a  week  the  lower  extremities  are  completely  paralyzed  and 
the  weakness  has  involved  the  trunk  and  upper  limbs.    The  breathing  becomes 

798 


LANDRY'S  PARALYSIS.  799 

superficial  from  involvement  of  the  diaphragm,  and  difficulty  of  swallowing 
soon  appears.  In  severe  cases  every  voluntary  muscle  below  the  face  is  com- 
pletely paralyzed  and  relaxed.  Cerebral  and  mental  symptoms  are  absent 
until  the  dyspnoea  or  cardiac  failure  is  pronounced  and  induces  them.  The 
sphincters  are,  as  a  rule,  not  relaxed ;  there  is  no  tendency  to  bed-sores  or  dys- 
trophy ;  the  tendon  and  superficial  reflexes  are  usually  present ;  the  electrical 
responses  are  normal ;  and  sensation,  together  with  the  special  senses,  is  not 
perverted.  If  a  fatal  issue  do  not  occur,  the  symptoms  of  paralysis  slowly 
recede  in  the  reverse  order  of  their  appearance,  and  when  they  have  distinctly 
subsided  from  the  upper  levels  recovery  may  be  anticipated. 

In  some  cases  the  onset  is  reversed,  the  upper  extremities  first  showing 
weakness  ;  and,  indeed,  the  ordinary  type  may  be  infinitely  modified,  as  can  be 
readily  understood  from  the  varying  anatomical  distribution  of  the  organic 
lesions  in  well-authenticated  observations.  In  one  case  falling  under  the 
writer's  attention,  where  the  clinical  history  was  typical,  complete  wasting  of 
isolated  muscle-groups  in  all  four  extremities  occurred,  and  was  persisting  four 
years  later,  without  any  appearance  of  ultimate  improvement.  Parsesthesia  and 
dyssesthesia  are  not  rare.  Loss  of  reflexes  has  been  noted.  The  progress  of 
the  paralysis  may  stop  at  any  point,  and  then  recede.  A  temperature  of  101° 
to  103°  F.  has  been  rarely  observed,  but  as  a  rule  it  does  not  rise  above  the 
normal. 

Course. — The  course  from  inception  to  fatal  termination  may  be  very  brief, 
less  than  two  days,  and  fatal  cases  usually  end  within  ten  days.  Prolonged 
cases  may  only  reach  their  acme  in  a  month.  After  a  stationary  period  of  vary- 
ing length  in  the  hopeful  cases,  improvement  takes  place  usually  in  a  retreat- 
ing order,  but  convalescence  is  slow  and  may  require  months.  On  the  other 
hand,  it  may  be  rapid,  or,  as  in  the  case  mentioned  above,  permanent  injury 
may  result. 

Diagnosis. — The  diagnosis  in  some  cases  must  necessarily  be  extremely 
difficult,  but  in  the  typical  form  is  readily  made,  providing  the  existence  of  this 
rare  disease  is  kept  in  mind.  It  rests  upon  the  method  of  invasion,  the  pure 
motor  paralysis,  the  negative  conditions  as  to  reflexes,  sensation,  and  electrical 
reactions,  and  the  history  of  some  possible  toxsemic  state.  Some  cases  are  com- 
plicated by  hysteria,  which  is  capable  of  greatly  obscuring  the  diagnosis.  When 
slight  electrical  changes  and  parsesthesia  are  present,  it  is  impossible  to  exclude 
neuritis,  and  the  integral  character  of  the  peripheral  disease  in  some  instances 
has  already  been  pointed  out.  In  general  myelitis  we  have  all  spinal  cord- 
functions  involved.     In  meningitis  the  pain  and  rigidity  are  distinctive. 

Prognosis  should  always  be  grave,  since  even  in  the  irregular  and  pro- 
longed cases  one  cannot  foretell  at  what  moment  bulbar  symptoms  may  appear, 
and  the  main  danger  to  life  depends  on  their  presence.  Rapidly-ascending 
symptoms  imply  a  speedy  termination,  but  there  is  no  invariable  rule.  Only 
when  the  tide  has  turned  and  symptoms  are  receding  can  one  entertain  a  rea- 
sonably hopeful  prognosis.  The  presence  of  neuritic  conditions  or  of  electrical 
changes  implies  a  prolonged  convalescence  and  some  doubt  as  to  ultimate  recov- 
ery. Where  cerebral  symptoms  appear,  they  are  of  bad  import,  signifying 
either  profound  toxic  conditions  or  the  near  approach  of  death  from  cardiac 
and  respiratory  failure. 

Treatment  will  be  directed  against  any  general  toxic  condition  present  or 
reasonably  suspected.  The  salicylates,  tincture  of  the  chloride  of  iron  in  full 
doses,  bichloride  of  mercury  to  the  point  of  toleration,  thorough  cleansing  and 
disinfection  of  the  alimentary  tract,  supportive  diet,  conservation  of  nervous 
energy  and  strength,  are  valuable.     To  the  spine  a  narrow  sinapism  the  whole 


800     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

length  of  the  back,  frequently  repeated,  is  of  service  ;  even  the  thermo-cautery 
is  advised  by  some.  Full  and  frequent  doses  of  ergot  or  ergotine  have  strong 
advocates.  The  paralyzed  limbs  should  be  gently  massaged  to  improve  circu- 
lation and  give  comfort.  When  swallowing  becomes  difficult  or  impossible,  feed- 
ing by  the  stomach,  nasal,  or  rectal  tube  must  be  adopted,  and  the  preference 
is  for  the  nasal  tube,  providing  care  be  exercised  to  avoid  passing  it  into  the 
larynx.  During  convalescence  massage,  electricity,  local  douches,  tonics, 
generous  diet,  and  general  measures  are  the  main  reliance. 


TUMORS  OF  THE  SPINAL  CORD. 

By  JAMES  HENDRIE  LLOYD,  A.  M.,  M.  D., 

Philadelphia. 


Under  the  head  of  Tumors  of  the  Spinal  Cord  will  be  considered  tumors 
not  only  of  the  cord  itself,  but  also  of  its  enveloping  membranes.  The  latter 
are  the  most  common.  Tumors  originating  in  the  bones  of  the  spine,  if  they 
make  pressure  upon  the  cord,  are  very  similar  clinically  to  tumors  of  the  mem- 
branes, but  they  are  exceedingly  rare.^ 

Tumors  of  the  spinal  cord  and  its  membranes  are  comparatively  rare  at  all 
ages,  but  they  are  not  unknown  among  children.  Thus  in  a  table  of  50  cases 
of  cord-tumors  analyzed  by  Dr.  Mills  and  the  author,  14  per  cent,  were  in 
patients  under  twenty  years  of  age.  Four  were  in  the  first  decade  of  life,  and 
three  in  the  second. 

Etiology. — The  causation  of  tumors  of  the  spinal  cord  is  usually  very  obscure, 
just  as  it  is  for  tumors  of  other  parts  of  the  body.  The  nature  of  these  growths, 
as  will  be  seen,  varies,  and  the  causes  that  produce  them  vary  as  well.  Syph- 
ilitic and  tuberculous  tumors  are  of  course  caused  by  their  respective  infections 
in  the  blood  and  tissues.  Carcinomata  and  sarcomata  have  here,  as  elsewhere, 
a  totally  unknown  essential  cause.  Gliomata  and  myxomata  are  equally  obscure 
in  origin.  The  gliomata  originate  always  in  the  neuroglia,  and  are  probably 
the  product  of  a  proliferation  of  germinal  tissue  which  has  remained  in  an 
embryonal  state.  They  are  most  apt  to  occur  in  the  central  gray  matter  and 
in  the  posterior  gray  commissure  in  the  neighborhood  of  the  central  canal.  In 
this  region  they  break  down  and  form  cavities  to  which  the  term  "syringomye- 
lia" is  applied.  As  this  process  is  now  recognized  as  a  distinct  disease,  it  has 
been  described  apart.  Other  cysts,  simulating  tumors,  may  be  caused  by  small 
haemorrhages,  and  possibly  by  emboli.  Parasitic  growths,  such  as  echino- 
coccus,  have  been  found  in  the  spinal  cord. 

As  a  direct  exciting  cause  trauma  has  been  regarded  by  many  as  not  infre- 
quent.. Where  there  is  predisposition  to  a  cancerous  growth  or  a  syphilitic 
deposit  it  is  possible  that  trauma  may  so  act.  Exposure  to  cold,  sexual  excess, 
and  overwork  have  probably  nothing  to  do  with  the  origin  of  tumors  of  the 
cord. 

These  growths  are  apparently  about  equally  divided  between  the  sexes.  In 
the  table  already  referred  to  it  is  seen  that  22  cases  occurred  in  males,  21  in 
females,  and  in  the  remaining  7  the  sex  is  not  recorded. 

Symptoms. — The  symptoms  of  tumors  of  the  spinal  cord  may  be  con- 
veniently classified  according  as  they  are  sensory,  motor,  trophic,  visceral,  and 
intracranial.     They  may  then  be  grouped  according  to  the  level  of  the  cord  at 

^  Mr.  Wright  of  Manchester  removed  a  fibro-sarcoma  of  the  neck  which  had  invaded  the 
spinal  canal  by  way  of  one  of  the  intervertebral  foramina,  causing  pressure  symptoms.  (Keported 
by  Thorburn,  Surgery  of  Spinal  Cord,  p.  168.) 

61  801 


802  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

which  the  tumor  occurs.  This  twofold  plan  will  be  adopted  here  for  the  sake 
of  both  clearness  and  brevity.  Finally,  a  comparative  study  of  symptoms  will 
be  made  under  a  separate  head  for  the  purposes  of  diagnosis. 

It  is  doubtful  if  a  distinction  can  always  be  made  in  diagnosis  between 
the  meningeal  and  medullary  growths.  In  some  cases,  however,  this  may  be 
possible.  The  tumors  springing  from  the  membranes  are  more  likely  to  cause 
pain  as  an  initial  and  persistent  symptom  than  are  tumors  within  the  substance 
of  the  cord.  They  cause  pressure  symptoms  later.  It  is  probable,  too.  that 
the  early  symptoms  caused  by  them  are  more  distinctly  local,  because  they 
press  upon  and  irritate  or  destroy  a  comparatively  small  area  of  the  cord  at 
first. 

The  sensory  symptoms  of  all  tumors  of  the  cord  and  its  membranes  are 
sooner  or  later  conspicuous.  Pain,  as  has  just  been  said,  is  common.  This 
pain  may  be  limited  in  the  early  stages  to  one  or  few  nerve-trunks,  in  one  of 
the  limbs  or  in  the  abdomen,  for  instance,  simulating  neuralgia,  or  it  may 
radiate  from  the  spine  in  association  with  stiffness  of  the  muscles  of  the  neck 
or  back.  It  is  often  an  urgent  and  distressing  symptom.  Hypersesthesia, 
Avhich  is  closely  allied  to  pain,  may  appear  in  the  course  of  the  disease.  In 
cases  in  which  the  lesion  is  unilateral  this  hypernesthesia  may  exist  in  the 
paralyzed  side:  in  other  cases  its  distribution  is  variable  and  its  duration 
uncertain.  Hyperaesthesia,  and  especially  pain,  may  exist  along  the  spinal 
vertebrae,  and  localized  pain  may  sometimes  be  elicited  by  tapping  vigorously 
on  the  spine  at  and  near  the  seat  of  the  tumor.  Paresthesia,  or  perverted 
sensibility — as,  for  instance,  burning  and  pricking  sensations  and  formication — 
is  closely  allied  to  hyperaesthesia,  and  may  appear  like  it,  especially  in  the  early 
and  middle  stages. 

AniTesthesia  is  a  very  common  symptom  of  these  tumors,  yet  the  time  of  its 
appearance,  as  well  as  its  distribution,  varies  greatly  according  to  the  site  and 
progress  of  the  neoplasm.  As  with  pain,  its  early  distribution  may  be  quite 
limited;  for  instance,  it  may  be  confined  to  the  area  of  distribution  of  one 
or  few  nerve-trunks  or  to  one  limb.  This  limitation  of  the  early  symp- 
toms, whether  motor  or  sensory,  is  a  characteristic  of  these  growths.  The 
anesthesia  may  be  associated  with  pain  in  the  affected  area — the  ancesthesia 
dolorosa.  In  the  later  stages  of  the  disease  the  anaesthesia  is  more  widely 
extended,  and  may  be  profound.  Thus  it  is  often  complete  in  the  trunk  and 
limbs  below  the  seat  of  the  tumor.  Thermo-anaesthesia  may  be  observed  in  some 
forms  of  cord-tumors :  perhaps  it  would  have  been  oftener  reported  if  it  had 
been  oftener  looked  for.  In  the  central  gliomata,  especially  when  they  form 
cavities,  as  in  syringomyelia,  anaesthesia  to  heat  and  cold  is  a  common  symp- 
tom ;  it  is  then  associated  with  analgesia,  while  tactile  sensation  is  preserved, 
thus  forming  a  "dissociation"  symptom  which  is  quite  characteristic.  This 
thermo-anaesthesia  is  probably  not  a  common  symptom  of  meningeal  growths ; 
in  fact,  it  is  doubtful  if  it  ever  appears  as  a  result  of  them,  especially  in  this 
dissociation.  Analgesia,  or  loss  of  pain-sense,  may  be  seen  in  some  cases  of 
tumor  of  the  cord.  It  may  be  associated,  as  above  noted,  with  loss  of  tem- 
perature-sense, or  it  may  exist  alone.  It  is  always  an  accompaniment  of  pro- 
found anaesthesia. 

A  not  uncommon  symptom  is  the  girdle-sense.  This  consists  of  a  feeling 
of  constriction,  as  of  a  cord  tied  around  the  part.  Its  location  varies  with  the 
seat  of  the  tumor.  Thus  it  may  be  felt  around  the  neck,  chest,  waist,  or  abdo- 
men, and  a  rare  case  is  reported  in  which  it  was  felt  even  in  the  legs. 

The  motor,  like  the  sensory,  symptoms  of  tumors  of  the  spinal  cord  vary 
in  kind  and  extent  according  to  the  seat  and  stage  of  growth  of  the  lesion. 


TUMORS   OF   THE  SPINAL    CORD.  803 

Like  them,  too,  they  are  apt  to  be  very  limited  when  they  first  appear,  and  to 
gradually  extend.  This  mode  of  appearance  and  extension  is  very  character- 
istic of  a  neoplasm  at  some  point  in  the  spinal  canal.  The  earliest  motor 
symptom  may  be  a  paresis  or  a  cramp  of  the  muscle,  or  these  may  alternate  or 
exist  at  the  same  time.  Paresis  may  be  limited  at  first  to  a  muscle-group, 
whence  it  may  gradually  extend  to  involve  a  limb  or  the  limbs  of  one  side  or 
both  lower  limbs.  Before,  however,  it  has  spread  thus  far,  it  will  most  prob- 
ably have  deepened  into  a  paralysis.  When  this  paresis  has  well  advanced, 
contractures  in  the  alfected  muscles  appear.  These  contractures  distort  the 
limbs,  and  often  become  so  firmly  set  that  they  can  be  overcome  only  with  great 
difficulty,  and  perhaps  only  with  great  pain  to  the  patient.  The  tone  of  the 
muscle  and  the  state  of  its  reflex  activity  to  a  tap  on  its  tendon  vary  accord- 
ing to  whether  its  centre  in  the  cord  is  involved  in,  or  is  below  the  seat  of, 
the  tumor.  In  the  former  case  the  muscle  is  flaccid  and  its  reflex  lost,  while 
in  the  latter  case,  the  centre  in  the  cord  being  cut  off"  from  the  inhibitory 
centre  in  the  brain-cortex,  the  myotonus  and  the  tendon  reflex  are  much 
exaggerated. 

Muscular  atrophy  may  be  caused  by  tumors  of  the  spinal  cord,  according 
to  the  well-known  pathological  law  that  a  muscle  wastes  when  its  trophic  centre 
in  the  cord  is  destroyed.  Hence  in  cases  of  these  tumors  the  atrophy  usually 
occurs  in  limited  muscle-groups,  or  in  one  limb,  or  possibly  in  both  arms  if 
the  cervical  enlarcrement  is  afi"ected,  or  in  both  less  if  the  tumor  is  in  the  lum- 
bar  enlargement  or  cauda  equina.  Hence  a  not  uncommon  type  of  motor  dis- 
order is  seen  in  cases  of  tumor  of  the  cervical  region ;  in  which  cases,  the 
trophic  centres  in  the  anterior  horns  being  destroyed,  a  muscular  atrophy  in  the 
arms  results,  while,  the  descending  motor  paths  in  the  lateral  columns  being 
injured,  a  spastic  paresis,  without  atrophy,  but  with  increased  knee-jerks  and 
with  ankle-clonus,  is  seen  in  the  legs.  When  the  process  in  the  cord  is  rapidly 
destructive,  the  atrophied  muscles  present  very  soon,  as  a  rule,  changes  in 
their  electrical  reactions.  During  the  very  early  stage,  or  stage  of  irritation, 
the  electrotonus  may  be  increased  to  both  currents,  but  sooner  or  later  this  is 
diminished,  while  modal  changes  occur ;  and  in  very  rapid  or  advanced  cases, 
in  which  the  anterior  horn  has  been  quickly  destroyed,  the  true  reactions  of 
degeneration  may  occur.  In  slowly  progressive  cases,  in  which  the  horn  is 
destroyed  very  gradually,  the  qualitative  changes  may  not  appear  in  a  typical 
manner. 

Spasms,  twitching,  and  contractures  of  the  aff'ected  muscles  are  frequently 
seen.  Cramps  in  the  back  and  limbs  are  sometimes  complained  of.  Con- 
tractures, as  already  said,  are  usually  secondary  to  advancing  paresis.  Fib- 
rillary contractions,  so  common  in  progressive  muscular  atrophy,  are  rarely  seen  : 
in  the  table  of  fifty  cases  referred  to  they  are  mentioned  only  once.  Epileptic 
convulsions  do  not  occur.  In  the  only  case  to  which  the  author  has  a  reference 
the  fit  must  have  had  some  origin  not  recognized.  Tetanoid  cramps  and 
spasms,  opisthotonos,  torticollis,  and  scoliosis  are  all  symptoms  which  may  arise 
in  the  course  of  tumors  of  the  spinal  cord. 

Ataxia  is  not  a  common  symptom  of  these  tumors.  This  may  be  because 
tumors  occupying  the  exact  region  of  the  lesion  of  locomotor  ataxia — i.  e.  the 
posterior  columns,  horns,  and  root-zones — must  be  exceedingly  rare. 

Various  trophic  lesions  may  occur.  These  lesions  are  identical  with  those 
caused  by  other  aff'ections  of  the  spinal  cord  producing  transverse  or  exten- 
sive destruction.  The  most  important  are  bed-sores.  These  bed-sores  may  be 
attended  in  time  with  septic  infection  of  the  blood,  and  thus  cut  short  the 
patient's  life.      Other  trophic  lesions  are  oedema,   glossy  skin,   maculae,  and 


804    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

bronzing  of  the  skin,  and  perhaps  in  some  cases  more  destructive  lesions. 
Vaso-motor  involvement  has  been  noted  by  some  observers.  Flushing  of  the 
skin  and  excessive  sweating  are  among  these  phenomena.  Alterations  in  tem- 
perature in  the  paralyzed  parts  occur.  The  most  common  permanent  alteration, 
especially  when  paraplegia  is  complete,  is  a  slightly  subnormal  temperature. 
Early  in  the  case  the  more  paralyzed  parts  may  present  an'  increase  in  tem- 
perature. 

The  visceral  symptoms  of  tumors  of  the  spinal  cord  depend  to  some  extent 
upon  the  location  of  the  growth.  The  most  common  is  paralysis  of  the  blad- 
der. It  is  the  most  common  because  the  centre  for  the  bladder  is  low  in  the 
cord,  and  consequently  is  cut  oiF  from  volitional  control  by  tumors  at  almost 
all  levels.  When  the  tumor  is  in  the  lumbar  enlargement  the  centre  for  the 
bladder  may  be  destroyed,  causing  complete  paralysis,  both  direct  and  reflex, 
of  the  viscus.  When  the  tumor  is  above  this  level,  however,  the  reflex  irrita- 
bility of  the  bladder  may  be  retained  for  a  while.  In  the  former  case  retention 
is  much  the  more  common  ;  in  the  latter,  incontinence.  Later,  in  all  cases, 
retention,  with  overflow,  is  apt  to  be  the  rule.  Paralysis  of  the  sphincter  ani 
is  caused  in  exactly  the  same  way  as  that  of  the  bladder. 

In  lesions  in  the  cervical  region  embarrassed  breathing  and  rapidity  of  the 
heart's  action  may  occur.  Choking  sensations  are  sometimes  experienced. 
Vomiting  is  not  a  common  symptom.     . 

Intracranial  symptoms  are,  from  the  very  nature  and  seat  of  the  growth, 
not  common  in  tumors  of  the  spinal  cord,  but  they  are  not  unobserved.  Vertigo 
has  been  recorded  in  one  case  in  which  the  tumor  was  high  in  the  cervical 
cord.  Changes  in  the  optic  disk  have  also  been  seen  in  similar  cases.  Head- 
ache is  noted  in  only  three  instances  in  the  table  of  fifty  cases  already  referred 
to.  Alteration  in  the  pupil  might  be  caused  by  paralysis  or  irritation  of  the 
sympathetic  centre  in  the  cervical  cord.  Mental  symptoms  are  not  caused  by 
tumors  in  the  spinal  canal  except  as  secondary  phenomena  due  to  pain,  weak- 
ness, and  abandonment  of  hope. 

Among  other  secondary  symptoms  are  cystitis  and  pyelo-nephritis.  Priapism 
has  been  reported  in  a  few  cases. 

Tumors  of  the  spinal  cord  present  several  clinical  types  according  to  the 
area  and  the  level  occupied  by  the  new  growth.  In  some  cases  in  the  early 
stages  one  lateral  half  of  the  cord  is  first  and  most  involved.  Such  a  case 
presents  the  type  first  described  by  Brown-S^quard.^  There  are  paralysis  and 
loss  of  muscular  sense,  with  hyperaesthesia,  on  the  side  of  the  lesion,'  and 
anaesthesia,  and  possibly  analgesia,  on  the  opposite  side.  This  distribution 
depends  on  the  fact  that  some  of  the  sensory  fibres  decussate  at  or  about  the 
level  of  their  entrance  into  the  cord.  A  notable  absence  of  sensory  symptoms 
occurred  in  a  patient  of  the  author's.  A  carious  spot  in  one  of  the  cervical 
vertebrae  caused  hemiplegia  without  any  sensory  involvement  whatever.  The 
case  exactly  resembled  hemiplegia  of  cerebral  origin.  An  operation  was  per- 
formed by  Dr.  Deaver. 

Other  types  depend  upon  the  level  of  the  cord  at  which  the  tumor  occurs. 
The  favorite  sites  for  these  tumors  are  the  cervical  and  lower  dorsal  regions. 
Of  the  50  cases  in  Mills  and  Lloyd's  table,  22,  or  almost  one-half,  were  inc'luded 
entirely  or  in  part  in  the  cervical  cord ;  4  were  in  the  upper  dorsal  region ;   12 

^  The  author  gives  a  place  in  the  text  to  a  description  of  this  type,  although  he  knows  that 
recent  experiment  throws  much  doubt  upon  the  accuracy  of  the  claim  to  anv  such  clinical  find- 
ings. Thus  Gotch  ("Recent  Research  on  the  Spinal  Cord,"  Liverpool  Med.-Chir.  Journ.,  Jan., 
1893)  says:  "Recent  physiological  research  shows  that,  in  opposition  to  the  views  formerly 
advocated  by  many  neurologists;  the  path  for  sensory  conduction  is  almost  entirely  on  the  same 
side  as  that  of  the  entering  sensory  nerves." 


TUMORS   OF   THE  SPINAL    CORD.  805 

in  the  lower  dorsal  ;  and  of  the  remainder,  4  were  in  the  lumbo-sacral  region, 
3  in  the  filum  terminale  and  cauda  equina,  and  the  rest  were  of  doubtful 
location  or  nature. 

The  type  presented  by  a  cervical  tumor  is  often  quite  characteristic.  Pain 
is  located  in  the  neck,  arms,  and  upper  part  of  the  back.  Torticollis  or  retrac- 
tion of  the  head  may  occur.  Anaesthesia  is  variously  distributed  according 
to  the  region  most  involved.  The  anterior  cornua,  entire  or  in  part,  on  one 
or  both  sides,  may  be  destroyed,  and  consequent  atrophy  of  muscles  in  the 
arm  or  arms,  with  altered  electrotonus,  may  be  observed.  Paraplegia,  begin- 
ning perhaps  as  crural  monoplegia,  is  sure  sooner  or  later  to  appear ;  and 
this  is  of  the  spastic  type,  with  increased  knee-jerks  and  ankle-clonus,  but 
without  muscular  atrophy  in  the  leg  muscles.  Complete  anaesthesia  in  the 
trunk  and  legs  supervenes ;  paralysis  of  the  bladder  and  bed-sores  complete 
the  picture. 

Tumors  in  the  dorsal  region  present  the  type  of  a  simple  transverse  lesion 
slowly  advancing  to  paraplegia  and  anaesthesia,  with  bed-sores,  incontinence, 
and  cystitis,  but  without  involvement  of  the  neck  and  arms.  The  signs  of 
irritation,  such  as  neuralgic  pains,  girdle-sense,  and  zone  of  hypersesthesia  at 
the  level  of  the  growth,  are  sometimes  very  characteristic.  Dyspnoea,  due  to 
partial  paralysis  of  respiration,  may  be  caused  by  tumors  in  the  cervical  and 
upper  dorsal  region. 

Tumors  in  the  lumbar  region  and  in  the  cauda  equina  give  a  still  dif- 
ferent type,  depending  upon  the  fact  that  the  trophic  cells  in  the  anterior 
horns,  the  anterior  nerve-roots,  and  the  nerve-trunks  are  implicated.  Hence, 
in  addition  to  paraplegic  symptoms  and  neuralgic  pains  about  the  lower  part  of 
the  trunk  and  in  the  legs,  there  may  be  muscular  atrophy,  reactions  of  degen- 
eration, and  abolished  tendon-reflexes  in  the  legs,  and  possibly  an  irregular  dis- 
tribution of  anaesthesia  in  areas  supplied  by  nerve-trunks  in  the  cauda  equina 
most  involved.  Moreover,  the  reflex  centre  for  the  bladder  in  the  lumbar 
cord  being  destroyed,  obstinate  retention,  with  overflow,  may  occur.  In  tumors 
limited  entirely  to  the  cauda  equina  the  symptoms  are  simply  those  of  neu- 
ritis— i.  e.  neuralgic  pain,  often  intense,  anaesthesia,  muscular  atrophy  with 
reactions  of  degeneration,  abolished  reflexes,  and  paralysis.  The  distribution 
of  these  symptoms  will  depend  entirely  upon  the  distribution  of  the  nerves 
implicated.  This  distribution  may  be  very  irregular,  and  by  this  irregularity 
constitute  a  distinct  type.     Paralysis  of  the  bladder  may  occur  in  these  cases. 

Morbid  Anatomy. — According  to  the  table  already  referred  to,  the  most 
common  forms  of  tumor  of  the  spinal  cord  are  the  sarcomata  and  the  structures 
allied  to  them.  Thus,  of  50  cases,  12  are  described  as  sarcomata  and  gliomata ; 
9  are  distributed  in  the  list  among  myxomata,  psammomata,  and  fibromata,  of 
which  number  it  is  fair  to  assume  that  some  at  least  were  structurally  similar 
to  the  sarcomatous  type  ;  while  of  the  2  described  vaguely  as  "  cancer,"  and  of 
the  6  unclassified,  a  proportion  would  probably  have  been  found  to  be  sarcoma 
or  glioma  on  more  exact  observation.  Carcinoma  occurred  but  once,  parasitic 
growths  three  times.  Syphilitic  growths  were  found  in  5  cases,  massive  tubercle 
in  4. 

Dr.  Herter,  in  a  contribution  to  the  pathology  of  solitary  tubercle  of  the 
spinal  cord,  has  analyzed  26  cases.  His  study  shows  that  the  afi"ection  is  a 
disease  of  adolescent  and  early  adult  life,  20  of  these  cases  occurring  before 
the  age  of  thirty-five.  In  all  but  one  the  massive  tubercle  was  solitary.  In 
most  of  the  cases  tubercular  disease  existed  in  other  parts  of  the  body  and 
antedated  the  cord  lesion.  Hayem,  however,  quoted  by  Herter,  reported  a 
case  which  he  regarded  as  primary. 


806    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Secondary  lesions  are  usually  found  in  cases  of  tumors  of  the  spinal  cord. 
Meningitis  and  oedema  of  the  membranes,  also  inflammatory  exudate,  are  occa- 
sionally noted.  The  cord  is  usually  compressed,  its  substance  softened  both 
above  and  below  the  tumor.  Secondary  degeneration  occurs  in  the  system- 
fibres  of  the  cord.  Haemorrhages  have  been  observed.  Cysts  may  be  formed, 
or  the  central  canal  may  be  dilated  (hydromyelia).  Gummata  and  carcinomata 
have  caused  erosion  of  the  vertebrae. 

Diagnosis. — Tumors  of  the  spinal  cord  may  be  confused  with  haemor- 
rhage, pachymeningitis,  transverse  myelitis,  spinal  caries,  fractures  of  the 
vertebrae,  neuritis,  and  hysteria. 

Haemorrhage  into  the  spinal  canal  or  spinal  cord,  unless  the  result  of 
\nolence,  is  extremely  rare.  When  it  happens  from  diseased  blood-vessels  it  is 
very  sudden,  and  the  symptoms  attain  almost  at  once  their  maximum  of  inten- 
sity. Compression  and  destruction  of  tissue  may  be  sufficient  to  cause  para- 
plegia in  a  few  hours.  It  is  possible  that  some  of  the  early  symptoms,  due  to 
compression,  might  abate  in  time,  and  that  the  permanent  results  would  be 
focal  with  secondary  degenerations.     The  usual  result,  however,  is  death. 

Pachymeningitis,  especially  in  the  cervical  region,  is  very  difficult  to  distin- 
guish from  a  tumor.  It  causes,  perhaps,  on  an  average,  more  acute  pain  and 
stiffness  in  the  neck  than  does  tumor,  and  it  is  more  widely  distributed  in 
vertical  extent. 

Transverse  myelitis  also  closely  simulates  tumor.  In  some  of  these  cases 
the  lesion  is  very  limited  in  vertical  extent.  The  onset  of  myelitis,  however, 
is  not  usually  so  gradual  as  that  of  tumor,  and  this  is  probably  the  best  dis- 
tinguishing point.  Another  distinction  is  the  degree  of  pain.  In  myelitis 
pain  is  sometimes  not  very  severe.  Cases  are  seen  in  which  the  girdle-sense 
and  a  zone  of  hypertesthesia  are  the  nearest  approach  to  it.  The  writer  has 
seen  also  white  softening  of  the  cord,  very  limited  and  entirely  transverse, 
cause  symptoms  very  similar  to  transverse  myelitis,  the  absence  of  pain  being 
very  conspicuous. 

Spinal  caries  in  its  early  stages  may  resemble  a  tumor,  but  the  cases  must 
be  very  rare  in  which  a  deformity  of  bone  cannot  be  detected  comparatively 
soon.  As  a  rule,  pressure-symptoms  do  not  appear  until  long  after  the  defor- 
mity is  apparent. 

Fractures  of  the  spinal  vertebrae  are  indicated  by  the  history,  even  though 
deformity  is  not  very  apparent,  as  is  sometimes  the  case.  It  is  not  probable 
that  confusion  could  often  arise  between  this,  or  any  other  fonn  of  trauma  in 
which  the  history  were  known,  and  tumor. 

Neuritis  might  simulate  a  neoplasm  in  some  cases ;  in  fact,  neuritis  is  one 
of  the  symptoms  of  tumor  of  the  spinal  cord.  When  it  is  caused,  however,  by 
a  tumor  within  the  spinal  canal,  it  is  not  likely  to  be  the  only  symptom  ;  thus 
evidence  of  compression  is  soon  made  manifest.  Multiple  neuritis  is  not  apt  to 
be  confined  to  the  arms  :  in  a  case  in  which  it  were,  compression  symptoms  in 
the  legs  would  be  wanting.  If  confined  to  the  legs,  it  Avould  not  cause  para- 
plegia with  involvement  of  the  bladder,  etc.  But  such  a  distribution  of  mul- 
tiple neuritis  is  rare.  It  is  usually  apparent  in  both  arms  and  legs,  in  which 
case  confusion  with  tumor  is  hardly  possible. 

It  is  customary  to  say  that  hysteria  simulates  all  diseases,  but  this  state- 
ment is  based  upon  superficial  observation.  Blocq  is  nearer  the  truth  when  he 
says  that  hysteria  does  not  simulate  any  disease  perfectly — that  there  is  always 
something  wanting.  To  detect  this  missing  element  is  often  the  rather  easy 
forte  of  the  expert.  No  rule  can  be  given  in  brief  space.  It  may  be  said, 
however,  that  the  symptoms  most  dependent  upon  organic  change  are  most  apt 


TUMORS    OF   THE  SPINAL    COBD.  807 

to  be  wanting  in  cases  simulating  tumor  or  other  organic  disease  of  the  cord ; 
excessive  knee-jerks,  very  free  ankle-clonue,  muscular  atrophy,  and  the  reac- 
tions of  degeneration  are  not  usually  seen.  In  fact,  the  latter  two  symptoms  are 
never  seen.  But  more  important  even  than  to  detect  the  negative  evidence  is 
to  observe  the  positive  symptoms  of  hysteria  itself.  These  are  the  so-called 
stigmata,  which  in  probably  all  cases  simulating  grave  organic  disease  can  be 
detected.  Among  these  stigmata  are  hemianaesthesia,  including  the  special 
senses,  concentric  narrowing  of  the  visual  fields  with  alteration  of  the  color 
fields,  segmental  anaesthesia  in  paralyzed  limbs,  tremor,  and  convulsive  phenom- 
ena. Transfer  and  suspension  of  symptoms  by  suggestion  (hypnotism)  may  be 
obtained.  The  mental  stigmata,  emotional,  lethargic,  etc.,  are  often  charac- 
teristic. 

Prognosis. — The  prognosis  of  tumors  of  the  spinal  cord  is  not  quite  so  bad 
as  formerly,  because,  in  some  cases  at  least,  surgery  may  come  to  their  relief. 
The  success  of  surgery  will  depend  primarily,  of  course,  upon  the  successful 
localization  of  the  growth  and  upon  its  situation  at  an  accessible  part  of  the 
spinal  canal.  Even  then  some  permanent  damage  may  have  been  done  by  the 
neoplasm  before  its  removal.  The  prognosis,  if  dependent  upon  treatment  by 
drugs,  is  uniformly  bad.  No  exception  to  this  rule  can  be  made  in  favor  of  a 
syphilitic  tumor,  because  syphilitic  lesions  large  enough  to  be  called  tumors  are 
not,  in  the  author's  experience,  removable  by  such  means. 

The  duration  of  these  cases  varies.  Some  cases  are  rapidly  fatal,  last- 
ing only  a  few  months  ;  others  are  reported  as  lasting  for  more  than  three 
years. 

Treatment. — As  has  just  been  said,  treatment  by  drugs  oifers  no  hope  in 
any  case  of  tumor  of  the  spinal  cord.  While  we  believe  that  the  syphilomata  are 
no  exception  to  this  rule,  we  should,  nevertheless,  give  the  patient  very  active 
antisyphilitic  treatment  if  he  had  a  clear  history  of  syphilis.  We  should  do 
this  in  the  hope  that  the  lesion  were  not  truly  a  tumor,  but  rather  a  more  dif- 
fused process,  such  as  pachymeningitis,  and  that  it  had  not  yet  irreparably 
damaged  essential  portions  of  the  cord.  When  the  syphilitic  neoplasm  has 
become  sufficiently  massive  to  be  worthy  of  the  name  of  tumor,  it  has  usually 
produced,  and  will  continue  to  produce,  such  destruction  of  the  nerve-elements 
that  repair  on  the  one  hand,  and  arrest  on  the  other,  cannot  be  obtained  by 
drugs.  The  writer  says  this  from  personal  experience,  not  exactly  with  syphi- 
litic tumors  of  the  cord,  but  with  their  congeners,  meningeal  gummata  within 
the  skull.  In  several  cases,  in  which  progressive  erosion  of  the  bone  occurred, 
no  perceptible  influence  was  exerted  by  the  so-called  specifics. 

Surgery  offers  the  only  rational  treatment  of  these  cases,  but  this  remedy 
must  be  used  with  rare  caution  after  the  most  painstaking  diagnosis,  and  with 
the  clear  understanding  that  success  may  not  be  obtained.  The  following  points, 
according  to  Thorburn,  must  be  considered  in  all  spinal  lesions :  First,  the  cura- 
bility without  operation  ;  second,  the  dangers  of  the  operation  ;  third,  disas- 
trous results,  such  as  weakening  of  the  vertebral  column  ;  fourth,  the  selection 
of  appropriate  cases.  In  the  case  of  a  spinal  tumor  it  may  be  said,  in  reference 
to  these  four  points,  that,  first,  the  case  is  not  curable  without  operation ; 
second,  that  the  dangers  of  the  operation  are  not  so  great  as  the  risk  of  going 
without  it ;  third,  that  the  spine  would  not  be  weakened  seriously,  except  in 
the  very  rare  event  of  extensive  erosion ;  and,  finally,  that  the  selection  of 
appropriate  cases  depends  entirely  upon  the  successful  diagnosis  and  localiza- 
tion of  the  tumor  at  as  early  a  stage  of  its  growth  as  possible.  Hence,  the 
operation  is  not  only  advisable,  but,  it  would  seem,  in  properly  selected  cases, 
imperative.     Tumors  of  the  spinal  cord  have  been  successfully  localized  and 


808    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

removed.  Such  an  operation  was  performed  by  Mr.  Horsley  on  a  man  with 
myxofibroma  in  the  upper  dorsal  cord.  The  symptoms  were  complete  para- 
plegia, motor  and  sensory,  of  slow  development,  accompanied  with  attacks  of 
agonizing  pain.  Although  degeneration  of  the  lateral  pyramidal  tracts  had 
existed,  as  shown  by  intense  spastic  paraplegia,  every  indication  of  this  is 
reported  by  Dr.  Gowers  to  have  since  passed  away. 

In  cases  in  which,  for  any  reason,  surgery  is  declined  or  ignored,  and 
exclusive  reliance  is  placed  upon  other  treatment,  the  most  important,  and,  in 
fact,  only  useful,  means  to  give  comfort  to  the  patient  are  the  water-bed  and 
opium.     Antiseptic  treatment  of  bed-sores  is  important. 


SYRINGOMYELIA. 

By  JAMES  HENDRIE  LLOYD,  A.  M.,    M.  D., 

Philadelphia. 


Syringomyelia  is  a  disease  of  the  spinal  cord,  characterized  by  the  growth 
of  a  gliomatous  tissue,  which  breaks  down  and  forms  a  cavity,  usually  in  the 
mid-region  of  the  gray  matter. 

Syringomyelia  has  been  recognized  within  only  a  comparatively  recent 
period.  The  word  was  coined  by  Ollivier  in  1837,  and  applied  by  him  to  all 
canals  or  cavities  in  the  cord.  Every  such  canal  or  cavity  was  considered 
pathological  until  Stilling  demonstrated  the  normal  central  canal.  Virchow 
and  Leyden  used  the  word  "hydromyelia"  to  designate  cavities  m  the  cord, 
which  they  claimed  were  always  dilatations  of  the  normal  central  canal. 
Simon,  in  1875,  pointed  out  the  pathological  process  which  interests  us  here. 
He  demonstrated  that  cavities,  quite  apart  from  the  central  canal,  may  occur 
in  the  cord  in  the  midst  of  a  newly-formed  gliomatous  tissue  by  the  breaking 
down  of  which  they  are  caused.  He  proposed  to  reserve  the  term  "  syringo- 
myelia" for  this  special  form  of  cavity;  and  this  specialization  is  now  accepted 
by  most  writers.  Svringomyelia  therefore  has  come  to  be  regarded  as  the  pro- 
duct of  a  gliomatosis.  The  word  "hydromyelia,"  on  the  other  hand,  may  be 
restricted  to  the  dilatation  of  the  central  canal,  which  happens  occasionally  as  a 
secondary  phenomenon  in  various  cord  lesions,  and  which  is  different,  both 
a-natomically  and  clinically,  from  true  syringomyelia. 

Of  late  years  a  quite  voluminous  literature  of  syringomyelia  has  grown  up. 
Among  monographs  we  may  note  especially  that  of  Bruhl,  which  brings  the 
subject  quite  up  to  1890.  Since  that  time  some  reports  of  cases,  proving 
the  accuracy  of  the  symptomatology  of  the  disease,  as  verified  by  the  post-mor- 
tem findings,  have  appeared.^  Doubt  lingered  in  the  minds  of  many  for  a 
long  time  whether  syringomyelia  could  justly  be  regarded  as  a  disease-entity, 
but  these  accumulating  observations  in  very  recent  years  must  effectually 
^il pn OP  fill  oriticisin. 

Etiology. — Syringomyelia  is  much  more  common  in  males  than  in  females. 
Bruhl  found  the  proportion  as  28  to  8.  Roth  is  reported  as  saying  that 
the  disease  is  three  times  more  common  in  males  than  in  females. 

The  disease  appears  usually  at  a  comparatively  early  age.  Charcot,  quoted 
by  Bruhl,  says  that  the  first  manifestations  appear  between  the  fifteenth  and 
twenty-fifth  years.  In  some  cases  the  time  of  the  ddbut  of  the  disease  is  uncer- 
tain. The  author's  case  was  in  a  male,  and  appeared  first  about  the  twenty- 
seventh  year. 

From  the  above  facts  it  is  seen  that  syringomyelia,  while  not  exactly  a  dis- 
ease of  childhood,  is.  usually  a  disease  of  adolescence  or  early  adult  life.     It 

1  See  report  of  a  case  by  the  author,  with  photographs  of  sections  of  the  spinal  cord,  Univ. 
Med.  Mag.,  Philada.,  March,  1893. 


810    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

probably  has  close  affiliations  with  at  least  one  well-recognized  disease  of  child- 
hood— viz,  hereditary  ataxia  or  Friedreich's  disease. 

Traumatism  and  exposure  to  cold  seem  to  have  been  exciting  causes  in  some 
cases.     The  infectious  diseases  also  have  appeared  to  be  the  starting-point. 

Syphilis  and  alcohol  do  not  seem  to  be  causes  of  this  disease. 

According  to  Bruhl,  syringomyelia  is  a  disease  probably  of  evolution,  a 
congenital  affection  having  its  origin  in  an  anomaly  of  development  of  the  epen- 
dyma.     We  shall  refer  to  this  subject  again. 

Pathology. — Cavities  in  the  cord,  as  already  said,  are  the  results  probably 
of  several  pathological  processes.  Thus  they  may  be  formed  by  the  dilatation 
of  the  central  canal,  this  dilatation  being  an  accompaniment  of  some  other 
morbid  state,  such  as  inflammation,  haemorrhage,  or  neoplasm.  They  result 
sometimes  perhaps  from  small  haemorrhages  into  the  substance  of  the  cord. 
Some  recent  authors,  notably  Hoffmann,  still  classify  all  these  varieties,  and 
make,  as  it  were,  one  general  group  of  them.  We  believe  this  is  wrong.  Most 
of  such  cavities  are  merely  accidents  or  terminal  products  left  by  various  patho- 
logical processes.  The  true  syringomyelia  is,  in  our  opinion,  a  process  sui generis, 
and  is  in  no  Avay  identical  with  the  other  members  of  the  rare  and  heterogene- 
ous groups  alluded  to.  We  accept  the  theory,  adopted  now  by  Schultze,  Bern- 
hardt, Simon,  Westphal,  Charcot,  Dejerine,  and  others,  that  syringomyelia  is  the 
product  of  a  true  gliomatosis,  which  occurs  usually  in  that  region  of  the  cord 
that  is  developmentally  the  weakest — ^.  e.  the  region  of  the  posterior  gray  com- 
missure and  posterior  median  septum.  This  proliferation  of  neurogliar  tissue 
leads  to  the  formation  of  a  cavity  by  the  gradual  softening  and  absorption  of  the 
new  gi'owth.  Its  usual  site  in  the  gray  commissure  and  posterior  septum  sug- 
gests that  it  may  result  from  an  anomaly  in  the  development  of  that  region  of  the 
cord  last  formed  by  the  folding  over  of  the  medullary  folds  in  the  embryo. 
According  to  this  theory,  the  central  canal  is  not  necessarily  the  starting-point 
of  the  process,  although  it  may  be  involved  ultimately  in  it.  In  the  author's 
case  this  profuse  overgrowth  of  neurogliar  tissue  was  a  conspicuous  feature, 
while  the  central  canal,  as  marked  by  a  mass  of  epithelial  cells,  was  entirely 
distinct  from  the  cavity.  In  another  case,  however,  published  recently  by  Dr. 
James  Taylor,  the  cavity  was  lined  in  some  places  with  epithelial  cells,  proving 
conclusively  that  the  central  canal  had  become  included  in  the  syringomyelia. 

Morbid  Anatomy. — The  cavity  is  usually  largest  in  the  cervical  region, 
whence  it  extends  downward  to  various  levels  in  different  cases.  In  some 
cases  it  trends  to  one  side.  It  may  extend  as  far  as,  or  even  into,  the  lumbar 
enlargement,  but  this  is  not  the  rule.  In  many  cases  the  lumbar  enlargement, 
with  exceptions  yet  to  be  noted,  is  normal.  At  its  seat  of  greatest  extent  the 
cord  may  be  literally  a  hollow  tube.  In  the  fresh  state  the  cord  is  flat  or 
ribbon-like,  and  gives  to  the  finger  a  sense  of  fluctuation.^  There  is  usually  not 
much,  if  any,  evidence  of  inflammation.  The  integral  parts  of  the  cord  are 
much  distorted  and  even  injured  by  the  syringomyelia.  The  cavity  (see  Fig.  1) 
occupies  the  central  gray  matter  or  commissure,  the  anterior,  or  white  com- 
missure, usually  escaping.  The  normal  central  canal  may  exist  apart,  in  which 
case  it  is  apt  to  be  disfigured,  and  perhaps  only  recognizable  by  its  epithelial 
cells,  or  it  may  be  included  in  the  cavity,  in  which  case  the  latter  is  lined  at 
places  with  columnar  epithelial  cells.  The  cavity  is  often  widely  extended 
laterally,  and  may  run  down  the  posterior  horns  or  even  the  posterior  median 
septum.  It  pushes  before  it  the  gray  matter,  which  is  seen  in  the  author's  case 
to  be  stretched  around  the  ends  of  it.     The  anterior  horns  are  distorted,  and 

'  In  two  cases  observed  post-mortem  by  the  writer,  this  macroscopic  appearance  was  very 
striking. 


8YBINO  OMYELIA . 


811 


the  multipolar  cells  in  them  are  in  many  instances  atrophied.  The  posterior 
horns,  the  posterior  root-zones,  and  the  posterior  columns  are  especially  liable 
to  injury.  The  horns  and  root-zones  may  be  distinguished  only  with  difficulty, 
and  the  posterior  columns  present  various  stages  of  degeneration.     The  lateral 


Fig.  1. 


Cervical  Kegion  of  the  Spinal  Cord  from  the  author's  case  of  Syringomyelia.    {TJniv.  Med.  Mag.) 

pyramidal  tracts  are  often  very  much  degenerated,  as  are,  also,  the  direct 
pyramidal  tracts.  The  cavity  itself  is  usually  surrounded  by  a  newly-formed 
tissue.  This  is  seen,  under  the  microscope,  to  be  a  densely  felted  tissue,  with 
fibrils  making  innumerable  meshes.  It  is  rich  in  neurogliar  nuclei.  Some 
writers  point  out  a  lining  membrane  to  the  cavity,  composed  apparently  of  a 
comparatively  more  densely  felted  layer  of  gliomatous  material.  Blood-vessels 
are  scattered  but  sparsely  through  this  tissue.     Above  and  below  the  region  of 

Fig.  2. 


Upper  Dorsal  Region  of  the  Spinal  Cord  from  the  author's  case  of  Syringomyelia.    {Univ.  Med.  Mag.) 


greatest  extent  of  cavity  the  morbid  anatomy  varies.  System-lesions  may 
extend  in  either  direction  according  to  their  nature.  The  medulla  oblongata 
is  variously  affected.  It  may  be  the  seat  of  nuclear  degenerations  identical 
with  those  of  bulbar  palsy.  In  the  author's  case  one  pyramidal  tract  was 
degenerated  through  the  decussation,  and  the  ascending  cerebellar  tract  on  one 
side,  as  well  as  the  funiculi  gracilis  and  cuniati  on  each  side,  was  deeply 
sclerosed.  Below  the  cavity  the  lateral  pyramidal  tracts  are  often  degenerated 
to  their  extreme  limits  in  the  lumbar  enlarcrement.  The  lumbar  enlargement, 
even  when  it  apparently  escapes  invasion,  may  exhibit,  on  close  microscopical 
search,  the  presence  of  gliomatosis  in  a  small  area  in  the  gray  commissure.  The 
anterior  horns  in  the  lumbar  cord,  unless  the  cavity  extends  thus  far,  are 
not  affected. 


812   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Symptoms. — The  symptoms  of  syringomyelia  may  be  divided  into  two 
classes,  according  as  they  are  dependent  upon  lesions,  first,  of  the  gray  matter 
of  the  cord,  and  second,  of  the  white  matter.  The  first  class  includes  the  essen- 
tial symptoms ;  the  second,  those  that  are  secondary  to  them.  These  essen- 
tial symptoms  may  be  subdivided  into  three  groups,  according  to  the  region  of 
the  gray  matter  affected. 

The  first  probably  of  these  essential  symptoms  to  appear  is  a  characteristic 
disorder  of  sensation.  This  presents  a  type.  It  is  an  analgesia,  or  loss  of 
pain-sense,  combined  with  thermo-angesthesia,  or  loss  of  power  of  distinguish- 
ing heat  and  cold,  without  true  tactile  anaesthesia  and  loss  of  muscular  sense. 
This  peculiar  type  has  been  called  by  Charcot  the  dissociation  symptom  of 
syringomyelia.  It  is  more  typical  of  the  disease  than  any  other  one  symptom- 
group,  and  is  truly  typical  of  no  other  affection,  although  occasionally  seen  in 
hysteria. 

These  sensory  changes  usually  show  a  segmental  distribution.  They  are 
sometimes  hemiplegic  in  type,  sometimes  monoplegic,  but  usually  distributed 
only  to  segments  of  the  limbs  or  trunk.  Exceptions  and  variations  occur. 
Thus  in  the  author's  case  zones  of  anaesthesia  were  found  on  the  shoulders  and 
about  the  waist.  Occasionally  areas  of  hyperaesthesia  exist ;  thus,  in  this  same 
case,  while  one  side  presented  quite  typically  the  "dissociation"  symptom,  the 
other  was  the  seat  of  hypersesthesia.  The  zone  of  anaesthesia  to  heat  and  that 
to  cold  do  not  always  exactly  correspond.  The  analgesia  of  syringomyelia  is 
often  very  profound,  so  that  the  patients  may  be  quite  insensible  to  most  destruc- 
tive trophic  or  traumatic  lesions,  to  which  reference  will  be  made  later.  The 
exact  affected  region  of  the  cord  that  gives  rise  to  the  sensory  symptoms  is 
probably  the  posterior  gray  commissure  and  parts  of  the  posterior  horns. 

The  essential  motor-symptoms  of  syringomyelia  depend  upon  a  progressive 
atrophy  of  the  cells  of  the  anterior  horns  of  the  gray  matter.  As  the  cervical 
enlargement  is  invaded  much  more  commonly  than  the  lumbar,  it  follows  that 
the  arms  rather  than  the  legs  are  the  parts  involved  in  the  consequent  mus- 
cular atrophy.  This  progressive  muscular  atrophy  is  usually  of  the  atonic 
variety — i.  e.  the  muscles  are  not  spastic  and  do  not  show  exaggerated  myo- 
tonic and  tendon  reflexes.  This  is  the  type  called  Aran-Duchenne.  There 
are  exceptions  to  this  rule,  however,  as  in  the  author's  case,  in  Avhich  the  tonic 
or  spastic  type,  with  exaggerated  reflexes,  was  present.  The  affected  muscles 
exbibit  fibrillary  movements.  Reactions  of  degeneration  are  not  seen  in  these 
muscles,  although  in  advanced  cases  quantitative  changes  occur,  and  in  extreme 
cases  very  little  if  any  response  can  be  elicited  by  either  current.  This  wasting 
often  begins  in  the  hand — for  instance,  in  the  thenar  and  hypothenar  eminences. 
It  may  be  the  first  symptom  to  attract  the  patient's  attention.  Loss  of  power 
is  proportionate  to  the  atrophy.  One  hand  may  be  affected  before  the  other. 
The  wasting  in  the  muscles  of  the  shoulders  and  arms  may  become  extreme. 
The  biceps,  deltoid,  infra-  and  supra-spinati  and  lower  part  of  the  trapezius 
may  be  almost  entirely  lost.  The  forearm  and  deeper  neck-muscles  also  may 
be  much  affected.  The  weakness  of  the  neck-muscles  may  become  so  extreme 
that  the  head  falls  forward  on  the  chest,  and  even  requires  an  assistant  to  sup- 
port it  when  the  patient  sits  upright.  Tremor  has  been  observed  not  unfre- 
quently,  especially  in  the  hands  and  fingers. 

The  third  group  of  essential  symptoms  is  a  somewhat  arbitrary  one.  It  is 
composed  of  those  symptoms  that  are  claimed  by  some  writers  to  depend  upon 
the  invasion  of  the  mid-region  of  the  central  gray  matter.  Bruhl  includes  in 
this  group  trophic  lesions,  scoliosis,  vaso-motor  disturbances,  weakness  of  the 
sphincters,    oculo-motor  disorders,  and    involvement  of  the  bulb.     Without 


SYRINGOMYELIA,  813 

criticising  this  grouping  we  may  accept  it  for  convenience  in  clinical  descrip- 
tion. Whatever  their  exact  origin,  it  is  certain  that  some  at  least  of  these 
symptoms  are  common  in  this  disease. 

The  trophic  lesions  occur  in  the  skin  and  in  the  bones  and  joints.  The 
skin  may  show  hypertrophies,  callosities,  ulcerations,  various  eruptions  and 
maculae,  or  may  be  glossy  in  places.  The  nails  of  the  fingers  and  toes  are 
sometimes  involved.  They  become  thickened,  have  transverse  ridges,  and  may 
even  fall  off.  Panaris,  or  whitlow,  is  an  obstinate  and  destructive  lesion  in 
that  form  of  the  disease  first  described  by  Morvan  and  named  for  him.  These 
whitlows  are  painless  and  chronic,  and  they  often  destroy  the  ends  of  the  affected 
fingers.  Abscesses  may  occur  in  various  places.  Arthropathies  are  not  unusual 
in  syringomyelia.  They  are  very  similar  to  those  occurring  in  locomotor 
ataxia.  They  cause  great  deformity  of  the  joints  affected,  with  exudation 
within  the  capsule,  increase  in  the  articular  surfaces,  denudation  of  bone, 
stalactites,  etc.  Any  one  of  the  large  joints,  either  the  knees,  shoulders, 
elbows,  hips,  or  ankles,  may  be  involved  :  occasionally  more  than  one  joint 
suffers.  Fragility  of  the  long  bones,  leading  to  easily-produced  fractures, 
occurs. 

Deviation  of  the  spine  is  a  very  common  affection  in  syringomyelia.  Bruhl 
says  it  is  present  in  50  per  cent,  of  cases.  The  most  common  form  of  deviation 
is  scoliosis.  In  the  author's  case  this  scoliosis  was  so  marked  in  the  neck  that 
it  presented  the  appearance  of  torticollis.  It  is  most  marked  usually  in  the 
dorsal  region.  Kyphosis  is  the  next  form  in  frequency,  and  lordosis  the  last. 
Scoliosis  may  be  an  early  symptom  of  the  disease.  Many  theories  have  been 
advanced  to  account  for  this  symptom,  but  that  of  Roth,  who  attributes  it  to  an 
atrophy  of  some  of  the  transverse  muscles  of  the  spine,  appears  to  us  the  most 
reasonable. 

Vaso-motor  disturbance  may  be  shown  by  oedema  or  coldness  of  the  extrem- 
ities, or  by  burning  sensations  in  them,  by  excessive  sweating  and  by  persis- 
tence of  lines,  marks,  or  maculae  left  after  contact  of  objects  with  the  skin. 
Pilocarpine  by  injection,  according  to  Dejerine,  is  delayed  in  its  action,  and 
causes  much  more  abundant  sweating  in  the  analgesic  regions  than  in  other 
parts. 

Affections  of  the  sphincters  are  certainly  rare  in  syringomyelia.  They 
might  occur  in  extreme  cases  in  which  the  cavity  in  the  cervical  region  was  so 
expanded  as  to  act  as  a  total  transverse  lesion.  Yet  in  the  author's  case,  in 
which  the  expansion  was  extreme,  there  was  no  interference  with  the  inner- 
vation of  either  the  bladder  or  bowel. 

Pupillary  and  oculo-motor  symptoms  have  been  reported.  The  sympathetic 
centre  in  the  cervical  cord  may  be  either  paralyzed  or  irritated,  causing  con- 
traction or  dilatation  of  the  pupil  as  the  case  may  be.  When  the  bulb  is 
involved,  the  symptoms  of  bulbar  palsy  may  appear.  In  Taylor's  recent  case 
the  aqueduct  of  Sylvius  was  dilated,  probably  causing,  by  involvement  of  the 
underlying  nuclei  of  the  third  nerve,  the  nystagmus  which  his  patient  had. 

The  second  class  of  symptoms  observed  by  us  includes  those  caused  by 
involvement  of  the  white  matter  of  the  cord.  These  are,  briefly,  the  symp- 
toms, first,  of  lateral  sclerosis ;  and,  second,  those  of  posterior  sclerosis. 
It  can  easily  be  understood  that  a  widely-extended  destructive  process,  like 
syringomyelia,  in  the  cervical  region,  must  involve  inevitably  some  of  the  fibres 
in  the  white  matter.  The  extent  of  this  involvement  of  course  varies.  The 
most  common  is  lateral  sclerosis.  This  produces,  as  is  well  known,  spastic 
paresis  in  the  legs.  The  knee-jerks  are  exaggerated,  ankle-clonus  is  present, 
the  gait  is  feeble,  the  muscles  are  spastic,  but  not  wasted,  and  the  innervation 


814    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  the  bladder  and  rectum  is  not  aflfected.  The  symptoms  of  posterior  scle- 
rosis, or  locomotor  ataxia,  are  not  so  common.  Ataxia,  however,  and  sway- 
ing with  closed  eyes,  may  be  present,  possibly  dependent  upon  involvement  of 
Clark's  column  and  the  ascending  cerebellar  tract.     Fulgurant  pains  are  rare. 

The  brain  is  not  involved  in  typical  cases  of  syringomyelia.  The  author 
once  saw,  however,  a  diflTuse  gliomatous  lesion  in  the  mid-brain  and  cerebellum 
which  strongly  suggested  an  identity,  in  all  but  position,  with  the  gliomatosis 
of  the  cord. 

Diagnosis. — The  diagnosis  of  syringomyelia  rests  upon  the  recognition  of 
certain  groupings  of  the  various  symptoms  already  described.  The  most  com- 
mon grouping  is  that  of  muscular  atrophy,  especially  in  the  shoulders  and  arms, 
spastic  paresis  of  the  legs,  the  "dissociation  "  sensory  symptom,  and  a  variety 
of  trophic  disorders.  The  most  characteristic  of  these  symptoms  is  the  pecu- 
liar disorder  of  sensation.  Hysteria  may  simulate  this  sensory  change,  but  it 
does  not  present  true  muscular  atrophy.  Anterior  poliomyelitis  does  not  cause 
sensory  changes.  Amyotrophic  lateral  sclerosis  is  undoubtedly  identical  in  some 
reported  cases  with  syringomyelia.  Tumors  of  the  cord  and  localized  myelitis 
njay  closely  simulate  the  disease,  and  can  best  be  distinguished  by  the  history 
of  the  case  and  a  careful  study  of  the  sensory  and  trophic  disorders.  Trophic 
changes  may  be  conspicuous,  and  direct  the  attention  from  other  symptoms. 
Thus,  desti'uctive  whitlow,  described  as  Morvan's  disease,  is  a  type  of  syringo- 
myelia. Friedreich's  ataxia  has  some  analogies  with  syringomyelia  :  Griffith's 
statistics  prove  that  25  per  cent,  of  autopsies  in  the  former  present  cavities  in 
the  cord.  Cases  of  precocious  locomotor  ataxia  ought  to  be  most  carefully 
studied  for  the  symptoms  of  central  gliomatosis.  Finally,  hemiplegia  and 
monoplegia  have  been  caused  by  syringomyelia  ;  they  could  probably  be  distin- 
guished by  sensory  and  trophic  symptoms. 

Prognosis. — The  course  of  syringomyelia  is  slow,  but  its  termination  is 
never  favorable.     Many  patients  die  from  some  intercurrent  affection. 

Treatraent. — There  is  no  specific,  or  even  palliative,  treatment  for  such  an 
inveterate  degenerative  process  as  that  which  produces  syringomyelia.  It  is 
possible  only  to  treat  some  of  the  isolated  symptoms,  to  preserve  the  strength, 
to  guard  against  accidents,  and  to  avert  the  tendency  to  death  by  intercurrent 
disease. 


HEREDITARY  ATAXIA, 

By  ABCHIBALD  CHURCH,  M.  D., 

Chicago. 


Hereditary  Ataxia,  or  hereditary  ataxic  paraplegia,  also  known  as  Fried- 
reich's disease,  is  a  form  of  spinal  sclerosis  appearing  usually  before  twenty 
years  of  age,  with  marked  hereditary  features.  It  is  usually  characterized  by 
generalized  ataxia  beginning  in  the  legs,  by  nystagmus,  and  by  impairment 
of  speech,  and  pursues  a  chronic  progressive  course. 

As  compared  with  Friedreich's  description  of  this  interesting  disease  pub- 
lished in  1863,  this  scant  definition  is  too  brief;  but  succeeding  groups  of  cases 
observed  in  various  parts  of  the  world,  practically  of  a  similar  nature,  have 
shown  that  features  of  the  malady  at  first  insisted  upon  as  essential  are  not 
invariably  present  or  even  usual.  Cramped  by  tbe  rigid  lines  of  the  early 
description,  many  observers  have  either  slavishly  followed,  seeing  only  what 
had  been  before  pointed  out,  or,  if  finding  marked  variations,  regarding  them 
as  unusual  and  anomalous.  Even  Ladame  so  late  as  1890  erected  a  clinical 
criterion  which  does  not  include  a  very  fair  proportion  of  these  cases,  although 
at  that  time  some  two  hundred  had  been  published,  and  probably  very  many 
more  overlooked  because  of  the  false  standard  of  measurement  that  was,  and 
still  is  followed.  Gray,  for  instance,  in  his  recent  work,  states  as  a  "  cardinal 
Bymptom  "  that  "  the  knee-jerk  is  always  absent,"  and  Gowers  looks  upon  the 
report  of  a  case  beginning  at  sixty-six  years  of  age  as  a  coincidence  to  be  rele- 
gated to  a  foot-note.  As  a  matter  of  fact,  aside  from  the  ataxia  and  perhaps 
the  family  history,  no  single  item  can  be  insisted  upon  m  every  case,  yet 
the  symptom-group  is  a  very  striking  one,  and  the  numerous  variations  are 
merely  the  expressions  of  an  unsystematized  and  widely-distributed  lesion. 

Etiology.— The  most  striking  fact  in  this  disease  is  its  transmission  Irom 
generation  to  generation,  either  in  the  same  form  or  by  related  sclero-neurotic 
disease,  and  the  increasing  susceptibility  that  is  encountered  m  the  later  gene- 
rations, where  it  numbers  many  members  of  the  same  immediate  family  and 
shows  a  distinct  tendency  to  appear  at  a  constantly  earlier  period  of  hie.  In 
this  way  may  be  explained  the  fact  that  many  of  the  progenitorial  cases  have 
been  misunderstood,  overlooked,  or  misclassed.  In  this  connection  I  wish  to 
refer  to  the  instructive  family  tree  published  by  Sanger  Brown,  and  here 
reproduced  by  his  permission.  (Fig.  1).  Nonne  describes  a  somewhat  similar 
group,  and  the  one  post-mortem  obtained  showed  only  an  abnormal  smallness 
of  all  the  parts  of  the  spinal  cord,  a  deficient  development  which  had  not  taken 
on  sclerotic  degeneration.  Occasionally  a  generation  escapes  this  disease,  but 
atavism  is  likely  to  occur.  The  developmental  defect  is  therefore  strongly  pro- 
nounced, and  constitutes  the  background  of  the  picture.  It  is  as  if  portions  of 
the  nervous  system,  especially  of  the  spinal  cord,  were  incapable  of  maintain- 
ing their  functions  in  accordance  with  the  demands  of  growth  and  active  lite, 
^Chicago  Medical  Recorder,  Feb.,  1892. 


815 


816    AMERICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 


and  underwent  regression,  producing  the  sclerotic  changes  to  be  described 
later. 

The  developmental  periods  of  life  are  those  at  which  it  is  most  likely  to 

Fig.  1. 


Family  Tree  of  Hereditary  Ataxy,  reported  by  Dr.  Sanger  Brown. 

^Thf  nunfb^r^toThrwf  tf  ^1^'°?"^«^  '"^icate  Hereditary  Ataxy.  Squares  indicate  males,  circles  females, 
ibe  numbers  to  the  eft  refer  to  the  cases  in  Brown's  paper:  the  first  number  to  the  right  the  age  at  death 
or  the  present  age.    f  indicates  deceased.    The  last  number  indicates  the  age  at  onset 

appear— the  seventh  and  eighth  years  of  age,  the  age  of  pubertv,  and  at  about 
twenty,  the  age  of  full  physical  and  sexual  strength.  But  it  sometimes  is  con- 
genital, and  may  appear  at  any  period  of  life.     This  is  clearly  shown  in  the 


PLATE  XVI. 


1,  2,  3,  4.  The  F.  Family.— Showing  Apathetic  Facies  Increasing  with  Duration  of  Disease  : 

1.  Tina  F.,  Five  years  old,  unaffected. 

2.  Oscar  F.,  Eight  years  old,  affected  one  year. 

3.  Frederick  F.,  Seventeen  years  old,  affected  three  years. 

4.  Rose  F.,  Twenty  years  old,  affected  five  years,  helpless. 


PLATE  X.'VJl. 


^ 


5,  6,  7.  The  S.  Family.— Showing  Factes  : 

5.  Ella  S.,  Nineteeu  years  old,  affected  two  years,  slightly. 

6.  Miles  S.,  Twenty-fire  years  old,  affected  four  years,  cannot  walk. 

7.  Hugh  S.,  Twenty-uine  years  old,  affected  fourteen  years,  helpless. 

8.  Lucy  E.,  Sixteen  years  old,  affected  one  year,  shows  mask-Uke  face. 

9.  Alfred  W.,  Nineteen  yeare  old,  affected  four  years.    A  sister  similarly  affected  at  sixteen  years  of  age 

met  an  accidental  death  at  twenty-one. 

8  and  9  have  increased  reflexes  and  double  ankle-clonus. 

2,  3,  4,  5,  6,  and  7  have  knee-jerks  abolished. 

3,  4,  6,  and  8  show  nystagmus  in  the  photographs. 

In  2,  3,  4,  6,  7,  8,  the  head  was  so  much  affected  that  it  required  to  be  supported  by  pillows  to  make  a 
four-second  photographic  exposure. 


HEREDITARY  ATAXIA.  817 

remarkable  series  of  Brown  and  of  Nonne,  in  the  cases  reported  by  Wells, 
and  in  the  instances  of  Everet  Smith.  The  sexes  are  about  evenly  affected, 
though  in  some  family  groups  males  or  females  greatly  predominate,  and  it  is 
somewhat  more  liable  to  be  transmitted  through  the  females  than  by  the  male 
branches,  probably  because  the  males  affected  early  do  not  marry,  and  in  later 
cases  are  impotent. 

Pathological  Anatomy. — With  the  exception  of  a  few  cases,  notably  one 
reported  by  Menzel,  post-mortem  changes  in  the  nervous  matter  have  been  con- 
fined to  the  spinal  apparatus,  including  the  posterior  nerve-roots  and  an  occa- 
sional peripheral  nerve,  and  to  the  cranial  nerves,  especially  the  hypoglossal, 
optic,  and  motor-oculi,  and  their  centres  in  the  medulla.  In  Menzel's  case 
gross  changes  were  traced  into  the  cerebrum  and  cerebellum,  and  the  latter  was 
markedly  atrophied.     Very  few  autopsies  are  on  record,  however. 

The  change  in  the  spinal  cord  is  histologically  practically  identical  with 
that  in  ataxic  paraplegia  and  locomotor  ataxia,  for  a  full  description  of  which 
the  reader  is  referred  to  articles  on  those  diseases.  Dejerine  and  Letulle, 
however,  basing  their  observations  on  a  single  case,  claim  that  the  sclerosis  in 
this  disease  is  peculiar  in  being  confined  to  neuroglial  hyperplasia  without  vascu- 
lar changes.  The  distribution  of  lesions  is  the  matter  of  most  interest,  for  upon 
it  depends  the  preponderance  of  symptoms  in  any  given  case.  In  every 
instance  subjected  to  a  post-mortem  examination,  except  Nonne's,  the  postero- 
internal and  postero-external  columns  have  been  found  involved  throughout 
the  entire  length  of  the  cord.  In  the  large  majority  of  cases  the  pyramidal 
motor-tracts  in  the  lateral  columns  have  been  sclerosed,  and  this  process  has, 
at  different  levels  in  different  cases,  invaded  the  anterior  horns,  the  anterior 
columns,  the  direct  cerebellar  tract,,  and  the  posterior  roots.  The  tract  of 
Lissauer  and  Clark's  columns  usually  escape.  It  is  this  multilocular  distribu- 
tion of  the  sclerosis  which  gives  rise  to  such  a  variety  of  clinical  manifestations 
and  accounts  for  the  confusion  in  literature.  It  is  apparent  that  as  the  poste- 
rior columns  or  the  pyramidal  tracts  are  principally  involved,  the  locomotor  and 
spastic  symptoms  will  vary,  just  as  occurs  in  ataxic  paraplegia.  It  is  not 
incredible  that  even  knee-jerks  lost  early  in  a  case  may  later  reappear,  or 
myotatic  irritability  of  a  highly  exaggerated  type  subsequently  diminish  or 
entirely  fail.^  The  lesion  has  been  traced  through  the  medulla  and  pons 
involving  the  post-pyramidal  nucleus.  In  the  posterior  columns  it  is  that  of 
an  extremely  intense  tabes,  and  the  involvement  of  the  posterior  roots  is  also 
analogous,  but  less  marked.  In  the  lateral  columns  it  is  that  of  spastic  para- 
plegia plus  the  involvement  of  the  cerebellar  tract,  the  anterior  direct  motor- 
tract,  and  the  frequent  implication  of  the  anterior  horn. 

Symptoms. — Unsteadiness  upon  the  feet,  a  tendency  to  tumble,  and 
clumsiness  are  the  first  noted  indications.  Ordinarily  the  symptoms  advance 
slowly.  As  a  rule,  and  in  the  type  of  Friedreich,  the  knee-jerk  is  lost  very 
early,  but  the  writer  now  has  two  cases  under  observation  in  which  it  is 
greatly  exaggerated,  and  in  both  of  them  there  is  ankle-clonus.  A  number 
of  Brown's  cases  also  show  increase  of  myotatic  excitability,  and  the  same 
thing  has  been  not  infrequently  recorded.  The  superficial  reflexes  may  be 
present  or  absent.  Sexual  power  is  frequently  undeveloped  or  disappears, 
though  in  one  of  the  cases  under  the  w^riter's  care,  where  the  deep  reflexes  are 
prominently  increased,  sexual  inclination  is  pronounced.  As  the  case  advances 
the  ataxia  increases,  though  standing  with  the  eyes  closed  is  often  possible 
when  the  gait  is  sprawling  and  extremely  bad.  The  trunk  may  be  involved, 
so  that,  in  sitting  on  a  chair  without  arm  or  back  support,  marked  swaying  is 

^  In  one  of  the  writer's  cases  an  ankle-clonus  is  rapidly  diminishing. 
52 


518    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

present.  The  gait  is  simply  staggering.  The  stamping  of  tabes  is  rarely 
seen,  and  even  in  the  cases  marked  by  clonus  and  exaggerated  knee-jerks  the 
stiff-legged  gait  of  spastic  cases  is  absent  or  only  slightly  present.  Eventually, 
the  upper  extremities  and  the  neck  are  involved,  so  that  the  patient  becomes 
practically  helpless,  and  the  head,  under  very  little  control,  rolls  around  on 
the  shoulders.  From  the  implication  of  the  musculature  of  vocalization 
speech  is  characteristically  modified.  It  is  drawling,  with  the  accent  and 
modulation  misplaced,  hesitating,  sometimes  slightly  explosive ;  in  a  word, 
ataxic.  Usually  early,  and  almost  invariably  late,  in  these  cases  nystagmus 
is  present.  It  is  readily  overlooked  if  the  patient  be  not  examined  carefully. 
It  is  not  constant,  subsiding  when  the  line  of  vision  is  directly  forward,  and 
only  occurring  when  the  eyes  are  moved.  Early  in  the  disease  it  is  necessary 
to  have  the  eyes  turned  sharply  outward,  upward,  or  outward  and  upward  to 
demonstrate  it.  The  nystagmic  movements  are  of  comparatively  short  range, 
une(j^ual  in  length,  and  tend  to  subside  as  the  eyes  settle  down  to  the  new  posi- 
tion, seeming  to  the  writer  to  be  part  and  parcel  of  the  general  lack  of  balance 
in  the  entire  voluntary  muscular  apparatus.  A  few  instances  of  temporary 
strabismus  and  diplopia  are  on  record.  Pupillary  symptoms  and  optic  atrophy 
are  absent  in  the  Friedreich  type,  but  frequent  in  Brown's  cases. 

There  is  not  much  pain,  even  in  the  markedly  ataxic  types ;  the  lightning 
pain  of  locomotor  ataxia,  the  girdle  sensations,  and  the  visceral  crises  are 
absent,  but  dull  rheumatoid  aching,  pain  on  starting  micturition,  and  painful 
cramps  at  night  are  not  infrequent.  Until  late  in  the  course  of  the  disease 
errors  of  sensation  are  slight  or  absent.  Slight  anaesthesia,  retardation  in  the 
transmission  of  sensations,  variations  in  sensitiveness  relative  to  temperatures, 
pressure,  and  electricity,  have  all  been  occasionally  noted. 

Muscular  power  is  ordinarily  greatly  reduced,  but  paralysis  only  appears 
very  late,  and  is  comparatively  of  moderate  extent.  Sometimes  there  is  dis- 
tinct atrophy,  owing  either  to  the  involvement  of  the  anterior  horns  or  to  an 
occasional  peripheral  neuritis,  and  it  is  only  in  these  cases  that  any  notable 
changes  in  electrical  responses  are  found.  After  the  patient  is  bedridden  gen- 
eral emaciation  ensues.  A  coarse  tremor  is  sometimes  present,  and  choreoid 
movements  of  head  and  limbs  of  an  ataxic  character,  ceasing  when  the  part  is 
supported,  are  common. 

The  facial  appearance  of  these  cases,  when  the  disease  is  moderately  well 
developed,  has  not  received  sufficient  attention.  The  lines  of  expression  are 
lost,  the  jaw  drops,  the  mouth  is  partly  open,  the  eyelids  droop  and  look  heavy, 
the  whole  expression  or  lack  of  expression  is  of  apathy,  and  even  of  imbecility. 
In  some  families  the  change  in  the  face  has  been  the  first  intimation  to  their 
relatives,  familiar  with  the  type,  of  the  invasion  of  the  malady,  though  an  intel- 
ligent examination  would  probably  have  sooner  discovered  it.  This  facies  is 
imperfectly  shoAvn  in  the  series  of  photographs  published  herewith.  When 
pleased  or  disappointed,  emotions  are  tardily  and  clumsily  or  grotesquely  shown 
in  their  faces,  which  shortly  return  to  an  appearance  of  blankness.  The  mind 
is  not  necessarily  impaired,  but  mental  enfeeblement  has  I'esulted  in  some  cases, 
and  the  enforced  inactivity  leads,  perhaps  naturally,  to  some  hebetude.  The 
drooping  head,  the  scoliotic  spine,  and  clubbed  foot,  which  are  common,  are 
other  evidences  of  muscular  weakness  and  lost  synergism.  Sexual  attributes 
are  greatly  delayed  in  the  younger  cases  or  fail  entirely  to  develop,  giving  the 
patient  a  childish  appearance  and  bodily  formation. 

Course. — The  disease  is  essentially  chronic,  and  very  rarely  the  immediate 
cause  of  death,  which  results  from  intercurrent  maladies,  to  which  the  inac- 
tivity of  the  patient  in  some  instances  no  doubt  conduces.     Some  cases  have 


HEREDITARY  ATAXIA.  819 

lasted  over  forty  years,  and  some  have  terminated  in  two  or  three.  As  in  other 
respects,  there  is  in  this  regard  a  striking  similarity  among  the  members  of  any 
family  group,  but  it  is  not  unusual  to  see  the  younger  members  of  such  a  family 
attacked  at  an  earlier  age  and  in  a  more  active  manner.  Some  cases  present 
long-stationary  periods  or  even  temporary  slight  improvement  under  treatment 
and  bettered  conditions  of  life.  The  progressive  tendency,  however,  toward 
physical  helplessness  is  apparently  invariable ;  and  even  after  the  patient  is 
bedridden  life  may  last  many  years  with  ordinary  care,  as  there  seems  to  be  no 
especial  liability  to  bed-sores  or  other  dystrophic  condition.  Occasionally  acute 
myelitis  has  terminated  the  case. 

Diagnosis. — The  diagnosis  hangs  upon  the  youth  of  the  patient,  the  slow 
onset,  the  history  or  presence  in  the  family  of  other  similar  cases  or  of  in- 
stances of  spinal  or  cerebral  sclerosis  (among  which  paretic  dementia  should  be 
included),  upon  the  ataxia,  the  nystagmus,  the  halting  peculiar  speech,  and 
possibly  upon  the  facial  appearance,  ilbsence  of  locomotor  pains,  of  pupillary 
symptoms,  of  acquired  syphilitic  infection,  and  of  pronounced  sensory  disturb- 
ances are  negative  conditions  of  corroboratory  value. 

Treatment. — The  prognosis  is  always  grave,  as  has  already  been  implied, 
and  treatment  seems  to  be  of  exceedingly  little  value.  A  course  of  arsenic, 
of  massage,  of  stretching  the  spinal  column,  especially  by  Benedickt's  method, 
have  all  apparently  caused  slight  amelioration  in  progressing  cases.  Those 
measures  recommended  in  tabes  should  be  tried,  and  cauterization  with  the 
thermo-cautery  over  the  spine  repeated  at  intervals  of  two  weeks  may  be  em- 
ployed for  a  prolonged  period.  A  light  touch  of  the  smallest  point  opposite 
each  vertebra  is  quite  sufficient  and  not  particularly  painful.  General  measures 
to  maintain  the  physical  state  are  of  course  always  in  order.  With  young 
patients  it  is  well  to  allow  a  reasonable  amount  of  instruction,  as  they  are  often 
dependent  upon  themselves  for  entertainment  during  long  years  of  helplessness. 


RAYNAUD'S  DISEASE, 

By  THOMPSON  S.  WESTCOTT,  M.  D., 
Philadelphia. 


In  a  thesis  published  at  Paris  in  1862,  Maurice  Raynaud  first  called  atten- 
tion to  a  complex  of  symptoms  to  which,  for  want  of  a  more  satisfactory  title, 
he  gave  the  descriptive  name  "  Local  Asphyxia  and  Symmetrical  Gangrene  of 
the  Extremities."  This  essay  was  founded  upon  the  clinical  histories  of  25  cases 
collected  from  various  sources,  only  five  of  Avhich  came  under  his  personal  obser- 
vation. .  Some  of  the  cases  drawn  from  other  sources  dated  back  many  years 
and  were  very  inadequately  reported,  but  Raynaud  succeeded  in  presenting  a 
clinical  picture  that  was  at  once  recognized  by  his  contemporaries,  and  which 
soon  took  a  place  in  medical  literature  as  a  new  disease  worthy  to  be  named  for 
the  author  who  first  described  it.  In  this  and  later  studies  Raynaud  defined 
the  disease  as  "  a  neurosis  characterized  by  enormous  exaggeration  of  the 
the  excito-motor  energy  of  the  gray  parts  of  the  spinal  cord  which  control  the 
vaso-motor  innervation."  The  stage  of  cyanosis  he  considered  as  due  to  a  spas- 
modic closure  of  the  arterioles  of  the  parts  affected,  with  a  regurgitation  of 
venous  blood  into  the  capillaries ;  and  if  this  condition  was  continued  sufiiciently 
long,  gangrene  of  more  or  less  gravity  supervened.  This  gangrene,  which  is 
often  strikingly  symmetrical  in  its  distribution,  he  distinguished  from  all  other 
varieties  of  local  death  as  not  being  due  to  embolism,  thrombosis,  or  changes 
of  an  inflammatory  character  in  the  intima  of  the  blood-vessels.  There  can 
be  no  doubt  that  many  of  the  cases  subsequently  described  under  this  name, 
and  indeed  some  of  those  collected  in  Raynaud's  original  thesis,  do  not  properly 
come  within  the  definition  laid  down  by  this  author.  So  recent  a  writer  as 
Sturmdorf,  of  New  York  (Medical  Record^  Aug.  1,  1891),  goes  so  far  as  to 
question  the  existence  of  such  a  disease,  which,  he  states,  cannot  be  diagnos- 
ticated during  life  ;  for,  "  admitting  the  possibility  of  excluding  all  other  con- 
ditions capable  of  producing  gangrene,  we  must  exclude"  that  form  of  "endar- 
teritis [Meigs]  whose  presence  could  be  demonstrated  only  on  the  post-mortem 
table,  and  whose  absence  is  a  sine  qua  non  to  the  acceptance  of  Raynaud's 
disease  in  the  sense  of  its  author's  conception."  It  is  quite  probable  that  modern 
pathology  may  succeed  in  disproving  the  existence  of  Raynaud's  disease  as  a 
morbid  entity,  but  it  is  certain  that  there  are  a  sufiicient  number  of  cases  on 
record — and,  curiously  enough,  many  of  them  are  in  children — which  bear  out 
in  all  essential  respects  the  original  clinical  picture. 

The  leading  characteristic  of  the  disease  consists  of  paroxysms  of  more 
or  less  continuous  and  complete  spasm  of  the  arterioles  of  the  extremities, 
usually  occurring,  with  a  fair  degree  of  symmetry,  upon  like  parts  of  the  two 
hands  or  two  feet,  or  upon  both  hands  and  feet,  or — and  this  less  frequently — 
upon  other  symmetrical  regions,  such  as  the  ears,  sides  of  the  nose,  or  but- 
tocks. This  spasm,  if  sufiiciently  long  continued,  gives  rise  to  more  or  less 
extensive  trophic  changes,  or  even  death  of  the  parts  involved. 

820 


BAYNAUDhS  DISEASE.  821 

Symptoms.— As  originally  described  by  Raynaud,  this  affection  may  be 
conveniently  divided  into  three  principal  stages  :  1,  Local  Syncope  ;  2,  Local 
Asphyxia  ;  3,  Gangrene.  The  first  stage,  local  syncope,  may  be  transitory,  or 
even  wanting  altogether,  but  when  the  disease  assumes  its  severest  form  the 
second  and  third  stages  always  occur  in  the  order  named. 

Local  Syncope.— This  term  was  employed  by  Raynaud  to  designate  a 
condition,  usually  of  one  or  more  fingers  or  toes,  which  in  its  slightest  manifesta- 
tion is  not  incompatible  with  health.  The  patient,  usually  a  female  of  neurotic 
temperament,  after  exposure  to  slight  cold,  or  even  under  the  influence  ot 
moral  emotion,  observes  one  or  more  of  the  fingers  become  pale  and  cold.  Ihe 
skin  assumes  a  dead-white  or  parchment-yellow  color,  cutaneous  sensibility  is 
quickly  abolished,  and  the  digit  feels  icy-cold  and  dead.  While  tactile  sensi- 
bility may  be  for  the  time  abolished,  the  heat-sense  may  still,  m  a  measure  be 
maintained.  At  times  a  cold  perspiration  may  cover  the  affected  part,  while 
at  others  it  is  dry  and  shrivelled  as  if  frozen.  This  spasm  of  the  arterioles, 
with  the  consequent  temporary  abolition  of  local  circulation,  which  is  popularly 
known  as  "the  dead  finger,"  is  insignificant  from  its  transitory  duration 
being  succeeded  by  a  variable  period  of  usually  very  painful  reaction  m  which 
the  blood  gradually  returns  to  the  part.  It  is  simply  an  exaggerated  lorm  ot 
what  so  commonly  occurs  after  the  hands  have  been  exposed  to  a  low  tempera- 
ture when  confined  in  tight  kid  gloves.  This,  the  slightest  and  m  some  cases 
the  only  stage  of  the  disease,  has  been  but  rarely  observed  m  children. 

Local  asphyxia,  or  cyanosis,  may  be  preceded  for  a  time  by  more  or  less 
frequent  occurrences  of  local  syncope,  or  may  be  the  first  manifestation  ot  the 
disease.    In  the  latter  case  the  onset  is  generally  sudden,  but  sometimes  is  pre- 
ceded by  par^sthesise  or  pain,  usually  limited  to  the  fingers  or  toes  about  to  be 
affected.     After  exposure  to  a  more  or  less  marked  depression  of  temperature, 
or  even  without  appreciable  cause,  one  or  more  fingers  or  toes  become  cold  and 
usually  somewhat  swollen.    The  particular  phalanx  or  phalanges  will  be  found  to 
have  assumed  a  dusky  or  cyanotic  tint  and  to  feel  icy-co  d  to  the  touch,  while 
the  whole  limb  is  colder  than  the  rest  of  the  body.     Tmglmg  or  shooting  pams 
of  varying  severity  are  felt,  and  hypersesthesia  or  anaesthesia  of  the  parts  may 
be  observed.      The   cyanosis  affects  most  intensely  the   distal  portion  ot  the 
phalanx,  but  it  may  extend  in  decreasing  degree  as  far  upward  as  the  wrist- 
ioint  or  ankle,  or  may  even  pass  beyond,  while  venous  marblmgs  may  be  traced 
far  up  the  limb.     This  condition  may  affect  one  phalanx  or  several  in  vary- 
ing degree,  either  upon  a  single  limi3  or  upon    both  hands  or  feet,  or  even 
upon  all   four  extremities.     When   both  hands  or  both  feet  are  affected,  the 
des-reeof  cyanosis  is  generally  more  marked  upon  one  side  ;  and  m  some 
paroxysms  in  the  same  patient  the  asphyxia  may  be  confined  to  one  member 
alone,  while  in  others  both  feet  or  both  hands  or  a  hand  and  foot  are  aflected. 
In  any  particular  case,  however,  in  the   successive   paroxysms  local  asphyxia 
generally  involves  the  same  phalanx  or  manifests  the  same  order  and  inten- 
sity of  involvement  of  several    phalanges.      After   a  variable    duration  the 
cyanosis  gradually  passes  away  and  the  parts  regain  their  color;  this  reaction 
may  even  be  excessive,  and  redness  and  burning  pain  be  noted.     Such  parox- 
vsms  vary  greatly  in   severity  and  duration.      In   some  instances  the   attack 
passes  off  in  a  few  seconds,  to  be  frequently  repeated  at  the  slightest  exposure 
to  a  change  of  temperature;  while  in  other  cases  it  is  prolonged  for  several 
hours  or  even  several  days.      Pain  is  also  a   very   variable  symptom,  some 
patients    experiencing    little  discomfort  during   the  asphyxial   attack    while 
others  complain  bitterly  of  intense  burning  sensations  m  the  part.     As  with 
the  preceding  stage,  local  asphyxia  may  be  the  most  serious  manifestation  ot  the 


822  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

disease,  and  in  this  case  we  find  it  occurring  at  irregular  intervals,  but  often  as 
frequently  as  several  times  daily,  usually  during  the  winter  months,  being  pro- 
voked by  the  slightest  exposure  to  cold. 

A  symptom  frequently  noted  during  this  stage  is  hsemoglobinuria,  to  which 
attention  has  been  lately  directed  principally  by  the  observations  of  Barlow 
and  Southey  in  England.  Shortly  after  the  beginning  of  a  paroxysm  of  local 
asphyxia  the  child  may  pass  very  dark  urine,  which  is  found  to  contain  albumin, 
and  responds  to  the  guiacum  test  for  haemoglobin.  Both  Southey  and  Barlow 
report  cases  of  this  kind  in  which,  during  some  of  the  paroxysms,  the  urine 
was  found  to  contain  no  blood-corpuscles,  but  showed  fine  granular  brown 
debris  and  a  profusion  of  oxalate-of-lime  crystals.  This  phenomenon  does  not 
occur  after  every  attack ;  but  it  has  been  observed  that  a  copious  deposit  of 
urates  may  at  tiioaes  replace  the  loss  of  haemoglobin.  It  is  most  likely  to  occur 
when  the  attack  is  preceded  by  yawning,  drowsiness,  nausea,  or  pain  in  the 
belly  referred  to  the  ensiform  cartilage,  which  are  the  symptoms  preceding 
hsemoglobinuria  due  to  other  causes. 

When  an  attack  of  local  asphyxia  has  lasted  several  days,  the  nail  ceases 
to  grow,  and  the  occurrence  is  marked  upon  the  nail  by  a  transverse  striation 
of  variable  distinctness.  When  paroxysms  have  frequently  occurred,  the 
afi"ected  digits  may  become  rather  soft  and  flabby  from  an  increase  in  the  sub- 
cutaneous fat. 

General  symptoms  are  very  slight,  and  fever,  if  present,  does  not  usually 
exceed  100°  F:  if  higher,  it  is  attributable  to  other  causes.  A  stage  of  local 
erythema  has  been  said  sometimes  to  replace  the  asphyxial  stage,'  being  ascribed 
to  an  irritation  of  the  vaso-dilator  nerves ;  but  it  has  rarely  been  followed  by 
gangrene,  and  would  seem  more  properly  to  be  classed  as  the  erythromelalgia 
of  Weir  Mitchell.  In  rare  cases  the  tip  of  the  nose  or  the  ears,  and  occasion- 
ally other  symmetrical  regions  of  the  body,  may  be  affected  with  local  asphyxia, 
but  the  symptoms  are  the  same  as  in  the  more  common  variety. 

Gaxgrexe. — When  local  asphyxia  persists  sufficiently  long,  the  vitality  of 
the  part  suffers.  Small  blebs  form  upon  the  tips  of  the  affected  digits,  partly 
at  the  expense  of  the  outer  layer  of  corium ;  these  rupture,  discharging  a  serous 
or  sei'o-purulent,  often  blood-stained,  fluid,  and  leave  an  excoriation  which 
heals  with  some  little  loss  of  substance.  When  this  process  has  attended 
repeated  attacks,  the  fingers  or  toes  exhibit  numerous  little  white  cicatrices, 
and  become  someAvhat  conical  in  shape,  with  distorted  nails  and  shrunken  parch- 
ment-like skin.  In  the  severer  cases  the  destructive  process  may  involve  a 
more  extensive  portion  of  one  or  more  digits.  In  this  event  there  are  no 
phlyctenulae,  but  the  part  at  once  assumes  a  dark  violet  or  blackish  color,  and 
passes  through  a  condition  similar  to  senile  gangrene,  with  subsequent  elimina- 
tion of  the  sphacelus — a  process  requiring  usually  two  or  three  weeks.  And 
thus  the  patient  may  pass  through  an  attack  with  the  loss  of  one  or  more 
distal  phalanges,  or  even  more  extensive  portions  of  the  member.  Loss  of  a 
portion  of  the  margin  of  the  external  ear  may  thus  occur,  but  similar  loss  of 
substance  of  the  tip  of  the  nose  has  rarely,  perhaps  never,  been  observed. 

Many  cases  of  symmetrical  gangrene  of  greater  severity  than  here  described 
have  been  reported  as  Raynaud's  disease  without  seemingly  good  grounds.  Some 
of  these  have  shown  concomitant  constitutional  symptoms  which  throw  grave 
doubt  upon  their  accepted  pathology :  and  in  others,  again,  ergotism  or  vas- 
cular disease  has  not  been  satisfactorily  excluded.  As  seen  in  children,  where 
the  ground  is  considerably  clearer,  the  most  carefully  studied  cases  have  rarely 
shown  lesions  more  serious  than  those  above  described. 

Etiology. — As  far  as  its  occurrence  in  children  is  concerned,  sex  or  age 


RAYNAUD'S  DISEASE.  823 

seems  to  have  little  influence.  It  occurs  most  commonly  during  the  winter 
months,  often  being  excited  by  exposure  to  the  slightest  depressions  of  tempera- 
ture. Heredity  seems  to  play  some  part.  Raynaud  observed  a  female  infant 
who  exhibited  a  marked  disposition  to  local  asphyxia  during  the  first  five 
months  of  life,  at  a  time  when  her  mother  was  passing  through  attacks  of  dry 
gangrene  of  all  the  extremities.  A  neurotic  family  history  must  be  accepted 
as  a  powerful  predisposing  cause,  since  many  victims  of  this  disease  show  a 
distinct  nervous  inheritance.  Makins  saw  symmetrical  gangrene  in  a  brother 
and  two  sisters  whose  mother  had  died  of  progressive  muscular  atrophy ;  and 
Colman  and  Taylor  report  local  syncope  in  a  girl  of  ten  years,  whose  mother 
was  extremely  neurotic,  and  whose  maternal  grandfather  and  grand-uncle  had 
suffered  from  similar  local  syncopal  attacks.  As  regards  previous  conditions 
of  health,  in  some  cases  the  disease  has  followed  upon  acute  and  depressing  ill- 
nesses ;   but  in  others  no  such  exciting  cause  could  be  assigned. 

Pathology. — Raynaud  ascribed  this  aifection  to  an  exaggerated  vaso-con- 
strictor  irritation  dependent  upon  an  increased  excitability  of  the  vaso-motor 
centres  of  the  cord,  since,  according  to  his  observation,  galvanization  of  the 
cord  modified  the  arterial  spasm,  and  in  one  case,  carefully  studied  by  himself 
and  Galezowski,  there  was  a  remarkable  coincidence  between  the  peripheral 
circulatory  disturbances  and  like  phenomena  observed  in  the  retinal  vessels. 
Weiss,  however,  inclined  to  the  theory  of  peripheral  irritation  arising  in  the  skin, 
viscera,  or  the  brain,  and  thus  ascribed  many  of  the  cases  observed  in  neurotic 
women  to  uterine  or  ovarian  irritation.  As  the  disease  is  rarely  in  itself  fatal, 
no  satisfactory  pathological  study  has  as  yet  been  possible.  The  most  import- 
ant addition  to  our  recent  knowledge  of  the  disease  is  the  occurrence  of  inter- 
mittent hgemoglobinuria.  Of  ten  children  suff'ering  from  local  asphyxia  and 
symmetrical  gangrene,  as  reported  principally  by  English  observers,  at  least 
eight  at  some  time  during  the  course  of  the  disease  exhibited  undoubted  evidence 
of  blood  coloring-matter  in  the  urine.  Dickinson,  the  chief  English  authority 
on  renal  diseases,  states  that  the  two  conditions,  Raynaud's  disease  and  inter- 
mittent haemoglobinuria,  seem  so  to  approach  each  other  and  mingle  as  to 
render  it  impossible  to  make  a  distinct  demarcation  between  them.  Abercrombie 
holds  that  we  are  warranted  in  believing  that  both  paroxysmal  hasmoglo- 
binuria  and  Raynaud's  disease  are  symptoms  of  a  more  general  affection,  and 
he  suggests  that  the  jaundice  sometimes  found  after  attacks  of  hsemoglo- 
binuria  (and  also  after  attacks  of  local  asphyxia)  is  the  result  of  arterial  spasm 
of  the  hepatic  vessels.  But  it  seems  more  probable,  as  Barlow  believes,  that 
this  jaundice  is  due  rather  to  breaking  up  of  blood  coloring-matter  elsewhere 
in  the  circulation.  Several  observers  have  noted  that  during  a  paroxysm  of 
intermittent  hsemoglobinuria  blood  drawn  from  a  cold  extremity  showed  changes 
in  the  red  corpuscles,  which  exhibited  a  decided  tendency  not  to  form  rouleaux 
and  appeared  markedly  crenated,  with  granular  masses  in  the  surrounding 
serum.  In  a  very  interesting  case  of  a  boy  of  twelve  years,  who  manifested 
both  intermittent  hsemoglobinuria  and  local  asphyxia  of  the  extremities,  with 
gangrene  of  the  tips  of  the  ears,  Myers  found  that  blood  taken  from  ears  and 
hands  during  an  attack  of  hgemoglobinuria  showed  changes  similar  to  those 
just  described.  It  is  thus  seen  that  in  this  case  blood-changes,  local  asphyxia 
and  gangrene,  and  hsemoglobinuria  occurred  in  the  same  patient. 

This  association  with  paroxysmal  hsemoglobinuria  at  once  suggests  a  rela- 
tion to  malarial  infection — a  relation  which,  in  not  a  few  cases  at  least,  is  borne 
out  by  the  existence  of  previous  malarial  attacks  in  such  patients.  Hereditary 
syphilis  also  has  obscured  the  earlier  history  of  several  children  suff'ering  from 
well-marked  Raynaud's  disease ;  and  it  is  doubtful  how  much  of  the  symptoms 


824    A3£EBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

in  these  cases  could  be  attributed  to  specific  endarteritis  capable  of  causing 
vascular  obstruction.  It  is  noteworthy,  perhaps,  that  both  Boas  and  Murri,  as 
well  as  Flensburg  more  recently,  mention  syphilis  together  with  ague  as  prob- 
able etiological  factors  in  the  production  of  haemoglobinuria. 

Course,  Duration,  and  Results. — As  observed  in  children,  symmetrical 
gangrene  pursues  a  more  benign  course  than  in  adults.  Local  asphyxia  may 
be  the  only  stage,  and  the  disease  may  be  a  regular  accompaniment  of  cold 
•weather,  disappearing  as  summer  approaches,  to  recur  the  next  Avinter.  Parox- 
ysms may  occur  frequently  during  the  day  on  the  slightest  exposure  to  cold, 
or  they  may  be  seen  at  irregular  and  longer  intervals.  Other  cases  may  termi- 
nate speedily  in  gangrene,  and  leave  the  child  with  deformed  fingers  or  toes 
and  only  a  tendency  to  blueness  of  these  extremities  after  exposure  to  severe 
cold ;  while,  again,  the  repeated  occurrences  of  superficial  sloughs  may  result 
in  painful  conical  fingers  with  blunted  tactile  sensibility. 

Diagnosis  is  comparatively  easy,  provided  satisfactory  exclusion  can  be 
made  of  cardiac  or  vascular  disease,  diabetes,  frost-bite  and  ergotism.  From 
chilblains  it  may  be  distinguished  by  the  history,  by  the  absence  of  itching, 
and  by  the  presence  of  pain  during  spasm  which  passes  off  after  relaxation. 
Its  localized  character  at  once  serves  to  exclude  congenital  cyanosis. 

Prognosis. — As  regards  life  prognosis  is  almost  always  good.  Only  in 
one  or  two  reported  cases  in  very  debilitated  children  has  a  fatal  result  been 
traceable  to  exhaustion  from  the  disease.  The  prospect  of  its  duration  as  a 
chronic  or  subacute  condition  or  as  a  periodical  visitation  Is  not  to  be  disposed 
of  so  easily,  and  there  seems  to  be  no  means  of  judging  upon  this  point  at  any- 
time during  the  earlier  paroxysms  of  the  disease.  The  occurrence  of  hgemo- 
globinuria,  so  far  as  yet  observed,  has  not  proven  more  than  a  curious  episode 
without  much  serious  import.  It  is  possible,  however,  that  aggravated  forms 
may  occur  in  which  a  more  profuse  loss  of  blood  may  seriously  aifect  the  out- 
come of  the  case. 

Treatment. — When  the  milder  stages  of  this  disease  are  first  manifested 
much  may  be  done  to  prevent  the  more  serious  results  of  repeated  paroxysms. 
If  the  general  health  and  constitution  of  the  child  be  satisfactory,  and  the 
symptoms  seem  to  depend  entirely  upon  exposure  to  cold,  great  care  must  be 
exercised  to  guard  against  all  chances  of  chilling  of  the  surface  or  the  extrem- 
ities. He  should  not  be  sent  out  into  the  open  air  until  he  has  partaken  of 
food;  woollen  underclothing  and  stockings  must  be  constantly  worn.  If  the 
child  is  ill-nourished  or  cachectic,  a  plentiful  supply  of  nourishing  food  and 
appropriate  constitutional  treatment  must  be  secured.  Imperfect  circulation 
of  blood  and  coldness  of  the  extremities  certainly  predispose  to  attacks  of  local 
asphyxia,  and  therefore  douches  may  be  ordered,  the  effect  of  which  must, 
however,  be  carefully  watched.  A  rapid  sponging  in  a  bath  of  water  at  a 
temperature  of  about  100°  F.  may  be  followed  by  a  douche  of  colder  water  of 
about  70°,  emptied  upon  the  back  and  shoulders  as  the  child  sits  in  the  warm 
water.  This  bath,  which  is  best  given  in  the  morning,  together  with  a  few 
minutes'  exercise  with  a  skipping-rope  or  football  after  breakfast,  will  do  much 
to  keep  the  extremities  warm  during  the  day.  By  this  means  attacks  of  local 
asphyxia  may  be  prevented :  but  if  they  should  occur  care  must  be  taken  not 
to  employ  the  bath  while  any  blueness  of  the  extremities  is  noticeable,  nor  for 
some  hours  after  the  subsidence  of  a  paroxysm. 

Raynaud  was  the  first  to  call  attention  to  the  beneficial  influence  of  gal- 
vanism applied  in  the  form  of  descending  currents  either  to  the  spine  or  down 
the  affected  extremity.  In  the  former  case  the  positive  pole  is  applied  over  the 
fifth  cervical   vertebra,   the  negative  near  the  commencement  of  the  cauda 


RAYNAUD'S  DISEASE.  825 

equina ;  while  in  the  latter  the  negative  pole  is  applied  to  the  closed  fingers  or 
the  toes.  Barlow  has  obtained  most  satisfactory  results  by  placing  one  elec- 
trode on  the  upper  part  of  the  limb  and  the  other  in  a  basin  of  warm  salt  water 
in  which  the  affected  extremity  is  immersed.  As  many  elements  as  the  patient 
can  bear  should  be  used,  and  the  current  should  be  made  and  broken  at  fre- 
quent intervals.  The  stance  should  be  given  daily  for  about  ten  minutes. 
Shampooing  is  often  valuable  in  conjunction  with  galvanism,  especially  in  the 
chronic  forms  in  which  the  extremity  of  the  limb  undergoes  atrophy. 

Beyond  an  appropriate  tonic  treatment  little  is  to  be  expected  from  internal 
medication.  Quinine  is  the  only  drug  whose  use  in  some  cases  has  apparently 
produced  beneficial  results,  as  might  be  expected  from  the  frequent  association 
with  symptoms  which  suggest  the  probable  etiological  importance  of  malarial 
infection.  This  drug  should  certainly  be  given  a  fair  trial  in  every  case. 
Nitrite  of  amyl  has  been  tried  during  the  asphyxic  stage  upon  theoretical 
grounds,   but  without  any  observed  effect. 

If  pain  is  severe,  much  relief  will  be  experienced  from  the  local  use  of 
chloroform  liniments.  In  some  cases,  curiously  enough,  cold  applications,  like 
the  ice-bag,  give  greater  relief  than  warmth. 

When  gangrene  has  begun  the  limb  should  be  maintained  in  an  elevated 
position,  well  wrapped  in  cotton,  and  kept  clean  with  an  antiseptic  wash. 
Stimulants  may  be  required  in  this  stage,  and  occasionally  hypnotics  and  seda- 
tives to  secure  sleep,  allay  restlessness,  and  alleviate  pain.  When  the  line  of 
demarcation  has  formed,  dry  hot  applications  should  be  kept  to  the  part  to 
favor  the  process  of  elimination  and  repair.  In  rare  cases  the  destruction  of 
tissue  may  be  so  great  as  to  demand  a  more  or  less  formal  amputation. 


PART    VIII. 
DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


DISEASES  OF  THE  NOSE. 

By  W.   E.  CASSELBERRY,  M.  D., 

Chicago. 


I.  Acute  Rhinitis. 


Acute  Rhinitis,  colloquiall}^  termed  "  cold  in  the  head,"  is  an  acute 
inflammation  of  the  mucous  membrane  lining  the  nasal  cavities  from  the  ante- 
rior nares  to  the  naso-pharynx.  It  is  prone  to  extend  to  adjoining  mucous 
surfaces,  and  usually  embraces  the  naso-pharynx,  at  least  to  some  degree,  and 
thence  invades,  not  infrequently,  the  middle  ear. 

Etiology. — Reasoning  from  analogy  and  from  its  pathology  and  clinical 
history,  we  must  regard  acute  suppurative  rhinitis  as  an  infection  by  pathogenic 
micro-organisms,  although  germs  specific  to  this  particular  form  of  suppuration 
have  not,  as  yet,  been  identified.  This  statement,  however,  will  bear  indefinite 
qualification,  which  we  must  limit  to  two  phases:  1.  Some  special  predisposing 
condition  of  the  part  is  essential  to  infection.  2.  It  follows  certain  exposures 
with  such  regularity  and  precision  that  we  must  infer  a  causal  relationship 
between  chilling  of  the  body  and  rhinitis.  A  draught  between  the  shoulders, 
permitting  the  feet  or  other  parts  of  the  body  to  become  cold  and  damp,  or  too 
rapid  checking  of  the  perspiration,  causes,  through  the  intervention  of  the  vaso- 
motor nervous  system,  a  sudden  turgescence  of  the  nasal  vessels,  especially  of 
of  the  turbinated  bodies.  In  the  majority  of  instances  this  congestion  is  but 
transitory,  passing  off  in  a  few  minutes  or  a  few  hours,  and  folloAved  merely  by 
increased  mucous  secretion ;  but  in  other  instances  it  does  not  subside,  but 
augments  in  violence,  and  is  followed  in  from  twelve  to  twenty-four  hours  by 
a  muco-purulent,  and  then  almost  a  purulent,  discharge.  The  congestion  of 
the  nasal  vessels  occasioned  by  thus  "taking  cold"  evidently  favors  a  microbic 
invasion  of  the  mucous  membrane  by  impairing,  in  some  manner,  its  powers  of 
resistance. 

Instances  are  not  wanting  of  direct  infection  of  one  person  by  the  discharges 
of  another — an  accident  which  is  apt  to  happen  among  children  by  the  use  of 
handkerchiefs  in  common.  Suppurative  rhinitis  in  infants  is  also  attributable 
to  direct  infection  from  the  vaginal  discharges  during  birth. 

S3nnptonis. — A  sense  of  stuffiness  in  the  nostrils,  with  burning  and  dry- 
ness, together  with  slight  febrile  reaction,  is  succeeded  in  a  few  hours  by  an 
acrid  watery  discharge,  which  later  leads  to  a  free  muco-purulent  secretion.  A 
simultaneous  congestion  of  the  frontal  sinuses,  which  occasions  headache,  is 
frequent,  but  this  does  not  argue  pressure  by  accumulated  muco-purulent  secre- 

826 


DISEASE8   OF   THE  NOSE. 


827 


tion  within  these  cavities,  for  actual  empyema  of  the  frontal  sinuses  is  very 
rare.  Mere  swelling  of  the  orifice  of  the  Eustachian  tube  will  occasion  tinni- 
tus aurium  and  impairment  of  hearing,  and  a  direct  extension  of  the  inflamma- 
tory process  to  the  middle  ear  is,  seemingly,  the  cause  of  nearly  all  cases  of 
abscess  of  the  cavity  of  the  tympanum.  Certain  individuals,  and  even  certain 
families,  manifest  a  decided  predisposition  to  this  complication.  Associated 
conjunctivitis  is  common,  and,  at  times,  the  external  nasal  appendage  appears 
swollen,  florid,  and  excoriated  by  the  irritating  discharges. 

Treatment. — It  is  much  too  customary  to  permit  this  acute  inflammatory 
disease  of  a  delicate  part  of  the  body  to  progress  without  efibrts  to  mitigate  and 
abbreviate  it.  Such  a  course  is  fraught  with  immense  possibilities  of  ultimate 
damage,  chronic  catarrh  of  the  nose  and  accessory  organs  being  thereby  estab- 
lished. Many  remedies  are  of  real  service,  but  a  multiplicity  of  recommenda- 
tions is  confusing  and  tends  to  lessen  confidence  in  any  one  line  of  treatment. 
We  will  therefore  describe  simply  our  own  methods  of  dealing  with  these  cases. 

If  it  is  sought  to  abort  the  attack  of  rhinitis,  a  single  average-sized  dose  of 
Dover's  powder,  proportionate  to  the  age  of  the  child,  is  given  at  bed-time,  also 
a  laxative  if  needed.  The  patient  is  especially  well  covered  in  bed,  outside  night 
air  is  excluded,  and  the  temperature  of  the  apartment  maintained  during  the 
night  at  60°  to  69°  F.,  but  no  effort  is  made  to  produce  profuse  perspiration. 

The  following  day,  or  even  the  first  day  if  called  upon  to  prescribe  before 
evening,  this  formula  will  meet  the  indications : 

I^.   Tr.  aconiti ttlxij. 

Tr.  belladonnae TTIxxiv. 

Morphinae  sulphatis g^*-  i- 

Potassii  bromidi 3j. 

Spts.  menthae  piperit?e 1TLxx, 

Aquae q.  s.  ad  fsiij. — M. 

Sig.  Adult  dose,  one  teaspoonful  every  hour,  to  be  lessened  for  children 
according  to  age. 

The  same  ingredients  could  readily  be  prepared  in  the  form  of  a  capsule, 
pill,  or  compressed  tablet. 

Local  treatment  is  of  the  utmost  importance,  and  the  following  mixtures 
render  satisfactory  service  by  atomization : 


Spray  No.  1. 

I^.   Cocainse  hydrochloratis.gr.  ij. 

Sodii  boratis gr.  xx. 

Sodii  bicarbonatis  .   .    .  gr.  xx. 

01.  eucalypti tTlj. 

01.  gaultheriae  ....  TTLj. 

Thymol g^-j- 

Menthol gr.  ss. 

Glycerini f^ss. 

Aquae  .    .    ,  .  q.  s.  ad  fij. — M. 

Sig.  Dilute,  adding  one  or  two  tea- 
spoonfuls  to  one  ounce  of  warm 
water  for  use  as  a  spray. 


Spray  No.  2. 

^.   Cocaines  hydrochloratis  .  gr.  ij. 
01.  pini  Canadensis.   .    .  TTLv. 
01.  gaultheriae  .  .    ...  KTLij. 

01.  eucalypti 1TLij- 

Thymol gr.  ss. 

Menthol g^-  j  • 

"Vaselin  oil"    ...    .  fgj.— M. 

Sig.  Use  with  double  bulb  (Davidson) 
atomizer,  either  alone  or  follow- 
ing the  use  of  Spray  No.  1. 


For  young  children,  who  are  often  terrified  by  spraying,  may  be  substituted 
a  small  syringe  or  an  ordinary  medicine-dropper  used  as  a  syringe,  with  which 


828    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

to  project,  gently,  either  of  these  solutions  through  the  nostrils.  Spraying  or 
gentle  syringing  in  this  manner  may  be  performed  twice  or  three  times  daily, 
or  even  every  three  hours  in  severe  cases.  The  cocaine  can  be  omitted  from 
either  spray  formula,  if  there  be  any  objection  to  its  use,  without  seriously 
impairing  the  effectiveness  of  the  reraedy.  All  solutions  for  nasal  use  should 
be  somewhat  wai'm. 

Of  the  many  inhalations,  we  will  mention  only  camphorated  steam  as  a 
domestic  remedy  of  power.  It  is  conveniently  used  by  placing  a  pint  of  steam- 
ing hot  water  in  a  glass  fruit-jar  and  adding  two  iluidrachms  of  spirit  of  cam- 
phor. A  funnel,  preferably  of  glass,  is  then  inverted  to  cover  the  mouth  of 
the  jar,  and  the  rising  steam  is  inhaled  through  the  nostrils  as  it  escapes  from 
the  small  end  of  the  funnel.  So  used,  especially  during  the  evening,  for  a  half 
hour,  it  conduces  to  a  comfortable  night's  rest  and  facilitates  recovery. 

n.  Simple  Chronic  Rhinitis  and  Pubulent  Rhinitis. 

Recurrent  attacks  of  acute  rhinitis  establish,  in  children  and  young  people 
especially,  a  chronic  inflammation  of  the  mucous  membrane,  which  is  charac- 
terized by  variable  degrees  of  proliferation  of  the  epithelium,  and  by  muco- 
purulent secretion,  which  is  often  profuse.  The  disease  is  not  accompanied  by 
material  enlargement  of  the  turbinated  bodies  or  distention  of  the  erectile  tis- 
sues, and  stenosis  is  not  a  prominent  symptom  ;  which  differentiates  it  from 
hypertrophic  rhinitis. 

Etiology. — Bosworth  plausibly  contends  that  children  are  particularly 
prone  to  inflammation  of  the  epithelial  lining  of  mucous  membranes,  and  that 
the  epithelial  proliferation  of  muco-lymphoid  glands  becoming  organized  with- 
out desquamation  accounts  for  enlargement  of  the  tonsils,  etc.,  while  an  allied 
inflammation  in  the  nose,  with  rapid  desquamation  of  the  epithelium,  con- 
stitutes the  most  important  element  in  purulent  rhinitis.  The  disease  bears  no 
constant  relationship  to  scrofula,  tuberculosis,  or  syphilis,  since  it  affects  chil- 
dren who  are  otherwise  robust  quite  as  frequently  as  it  does  the  subjects  of 
these  dyscrasiffi.  Inattention  to  hygienic  matters,  leading  to  frequent  attacks 
of  acute  rhinitis,  and  failure  to  treat  the  same  effectively,  are  potential  factors 
in  the  establishment  of  this  form  of  catarrh. 

Symptoms. — A  profuse  muco-purulent  discharge  from  both  nostrils,  swell- 
ing and  redness  of  the  external  nasal  appendage,  and  excoriation,  with  incrus- 
tation of  the  anterior  nares,  are  the  chief  manifestations,  a  too  profuse  dis- 
charge being  the  sole  complaint  in  the  milder  cases. 

In  the  course  of  years,  if  the  purulent  type  of  rhinitis  be  not  arrested,  the 
mucous  glands  atrophy,  the  secretion  grows  less  but  thicker,  and  tends  to  accu- 
mulate in  crusts.  In  other  words,  the  disease  passes  gradually  into  the  atrophic 
form  of  rhinitis,  which  is  the  successor  to  purulent  rhinitis  perhaps  more  fre- 
quently than  to  hypertrophic  rhinitis,  although  commonly  credited  to  the  latter 
disease. 

On  the  other  hand,  if  simple  chronic  rhinitis  does  not  assume  the  purulent 
type,  it  is  prone  to  pass  gradually  into  hypertrophic  rhinitis. 

Diagnosis. — Hypertrophic  rhinitis  is  accompanied  by  more  nasal  obstruc- 
tion and  less  secretion,  although  it  is  sometimes  diSicult  to  draw  the  line 
between  these  two  affections,  however  distinct  one  type  may  be  from  the  other ; 
indeed,  in  rai-e  instances  the  two  pathological  processes  are  seemingly  associ- 
ated. Hereditary  syphilitic  rhinitis  can  be  excluded  by  rhinoscopic  exami- 
nation, and  the  purulent  discharge  occasioned  by  a  foreign  body  in  the  nose  is 
commonly  unilateral,  and  the  object  can  be  discovered  by  the  probe. 


DISEASES   OF   THE  NOSE.  829 

Treatment. — The  first  indication  and  most  important  point  in  the  treat- 
ment of  purulent  rhinitis  is  to  maintain  absolute  cleanliness  of  the  nostrils. 
Muco-pus  must  not  be  permitted  to  accumulate  and  decompose  in  the  sinuosities 
around  the  turbinated  bodies,  thus  perpetuating  the  disease.  In  not  too  invet- 
erate cases  thorough  cleansing  by  means  of  an  antiseptic  alkaline  and  mildly 
astringent  sprav,  used  three  or  four  times  daily  with  a  hand-ball  atomizer,  is  all 
that  i°s  necessary  to  effect  a  cure.  The  following  modification  of  Dobell  s 
solution  answers  "this  purpose  admirably  : 

^.   Sodii  boratis gr.  xv. 

Sodii  bicarbonatis gr.xv. 

01.  eucalypti Ttlj- 

01.  gaultherise     ...........  TTlj' 

Thymol gr-j- 

Menthol gi'-  ss. 


Glyceri 


f.lss. 


Aqu^ q.  s.  adf5j.— M. 

Sig.  Dilute,  adding  two  teaspoonfuls  to  one  ounce  of  warm  water  for  use 
as  a  spray. 

The  patient  should  be  directed  to  use  the  spray  several  times  at  intervals 
of  five  minutes,  especially  during'  the  morning  and  evening  toilet,  and  to 
cleanse  the  nose  by  "blowing"  in  each  interval. 

If  a  more  active  astringent  is  necessary  to  check  the  hypersecretion,  sul- 
pho-carbolate  of  zinc,  two  to  five  grains  to  the  ounce,  may  be  used  as  a  spray 
followin^Tthe  cleansing  solution.  In  young  children,  who  are  terrified  by  spray- 
ing, these  solutions,  well  warmed,  can  be  used  by  means  of  a  small  syringe. 

°'Where  the  purulent  type  of  the  disease  is  complicated  by  the  presence  of 
hypertrophies  of  the  turbinated  bodies,  deformity  of  the  septum,  adenoid 
veo-etations,  etc.,  any  of  which  obstructions  will  impair  the  drainage  and  cause 
a  muco-purulent  discharge,  surgical  treatment  appropriate  to  this  special  cause 
or  complication  is  usually  indicated.  However,  the  case  should  not  then  be 
regarded,  strictly  speaking,  as  one  of  simple  rhinitis. 

TTT    Hypertrophic  Rhinitis. 

This  is  a  chronic  inflammation  of  the  mucous  and  submucous  tissues  of  the 
nose,  characterized  by  enlargement,  especially  of  the  turbinated  bodies,  which 
encroach  upon  the  normal  lumen  of  the  nostrils  and  cause  impairment  of  nasal 
respiration  and  drainage.  The  disease  is  stated  to  be  rare  with  children,  espe- 
cially under  ten  or  twelve  years  of  age,  but  we  are  convinced  that  a  mild  form, 
or  early  stage,  of  the  affection  is  very  common  at  all  ages. 

Pathology. — Advanced  hypertrophic  rhinitis  is  characterized  by  enlarge- 
ment and  proliferation  of  all  the  elements  which  compose  the  turbinated  bodies: 
the  epithelial  surface  is  thickened ;  the  adenoid  layer,  which  lies  between  the 
epithelial  and  submucous  lavers,  is  wider,  and  the  lymph-corpuscles  and  fibrous 
connective-tissue  bundles  are  more  numerous ;  the  acinous  mucous  glands  are 
increased  in  number  and  size.  The  submucosa,  which  is  composed  largely  of 
blood-vessels  of  a  venous  character — sometimes  called  a  venous  plexus — is  par- 
ticularly affected,  the  vessels  being  enlarged,  more  numerous,  their  walls  thick- 
ened, and  the  intervascular  connective  tissue  proliferated.  The  blood-vessels 
are  more  or  less  continually  congested,  causing  "erection"  of  its  structures, 
and  they  are  no  longer   capable  of  complete   "retraction"   under  favorable 


830    A3fERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

influences  or  under  the  action  of  cocaine,  but  shrink  only  moderately  or  but 
little. 

As  Bosworth  truly  remarks  :  "  These  are  changes  which  can  only  ensue 
during  the  lapse  of  years;"  and  to  this  extent  Ave  would  not,  therefore,  expect 
to  encounter  them  in  children.  However,  in  children  and  adolescents  persistent 
enlargements  of  the  turbinated  bodies  can  and  do  present  themselves  in  conse- 
quence of  mere  dilatation  and  engorgement  of  the  vessels  of  the  submucosa, 
without  any  considerable  degree  of  cell-proliferation.  Complete  retraction  in 
this  form  is  possible,  either  spontaneously  on  one  or  both  sides  at  intervals,  or 
by  means  of  cocaine,  the  mucous  membrane  shrinking  close  to  the  bony  base. 

This  condition  is  occasionally  referred  to  as  a  vaso-motor  paresis,  permitting 
over-distention  of  the  vessels  of  the  turbinated  bodies  and  other  parts  affected ; 
or,  again,  it  is  designated  by  Ingals  as  a  distinct  affection  under  the  name  of 
"  intJumescent  rhinitis."  But  I  am  disposed  to  view  it  simply  as  an  early  stage, 
or,  at  most,  a  variety  of  hypertrophic  rhinitis,  for  cases  which  present  each 
de<yree  of  orradation  between  this  and  the  advanced  stage  of  the  disease  above 
described  are  continually  encountered. 

In  addition  to  the  intumescent  type,  even  somewhat  advanced  grades  of 
hypertrophic  rhinitis  are  certainly  met  with  in  children. 

Etiology. — The  most  prolific  source  of  hypertrophic  rhinitis  in  young  chil- 
dren is  adenoid  vegetations,  Avhich  by  partial  occlusion  of  the  posterior  choan?e 
interfere  w^ith  the  proper  drainage  and  evaporation  of  nasal  secretions,  the  irri- 
tation of  retained  and  decomposing  secretions  serving  to  excite  proliferative 
changes  in  the  nose.  It  would  seem,  also,  that  the  same  dyscrasia — lympha- 
tism,  which  predisposes  certain  children  to  hypertrophy  of  the  tonsils  and  to 
naso-pharyngeal  adenoid  hypertrophy — favors  the  development  of  hypertrophic 
rhinitis.  Clinically,  these  conditions  are  frequently  conjoined,  and  it  is  cer- 
tain that  they  sustain  some  dependence  upon  each  other,  for  removal  of  the 
"adenoids"  is  often  followed  by  subsidence  of  the  nasal  hypertrophies. 

Recurrent  acute  rhinitis  is  another  potent  factor  in  the  development  of 
hypertrophic  rhinitis,  and,  therefore,  whatever  serves  to  excite  acute  rhinitis 
must  be  accorded  etiological  consideration  in  reference  to  hypertrophic  rhinitis. 

Symptoms. — Nasal  stenosis,  or  obstruction  on  one  or  both  sides,  is  the 
most  prominent  symptom,  together  with  many  indirect  effects  due  to  the  stenosis. 
As  a  rule,  one  side  of  the  nose  is  stopped  at  a  time,  the  two  sides  alternating 
in  this  respect,  sometimes  changing  with  great  rapidity  and  without  apparent 
cause.  Again,  absolute  stoppage  of  one  or  both  nostrils  may  manifest  itself 
only  under  certain  conditions,  as  during  railroad  travel  or  otherwise  from  inha- 
lation of  dust,  from  superheated  apartments,  and  from  exposui'e  to  a  cold,  damp 
atmosphere — conditions  which  necessarily  arise  so  commonly  as  to  cause  much 
annoyance  to  the  patient. 

The  secondary  results  of  nasal  stenosis  are  a  nervous  restlessness,  which  is 
excited  in  many  by  the  sense  of  obstruction  and  pressure  in  the  nose,  inability 
to  sleep  soundly  at  night  or  intellectually  to  apply  themselves  persistently  by 
day,  together  with  headache  and  reflex  pressure  symptoms,  such  as  hemicrania, 
or  nervous  sick  headache,  asthma,  spasm  of  the  glottis,  and  even  epileptoid 
seizures.  The  most  frequent  of  the  reflex  nasal  symptoms  in  childhood  are 
asthma  in  association  with  bronchitis,  and  spasm  of  the  glottis  in  association 
with  laryngitis;  in  fact,  so  common,  in  childhood,  is  dependence,  at  least  in 
part,  of  chronic  bronchitis  with  asthmatic  symptoms  upon  nasal  stenosis  and 
adenoid  vegetations  that  the  closest  scrutiny  and  attention  should  be  given  to 
the  upper  respiratory  tract  in  all  such  cases. 

Plethora  of  the  blood-vessels  of  the  nasal  mucous  membrane  tends  to  develop 


DISEASES    OF   THE  NOSE.  831 

a  like  plethora  in  the  bronchial  mucous  membrane,  and  ansemia  induced  in  the 
turbinated  tissues  tends  to  eiFect  an  anaemic  state  of  the  bronchial  tubes.  The 
physiological  relationship  between  the  two  regions — the  nasal  erectile  tissues 
being  designed  to  warm  and  moisten  the  inspired  air — demands,  through  the 
vaso-motor  system,  an  intimate  correspondence  between  their  blood-supplies. 
As  might  therefore  be  expected,  a  pathological  correspondence  also  obtains, 
and,  without  entering  into  a  discussion  of  the  hypothetical  details  of  nervous 
mechanisms,  we  simply  state  the  oft-observed  fact,  that  turgescence  and  vaso- 
motor paresis  of  the  nasal  erectile  tissues  may  occasion  vaso-dilation,  congestion, 
and  inflammation  of  the  bronchial  mucous  membrane. 

The  term  "reflex"  is  doubtless  often  misappropriated,  yet  it  has  a  definite 
significance,  and  the  pathological  reflexes  which  originate  in  nasal  or  naso- 
pharyngeal irritation,  and  terminate  in  cough,  laryngeal  spasm,  or  asthma,  fol- 
low much  the  same  pathway  as  the  physiological  reflex  known  as  sneezing. 
The  nasal  branches  of  the  ophthalniic  division  of  the  fifth  nerve  and  the  nasal 
branches  of  the  anterior  palatine,  descending  from  Meckel's  ganglion,  which 
is  in  connection  with  the  superior  maxillary  division  of  the  fifth  nerve,  conduct 
the  sensory  impression  to  the  medulla.  It  is  there  reflected  to  the  respiratory, 
pneumogastric,  and  other  centres,  whence  the  deep  inspiration,  forced  expira- 
tion, and  the  coincident  spasm  of  the  pharyngeal  and  laryngeal  muscles,  termed 
a  sneeze.  This  mechanism,  of  course,  varies  somewhat  with  the  difierent 
pathological  reflex  acts. 

But  nasal  irritation  does  not  in  every  case  result  in  reflex  phenomena. 
Evidently,  still  other  conditions  are  essential,  which  must  be  sought  in  func- 
tional derangement  tending  toward  special  susceptibility  of  certain  nerve-cen- 
tres, including  those  wrought  upon  by  peripheral  nasal  irritation ;  and  in  chronic 
inflammation  or  a  predisposition  to  acute  congestive  states  of  particular  organs, 
which  unquestionably  favors  the  development  in  that  organ  of  the  ultimate 
link  in  the  reflex  chain.  Thus,  one  afl"ected  with  bronchitis  would  suffer  the 
more  readily  from  asthma,  excited  reflexly  by  nasal  irritation ;  laryngitis  predis- 
poses under  like  conditions  to  spasm  of  the  glottis,  and  digestive  derangements 
to  migraine.  So,  in  the  completed  cycle,  three  factors  obtain — nasal-irritation, 
superexcitable  nerve-centres,  and  a  susceptive  peripheral  organ.  But  the  nasal 
irritation  is  the  initial  link  without  which  the  peculiar  reflex  is  not  excited, 
and  to  which  the  other  factors  are  subservient. 

Another  symptom  of  hypertrophic  rhinitis,  secondary  to  this  stenosis,  is 
cornpulsory  mouth-breathing  with  its  many  deplorable  consequences — e.  g.  dry- 
ing out  of  the  mouth  and  pharynx,  facial  deformity,  and  mental  obtundity — a 
symptomatic  sequence  which  has  been  sufficiently  elaborated  in  the  article  on 
" Naso-pharyngeal  Adenoid  Hypertrophy." 

Also,  concerning  secondary  impairment  of  hearing,  what  is  said  in  that 
article  pertains  equally  to  this  disease. 

A  very  annoying  symptom,  and  one  which  may  first  attract  attention,  is 
dysphonia  ;  in  fact,  such  children  are  constantly  declared  to  be  tongue-tied  and 
the  lingual  frsenum  cut  without  benefit,  when  the  real  defect  in  speech  lies  in 
occlusion  of  the  nares  or  naso-pharynx. 

Diagnosis. — This  is  established  by  direct  rhinoscopic  examination  ante- 
riorly and  posteriorly  ;  the  latter,  however,  is  not  always  possible  with  young 
children.  The  turbinated  bodies  appear  red,  turgid,  and  swollen,  but  they 
occupy  their  natural  positions  and  maintain  their  normal  relations  to  each  other 
and  to  surrounding  parts ;  by  which  fact  this  disease  can  readily  be  distin- 
guished from  nasal  polypus.      A  polypus  occupies  one  of  the  spaces  beneath. 


832    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

between,  or  beside  the  turbinated  bodies ;  it  is,  moreover,  movable,  and  is  of 
paler  color  than  the  inflamed  mucous  membrane. 

Treatment, — When  dependent  upon  adenoid  vegetations,  the  surgical  re- 
moval of  these  growths  in  children  usually  results  in  subsidence  of  the  hyper- 
trophic rhinitis.  Resolution  will  be  favored  in  these  cases,  however,  as  well  as 
in  the  milder  forms  of  the  disease  not  secondary  to  naso-pharyngeal  adenoid 
hypertrophy,  by  the  use  twice  daily  of  an  antiseptic,  alkaline,  and  mildly 
astringent  spray  or  lotion,  formulated  as  prescribed  in  the  section  on  "  Simple 
Chronic  Rhinitis."  This  is  especially  important  as  a  cleansing  measure  in 
cases  in  which  some  degree  of  hypertrophy  is  conjoined  with  the  suppurative 
type  of  rhinitis.  Refined  petroleum  products,  variously  known  as  "  albolene," 
lavolene,  benzoinol,  etc.,  are  just  now  extensively  employed  in  many  combina- 
tions in  all  forms  of  rhinitis,  but  antiseptic,  alkaline,  aqueous  solutions  are 
certainly  more  effective  when  the  parts  are  to  be  cleansed  of  muco-purulent 
accumulations.  Petroleum  sprays  are,  however,  often  soothing  and  protective 
to  the  parts,  especially  at  times  of  acute  and  subacute  exacerbations,  and  may 
be  used  in  such  cases  following  the  aqueous  spray  twice  daily,  or  used  alone 
with  patients  who  have  no  retained  muco-purulent  secretions.  "  Vaselin  oil," 
being  more  viscid  than  the  whiter  products,  and  yet  sufficiently  fluid  to  be  con- 
verted into  spray  by  a  good  double-bulb  hand-atomizer,  is  best  adapted  to  this 
use,  and  may  be  prescribed  in  the  following  combination  : 

^.  01.  pini  Canadensis TTLv. 

01.  gaultherise •     ....  Tllij. 

01.  eucalypti Ulij- 

Thymol      gr.  ss. 

Menthol gr.  j. 

"  Vaselin  oil" q.  s.  adfgj. — M. 

Sis:.  Use  with  a  double-bulb  atomizer. 

A  more  astringent  spray  is  occasionally  beneficial,  although  strong  astrin- 
gents are  not  well  borne  by  the  nasal  mucous  membrane : 

I^.  Zinci  sulphocarbolatis g^"-  v. 

lodi gr.j; 

Potassii  iodidi gi'-  ij- 

Menthol gr.  j. 

01.  gaultheriaj TTLiij. 

Glycerini       f.?j. 

Aquae q.  s.  adfgj. — M. 

Sig.  Use  with  atomizer.^ 

Persistent  use  of  these  remedies,  together  with  the  surgical  removal  of  ade- 
noid vegetations  and  enlarged  faucial  tonsils,  and  hygienic  guards  to  prevent 
frequent  "colds,"  will  effect  a  recovery  in  the  majority  of  cases  of  hypertrophic 
rhinitis  of  children.  A  minority,  however — which  includes,  especially,  the 
older  children — will  not  yield  to  this  treatment,  and  will  require  reduction  of 
the  hypertrophy  by  means  of  the  electro-cautery  in  order  to  overcome  the  nasal 
stenosis.  One  should  not  hesitate  to  adopt  this  method  in  suitable  subjects, 
for  the  results  are  very  satisfactory  and  the  disadvantages  trivial ;  but  consider- 
able technical  skill  is  necessary  to  ensure  entire  safety  ;  consequently  it  should 
not  be  attempted  by  one  Avho  is  unfamiliar  with  intranasal  operating. 

^ "  Vaselin  oil "  or  albolene  can  be  substituted  for  the  glycerin  and  water  in  this  formula. 


DISEASES    OF    THE   XOSE.  833 

Five  per  cent,  cocaine  solution  on  cotton  is  first  placed  in  contact  with  the 
whole  length  of  the  inferior  turbinated  body  for  ten  minutes.  The  knife  elec- 
trode is  commonly  usSd,  but  we  prefer,  as  better  adapted  to  the  purpose,  the 
ordinary  point  electrode,  which  we  curve  slightly  upon  the  flat,  using  the  sur- 
face of  the  platinum  end,  and  not  the  very  point,  with  which  to  burn.  This 
makes  a  broader  eschar  than  the  knife  electrode,  it  is  less  apt  to  occasion 
haemorrhage,  it  requires  less  space  in  transit  through  the  nostrils,  and  it  adapts 
itself  better  to  the  curved  contour  of  the  turbinated  body,  permitting  appli- 
cation farther  toward  the  posterior  end  of  that  body. 

The  cocaine  retracts  the  erectile  structures  and  temporarily  provides  space 
through  which  the  unhealed  electrode  is  passed  :  the  length  of  the  platinum  tip 
is  pressed  against  the  turbinated  body,  commencing  as  far  posteriorly  as  one 
can  see,  and  then,  when  at  white  heat  from  the  battery,  it  is  drawn  slowly  for- 
ward, marking  its  passage  by  the  production  of  a  white  linear  eschar.  Through 
this  same  linear  eschar,  in  order  to  deepen  it,  one  now  draws  the  instrument  a 
second  and  a  third  time.  Many  will  direct  that  the  electrode  be  employed  at  a 
cherry-red  heat,  but  dui'ing  use  the  point  is  sunk  in  a  moist  tissue,  and  what  is 
a  white  heat  in  the  atmosphere  is  no  more  than  a  cherry  heat  when  in  contact 
with  the  moisture  of  the  turbinated  body. 

The  two  nostrils  should  never  be  treated  at  the  same  sitting,  and  more  than 
one  linear  cauterization  should  not  be  made  at  one  time,  although  it  may  be  well 
to  draw  the  electrode  two  or  three  times  along  the  same  track  in  order  to  obtain 
sufficient  depth,  as  the  subsequent  cicatrix,  in  addition  to  breaking  up  the  free 
continuity  of  blood-vessels  and  substituting  a  certain  overplus  of  tissue,  should 
serve  also  to  bind  down  the  neighboring  portions  by  attachment  to  the  bony  base. 
Bad  cases  require  six  to  eight  applications  of  the  cautery  at  intervals  of  one  to 
two  weeks,  two  or  three  on  each  lower  turbinated  body,  and  others  of  less 
extent  on  the  middle  bodies.  Antiseptic  cleansing  sprays  should  be  used  dur- 
ing the  intervals.  Moderate  sepsis  has  followed  this  operative  treatment  in  a 
few  instances  ;  consequently  it  is  best  to  see  the  patient  on  the  second  and 
fourth  day  after  operating  for  the  purpose  of  efiecting  absolute  cleanliness. 

The  best  substitute  for  the  galvano-cautery  when  this  is  not  available  is 
chromic  acid,  which  may  be  used  by  fusing  a  bead  on  the  end  of  a  probe  and 
applying  it  much  as  one  would  the  electrode.  It  is  apt  to  produce  excessive 
breadth  and  insufficient  depth  of  eschar. 

IV.  Atrophic  Rhinitis. 

This  disease,  termed  also  diy  catarrh,  ozgena,  and  fetid  rhinitis,  is  charac- 
terized by  atrophy  of  the  mucous  membrane,  of  the  underlying  cavernous  struc- 
tures, and  of  the  bony  projections  within  the  nose,  which  leads  to  increased 
spaciousness  of  the  nostrils :  also  by  atrophy  with  impairment  of  function  of 
the  mucous  glands,  by  reason  of  which  the  muco-purulent  secretion  becomes 
inspissated  and  accumulates  in  the  form  of  crusts,  which,  in  turn,  undergo 
decomposition  and  occasion  fetor. 

Etiology. — Frankel  first  promulgated  the  theory  that  atrophic  rhinitis  was 
a  sequel  to  hypertrophic  rhinitis,  a  late  stage  of  that  disease  ;  and  his  views 
have  seemingly  been  adopted  by  most  other  writers,  a  few  guarding  this  dictum 
by  stating  that  this  disease  can  also  arise  independently. 

In  a  discussion  before  the  American  Larvnccolocrical  Association  in  1891,  I 
made  this  statement :  "  With  regard  to  the  transition  of  hypertrophic  rhinitis 
into  atrophic  rhinitis,  ....  I  have  never  seen  a  case  in  which  distinct  hyper- 
trophy had  passed,  definitely,  into  the  atrophic  condition." 


834  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  life-histories  of  the  two  affections  are  dissimilar.  Atrophic  rhinitis  is 
common  in  childhood  and  early  adult  life,  becomes  rare  after  thirty-five  years 
of  age,  and  is  very  infrequently  observed  in  patients  exceeding  forty  years  of 

age. 

Hypertrophic  rhinitis  of  the  early  intumescent  variety  is  not  uncommon  in 
childhood  and  early  adult  life,  but  the  disease  does  not  become  firmly  estab- 
lished, with  permanently  organized  infiltration  of  the  turbinated  bodies,  at  least 
until  maturity;  and  in  the  vast  majority  of  cases  the  quantity  and  density  of 
infiltrated  tissue  continues  to  increase  until  advanced  age. 

Since  it  is  conceded  that  about  ten  years'  duration  of  the  hypertrophic  type 
is  usual  before  transition  into  the  atrophic  type,  it  is  apparent  that  this  theor}'- 
leaves  us  without  an  adequate  exj^lanation  of  the  many  cases  of  atrophic  rhin- 
itis which  occur  in  eai'ly  life. 

The  few  cases  which  are  explicitly  reported  by  competent  observers  as 
having  undergone  this  transition  Avere  doubtless  illustrations  of  coincidence,  in 
which,  notwithstanding  the  previous  existence  of  hypertrophy,  some  other 
unnoticed  or  obscure  intercurrent  cause  had  served  to  effect  the  atrophic  change. 
Bosworth  has  advanced  the  most  rational  explanation  of  the  etiology  of  atrophic 
rhinitis  in  designating  "suppurative  rhinitis  of  children  "'  as  the  real  cause — 
a  view  which  harmonizes  with  the  life-history  of  the  disease,  and  which  is  con- 
sistent with  the  undoubted  occurrence  of  the  coincidence  above  mentioned  ;  for 
it  is  possible  for  one  already  the  subject  of  hypertrophic  rhinitis  to  acquire,  in 
addition,  the  suppurative  type  of  rhinitis,  which  latter  may  terminate  in  the 
atrophic  state  in  spite  of  the  previously  existing  hypertrophy. 

Bosworth's  theory,  moreover,  is  of  special  value  from  a  prophylactic  stand- 
point, since  it  teaches  us  the  importance  of  promptly  suppressing  chronic  sup- 
purative rhinitis,  viewed  as  a  cause  the  ultimate  effect  of  which,  atrophic 
rhinitis,  is,  itself,  difficult  of  suppression. 

Bosworth  says,  in  brief,  that  the  predominating  morbid  condition  of  puru- 
lent rhinitis  is  desquamation  of  epithelium  ;  that  as  long  as  this  desquamation 
is  confined  to  the  superficial  epithelial  cells  the  disease  is  attended  with  a  thin 
and  fluid  muco-purulent  discharge,  but  that,  sooner  or  later,  the  desquamative 
process  extends  to  the  epithelial  lining  of  the  muciparous  and  follicular  glands ; 
the  glandular  function  is  then  impaired,  and  the  muco-purulent  discharge 
becomes  thick  and  firmly  adherent,  in  the  form  of  crusts  and  scales,  to  the 
sinuosities  of  the  nose.  Further,  that  this  film  of  desiccated  muco-pus,  in 
drying,  contracts,  and  embraces  the  underlying  turbinated  tissues  in  a  grasp 
which  necessarily  must  interfere  with  the  circulation  of  blood — a  condition 
which  limits  glandular  action  still  more  and  conduces  to  general  atrophy. 

Hereditary  predisposition  to  atrophic  rhinitis  is  often  pronounced.  For 
instance,  a  patient,  aged  twenty-two,  has  developed  the  disease  during  the  last 
two  years  ;  her  mother,  for  some  years  deceased,  suffered  from  the  disease  in  a 
typical  form  ;  the  patient's  child,  aged  three  years,  is  likewise  affected. 

Pathology. — The  prominent  features  of  the  atrophic  process  are  thus 
summarized  by  Bosworth:  '•''First. — Decrease  of  covering  epithelium,  with 
profuse  desquamation.  Second. — Decrease  of  the  adenoid  layer,  with  lack 
of  blood-vessels,  together  with  destruction  of  the  acinous  glands.  Third. — 
A  total  disappearance  of  the  venous  sinuses  of  the  submucous  layer  of  the 
membrane." 

Symptoms. — Crust-formation  and  fetor  are  the  most  prominent  symp- 
toms of  the  disease,  although  other  secondary  manifestations  are  numerous. 

The  crusts  may  accumulate  only  in  thin  scales  or  in  large  masses  of 
horny  consistency,  which  may  even  occlude  the  nostrils  at  times,  being  firmly 


DI8EA8E8    OF   THE  NOSE.  835 

adherent  and  impacted  in  the  sinuosities  of  the  nares,  until  by  decomposition 
and  softening  of  the  layer  adjoining  the  mucosa  they  are  finally  cast  loose  and 
expelled  in  large  pieces  by  blowing,  often  leaving  abraded  surfaces  behind. 

The  fetor  varies  in  intensity  in  different  cases,  but  is  rarely  entirely 
absent,  and  in  its  severe  forms  is  so  horribly  nauseating  and  penetrating  as 
to  contaminate  the  atmosphere  of  an  entire  room  in  a  few  minutes,  and  to 
necessitate  comparative  isolation  of  the  patient.  The  fetid  odor  is  apparently 
due  solely  to  decomposition  of  the  incrusting  secretion  in  situ,  but  there  is 
reason  to  believe  that  this  decomposition  may  extend  to  the  secretion  which  is 
still  in  process  of  elaboration  in  the  substance  of  the  glands  themselves, 
although  this  is  difficult  of  absolute  demonstration ;  for,  however  thoroughly 
one  may  cleanse  the  parts,  fetor,  persisting,  might  still  be  caused  by  small 
invisible  particles  of  crust  in  the  accessory  cavities,  ethmoid  cells,  or  sphenoid 
sinuses. 

In  advanced  cases,  commonly,  the  sense  of  hearing  is  impaired,  the  patient's 
own  sense  of  smell  obtunded,  the  external  nose  broadened,  its  alee  thickened, 
and  the  physiognomy  lacking  in  acuteness  of  expression. 

The  disease  extends  after  a  time  to  adjoining  surfaces,  constituting  atrophic 
naso-pharyngitis  and  atrophic  pharyngitis.  The  naso-pharynx  becomes  so 
incrusted  that  the  fetid  masses  must  be  literally  pried  out  with  probes  and  for- 
ceps. The  pharynx  presents  a  capacious,  glazed,  and  dry  aspect  characteristic 
of  the  disease.  Much  more  rarely  even  the  larynx  and  trachea  become  in- 
volved, crusts  accumulating  in  these  passages  to  the  point  of  occasioning 
dyspnoea. 

Diagnosis. — On  rhinoscopic  examination,  both  anteriorly  and  posteriorly, 
one  is  impressed  by  the  spaciousness  of  the  nasal  cavities  and  the  presence  of 
scales  or  crusts.  After  thorough  cleansing  the  mucous  membrane  appears 
smooth  and  thin,  although  oftentimes  congested  and  abraded  in  spots  from  the 
irritation  of  long-retained  incrustation.  In  advanced  cases  the  turbinated 
bodies  appear  merely  as  rudiments. 

The  disease  is  likely  to  be  confounded,  especially  in  childhood,  with  heredi- 
tary syphilitic  rhinitis,  which  is  also  accompanied  by  fetor  and  incrustation. 
Unfortunately,  by  reason  of  the  fetor  the  term  "  ozsena  "  has  been  applied  to 
both  diseases ;  consequently  it  is  a  bad  name  for  either  affection,  especially 
since  it  refers  only  to  the  symptom  fetor. 

In  atrophic  rhinitis  there  is  uniform  atrophy  and  incrustation  without  deep 
destructive  ulceration.  In  syphilitic  rhinitis  the  atrophic  process,  if  present  at 
all,  is  not  uniformly  distributed,  the  nostrils  being  contorted  by  deep  ulceration 
and  destruction,  with  subsequent  cicatrization,  of  various  parts.  Reference 
may  be  made  to  the  section  on  hereditary  syphilis  of  the  nose  for  additional 
details. 

Prog-nosis. — Atrophic  rhinitis  requires  persistent  thorough  treatment  over 
a  period  of  from  four  months  to  two  years,  in  order  to  effect  recovery  even  in 
young  subjects  and  in  recent  cases.  Both  patient  and  physician  are  prone  to 
become  discouraged  and  to  abandon  treatment,  much  to  the  disadvantage  of  the 
former.  Old,  inveterate  cases  must  continue  cleansing  measures  for  years,  as 
part  of  the  toilet,  with  the  same  regularity  that  is  given  to  the  teeth.  In  the 
worst  cases  the  difference  between  persistent  treatment  and  total  inattention  is 
the  difference  between  the  lot  of  an  acceptable  member  of  society  and  that  of  a 
social  outcast. 

The  fact  that  the  disease  is  rarely  observed  at  an  age  of  over  thirty-five  to 
forty  years  argues  a  natural  predisposition  to  recovery  as  life  progresses,  and 
should  operate  as  a  further  incentive  to  persistent  treatment. 


836  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Treatment. — The  first  essential  to  successful  treatment  is  absolute  and 
continuous  cleanliness  of  the  parts.  The  crusts  must  not  be  allowed  to  form, 
much  less  to  undergo  decomposition.  One  of  the  most  efficient  means  to  this 
end,  especially  for  young  children,  is  the  nasal  douche.  I  believe  it  to  be 
justifiable,  for  the  sake  of  efficient  treatment  of  this  particular  disease,  to 
assume  the  slight  risk  of  inflammation  of  the  ear  possible  by  this  instrument. 
This  risk,  with  proper  use  of  the  instrument,  is  remote  in  comparison  with  the 
danger  to  the  same  organ  from  atrophic  rhinitis  inefficiently  cleansed.  The 
original  instrument  of  Thudicum  was  of  glass,  but  the  ordinary  soft-rubber 

bag  gravity  douche,  fitted  with  a  nasal  noz- 
FiG.  1.  zle  (Fig.  1),  answers  the  purpose  still  bet- 

ter. It  should  be  suspended  from  a  nail 
over  a  convenient  basin  at  such  a  moderate 
height  that  the  bottom  of  the  bag  is  only 
about  three  inches  above  the  level  of  the 
nose  as  the  head  is  held  over  the  basin. 
The  patient  must  maintain  breathing  by  the 
mouth,  well  opened  :  when  on  applying  the 
nozzle  to  one  nostril  the  liquid  will  gravi- 
tate gently  and  slowly  into  one  nasal  pas- 
sage and  out  through  the  other,  the  oral 
respiration  sufficing  to  close  the  naso-phar- 
ynx  from  the  oro-pharynx  by  the  velum 
palati.  Not  force,  but  thorough  maceration, 
is  requisite  to  detach  the  crusts  ;  therefore 
one  to  two  pints  of  fluid  should  be  gently 
and  slowly  used  twice  daily  as  a  part  of 
the  morning  and  evening  toilet.  The 
liquid  employed  should  be  alkaline,  to 
facilitate  solution  of  the  crusts  ;  antiseptic, 
to  counteract  the  fetor ;  and  stimtdatiyig,  to  encourage  regeneration  of  the 
atrophied  glands.     These  qualities  are  provided  in  the  following  formula : 

I^.   Sodii  bicarbonatis 3iij. 

Sodii  boratis  Siij. 

Extracti  pini  Canadensis  fluidi     .    .    .  fsj. 

Glycerini f^iv. 

Aquse q.  s.  ad  f^viij. — M. 

Sig.   To  be  diluted  according  to  tolerance,  adding  one  ounce  to  the  pint 
or  quart  of  warm  water  for  use  with  the  nasal  douche. 

With  older  children,  who  can  be  taught  the  necessary  manipulation,  War- 
ner's post-nasal  douche  (Fig.  2)  should  be  substituted  for  the  anterior  douche 
of  Thudicum,  on  account  of  greater  safety  relative  to  the  ear.  The  same 
solution  in  the  same  proportion  can  be  used  with  it.  One  must  first  draw 
up  a  part  of  the  liquid  through  the  instrument  into  the  rubber  ball;  then 
insert  the  curved  nozzle  through  the  mouth,  behind  the  velum  palati,  into 
the  naso-pharynx,  and  squeeze  the  ball,  thus  expelling  its  contents  forward 
through  the  nasal  passages.  This  procedure  should  be  repeated  until  half  a 
pint  of  liquid  is  thus  used  morning  and  evening.  Children  who  will  not 
tolerate  either  of  these  means  can  conveniently  have  the  nostrils  syringed  by 
an  ordinary  soft-rubber-tipped  ear-syringe. 

Peroxide   of  hydrogen    has    the    property,    by   rapid  oxidation,  of  disin- 


Anterior  Nasal  Douche  and  Method  of  Using 
It 


DISEASES    OF    THE   NOSE, 


837 


Fig.  2. 


tegrating  muco-purulent  matter,  and,  when  sprayed  into  the  nostrils,  it  will 
thus  assist  materially  in  loosening  the  desiccated  secretion. 
It  should  be  used  a  few  minutes  before  the  employ- 
ment of  either  form  of  douche,  of  a  strength  just  insuffi- 
cient to  cause  smarting,  sprayed  by  a  powerful  double- 
bulb  hand-atomizer.  On  account  of  variability  and 
instability  of  the  drug,  an  exact  strength  cannot  be 
named,  but  a  20  to  40  per  cent,  solution  of  a  10-  to  15- 
volume  peroxide  of  hydrogen  is  suitable. 

The  patient  should  receive  treatment,  preferably, 
from  one  to  three  times  weekly  in  the  office,  at  which 
time  any  resistino;  crusts  should  be  detached  bv  a  cotton 
probang,  and  more  actively  stimulating  and  antiseptic 
medicaments  applied.  Of  these,  the  powder  insufflation 
of  dithymol  iodide  (aristol)  is  one  of  the  most  satis- 
factory. 

For  the  excoriation  and  incrustation  around  the  ante- 
rior nares  and  over  the  cai^tilaginous  septum,  which  is 
often  one  of  the  most  annoying  features  with  children, 
the  following  ointment,  thoroughly  used  each  night,  being 
inserted  into  the  nostrils  as  far  as  the  finger  will  reach, 
crives  the  most  satisfactory  results: 


Post-nasal  Douche. 


?!••  J- 

IJ.-M. 


I^,   Hydrargyri  oxidi  flavi 

"  Yaselin" 

Sig.  For  local  application. 

Sprays  of  '-liquid  vaselin.""  with  which  antiseptic  and  stimulating  medica- 
ments, such  as  thymol  and  menthol,  may  be  incorporated,  are  also  serviceable 
at  times,  tending  to  retard  crust-formation. 

Of  extraordinary  measures,  electricity  is  advocated  by  Delavan  of  New 
York,  and  "vibratory  massage"  by  Braun  of  Trieste. 

Cod-liver  oil  and  syrup  of  iodide  of  iron  are  seemingly  the  most  useful 
internal  remedies,  although  neither  can  be  relied  upon  to  the  exclusion  of  local 
treatment. 

V.  Nasal  Myxomata. 

Xasal  myxomata,  or  mucous  polypi,  are  connective-tissue  neoplasms  which 
originate  from  the  mucous  and  submucous  tissues  of  the  nose.  The  disease  does 
not  exist  as  a  primary  affection — a  dictum  which  is  more  emphatically,  albeit 
less  elegantly,  expressed  by  stating  that  polyps  will  not  grow  in  healthy  noses. 
They  are  always  associated  with,  and  caused  by,  some  other  nasal  malady. 
Indeed,  the  removal  of  such  associated  maladies  together  with  the  polypi  is  the 
"keynote"  to  the  proper  and  effective  handling  of  the  patient. 

Polyps  are  stated  to  be  rare  with  children,  but  are  probably  only  relatively 
so.  since  the  diseases  which  influence  their  development  are  somewhat  less 
usual  in  young  children  than  in  adults.  We  have  observed  them  in  children 
from  the  age  of  eight  years  upward. 

Recognition  of  the  exact  points  of  origin  of  the  neoplasms  is  essential  to  a 
clear  understanding  of  their  etiology  and  treatment. 

In  the  outer  wall  of  the  middle  meatus  of  the  nose  is  the  ethmoidal  fissure, 
or  hiatus  semilunaris^  the  antero-inferior  boundary  of  which  is  a  sharp-edged 
ridge  of  hook-like  curve,  and  hence  termed  the  unciform  process  of  the  ethmoid 


838    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


bone  (Fig.  3).  The  fissure  itself  communicates  through  its  upper  end  with  the 
frontal  sinus,  and  through  its  lower  extremity-,  the  ostium  maxillare,  with  the 
antrum  of  Highmore.     All  of  these  parts  lie  high  up   beneath  the    middle 


Fig.  3. 


Representing  the  Outer  Wall  of  the  Left  Xasal  Fossa,  with  the  middle  turbinated  body  turned  upward  to 
.show  beneath  the  hiatus  semilunaris  (printed  in  deep  black),  to  the  edges  of  which  polyps  are  fre- 
quently attached. 

turbinated  bone,  which,  in  the  natural  state,  hangs  down  over  them  like  a 
curtain. 

To  summarize  Zuckerkandl's  post-mortem  observations  of  forty-two  distinct 
growths,  he  found  that  ttvo-tkirds  originated  from  the  middle  meatus,  and  that, 
approximately,  tivo-tliirds  of  this  number  were  attached  to  the  edges  of  the 
hiatus  semilunaris.  With  this  knowledge,  and  judging  from  the  superficial 
position  of  the  neoplasm  and  the  direction  of  its  pedicle  toward  its  attachment, 
we  can  be  reasonably  certain  of  the  deep  point  of  origin  even  when  such 
is  not  visible,  and  can  often  destroy  the  very  root  of  the  growth  by  insin- 
uating a  properly-curved  cautery  point-electrode  to  the  spot. 

Etiology. — The  most  common  complication,  acting  also  in  a  causal  relation 
to  nasal  polypus,  is  hypertrophic  rhinitis.  Of  course,  additional  factors  are 
necessary  to  influence  the  perversion  of  a  simple  hyperplasia  of  the  mucosa  into 
one  of  myxomatous  type. 

Stenosis,  whether  induced  by  hypertrophy  of  the  inferior  turbinated  bodies, 


DISEASES    OF   THE  NOSE. 


839 


septal  deflections,  or  excrescences,  results  in  defective  drainage.  Muco-purulent 
secretion,  imprisoned  and  decomposing  in  the  middle  meatus  and  around  the 
middle  turbinated  body,  excites  irritation  and  furnishes  the  most  favorable  soil 
for  polyp  growth. 

Very  narrow  nostrils,  because  more  readily  stenosed,  are  predisposed,  in  this 
manner,  to  myxomata,  and  peculiar  curvatures  or  deformities  of  the  septum  and 
middle  turbinated  bodies,  by  obstructing  drainage,  have  a  like  effect. 

A  tendency  to  vaso-motor  paresis  of  a  diathetic  or  hereditary  nature,  which, 
in  certain  subjects  constitutes  the  basic  lesion  of  bronchial  asthma,  will  in  the 
same  individual  underlie  the  development  of  nasal  myxomata. 

The  influence  of  hypertrophic  rhinitis  on  the  etiology  and  treatment  is  well 
illustrated  in  the  following  history  : 

Miss  T ,  aet.  ten  years.     Total  obstruction  of  the  left  nostril  of  one 

year's  duration.  Enormous  hypertrophy  of  the  inferior  turbinated  bodies. 
Numerous  polypi  were  closely  impacted  between  the  turbinated  bodies  and  the 
septum ;  they  proceeded  from  the  middle  meatus,  and  were  continuously  im- 
bedded in  a  mass  of  thick,  viscid  muco-purulent  secretion  (Figs.  4  and  5).    The 


Fig.  4. 


Fig.  5. 


Polypi  in  the  Middle  Meatus, 
caused  by  hypertrophy  o-f 
the  inferior  turbinated  body 
(child  aged  ten  years). 


Lateral  View  of  the  Same  (Fig.  4). 


polypi  seemed  secondary  to  the  hypertropic  rhinitis  and  defective  drainage. 
On  the  right  side  hypertrophy  was  present,  but  was  insufiicient  to  obstruct  the 
drainage,  and  no  polypi  were  visible. 

Operations  first  by  the  cold  wire  snare  resulted  in  the  removal  of  numerous 
growths  during  repeated  sittings,  but  without  improvement.  The  polypi 
developed  as  rapidly  as  removed,  springing  up  like  mushrooms  in  the  soggy 
soil  maintained  by  the  imprisoned  secretions.  The  inferior  turbinated  body 
was  next  cauterized  along  its  entire  extent,  being  reduced  in  front  almost  to 
a  rudiment,  where  it  previously  interfered  with  vision,  instrumental  passage,  and 
drainage.  One  was  enabled  then  to  trace  the  tumors  to  their  exact  seat 
of  attachment  in  the  immediate  vicinity  of  the  hiatus  semilunaris,  and  to 
thoroughly  eradicate  them  by  reaching  that  position  with  a  cautery  point.  No 
recurrence.     Cure  complete. 

Again,  Miss  R ,  aet.  twelve  years.     Has  had  catarrhal  symptoms  for 

some  years,  with  adenoid  vegetations  and  obstruction  to  the  left  nostril.  Exami- 
nation Feb.,  189-3.  A  single  polypus  proceeds  from  the  left  middle  meatus, 
and  is  traceable  in  the  direction  of  the  hiatus  semilunaris,  to  which  it  is  evi- 


840   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

dently  attached  (Fig.  6).    The  inferior  and  middle  turbinated  bodies  are  hyper- 
trophied,  and  obstruct  drainage  from  the  middle  meatus. 

In  Fig.  7,  taken  from  an  older  subject,  is  depicted  the  manner  in  which  a 
septal  excrescence,  by  serving  as  an  obstruction  to  respiration  and  drainage, 


Fig.  6. 


Fig.  7. 


Single  Polypus  in  the  Middle 
Meatus,  caused  by  hyper- 
trophic rhinitis  (child  aet. 
12). 


Polypus  in  the  Middle  Meatus, 
associated  with  hypertrophy 
of  the  inferior  turbinated 
body  and  excrescence  of  the 
septum. 


especially  when  conjoined  with  hypertrophy  of  the  opposite  turbinated  body,  as 
illustrated,  may  dam  up  the  secretions  in  the  middle  meatus  and  encourage  the 
growth  of  polyps. 

Septal  excrescence  often  originates  during  the  developing  period  of  child- 


FiG.  8. 


hood,  and  is  a  deformity  of  the  septum  narium  characterized  by  an  exuberant 
and  projecting  growth  of  bone  and  cartilage  along  the  sutural  lines  of  the  com- 
ponent bones  and  cartilages  of  the  septum  narium.    The  most  frequent  location 


DISEASES    OF    THE  NOSE. 


841 


Fig.  9. 


is  the  sutural  line  of  the  vomer  and  the  superior  maxilla  and  cartilaginous 
septum  just  within  the  anterior  nares  and  close  to  the  floor  of  the  nose  (Fig.  8). 

Necrosing  ethmoiditis  of  Woakes  also  figures  as  a  persistent  cause  and  com- 
plication of  nasal  polypus.  It  involves  the  nasal  tributaries  of  the  ethmoid  bone, 
especially  its  process,  the  middle  turbinated  body,  which  usually  appears  cleft 
asunder,  leaving  a  fissure  down  its  centre,  from  which  will  protrude  the  polypi. 
This  is  illustrated  in  Fig.  9,  which  was  taken  from  a  patient,  aged  twenty  years, 
who  had  suffered  since  childhood. 

Empyema  of  the  antrum  of  Highmore,  although 
rare  with  children,  is  also  a  prolific  source  of  nasal 
polypus  in  adults,  apparently  caused  by  the  constant 
presence  of  fetid  pus  in  the  middle  meatus  as  it  escapes 
from  the  antrum  through  the  hiatus  semilunaris. 

The  form,  aspect,  and  consistence  of  a  myxoma  has 
been  compared  to  a  grape-pulp.  The  natural  shape  is 
pyriform,  but  this  is  often  varied  by  pressure.  When 
small,  it  is  sessile,  but  it  becomes  pedunculated  by 
gravity  as  development  proceeds,  and  the  point  where 
the  pedicle  is  confounded  with  the  tissues  of  attach- 
ment is  known  as  the  "  root."  The  color  varies  accord- 
ing to  vascularization  from  gray  to  yellow  and  from 
yellow  to  pink  and  red. 

Pathological  Histology. — A  typical  myxoma,  or 
"myxoma  hyalinum,"  resembles  in  structure  the  vitre- 
ous body  of  the  eye  and  the  gelatin  of  Wharton  of  the  umbilical  cord.  Micro- 
scopically, there  are  observed  either  a  few  roundish  cells,  as  in  the  vitreous 
body,  or  scattered  fusiform  and  stellate  cells  which  send  off  anastomosing 
trabeculae,  as  in  Wharton's  gelatin,  or  both  together,  and  these  are  imbedded 
in  a  large  quantity  of  a  homogeneous  gelatinous  mucin  containing  intercellular 
substance. 

But  myxomata  rarely  appear  in  this  purely  typical  form,  the  "  myxoma 
hyalinum  "  being  prone  to  transformation  into  allied  histological  structures  or 
to  be  represented  from  the  beginning  by  one  of  its  modified  forms.  Of  these, 
the  most  common  is  the  myxo-fibroma,  which  contains  a  greater  but  variable 
quantity  of  fibrous  tissue.  Those  which  are  ordinarily  called  myxomata  usu- 
ally contain  enough  of  the  fibrous  element  to  include  them,  strictly  speaking, 
within  the  class  of  myxo-fibromata. 

Symptoms. — The  chief  symptom  is  nasal  stenosis,  which  increases  with 
the  development  in  size  and  number  of  the  polypi  until  complete  obstruction 
of  one  or  both  nostrils  results.  Mucous  or  muco-purulent  discharge,  cephal- 
algia, aural  complications,  and  other  symptoms  of  a  catarrhal  nature,  together 
with  those  incident  to  mouth-breathing,  are  observed.  To  quote  the  words  of 
a  sufferer :  "It  affects  the  sight,  the  hearing,  the  taste,  and  the  smell,  of  course." 
Spasmodic  asthma,  paroxysmal  cough,  and  sneezing  attacks  are  among  the  reflex 
phenomena  which  are  occasionally  excited. 

Diagnosis. — For  diagnostic  purposes  it  is  usually  only  necessary  to  look 
with  a  good  light  and  to  feel  with  a  probe  in  order  to  establish  correspondence 
with  the  physical  characters  just  described,  but  more  rarely  an  accurate  know- 
ledge of  all  pathological  states  is  essential  to  a  precise  diagnosis. 

Treatment. — The  treatment  consists  flrst  in  the  establishment  of  free  nasal 
passage  for  respiration,  drainage,  vision,  and  instrumental  manipulation,  and,  to 
this  end,  in  the  reduction  of  hypertrophied  turbinated  bodies,  and  removal  when 


842    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

necessary  of  septal  excrescences  by  means  of  the  nasal  saw.  Adenoid  vegeta- 
tions, if  present,  should  be  removed. 

While  this  work  is  progressing  such  polypi  as  can  be  reached  should  be 
removed,  and  others  as  rapidly  as  access  is  gained.  This  is  done  preferably  by 
the  cold  wire  snare. 

But  the  real  success  of  the  treatment,  after  having  gained  access  to  the 
polypi,  consists  in  tracing  them  to  their  points  of  attachment,  and  in  thoroughly 
cauterizing  these  so-called  roots ;  if  not  at  the  same  sitting,  then  at  the  next, 
remembering  meanwhile  the  exact  spot.  Knowing  the  hiatus  semilunaris  to 
be  a  favorite  point  of  origin,  those  polypi  which  proceed  from  beneath  the 
middle  turbinated  body  should  be  followed  up  by  insinuating  to  this  point  a 
fine  electrode  slightly  curved  on  the  flat. 

The  permanent  success  of  the  treatment  will  depend  upon  the  possibility, 
in  individual  cases,  of  thus  reaching  the  deep  points  of  origin,  and  upon  the 
establishment  of  good  drainage  in  the  nose. 

VI.  Hereditary  Syphilis  of  the  Nose  and  Throat. 

Hereditary  syphilis  manifests  itself  in  children  at  any  time  from  birth  to 
four  months  of  age.  It  has,  of  course,  originated  during  intra-uterine  life, 
and  simply  progresses  to  the  point  of  becoming  particularly  apparent  in  the 
upper  respiratory  tract  during  the  period  stated.  In  rarer  cases  it  seemingly 
thus  manifests  itself  first  at  the  age  of  puberty,  or,  indeed,  at  any  time  pre- 
vious to  this  age,  but- in  these  cases  it  is  doubtful  whether  the  slighter  symp- 
toms at  the  earliest  period  of  life  have  not  simply  been  overlooked. 

From  birth  onward  the  disease  passes  through  stages  which  in  their  symp- 
tomatology and  pathology  are  identical  with  the  secondary  and  tertiary  stages 
of  acquired  syphilis.  Thus,  soon  after  birth  syphilitic  rhinitis  is  manifested 
by  coryza,  As-hich,  as  the  disease  progresses,  gradually  develops  into  a  muco- 
purulent discharge,  the  acrid  secretion  causing  excoriation  and  incrustation  at 
the  margins  of  the  nostrils.  It  is  probable  that  infiltration  of  the  superficial 
layers  of  the  mucosa  by  embryonic  cells,  and  subsequent  degeneration  of  the 
same  into  "mucous  patches,"  also  occur;  but  a  satisfactory  examination  of  the 
interior  of  the  nose  is  impossible  at  this  early  age,  and  a  definite  diagnosis  of 
this  stage  may  be  dependent  upon  the  concomitant  symptoms  of  syphilis.  The 
disease,  however,  usually  runs  a  rapid  course,  and  the  later  manifestations, 
which  correspond  to  the  tertiary  symptoms  of  the  acquired  form,  are  sufficiently 
characteristic.  A  gummatous  infiltration,  either  difi"used  or  circumscribed, 
occurs  in  the  depths  of  the  tissues,  the  entire  thickness  of  the  mucosa,  the  car- 
tilages, and  bones  being  alike  subject  to  an  infiltrating  deposit  of  small  round 
cells  of  embryonic  type.  These  deposits  readily  undergo  degeneration,  and 
result  in  deep  destructive  ulceration  of  the  tissues  and  cartilages  and  in  necrosis 
of  bones. 

The  disintegration  may  commence  either  in  the  centre  or  depths  of  the  tis- 
sue or  upon  its  surface,  and  is  seemingly  occasioned  by  the  cutting  ofi"  of  the 
blood-supply  to  this  lowly-vitalized  material  by  pressure  exerted  in  all  direc- 
tions by  the  cells  themselves.  The  cartilaginous  septum  narium  soon  disap- 
pears, the  vomer  is  attacked,  the  nasal  bones  affected,  and  the  external  nasal 
appendage  sinks  backward  and  downward,  acquiring  the  "saddle-back  "  deform- 
ity or  "flat  nose."  One  or  both  al?e  are  not  uncommonly  destroyed,  and  sub- 
sequent cicatrization  may  obliterate  the  nasal  orifices.  In  fact,  there  is  no 
limit  to  the  horrors  of  this  disease  when  left  unchecked,  necrosis  continuing 
until  death  is  caused  by  hsemorrhacre  or  menincritis. 


DISEASES    OF   THE  NOSE.  843 

In  the  throat  favorite  points  of  attack  are  the  velum  palati  and  the  junc- 
tion of  the  velum  with  the  hard  palate,  as  well  as  the  palatal  processes  of  the 
palate  bone  and  of  the  superior  maxillary  bone.  Thus,  the  cavities  of  the  nose 
and  mouth  are  caused  to  communicate  by  perforations  of  greater  or  less  extent. 
The  pillars  of  the  fauces  and  the  posterior  pharyngeal  wall  are  by  no  means 
exempt.  The  ulceration  being  deep,  the  folloAving  cicatrices  must  be  exten- 
sive, and  are  found  to  be  thick,  dense,  and  prone  to  extreme  degrees  of  con- 
traction, so  that  they  appear,  oftentimes,  stellated  or  twisted  and  contorted 
into  various  shapes.  They  are  comjjarable  to,  but  worse  than,  the  cicatrices 
which  follow  deep  burns.  In  this  way  the  pharynx  and  velum  become  adhe- 
rent, the  throat  being  contorted  and  twisted  apparently  into  one  cicatricial  mass, 
which  may  leave  but  a  minute  opening  between  the  pharynx  and  naso-pharynx. 
Crusts  accumulate  in  the  nasal  cavities,  and  the  fetor  is  intense,  occasioned 
both  by  the  decomposing  incrustations  and  necrosis  of  bone. 

Treatment. — The  patient  should  be  placed  as  rapidly  as  possible  under  the 
influence  of  mercury,  which  is  best  done  by  inunction  with  mercurial  ointment. 
In  many  cases  mercury  alone  seems  superior  to  the  potassium  iodide  or  the 
mixed  treatment.  Attention  to  the  bowels  and  care  of  the  general  health  are 
not  to  be  omitted,  nutritious  diet,  fresh  air,  and  tonics  being  indicated. 

The  local  treatment  is  of  the  utmost  importance.  The  ulcers  must  be  kept 
absolutely  clean  and  free  from  decomposing  discharges.  The  means  to  this  end 
are  the  same  as  those  detailed  in  connection  with  atrophic  rhinitis.  As  a 
topical  application  to  the  ulcers  we  value  most  highly  the  following  solution : 

^.  lodi, 

Acidi  tannici, -    .    . 

Potassii  iodidi eld  3^. 

Glycerini f  §ss. 

Aquae q.  s.  ad    f5j. — M. 

Sig.  Apply  by  a  cotton  swab. 

Under  this  treatment  it  is  a  veritable  pleasure  to  watch  the  absorption  of 
i»filtrated  masses  and  the  cicatrization  of  the  ulcers. 


CATARRHAL  LARYIS^GITIS  (SPASMODIC  CROUP). 


By  H.  ILLOWAY,  M.  D., 

Cincinnati. 


Catarrhal  Laryngitis,  termed  also  spasmodic  laryngitis,  pseudo-croup 
(false  croup),  and  acute  laryngitis,  is  an  acute  inflammation  of  the  mucous  mem- 
brane lining  the  larynx,  and  not  infrequently  involves  that  of  the  trachea.  The 
disease  may  present  itself  with  varying  intensity ;  clinically,  three  distinct  forms 
have  been  recognized — the  mild,  the  severe,  and  the  very  grave. 

In  addition  to  the  usual  symptoms  we  may  have — and  this  is  more  especially 
true  of  the  severe  form — paroxysms  of  dyspnoea  manifesting  themselves,  which 
bv  some  are  regarded  as  true  laryngeal  spasms.  The  catarrhal  laryngitis 
with  the  paroxysms  of  dyspnoea  superadded,  which  is  frequently  treated  as  a 
distinct  disease,  has  been  designated  laryngitis  stridulosa,  angina  stridulosa, 
and  spasmodic  laiyngitis;  it  is  also  called  pseudo-croup  or  false  croup,  to  dis- 
tinguish it  from  true  croup  or  pseudo-membranous  laryngitis. 

Catarrhal  laryngitis  is  a  disease  that  occurs  at  all  periods  of  child-life  from 
birth  up  to  the  fifteenth  year.  Pseudo-croup  is  seen  with  greatest  frequency 
between  the  second  and  fourth  years.  It  is  rarely  seen  before  the  second  year, 
and  still  more  rai*ely  after  the  fifth  year.  It  attacks  children  both  strong  and 
weak,  and  does  not  make  much  distinction  between  the  children  of  the  rich 
and  those  of  the  poor.  It  is  said  that  boys  are  more  prone  to  the  disease  than 
girls;  there  are,  however,  no  sufficiently  reliable  statistics  upon  this  point,  as 
this  disease  has  been  confounded  by  many  writers  with  laryngismus  stridulus 
(spasm  of  the  glottis),  for  which  this  statement  holds  good. 

Catarrhal  laryngitis  presents  itself  either  as  an  idiopathic  affection  or  as  a 
secondary  and  symptomatic  one,  and  then  usually  in  the  course  of  some  general 
disease.  It  occurs  with  greatest  frequency  in  the  colder  months,  about  the 
bewinninor  and  end  of  winter.  In  certain  latitudes,  where  the  winters  are  rather 
mild  and  the  snow  melts  very  quickly  and  the  streets  are  thus  wet  and  slushy, 
it  prevails  throughout  the  whole  winter.  The  sudden  setting  in  of  cold,  wet 
days  in  summer  may  cause  an  outbreak  of  catarrhal  laryngitis. 

Etiolog-y. — The  principal  etiological  factor  is  taking  cold.  A  very  young 
child  may  contract  a  cold  by  sitting  on  a  cold  floor,  by  throwing  ofi"  the 
coverlet  at  night  after  the  temperature  of  the  room  has  cooled  considerably, 
by  a  sudden  transference  from  a  very  warm  to  a  cold  room,  more  particu- 
larly a  cold  draughty  hall,  or  by  being  taken  out  on  a  cold,  windy,  blustery 
day;  older  children  take  cold  by  going  out  insufficiently  clothed,  by  taking  off 
top-coats  in  the  street  after  having  become  heated  at  play,  by  wading  in  water 
or  in  snow.  Cold  air  inspired  directly,  and  especially  whilst  the  vocal  organs  are 
violently  exercised,  as  in  screaming  or  yelling,  is  not  an  infrequent  cause  of 
laryngeal  catarrh.  In  some  instances  I  have  attributed  attacks  of  pseudo- 
croup  to  the  cold,  moist  atmosphere  created  in  the  bed-room  by  a  floor  scrubbed 
late  in  the  evening  and  not  thoroughly  dried  before  the  child  was  put  to  bed. 

8t4 


CATARRHAL    LARYNGITIS.  845 

In  some  children  a  predisposition  to  catarrhs  of  the  upper  air-passages  un- 
doubtedly exists  as  the  result  of  a  faulty  physical  training,  faulty  domiciliary 
hygiene,  and  perhaps  improper  diet  in  combination  with  some  of  the  other 
factors.  Scrofulous,  weak,  anaemic  children,  with  proneness  to  coryza  and  to 
inflammatory  aflections  of  the  tonsils,  are  more  especially  liable  to  attacks  of 
pseudo-croup.  A  characteristic  of  this  latter  form  of  catarrhal  laryngitis  is 
the  tendency  to  recurrence :  children  who  have  once  had  an  attack  of  spasmodic 
laryngitis  are  liable  to  have  a  like  attack  after  every,  even  very  slight,  expo- 
sure. After  the  fifth  year,  especially  if  placed  under  more  favorable  hygienic 
conditions,  they  soon  outgrow  this  tendency;  I  have,  however,  observed  in- 
stances where  children  have  remained  croupy  as  late  as  their  ninth  year.  It  is 
this  afi'ection  which  people  really  mean  when  they  speak  of  their  children  having 
had  three,  four,  or  more  attacks  of  croup. 

Whilst  catarrhal  laryngitis  may  be  of  the  mild  or  severe  type  from  the  onset, 
the  grave  form  is  always  an  acute  progression,  chiefly  due  to  neglect,  of  one  or 
the  other  milder  form.  The  child  is  allowed  to  play  around  at  its  will  despite 
hoarseness  and  cough,  to  expose  itself  to  draughts,  to  get  wetted  by  rain,  till 
all  at  once' the  symptoms  of  the  grave  type  manifest  themselves.  The  majority 
of  the  cases  of  this  character  observed  by  me  were  due  to  premature  exposure 
after  an  attack  of  measles,  before  the  catarrhal  laryngitis  that  usually  accom- 
panies that  disease  had  fully  subsided. 

Laryngo-trachitis  is  frequently  but  part  of  a  general  inflammatory  con- 
dition extending  downward  from  the  nose  to  the  bronchi ;  more  rarely  it  is  due 
to  the  upward  extension  of  a  tracheo-bronchitis. 

Occasionally  it  is  due  to  the  exciting  influence  of  local  irritants.  The  in- 
halation of  hot  steam,  a  very  dusty  at^mosphere,  and  irritating  vapors  are  not 
infrequent  causes  of  catarrhal  laryngitis.  Baginsky  reports  a  case  where  the 
prolonged  inhalation  of  coal-gas  produced  a  violent  laryngo-trachitis. 

As  a  symptomatic  expression  of  a  general  afi'ection  catarrhal  laryngitis 
occurs  in  measles,  scarlet  fever,  variola,  and  erysipelas.  It  may  appear  as  a 
complication  in  typhoid  fever,  in  broncho-pneumonia,  and  in  pulmonary  phthisis. 

Pathology. — The  most  reliable  data  concerning  the  coarser  anatomical 
changes  occurring  in  this  disease  have  been  obtained  by  laryngoscopic  exami- 
nation. The  principal  features  of  a  catarrhal  laryngitis  are  hypersemia,  swelling 
of  the  mucous  membrane,  and  rather  abundant  muco-purulent  secretion,  some- 
what viscid  in  character  and  found  adhering  to  various  sections  of  the  laryngo- 
tracheal mucous  membrane.  Difi"usion  and  intensity  of  the  hypersemia  may 
vary  greatly.  The  infiammation  may  be  confined  to  the  entrance  of  the  larynx 
or  to  the  epiglottis  (angina  epiglottidea) ;  it  may  be  more  marked  in  the  mid- 
dle portion  of  the  laryngeal  cavity ;  it  may  attack  only  the  vocal  cords  and  the 
posterior  commissure,  or  it  may  be  difi"used  over  the  whole  of  the  larynx.  The 
color  of  the  mucous  membrane  may  range  from  that  of  a  slight  vascular  in- 
jection to  a  deep  dusky  red.  The  vocal  cords  may  present  an  almost  normal  ap- 
pearance, their  lustre  perhaps  somewhat  dimmed ;  they  may  be  more  or  less 
hypergemic,  or  they  may  appear  as  two  large  rolls  of  deep  red  color  by  reason 
of  marked  swelling  of  their  under  surface.  The  tumefaction  also  varies  in 
extent — sometimes  so  slight  as  just  to  prevent  free  movement  of  the  vocal 
cords,  at  other  times  so  great  as  to  cause  marked  stenosis.  The  epithelium  is 
exfoliated  in  patches,  and  shallow  erosions  there  appear ;  in  other  parts  it  will 
be  seen  swollen  up  and  forming  grayish  circumscribed  elevations.  Small  ulcers 
are  sometimes  seen,  the  result  of  destruction  of  the  epithelial  covering  and  of 
bursting  of  distended  muciparous  follicles.  The  secretion  is  at  first  scant,  and 
if  the  catarrh  be  of  the  mild  form  and  remain  limited  to  the  vocal  cords,  may 


846    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

continue  so  throughout  the  whole  course  of  the  disease.  Usually  it  is  at  first 
viscid  and  transparent  like  glass ;  later  on,  by  the  addition  of  cell-detritus,  it 
becomes  turbid  and  yellowish  gray. 

In  the  severe  forms  of  catarrhal  inflammation  of  the  larynx  the  epiglottis 
presents  a  characteristic  change  of  form  ;  the  incurvation  of  its  lateral  borders, 
which  to  a  certain  extent  is  normal  in  childhood,  becomes  greater,  and  fre- 
quently gives  it  the  appearance  of  a  deep-red  swollen  stump,  which  can  be 
seen  even  without  a  mirror  by  simply  depressing  the  tongue. 

In  the  trachea  the  vascular  injection  is  rarely  a  diffused  one ;  only  in  the 
more  intense  forms  do  we  find  the  whole  mucous  membrane  deep  red  and 
velvety.  Ordinarily  the  redness  is  here  found  in  patches ;  the  tracheal  rings 
can  be  readily  recognized,  and  the  mucous  membrane  covering  them  is  less 
injected,  paler  than  that  of  the  interspaces. 

In  the  grave  form  the  inflammation  frequently  involves  the  submucous 
tissue. 

For  greater  lucidity  and  better  comprehension  the  various  types  will  now 
be  considered  separately. 

I.  The  Mild  Form  (Laryngitis  Oatarrhalis  Simplex;   Supraglot- 

Tic  Laryngitis). 

Symptoms. — The  main  features  of  the  disease  are  the  change  in  the  voice 
or  cry  and  the  cough.  In  young  infants  it  is  only  the  cry  that  is  altered, 
whilst  in  older  children  the  speaking  voice  is  also  changed ;  they  are  hoarse. 
This  hoarseness  may  be  very  slight,  only  noticeable  to  those  familiar  with  the 
child,  or  marked  and  apparent  at  once  to  every  one.  There  is  almost  never 
aphonia ;  however,  in  infants  who  cry  and  scream  a  great  deal  aphonia  may 
result  from  this.  Older  and  more  intelligent  children  may  complain  of  a  tick- 
ling or  burning  in  the  larynx  or  about  the  sternal  region.  Pressure  over  the 
cricoid  cartilage  or  over  the  trachea  usually  produces  manifestations  of  pain. 
There  is  not  much  cough  ;  it  is  chiefly  due  to  voluntary  eflbrts  at  expulsion  of 
mucus.  The  cough  is  dry  at  the  outset,  but  very  soon  becomes  looser  and 
softer,  an  indication  of  the  resolution  of  the  catarrhal  process.  It  never  has 
the  barking  tone  of  the  severe  type.  Respiration  remains  unchanged.  There 
are  no  paroxysms  of  dyspnoea.  Generally  there  is  greater  hoarseness  and 
more  cough  in  the  morning  just  upon  awakening  and  in  the  evening.  Fever 
is  most  frequently  wanting ;  when  it  does  present  itself,  it  is  usually  of  slight 
degree.  There  is  but  little  disturbance  of  the  economy  as  a  rule ;  the  child 
eats,  plays  and  sleeps  about  as  usual.  Acute  rhinitis  is  almost  always  present ; 
at  times  some  redness  and  swelling  of  the  pharyngeal  mucous  membrane  may 
be  noted.  In  some  instances  the  child  may  complain  of  earache,  which,  how- 
ever, very  soon  disappears,  or  he  may  complain  of  a  "cracking"  in  the  ear, 
heard  in  the  act  of  swallowing.  Occasionally  some  bronchial  catarrh  may  be 
present,  as  indicated  by  rales  heard  over  the  thorax. 

Laryngoscopic  examination  discloses  a  moderate  hypersemia  of  the  larynx 
or  a  more  intense  hyperaemia  of  the  larynx  and  trachea.  In  the  majority  of 
cases  it  is  limited  to  the  supraglottic  portion  of  the  larynx.  The  posterior  por- 
tion of  the  vocal  cords,  the  posterior  commissure,  and  the  mucous  membrane  of 
the  ventricular  bands  are  the  principal  seat  of  the  catarrh.  There  is  but  very 
little  or  no  swelling  of  the  mucous  membrane. 

Course  and  Duration. — Under  fair  conditions  the  disease  runs  a  very 
rapid  and  favorable  course,  ending  in  recoveiy.  Its  duration,  dependent  some- 
what upon  the  degree  of  intensity,  is  from  three  to  eight  days.     Either  from 


CATARRHAL   LARYNGITIS.  847 

neglect  of  the  primary  affection  or  from  some  inherent  idiosyncrasy  the  disease 
may  become  chronic ;  this,  however,  is  rather  a  rare  occurrence  in  young 
children.  An  acute  progression  into  the  seyerer  forms  is  not  very  frequent. 
Complications. — Bronchitis  or  catarrhal  pneumonia  may  develop  in  the 
course  of  a  catarrhal  laryngitis  as  a  result  of  the  downward  extension  of  the 
inflammatory  process. 

Diagnosis. — The  diagnosis  is  not  difficult.  The  hoarseness  of  the  cry  or 
of  the  voice,  the  cough,  and  the  tenderness  over  the  larynx  will  clearly  indicate 
the  seat  of  the  affection.  The  mildness  of  the  special  symptoms,  the  absence 
of  fever  or  its  low  degree,  the  undisturbed  condition  of  the  general  economy, 
and  the  coincident  rhinitis  will  indicate  the  type. 

Prognosis. — The  prognosis  is  always  favorable  :  recovery  is  the  rule- 
Treatment. — The  treatment  is  simple.  The  child  must  be  kept  in  the 
house  and  if  possible  in  one  well-ventilated  room,  the  atmosphere  of  which  is 
maintained  at  an  equable  temperature.  If  the  room  be  heated  by  a  stove,  a 
pot  of  water  should  be  kept  constantly  thereon  to  moisten  the  air.  Attention 
must  be  paid  to  the  child's  clothing  that  it  shall  be  sufficiently  warm,  lest 
he  should  t)e  chilled  every  time  the  door  is  opened  or  if  he  should  happen  to 
run  out  into  an  adjoining  room  or  hall.  If  the  bowels  are  costive,  a  laxative 
— e.g.  a  dose  of  castor  oil — must  be  administered.  When  children  object  to 
taking  oil -or  do  not  retain  it  upon  the  stomach,  I  have  found  the  following 
formula  answers  the  purpose  very  well : 

^.  Mass.  hydi'argyri grs.  ij. 

Syr.  mannae .  f  3v. 

Syr.  rhei  aromat f^iij- — M. 

Sig.  One  teaspoonful  every  two  hours  till  bowels  are  moved  (for  a  child 
from  two  to  four  years  old). 

Or  this, 

I^.  AqufB  laxativae  Viennensis  (Ph.  G.)^     .    .    .    .  f  Ij. 

Syr.  rhei  aromat f  3iij- — M. 

Sig.   One  teaspoonful  every  two  hours  till  bowels  are  moved. 

For  the  local  process  in  the  larynx  mild  demulcent  drinks  are  given,  as 
warm  milk  sweetened,  or  milk  and  seltzer  water,  or  oatmeal-  or  barley-water 
sweetened.  Of  medicines,  some  preparation  of  ammonia  (I  prefer  the  carbon- 
ate on  account  of  its  more  agreeable  taste),  of  ipecacuanha,  or  of  both  com- 
bined, or  a  combination  of  syrup  of  ipecacuanha  and  syrup  of  senega,  will  be 
of  great  benefit.     For  example: 

^.  Ammonii  carbonatis grs.  ij— v- 

Syr.  ipecacuanhge f^ij— 3iij. 

Syr.  senegse f  3ij-5iij. 

Syr.  tolutan q.  s.  ad  fsj. — M. 

Sig.   One  teaspoonful  every  two  hours  (for  children  from  two  to  five  years 
old). 

^  Very  much  like  the  infusum  sennse  compositum  of  the  U.  S.  P. ;  instead  of  Epsom, 
Rochelle  salts  are  used. 


848    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

For  children  under  two  years  I  use  the  following  formula : 

'B^.  Ammonii  carbonatis grs.  ij. 

Mucilag.  acacise f3ij- 

Vin.  ipecacuanhge gtt.  xxxv. 

Syr.  senegae f  3J. 

Syr.  tolutan q.  s.  ad  f  §i. — M. 

Sig.   One  teaspoonful  every  two  hours. 

Externally  a  stimulating  embrocation,  as  camphorated  oil,  with  or  without 
the  addition  of  a  little  turpentine  or  of  tincture  of  ginger,  or  amber  oil,  may 
be  applied. 

If  the  child  be  of  sufficient  age  and  of  sufficient  intelligence,  an  inhalation 
from  a  steam  atomizer  of  a  mild  solution  of  sodium  bicarbonate  in  glycerin 
and  water  (a  few  drops  of  carbolic  acid  can  be  added  to  the  solution  for  its 
antiseptic  properties)  may  be  given  twice  a  day.  In  very  young  children 
inhalations  cannot  be  satisfactorily  administered,  and  are  therefore  useless. 

The  rhinitis  that  is  usually  present  should  receive  prompt  attention.  The 
nose  should  be  sprayed  every  four  hours ;  for  this  purpose  either  a  1  or  2  per 
cent,  solution  of  menthol  in  albolene  or  some  astringent  solution,  like  the 
following,  should  be  used : 

'Sf.   Cocaine  hydrochlorat grs.  ij-iij. 

Acid,  tannic • grs.  v. 

Aq.  destillat f^iv. 

Hydrogen  peroxide f3J- 

Glycerini      f^iii- — M. 

Sig.  Use  as  a  spray. 

If  fever  be  present,  a  few  small  doses  of  quinine  will  allay  it.  The  choco- 
late quinines  (for  very  young  children  I  have  them  powdered  and  administered 
in  milk)  are,  by  reason  of  their  tastelessness,  excellent  for  this  purpose ;  two  to 
four  tablets  may  be  given  every  four  hours.  If  the  cough  is  very  troublesome 
at  night,  one-half  to  two  grains  of  Dover's  powder  or  five  to  fifteen  drops  of  the 
syrup  of  Dover's  powder,  according  to  the  age  of  the  child,  or  a  few  doses  of  the 
bromide  of  ammonium,  will  procure  a  good  night's  I'est. 

Throughout,  the  diet  should  be  a  bland  but  nutritious  one. 

n.   The  Severe  Form  ;   Spasmodic  Laryngitis  (Laryngitis  Stridu- 
LOS  A  ;  Pseudo-Croup  ;  Catarrhal  Croup). 

Symptoms. — The  characteristic  feature  of  the  disease  usually  sets  in  sud- 
denly. The  child  has  been  asleep  for  three  or  four  hours,  sleeping  quietly,  when, 
either  with  preceding  manifestations  of  restlessness  or  suddenly,  it  wakes  up 
Avith  a  suffocative  attack.  It  coughs  ;  the  cough  is  short,  barking,  deep-toned  ; 
between  the  coughs  the  deep  inspirations  have  a  stridulous,  crowing  sound. 
Great  anxiety  is  manifested  by  these  little  patients  ;  very  young  children  will 
want  to  be  taken  up  and  held  upon  the  arm  ;  older  children  will  sit  up  in  bed 
and  clutch  at  the  throat,  as  if  to  remove  the  obstacle  they  imagine  there. 
The  face  is  somewhat  congested  ;  the  skin  is  bathed  in  perspiration,  and  the 
pulse  is  accelerated.  Generally  the  accessory  respiratory  muscles  are  not  called 
upon  ;  at  most  there  may  be  noticed  a  slight  distention  or  increased  movement 
of  the  alae  nasi.  In  very  severe  paroxysms,  which  are  of  exceptional  occur- 
rence, the  accessory  respiratory  muscles  are  called  into  activity,  the  epigas- 


CATARRHAL   LARYNGITIS.  849 

trium  and  false  ribs  are  drawn  in  on  inspiration,  and  the  face  is  somewhat 
cyanotic.  The  dyspnoea  lasts  for  about  a  minute,  a  little  longer  in  the  very 
severe  cases,  when  it  begins  to  diminish  in  intensity,  and  in  half  an  hour  has 
entirely  or  almost  entirely  disappeared.  In  about  an  hour  the  child  has  quieted 
down,  and  soon  goes  to  sleep  again.  It  may  cough  several  times  during  the 
night :  that  short,  barking  cough,  without,  however,  being  disturbed  thereby. 
The  next  morning  the  child  is  apparently  well ;  older  children  will  want  to 
get  out  of  bed  or  even  out  of  the  room,  and  nothing  but  an  occasional 
raw,  barking  cough  remains  to  tell  of  what  has  occurred  the  preceding  night 
Occasionally  towards  the  afternoon  the  cough  may  become  dryer  and  tighter, 
and  the  child  have  another  suffocative  paroxysm  the  succeeding  night.  This 
usually  ends  the  matter,  and  nothing  but  a  loose  cough  remains. 

There  may  be  some  variation  in  this  picture.  The  dyspnoea  may  last  for  a 
longer  period  than  above  described,  although  the  child  may  fall  asleep  after 
a  while ;  but  even  during  sleep  the  inspiration  will  be  attended  by  a  stridulous 
or  sawing  noise.  Or  there  may  be  no  dyspnoea  at  all,  nothing  but  the  croupy, 
barking  cough  (and  that  is  the  phenomenon  that  fills  the  family  with  terror). 
This  is  more  frequently  the  case  when  this  form  of  catarrhal  laryngitis  occurs 
in  older  children,  those  beyond  the  fifth  year. 

It  is  stated  that  there  may  be  a  recurrence  of  the  paroxysms  for  from  three 
to  five  nights.  In  a  large  experience  I  have  never  seen  such  recurrence;  in 
fact,  never  noted  a  recurrence  on  the  second  night.  Steiner  and  Monti  observed 
the  recurrence  of  the  suffocative  attacks  for  ten  or  twelve  nights;  this  was, 
however,  more  particularly  noted  in  rachitic  children.  The  special  tendency 
of  such  children  to  laryngismus  stridulus  is  perhaps  no  unimportant  factor  in 
the  protraction  of  an  attack  of  pseudo-croup. 

The  occurrence  of  an  attack  of  spasmodic  laryngitis  during  the  morning  or 
day  sleep  is  exceedingly  rare.  Barthez  and  Rilliet  state  that  they  have  occa- 
sionally observed  the  second  paroxysm  to  set  in  during  the  early  morning 
hours. 

Frequently  the  paroxysms  are  preceded  a  day  or  a  few  hours  by  a  mild 
catarrh  of  the  upper  respiratory  tract — a  coryza;  there  may  have  been  some 
hoarseness  of  voice  and  some  cough,  but  of  so  mild  a  character  that  no 
attention  was  paid  to  them  by  the  parents,  and  no  measures  for  their  cure 
instituted.  Or  there  may  have  been  marked  hoarseness  and  sonorous  cough. 
Occasionally,  and  not  infrequently,  no  such  preliminary  manifestations  have 
occurred,  the  suffocative  attack  setting  in  suddenly  after  some  prolonged 
exposure  on  the  part  of  the  child  some  hours  previously. 

As  to  the  mechanism  of  the  paroxysm  of  dyspnoea  opinions  differ.  It  is 
possible  that  true  spasm  of  the  laryngeal  muscles  may,  in  a  certain  category 
of  cases,  as  in  rachitic  children  or  children  who  have  at  one  time  been  afilicted 
with  laryngismus  stridulus,  be  a  prominent  factor  in  its  production;  in  the 
majority  of  instances,  however,  it  is  undoubtedly  primarily  due  to  the  increase 
of  the  tumefaction  during  sleep,  when  the  child  is  lying  down — to  the  dryness 
of  the  laryngeal  and  pharyngeal  mucous  membrane  at  this  time,  and  the  incrus- 
tation of  mucus  upon  the  vocal  cords,  still  further  narrowing  the  already  some- 
what contracted  glottis,  and  producing  an  impediment  to  respiration  sufficient 
to  wake  the  child.  That  these  are  the  main  and  necessary  conditions  for  its 
production  is  proven  by  the  rapidity  with  which  the  symptoms  abate  after  the 
child  has  been  taken  up  and  some  warm  drink  given  it.  It  is  also  more  than 
probable  that  the  hoarse,  barking  cough  with  which  the  child  usually  awakes 
is  the  result  of  reflex  irritation  proceeding  from  the  inspissated  mucus — in 
other  words,   the  attempt  of  nature  to  dislodge  it. 

64 


850    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

There  is  not  much  elevation  of  temperature.  I  have  never  found  the  ther- 
mometer to  indicate  more  than  101.5°-102°  F.  shortly  after  the  abatement 
of  the  paroxysm. 

Laryngoscopic  examination  will  disclose  considerable  hyperemia  and  tume- 
faction of  the  mucous  membrane,  especially  of  the  ventricular  bands,  so  that 
these  may  lie  over  the  true  vocal  cords  and  the  latter  appear  narrower.  The 
vocal  cords  themselves  may  have  a  tumefied  and  rosy  appearance,  the  tume- 
faction pertaining  more  particularly  to  their  under  surface.  The  mucous  mem- 
brane of  the  thyroid  cartilages,  of  the  ary-epiglottic  folds,  and  of  the  trachea,  is 
considerably  swollen,  and  either  uniformly  injected  a  deep  red  or  hyper?emic 
only  in  spots ;  the  surface  sometimes  presents  a  grayish  appearance,  as  if  it  had 
been  touched  with  caustic;  this  is  undoubtedly  due  to  a  swelling  of  the  epi- 
thelium. Incrusted  mucus  is  also  seen  upon  the  interarytenoid  mucous  mem- 
brane and  along  the  posterior  portions  of  the  vocal  cords. 

Coiirse  and  Duration. — The  disease  with  proper  attention  usually  runs  a 
mild  course:  the  cough  soon  becomes  loose  and  soft:  there  are  no  further 
returns  of  the  paroxysms,  and  in  from  five  to  fourteen  days  the  child  has 
entirely  recovered.  It  is  well  enough,  however,  to  remember  the  fact,  already 
mentioned,  that  there  is  a  tendency  to  a  recurrence  of  the  disease  with  every 
fresh  exposure. 

Complications. — Bronchitis  and  broncho-pneumonia. 

Diagnosis. — The  diagnosis  of  pseudo-croup  does  not  usually  present  any 
difiBculties.  The  brief  invasion,  the  characteristic  paroxysm  with  its  sonorous, 
barking  cough,  and  the  rapidity  with  which  it  passes,  the  time  of  onset,  the 
rather  mild  febrile  movement,  are  features  sufficiently  distinctive  to  make  error 
almost  impossible.  The  only  two  diseases  with  which  it  could  be  confounded 
are  laryngismus  stridulus  and  true  croup.  From  the  former  it  is  readily  dis- 
tinguished by  the  cough,  the  hoarseness  in  the  voice,  and  the  fever — phenomena 
altogether  wanting  in  laryngismus  stridulus.  From  the  latter,  for  which  only 
a  very  severe  attack  of  spasmodic  laryngitis  could  be  mistaken,  the  differential 
diagnosis  can  be  made  by  remembering  the  following  points :  In  true  croup  the 
symptoms  are  at  the  outset  very  mild  and  gradually  grow  in  intensity.  This 
increase  in  gravity  continues  both  dav  and  night.  The  difficulty  in  breathing 
grows  by  degrees,  and  continues  so  to  grow  till  the  climax,  marked  dyspnoea, 
is  reached.  The  cough  is  harsher  and  more  smothered.  The  voice  is  hoai-se 
and  rather  muffled.  There  is  a  high  degree  of  fever  and  great  disturbance  of 
the  general  economy.  Furthermore,  in  50  per  cent,  of  the  cases  of  true  croup 
false  membrane  can  be  seen  upon  the  tonsils,  uvula,  fauces,  or  pharynx.  In 
pseudo-croup  the  suffocative  attack  comes  on  suddenly  in  the  night,  at  once 
with  maximum  intensity,  and  abates  entirely  in  a  very  shoi't  time.  The  cough 
is  sonorous.  The  voice,  soon  after  the  paroxysm  is  over,  regains  tone,  though 
it  may  be  somewhat  hoarse.  There  is  much  less  fever  and  much  less  dis- 
turbance of  the  general  economy. 

ProgTiosis, — The  prognosis  is  as  a  rule  favorable ;  no  death  from  pseudo- 
croup  has  ever  been  reported.  Nevertheless,  it  should  be  a  guarded  one.  for 
the  reason  that  this  form  of  catarrhal  laryngitis  may.  either  from  total  neglect 
or  even  insufficient  attention  to  the  child,  progress  into  the  grave  form,  or  that 
a  pseudo-membranous  laryngitis  may  supervene  upon  the  catai'rhal.  the  in- 
flamed mucous  membrane  forming  an  excellent  nidus  for  the  lodgement  and 
propagation  of  disease  germs. 

Treatment. — Ordinarily  the  paroxysm  per  se  does  not  require  the  atten- 
tion of  the  physician ;  it  is  usually  over  by  the  time  he  reaches  the  hou.se. 
Only  in  exceptional  cases,  where  the  paroxysm  is  very  much  prolonged,  where 


CATARRHAL   LARYNGITIS.  851 

spasm  of  the  laryngeal  muscles  has  probably  been  excited  by  the  laryngitis, 
must  special  measures  for  its  abatement  be  instituted.  For  this  purpose  the 
child  should  be  placed  in  a  warm  bath,  temperature  100°-101.5°  F.,  and 
allowed  to  remain  therein  from  ten  to  fifteen  minutes,  so  as  to  obtain  its  full 
relaxing  effect ;  or  a  hot  mustard  foot-bath  may  be  given  in  its  stead.  A  sponge 
wrung  out  of  hot  water  may  be  applied  over  the  pomum  Adami,  as  described 
farther  on.  Or  20-25  drops  of  ether  may  be  given  to  a  child  two  years  of  age, 
and  if  necessary  it  may  be  allowed  to  inhale  a  little.  The  ether  acts  by  its 
relaxing  effect  on  the  laryngeal  muscles  and  its  expectorant  effect  on  the  mucous 
membrane.  (For  other  remedial  measures  employed  for  this  purpose  see  the 
article  on  Laryngismus  Stridulus.) 

The  treatment  of  pseudo-croup,  with  the  exception  above  noted,  is  rather 
simple.  The  remedy  mainly  indicated  is  one  that  has  both  expectorant  and 
relaxing  properties,  and  the  one  that  best  fulfils  these  indications  here  is  some 
form  of  ipecacuanha.  The  formula  I  have  employed  with  unvarying  success 
is  this : 

^.  Vin.  ipecac fjj. 

Tinct.  aconiti IfTL  ij- 

Syr.  tolutan f^iij- 

Liquor,  ammonii  acetat f§i. — M. 

Sig.  Teaspoonful  every  hour  till  cough  is  loosened ;  then  every  two  hours. 

In  children  under  two  years  I  use  the  following  formula : 

I|i.  Liquor,  ammonii  acetat .  f^vj. 

Tinct.  aconiti TTLj- 

Syr.  ipecac fgiiss. 

Syr.  tolutan f^iss. — M. 

Sig.   Teaspoonful  every  two  hours. 

In  these  formulae  we  have  the  expectorant  properties  of  the  ipecacuanha 
aided  by  those  of  the  mild  ammonium  preparation  and  by  the  relaxing  effect 
of  the  aconite.  The  liquor  ammonii  acetatis  has,  furthermore,  diaphoretic 
properties  very  advantageous  in  the  treatment  of  inflammations  of  the  respi- 
ratory tract.  The  aconite  acts  as  a  febrifuge  and  is  reinforced  by  the  ipecac- 
uanha. 

If  after  twelve  to  eighteen  hours  I  find  that  the  respiration  is  still  accom- 
panied by  a  sawing  noise,  is  still  somewhat  stridulous  or  whistling,  although 
there  is  no  dyspnoea  present,  I  prescribe  pilocarpine : 

^.  Pilocarpin.  hydrochlorat gr.  J. 

Acid,  hydrochloric,  dilut TTL  v. 

Aq.  destillat f^iij- 

Ext.  ipecac,  fl tUiij- 

(aut,  vin.  ipecac f3J.) 

Syr.  scillee fsiij- 

Syr.  tolutan f^ss. — M. 

Sig.   Teaspoonful  every  two  hours  for  a  child  two  and  a  half  years  old. 

I  have  never  derived  any  benefit  from  the  other  preparations  of  ammonium 
usually  employed,  the  muriate  and  the  carbonate,  in  any  form  of  acute  sub- 
glottic laryngitis  ;  on  the  contrary,  I  have  always  found  them,  more  especially 
the  latter,  absolutely  detrimental.     I  have  had  such  uniform  success  with  the 


852     A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

described  remedies  and  formulae  that  I  have  never  had  occasion  to  resort  to 
opiates ;  and  in  this  respect  I  agree  with  Bosworth  that,  as  a  rule,  they  should 
be  avoided.     Emetics  are  never  required. 

Externally,  an  application  of  camphorated  oil,  as  already  described,  may 
be  made,  or  a  layer  of  fat  bacon  or  a  piece  of  fat  salt  pork,  upon  which  some 
pepper  is  sprinkled,  may  be  tied  around  the  throat.  Sometimes  benefit  is 
derived  from  the  application  of  Avarm  flaxseed  poultices. 

If  rhinitis  be  present,  it  will  be  treated  as  already  described  in  the  pre- 
vious section. 

The  child  must  be  kept  in  a  warm,  well-ventilated  room,  and  under  no  con- 
sideration allowed  to  be  taken  out  or  to  go  out.  After  five  or  six  days,  if  the 
disease  have  progressed  favorably  and  the  weather  be  good,  it  can  be  taken 
out  for  a  couple  of  hours  during  the  warmest  part  of  the  day.  The  diet  must 
be  bland,  but  nutritious.     The  bowels  must  be  kept  soluble. 

m.  The  Grave  Form.  (Laryngitis  Hypoglottica"  Acuta  Gravis; 
Acute  Subglottic  Laryngitis,  of  Grave  Form  ;  Spasmodic 
Laryngitis,  Severe  Form  ;  Catarrhal  Croup.) 

S3miptoins. — This  form  of  catarrhal  laryngitis  is  almost  always  an  acute 
progression  of  one  or  the  other  of  the  milder  forms.  This  progression  may 
be  slow,  requiring  from  five  to  ten  days  till  the  climax  is  reached,  or  it  may 
be  very  rapid,  thirty -six  hours  to  two  days.  It  is  marked  by  an  exagge- 
ration of  all  the  phenomena  above  described.  The  suffocative  paroxysms  are 
of  greater  intensity  and  of  longer  duration ;  in  fact,  once  established,  the 
dyspnoea  is  continuous,  with  but  temporarily  diminished  intensity  during  longer 
or  shorter  intervals.  Usually  the  onset  is  marked  by  increased  frequency 
of  cough,  which  is  short,  hoarse,  and  markedly  croupal ;  it  is  a  dry  cough  ; 
it  is  painful,  the  child  crying  between  the  coughs  and  complaining  that  it 
hurts  him.  The  voice  is  very  hoarse  or  altogether  extinguished.  The  effort 
at  speaking  is  frequently  painful,  and  the  little  patient  will  indicate  his  wants 
by  pantomimic  motions.  Then  the  respiration  becomes  somewhat  difificult  and 
rather  loud,  and  the  child  becomes  restless  and  irritable,  and  wants  to  be  held 
upon  the  mother's  arm  or  lap.  After  a  longer  or  shorter  period,  preferably 
in  the  night,  the  .suffocative  paroxysm  manifests  itself  in  all  its  severity.  The 
cough  is  continuous,  hoarse,  barking,  short ;  it  is  not  sonorous,  rather  more 
muffled;  the  respiration  whistling  and  long  drawn;  the  long-drawn,  stridulous, 
crowing,  or  hissing  inspiration,  interrupted  by  short,  hoarse,  rather  muffled 
coughs,  and  followed  by  the  prolonged  expiratory  sound,  can  be  heard  at  a  dis- 
tance. With  every  respiration  the  larynx  makes  marked  excursions.  All  the 
accessory  respiratory  muscles  are  brought  into  full  play ;  the  sterno-cleido-ma.s- 
toid,  the  pectoral,  the  serrati,  and  other  muscles  are  observed  acting  energetic- 
ally. With  every  inspiration  the  thorax  is  markedly  elevated,  whilst  at  the 
same  time  the  jugulum,  the  intercostal  spaces,  and  the  epigastrium  sink  in 
deeply;  on  the  following  expiration  the  thorax  does  not  at  once  return  to  its 
normal  position,  and  the  active  efforts  of  the  abdominal  muscles  are  required 
to  effect  this.  The  veins  of  the  neck  are  distended  and  filled  with  dark  blood. 
The  extremities  ai-e  slightly  cyanotic.  The  skin  is  somewhat  turgid;  perspi- 
ration may  be  abundant  over  the  Avhole  surface,  or  only  a  cold,  clammy  sweat 
cover  both  head  and  face.  These  symptoms  persist,  with  perhaps  somewhat 
lessened  intensity,  throughout  the  night ;  generally  toward  morning  there  is  more 
marked  abatement ;  the  child  will  fiill  asleep,  gain  a  few  hours'  rest,  and  wake 
up  again  with  another  suffocative  attack.     The  cough  is  now  almost  toneless, 


CATABBHAL    LABYNGITIS.  853 

occurs  at  but  long  intervals,  and  is  very  short.  If  the  voice  vas  only  hoarse 
at  the  outset,  it  is  now  altogether  abolished.  The  respiration  is  much  more 
difficult ;  all  the  accessory  respiratory  muscles  are  in  activity ;  the  whole  atten- 
tion and  energy  of  the  patient  are  directed  to  his  breathing;  the  stridulous, 
sawing  noise  accompanying  inspiration  is  still  more  marked.  The  child  can- 
not lie  down,  but  sits  propped  up  in  bed  or  upon  the  mother's  lap.  Gradually 
there  is  an  apparent  relaxation  in  the  patient's  efforts  at  breathing;  he  lies 
back  a  little  more;  the  pulse  becomes  small  and  thready  and  extremely  rapid; 
the  face  assumes  a  pale,  cadaveric  appearance;  the  child  becomes  comatose  or 
delirious,  and  death  supervenes  either  from  asphyxia  or  in  an  attack  of  general 
convulsions. 

Exceptionally  the  laryngitis  may  be  of  the  grave  type  from  the  outset,  its 
first  manifestations  being  the  severe  suflFocative  jDaroxysm  just  described. 

The  course,  however,  is  not  always  so  stormy :  in  rare  instances  the  pro- 
gress of  the  disease  is  very  insidious;  the  symptoms  are  of  a  comparatively 
mild  character,  until  suddenly,  without  any  warning,  death  seems  imminent. 
The  child  has  a  laryngitis  of  mild  type,  to  which  no  attention  is  paid,  and  he 
is  allowed  to  run  around  at  pleasure.  After  a  few  days,  perhaps  a  week,. he 
becomes  aphonic;  there  is  but  little  cough,  and  that  very  much  muffled  and 
dry.  Suddenly  the  parents  observe  that  the  child,  which  has  lain  down,  is 
evidently  unconscious ;  the  eyeballs  are  rolled  up  under  the  upper  lids,  the  face 
is  cyanotic  or  of  cadaveric  paleness ;  the  body  is  cool ;  the  pulse  very  feeble, 
nearly  imperceptible;  the  respiration  almost  completely  arrested.  With  an 
effort  the  child  may  be  recalled  to  consciousness  for  a  few  moments,  but  he  will 
quickly  relapse  into  the  state  of  stupor,  from  which  he  may  never  awake. 

The  fever,  except  in  the  class  of  cases  last  described,  is  always  very  high ; 
the  thermometer  ranges  from  102°  to  103°  F.  at  the  onset,  and  from  104°  to 
105°  and  higher  at  the  period  of  greatest  intensity.  There  is  generally  great 
thirst,  the  patient  constantly  craving  cold  drinks,  of  which  he  will  take  but  a 
sip,  on  account  of  the  interference  with  respiration.  The  appetite  is  completely 
gone,  and  it  is  with  greatest  difficulty  that  the  child  can  be  persuaded  or  made 
to  take  a  little  milk  or  beef-tea. 

When  the  disease  tends  toward  recovery  the  severity  of  the  symptoms 
gradually  abates,  and  when  convalescence  is  fully  established  they  have  all 
disappeared,  with  the  exception  of  the  aphonia,  which  frequently  continues  for 
a  considerable  time ;  or,  even  if  the  voice  be  regained  soon,  it  will  have  a 
husky  tone  for  quite  a  long  time. 

Laryngoscopic  examination  discloses  an  exaggeration  of  the  picture  described 
in  the  previous  section.  The  mucous  membrane  of  the  whole  larynx  and 
trachea  is  markedly  hypersemic  and  swollen  ;  the  ventricular  bands  are  greatly 
injected;  the  vocal  eords  are  either  pinkish  or  normal  in  color;  beneath 
these,  projecting  into  the  line  of  vision,  can  be  seen  the  deep-red  or  almost 
purplish  rounded  masses  of  tumefied  subglottic  tissue,  bellying  out  far  beyond 
the  line  of  the  true  vocal  cords  and  narrowing  the  glottis  down  to  a  slit.  On 
the  free  border  of  these  folds  of  infiltrated  subglottic  tissue  the  muco-purulent 
secretion  collects,  becomes  inspissated,  and  forms  ragged  and  jagged  incrusta- 
tions, which  tend  to  still  further  aggravate  the  stenosis.  As  the  disease  abates 
these  incrustations  disappear,  and  the  folds  diminish  in  size  and  become  pale 
in  color. 

Course  and  Duration. — The  course  and  duration  of  the  disease  depend 
to  a  great  extent  upon  the  degree  of  intensity  developed,  upon  the  period  at 
which  medical  treatment  is  resorted  to,  whether  early  or  late,  and  upon  the 
mode  of  treatment.     Usually  with  a  sufficiently  energetic  treatment  the  acute 


854    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

symptoms  subside  in  from  two  to  three  days.  They  never  last  over  five  days. 
The  duration  of  the  disease  from  its  onset  to  its  definite  cure  may  occupy  a 
period  of  from  two  to  three  weeks. 

Complications. — Bronchitis,  broncho-pneumonia,  convulsions. 

Prognosis. — The  prognosis  will  depend  in  a  great  measure  upon  the  period 
at  which  the  physician  first  sees  the  case.  If  at  an  early  period,  before  the 
pathological  process  has  involved  the  submucous  tissues,  before  the  disease  has 
reached  its  climax,  a  favorable  prognosis  can  usually  be  made  at  once.  If, 
however,  he  is  called  at  a  late  period,  when  the  laryngeal  stenosis  is  already 
very  marked,  it  should  be  very  guarded,  and  more  especially  so  if  the  con- 
dition be  due  to  too  early  exposure  after  measles.  In  my  experience  these  have 
been  the  hardest  to  deal  Avith,  and  I  have  seen  such  cases  die  despite  trache- 
otomy, despite  intubation.  Then  it  must  be  remembered  that  one  or  the  other 
of  the  complications  mentioned  may  develop  and  carry  off  the  patient. 

Treatment. — In  the  early  stage,  when  the  grave  form  is  just  developing, 
Avhen,  although  the  voice  is  very  hoarse  or  altogether  lost,  the  short  cough  is 
still  somewhat  sonorous  or  but  slightly  muffled,  the  respiration  is  still  com- 
paratively easy,  without  very  much  stridor,  excellent  results  will  be  obtained 
with  very  small  doses  of  tartar  emetic : 

^.  Antimonii  et  potassii  tartrat gr.  ^|. 

Syr.  tolutan fiss. 

Aq.  destillat f^iss. — M. 

Sig.  One  teaspoonful  every  two  hours,  for  children  from  two  to  four  years 
old.  If  this  dose  produces  emesis  or  nausea,  but  one-half  to  one-third 
of  a  teaspoonful  are  subsequently  given. 

When  the  disease  is  fully  developed  and  the  dyspnoea  great,  energetic 
treatment  is  required. 

It  is  in  this  form  of  catarrhal  croup  that  the  emetic  finds  its  justification, 
and  should  be  promptly  administered. 

The  preferable  one  here  again  is  tartar  emetic : 

I|i.  Vin.  antimonii 

Oxymel.  scilljB aaf^ss. — M. 

Sig.  One-half  to  one  teaspoonful  every  ten  or  fifteen  minutes  till  emesis 
results. 

Or  it  may  be  combined  with  ipecacuanha : 

I^.  Vin.  antimonii f^iij- 

Syr.  ipecac f^v. — M. 

Sig.  One-half  to  one  teaspoonful  every  ten  or  fifteen  minutes  till  the  de- 
sired effect  is  obtained. 

Or  the  compound  syrup  of  squills  may  be  employed,  though  the  stimulating 
character  of  the  squills  and  senega  contained  therein  makes  it  less  desirable 
than  the  preceding  formulae.  If  the  effect  be  delayed,  it  can  be  hastened  by 
tickling  the  fauces  Avith  the  finger  or  with  a  feather.  After  this  the  antimony 
is  continued  in  fractional  doses,  as  above  described. 

If,  despite  free  emesis,  the  dyspnoea  continues  marked  and  threatening,  the 
application  just  above  the  manubrium  sterni,  or  the  jugulum,  of  from  two  to  six 
leeches,  according  to  the  age  of  the  child,  is  recommended  by  some  authors. 
Though  bleeding  is  not  favored  by  many  paediatrists,  nevertheless  in  children 


CATARRHAL   LARYNGITIS.  855 

of  full  habit,  and  if  care  be  taken  to  arrest  the  haemorrhage  promptly  as  the 
leeches  fall  off,  the  measure  will  undoubtedly  be  of  great  benefit.  If  the 
stridor  in  the  respiration  continues  marked,  though  the  dyspnoea  has  greatly 
abated,  the  application  of  a  blister  to  the  neck  at  the  side  of  the  larj^nx, 
followed  by  a  dressing  of  unguentum  hydrargyri,  is  likewise  recommended  by 
some  writers. 

If  the  bowels  are  confined,  they  should  be  freely  moved,  and  for  this  pur- 
pose a  dose  of  calomel,  alone  or  in  combination  with  sodium  bicarbonate,  may 
be  prescribed  ;  and  if  its  action  be  tardy,  it  can  be  hastened  by  an  enema  of 
water  or  of  glycerin. 

J.  Forsyth  Meigs  recommended  the  following  formula  as  one  that  had  given 
him  good  results : 

I^.   Hydrarg.  chloridi  mitis gr.  vj. 

Antimonii  sulphuret.  prgecipitat g^'-  j- 

Potass,  nitrat gr.  xij-xxij. — M. 

Ft.  pulv.  et  divide  in  part,  sequal.  No.  xij. 
Sig.  Powder  every  two  hours. 

He  also  stated  that  in  some  cases  where,  despite  emetics,  bleeding,  and 
antimony,  the  dyspnoea  had  gone  on  for  four  or  five  days,  it  yielded  rapidly 
under  the  sedative  and  cathartic  effect  of  four  grains  of  calomel  administered 
in  one-grain  doses  every  hour. 

Rauchfuss  reports  some  cases  that  he  treated  with  calomel  in  small  doaes 
internally,  and  inunctions  of  mercurial  ointment,  with  excellent  results. 

In  addition  to  the  measures  already  described,  inhalations  from  a  steam 
atomizer  or  sprays  of  a  solution  of  sodium  bicarbonate,  with  the  addition  of  a 
little  carbolic  acid,^  will  prove  of  great  advantage. 

During  the  paroxysm  counter-irritation  by  means  of  mustard  plasters  can 
be  resorted  to,  or  the  measure  so  highly  recommended  by  Trousseau  may  be 
employed  :  A  sponge  is  dipped  in  water  as  hot  as  can  be  borne,  placed  under 
the  chin,  and  gradually  pressed  out,  so  as  to  have  the  hot  water  flow  over  the 
larynx ;  in  ten  or  fifteen  minutes  the  process  is  repeated.  Rauchfuss  also 
recommends  cleansing  the  pharynx  and  the  vestibulum  laryngis  by  means  of  the 
finger,  brush,  or  the  cotton-holder  Avrapped  Avith  cotton,  and  believes  that  by 
the  coughing  and  choking  thereby  excited  better  results  are  obtained  than  with 
an  emetic.  Or  the  administration  and  inhalation  of  ether,  as  already  described, 
may  be  resorted  to. 

Warm  drinks,  especially  warm  milk,  should  be  freely  given.  Even  when 
the  child  has  fallen  asleep  after  the  subsidence  of  the  most  threatening  symp- 
toms, it  should  be  awakened  every  few  hours  and  a  warm  drink  given  it,  and, 
if  it  be  old  enough,  an  inhalation,  to  keep  the  parts  moist  and  thus  prevent  a 
return  of  the  paroxysm. 

When,  despite  these  measures,  the  dyspnoea  grows  greater  and  asphyxia  is 
imminent,  as  indicated  by  stupor,  and  by  rolling  up  of  the  eyeballs  underneath 
the  upper  lids ;  or  if  these  symptoms  have  already  supervened  at  the  time  the 
physician  is  called,  intubation  or  tracheotomy  should  be  at  once  resorted  to. 

^  R .  Sodii  bicarb .^j_. 

Sodii  benzoat Qiss. 

Acid,  carbol.  cryst frt  xij. 

Glycerin f  .5J- 

Aq.  destill fgij.— M. 

Sig.  Two  teaspoonfuls  with  an  equal  quantity  of  water  in  cup  of  steam  atomizer. 


856    A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

After  the  imminent  danger  has  been  averted  one  or  the  other  method  of 
treatment  can  be  employed.  If  antimony  be  selected,  it  should  be  the  wine 
that  is  directed,  and  in  such  small  doses  that  it  cannot  produce  retching  or 
emesis,  so  as  not  to  dislodge  the  tube.  Intubation  is,  in  my  opinion,  to  be 
preferred  to  tracheotomy  for  the  middle  and  poorer  classes,  as  it  is  almost  im- 
possible for  them  to  give  the  necessary  attention  to  the  patient  that  is  required 
after  the  operation.  The  tube  can  be  removed  in  from  twelve  to  twenty-four 
hours. 

During  the  attack  the  child  must  be  kept  in  bed  in  a  well-ventilated  room, 
the  atmosphere  of  which  should  have  a  certain  amount  of  moisture ;  after  sub- 
sidence of  the  attack,  although  he  may  be  allowed  to  be  up  in  the  room,  great 
care  must  be  taken  that  he  shall  not  run  out  or  expose  himself  in  any  way. 

Convalescence  being  fully  established,  the  warm  drinks  may,  to  a  great 
extent,  be  withheld  and  the  moisture  of  the  room  markedly  lessened.  The 
inhalations  can  be  continued  for  some  time,  a  weak  astringent  solution  (alum 
1  per  cent.)  taking  the  place,  later,  of  the  soda  solution. 

An  accompanying  bronchitis  or  coryza  must  not  be  neglected. 

Prophylactic  Treatment. — "With  children  who  have  a  tendency  to  catar- 
rhal aifections  of  the  upper  respiratory  tract  a  prophylactic  treatment  should 
be  instituted  early.  They  should  be  accustomed  in  the  summer  months  to 
cold  bathing,  cold  sponging,  and  cold  frictions.  If  possible,  they  should  be 
taken  to  the  sea-shore  or  to  the  mountains  for  the  summer.  In  winter,  after 
being  washed  with  warm  water,  the  face,  neck,  and  hands  should  be  sponged 
off  Avith  cold  water  (just  as  it  flows  from  the  hydrant) ;  after  their  warm  bath 
(which  should  always  be  given  in  a  warm  room)  the  body  should  be  well  rub- 
bed with  cold  water  or  cold  alcohol  and  water,  and  thoroughly  dried.  They 
should  not  be  allowed  to  keep  on  topcoats  or  hats  or  shawls  whilst  in  the  house, 
or  to  run  out  of  the  house  insufficiently  clad.  They  should  be  dressed  properly 
and  not  made  sacrifices  to  the  vanity  of  their  parents,  especial  attention  being 
paid  to  their  foot-gear  that  it  be  water-proof;  during  wet  or  snowy  weather  the 
shoes  should  be  changed  two  or  three  times  in  the  day.  Their  diet  should  be 
plain  and  wholesome,  and  not  too  stimulating.  They  must  not  be  overburdened 
with  studies.  They  should  be  allowed  sufficient  exercise  in  the  fresh  air,  even 
on  very  cold  days,  but  with  the  direction  that  as  soon  as  tired  they  must  come 
into  the  house  to  rest :  they  must  not  rest  out  of  doors. 

If  the  children  are  anaemic  or  have  a  scrofulous  taint,  the  proper  remedies 
must  be  administered. 


LARYl^GISMUS  STRIDULUS. 

By  H.  ILLOWAY,  M.  D., 

Cincinnati. 


This  condition — termed  also  Spasmus  glottidis  (spasm  of  the  glottis) ; 
Asthma  Millarii ;  Asthma  thymicum  Koppii  (thymic  asthma) ;  Asthma  rachiti- 
cum — consists  of  paroxysms  of  spasmodic  closure  or  narrowing  of  the  glottis, 
causing  complete  or  almost  complete  arrest  of  respiration,  and  occurring  at 
longer  or  shorter  intervals. 

Laryngismus  stridulus  is  a  neurosis  of  the  larynx,  that  organ  being  gener- 
ally in  a  healthy  state.  It  is  an  affection  entirely  distinct  from  spasmodic 
laryngitis  (pseudo-croup),  with  which  it  has  been  identified,  especially  by  many 
English  writers.  It  is  not  to  be  confounded  with  true  infantile  asthma,  which 
is  an  entirely  different  disease.  Neither  must  it  be  confounded  with  internal 
convulsions  (inward  spasms),  though  it  is  true  that  spasm  of  the  glottis  may  occur 
in  inward  spasms,  and,  vice  versd,  inward  spasms  may  occur  in  the  course  of  a 
protracted  case  of  laryngismus  ;  in  either  instance,  however,  it  is  more  in  the. 
nature  of  a  complication  which  adds  to  the  dangers  of  the  primary  affection  and 
makes  its  prognosis  more  unfavorable. 

The  paroxysm  sets  in  always  during  inspiration,  and  is  produced  by  spastic 
contraction  of  the  muscles  which  normally  possess  the  function  of  narrowing  or 
closing  the  glottis — the  adductors,  the  two  thyro-arytenoids,  the  two  lateral 
crico-arytenoids,  and  the  arytenoideus  muscle.  This  abnormal  muscular  action 
is  the  result  of  irritation,  either  direct  or  reflex,  of  the  laryngeal  recurrent 
nerve,  or  of  the  vagus  above  the  point  where  the  laryngeal  recurrent  is  given 
off. 

Escherich,  in  his  address. before  the  Tenth  International  Congress,  clearly 
indicates  his  belief  that  laryngismus  stridulus  is  not  a  morbid  entity,  but  merely 
a  symptom  of  another  affection — namely,  latent  tetany.  He  claims  to  have 
found  the  characteristic  symptoms  of  the  latter  disease  (Trousseau  phenomenon, 
etc.)  in  all  the  cases  presenting  themselves  for  treatment  for  laryngospasm. 
Loos  by  his  investigations  confirms  the  views  of  Escherich.  He  also  aflHrms 
that  in  all  cases  coming  under  his  observation  for  laryngospasm  he  found,  like 
Escherich,  the  characteristic  symptoms  of  tetany.  In  his  summary  he  says  that 
it  remains  to  be  proven  whether  we  ever  have  laryngospasm  independent  of  the 
other  symptoms  of  tetany. 

The  disease  is  somewhat  frequent  in  France  ;  more  prevalent  in  England 
and  Germany.  From  the  latter  country  we  have  the  greatest  number  of  cases 
reported.  According  to  good  authority,  it  appears  to  be  much  more  frequent 
in  certain  localities  there  than  in  others.  In  this  country  it  is  exceedingly 
rare,  and  but  few  American  physicians  have  the  opportunity  of  studying  it  by 
personal  observation.  This  rarity  is,  I  believe,  readily  explained  by  the  fact 
that  pap-feeding  to  infants  is  almost  entirely  unknown  here. 

857 


858    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Laryngismus  stridulus  is  essentially  a  disease  of  infantile  life,  from  birth  to 
the  close  of  the  first  dentition — two  and  a  half  years.  '  The  period  of  most  fre- 
quent occurrence  is,  according  to  Friedreich,  from  the  fourth  to  the  fourteenth 
month.  Barthez  and  Rilliet  have  observed  the  spasm  almost  exclusively  be- 
tween the  third  week  and  the  eighteenth  month  ;  Flesh,  between  the  fifth  week 
and  twenty-first  month.  Of  226  cases  of  laryngospasm  observed  by  Steiner, 
174  were  in  their  first  yeai',  52  in  their  second  or  third  year,  Salath^  saw  four 
cases  of  laryngospasm  in  new-born  infants ;  Bowen,  a  fatal  case  in  an  infimt 
six  days  old.  The  majority  of  cases  occur  undoubtedly  between  the  fourth  and 
eighteenth  months.  This,  however,  does  not  preclude  the  occurrence  of  the 
disease  at  a  much  later  period  of  child-life  :  Steffen  reports  a  case  of  spasm  of 
the  glottis  in  a  boy  eight  years  old;   Salathd,  one  of  a  child  of  twelve  years. 

As  regards  sex,  it  is  the  consensus  of  observers  that  male  children  are  more 
liable  to  the  disease  than  female  children.  This  is  very  clearly  demonstrated 
by  Steffen:  of  554  cases  compiled  by  him,  386  were  boys  and  168  were  girls. 

The  greater  number  of  children  attacked  are  rather  stout  and  present  a 
bloated  appearance,  as  if  they  had  undergone  the  stuffing  process;  much  less 
frequently  are  really  atrophic  children  affected.  Most  of  them  are  markedly 
nervous ;  they  do  not  sleep  very  well,  cry  a  great  deal  and  without  cause,  have 
a  tendency  to  holding-breath  spells,  have  very  bad  tempers,  and  want  to  be 
carried  around  the  greater  part  of  the  time. 

The  disease  is  most  prevalent  in  the  cold  months  of  the  year,  winter  and 
early  spring,  especially  in  March.  Some  would  have  this  frequency  due  to  the 
greater  prevalence  of  catarrhal  conditions  at  these  periods.  According  to  Flesh, 
it  is  due  to  the  fact  that  children  are  kept  much  more  confined  to  the  house 
during  these  months.  The  experience  of  Mr.  Robertson  seems  to  fully  cor- 
roborate this:  he  recommends  "the  free  exposure  of  the  infant  out  of  doors 
for  many  hours  daily  to  a  dry  cold  atmosphere,  and,  if  the  air  be  dry,  the 
colder  the  better."    It  is  more  frequent  in  northern  than  in  southern  latitudes. 

Etiolog-y. — The  etiological  factors  of  this  disease  can  be  properly  divided 
into  two  groups:  the  constitutional  and  the  local. 

Constitutional  Causes. — Rickets. — Two-thirds  of  the  children  affected 
with  laryngospasm  present  the  stigmata  of  rickets,  and  some  of  these  can  be 
detected  as  early  as  the  third  month.  The  causal  relation  between  the  consti- 
tutional state  and  the  laryngospasm  is  therefore  apparently  established ;  as  to 
its  nature,  opinions  differ.  Elsasser  believed  that  it  lay  in  the  craniotabes. 
This  view  has,  however,  been  sufficiently  controverted  by  the  observations  of 
many  that  the  paroxysms  occur  not  only  when  the  child  is  lying  down,  but 
also  Avhen  it  is  held  up  upon  the  arm  or  sitting  up  in  its  chair,  and  no  pressure 
upon  the  head  made.  Furthermore,  in  many  cases  craniotabes  has  been  found 
altogether  wanting,  although  other  symptoms  of  rickets  were  present. 

In  children  afflicted  with  rickets  the  general  nervous  irritability  is  morbidly 
exaggerated.  This  Steffen  holds  responsible  for  the  laryngismus.  Moreover, 
by  reason  of  the  characteristic  change  in  the  shape  of  the  thorax  the  respira- 
tions are  more  superficial  and  necessarily  more  frequent.  Now,  if,  by  any  cause, 
as  an  attack  of  coughing,  screaming,  great  fright,  swallowing  the  food  too  has- 
tily, sudden  awakening  or  being  awakened,  sudden  change  of  temperature 
from  warm  to  cold  (when  the  child  is  carried  from  a  warm  to  a  rather  cold 
room),  the  uniform  rhythm  of  respiration  is  interrupted,  a  hypergemia  of  the 
brain  and  medulla  is  produced,  and  the  conditions  favorable  to  the  production 
of  a  spasm  of  the  larynx  developed. 

Flesh  admits  the  very  frequent  coincidence  of  laryngismus  and  rickets  as 
set  forth,  but  does  not  believe  in  the  causal  relation  of  the  latter  to  the  former. 


LARYNGISMUS  STRIDULUS.  859 

For  him,  not  the  rachitis,  but  the  factors  that  gave  rise  to  the  cachexia,  are 
the  causes  of  the  laryngeal  spasm.  "Faulty  nutrition  and  injurious  food,  this 
and  nothing  else,  are  ihefons  et  origo  of  spasm  of  the  glottis." 

Heredity. — Instances  have  been  reported  where  the  greater  number  or 
nearly  all  of  the  children  of  one  family  were  affected  with  this  neurosis.  An 
hereditary  predisposition  has  therefore  been  presumed.  The  cases,  however, 
really  prove  nothing  more  than  a  continuance  of  the  same  vicious  mode  of  nur- 
ture that  called  forth  the  disease  in  the  first  child ;  for  in  other  instances,  where 
already  two  or  more  children  had  been  affected,  better  attention  to  hygienic 
requirements  and  correct  feeding  kept  all  the  subsequent  children  free  there- 
from. The  supposed  special  hereditary  influence  as  an  etiological  factor  has 
been  discarded  by  most  authors. 

Local  Causes. — Dyspepsia;  over-filling  of  the  stomach ;  intestinal  catarrh ; 
over-distention  of  the  intestines  by  faecal  masses;  great  flatulence.  Kopp's 
theory  that  the  disease  is  always  due  to  enlarged  thymus  gland  has  been  proven 
untenable  by  Friedleben  and  others.  In  rare  instances  it  may  be  the  etiolog- 
ical factor.  Bronchial  or  tracheal  glands  enlarged  or  undergoing  caseous 
degeneration,  diseases  of  the  heart,  and  enlarged  liver  are  occasional  causes 
of  the  spasm.  Material  diseases  of  the  brain  do  not,  according  to  Steffen's 
observations,  produce  spasm  of  the  glottis.  Kyll  quotes  a  case  from  Corrigan 
of  Dublin  which,  despite  all  treatment,  had  lasted  over  three  months.  Acci- 
dentally it  was  discovered  that  pressure  over  the  third  and  fourth  cervical  verte- 
brae was  very  painful  and  produced  loud  cries  from  the  child.  Two  applications 
of  four  leeches,  at  an  interval  of  two  days,  over  the  painful  point  removed  all  the 
symptoms  and  the  child  made  a  perfect  recovery. 

Deyititioyi  is  banished  by  many  from  the  category  of  causes.  Nevertheless, 
it  is  not  at  all  improbable  that  in  such  vitiated  states  of  the  system,  with  per- 
version of  many  of  the  physiological  functions,  as  the  majority  of  the  children 
present,  the  process  of  teething  has  a  certain  causative  influence  in  the  produc- 
tion of  morbid  phenomena. 

Catarrhs  of  the  larynx,  trachea,  or  bronchial  tubes  cannot  of  themselves 
produce  spasm  of  the  glottis  by  reflex  irritation,  but  Avhen  they  supervene  in 
cases  where  it  already  exists  they  will  aggravate  it,  and  even  recall  it  if  it  be 
disappearing. 

Mantel  reports  the  case  of  a  rachitic  infant  eight  weeks  old,  in  whom  a 
very  much  thickened,  congested,  and  elongated  uvula  appeared  to  be  the  cause 
of  the  spasm ;  its  removal,  after  other  measures  had  failed,  was  followed  by  per- 
fect recovery. 

J.  H.  Bryan  reports  the  case  of  a  child  suffering  since  its  second  week  with 
tonic  spasms  of  the  larynx.  The  epiglottis  was  found  irregular  in  outline  and 
bent  backward  over  the  laryngeal  cavity.  The  child  also  had  a  phimosis,  and 
was  fed  upon  undiluted  cow's  milk.  The  spasm  was  attributed  to  a  binding  of 
the  epiglottis,  causing  the  aryteno-epiglottic  folds  to  come  almost  into  apposition, 
so  that  a  slight  stridor  was  produced  on  inspiration.  With  reference  to  this  last 
point,  it  is  well  known  that  a  certain  amount  of  recurvation  of  the  epiglottis  is 
normal  in  young  children,  and  cannot  be  regarded  as  a  cause  of  the  spasm. 
This  seems  confirmed  by  the  results  of  the  treatment  in  the  case  just  referred 
to.  On  diluting  the  milk  and  relieving  the  phimosis  by  gradual  dilatation  the 
respirations  lost  their  spasmodic  character  and  became  normal.  Whether  the 
phimosis  had  any  direct  effect  in  the  production  of  the  cramp  remains  to  be 
determined  by  further  observations:  that  it  may  give  rise  to  morbid  nervous 
phenomena  is  well  known. 

In  easily  excitable  children  violent  and  prolonged  crying,  undue  exertion 


860    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

in  running  so  as  to  materially  interfere  with  the  respiration,  are  capable  of  pro- 
voking a  mild  attack  of  spasm  of  the  glottis. 

In  a  small  number  of  cases,  and  more  particularly  of  those  occurring  after 
the  third  year,  no  special  cause  for  the  cramp  can  be  discovered.  According 
to  my  observation,  a  hot,  vitiated  atmosphere  in  the  sleeping  apartment,  whole 
families  sleeping  in  one  room,  two,  three,  or  more  children  in  one  bed,  Avith 
doors  and  windows  tightly  closed,  will  account  for  some  of  these.  In  support 
of  this  view  I  would  recall  here  the  influence  of  this  factor  in  the  production 
of  trismus. 

Patholog-y. — The  structural  changes  found  upon  necropsy  vary  consider- 
ably. In  so  far  as  the  spasm  itself  is  concerned,  the  results  are  entirely  nega- 
tive, nothing  abnormal  having  as  yet  been  discovered  either  in  the  nerves  or 
the  muscles  of  the  larynx. 

In  the  majority  of  cases  the  rachitic  changes  in  the  bones  and  soft  tissues 
present  themselves.  Craniotabes  is  frequently  found  wanting.  Various  morbid 
changes  are  found  in  the  brain,  mainly  those  due  to  the  cachexia.  In  rare 
instances  softening  of  the  medulla  oblongata  has  been  seen.  In  the  larynx 
traces  of  catarrh  have  been  found;  occasionally  a  croupous  exudation  upon  the 
larynx  and  trachea;  very  rarely  ulceration.  Bronchial  or  tracheal  glands 
enlarged  or  undergoing  caseous  degeneration  are  sometimes  found.  The  thy- 
mus gland  is  occasionally  voluminous  and  juicy.  A  variable  degree  of  pul- 
monary emphysema,  as  the  result  of  the  spasm,  is  always  present.  Various 
cardiac  lesions  have  been  noted. 

The  stomach  is  not  much  affected.  In  the  jejunum  and  ileum  the  solitary 
glands  and  Peyer's  patches  are  enormously  swollen,  broad,  and  pale  ;  concomi- 
tantly we  have  hyperplasia  and  sometimes  caseation  of  the  mesenteric  and  retro- 
peritoneal glands.     The  liver  presents  evidences  of  fatty  degeneration. 

Symptoms. — A  typical  paroxysm  presents  the  following  picture :.  Sud- 
denly, without  any  prodroma  on  the  part  of  the  larynx  or  the  other  respiratory 
organs,  the  child,  Avho  has  just  been  sleeping  nicely  or  has  been  lively  and  play- 
ful upon  its  mother's  arm,  in  its  chair,  or  has  perhaps  been  a  little  fretful  and 
crying,  is  seen  to  gasp  for  breath.  It  becomes  rigid  ;  the  head  is  thrown  back 
and  the  neck  arched  forward.  The  face,  more  particularly  about  the  nose  and 
mouth,  becomes  pale,  cyanotic,  or  dusky  red.  The  alfe  nasi  are  distended,  and 
the  forehead  is  covered  with  a  cold  perspiration.  After  a  few  seconds  to  a 
quarter  of  a  minute  a  few  whistling  or  crowing  inspirations  are  heard  ;  arrest 
of  respiration  again  follows,  lasting  from  a  few  seconds  to  a  minute,  when  the 
Avhistling  sounds  are  again  heard.  After  two  or  three  more  repetitions  of  this 
alternate  crowing  inspiration  and  arrest  of  respiration  the  crowing  inspirations 
ai'e  followed  by  expirations,  the  child  can  soon  cry  out  lustily,  normal  respira- 
tion is  established,  and  the  paroxysm  -is  over.  These  whistling  or  crowing 
sounds  are  made  by  the  entrance  of  air  through  the  narrowed  glottis,  and 
are  not  followed  by  expiration  until  the  spasm  is  over.  In  the  milder  forms 
these  crowing  sounds  are  heard  several  times  in  each  paroxysm ;  in  the  very 
gravest  form  they  are  heard  only  at  the  beginning  and  end  of  the  paroxysm, 
respiration  being  entirely  arrested  during  the  middle  period.  When  the  closure 
of  the  glottis  is  complete,  the  thorax,  diaphragm,  and  abdominal  muscles 
become  immobile ;  when  it  is  incomplete,  laborious  respiratory  attempts  on  the 
part  of  the  various  muscles  concerned  may  be  noted.  The  heart's  action  is  at 
first  stronger  but  irregular,  then  feebler  and  more  frequent,  and  the  pulse 
becomes  small,  sometimes  barely  perceptible.  The  severer  the  seizure  the  ear- 
lier there  is  loss  of  consciousness.  Frequently  there  is  involuntary  discharge 
of  the  urine  and  faeces. 


LARYNGISMUS  STRIDULUS.  861 

The  paroxysms  vary  in  severity.  In  the  mildest  form,  which  may  pass 
unnoticed  by  the  parents,  especially  if  it  occur  during  the  night,  there  is  but 
a  momentary  suspension  of  respiration,  followed  by  a  few  whistling  or  crowing 
inspirations,  and  the  attack  is  over. 

The  number  of  seizures  in  the  twenty-four  hours  varies  from  a  few  to  as 
many  as  thirty  or  fort3^  Frequently  a  few  seizures  will  follow  each  other  in 
rapid  succession ;  then  a  longer  period  of  rest  and  well-being  for  the  child 
ensues,  to  be  interrupted  again  by  a  recurrence  of  the  spasm.  It  has  been 
observed  that  the  shorter  the  intervals  between  them  the  milder  are  the 
paroxysms.  A  number  of  very  mild  attacks  may  be  followed  by  a  very  severe 
one.  The  spasm  cannot  last  longer  than  two  minutes  at  most  without  bringing 
about  a  fatal  issue.  The  paroxysms  occur  as  frequently  in  the  daytime  as 
during  the  night ;  there  is  no  special  predilection  for  the  night,  as  has  been 
supposed  by  some.  With  the  progress  of  the  disease  convulsive  phenomena — 
namely,  tonic  spasms  in  other  parts  of  the  body — generally  make  themselves 
manifest.  The  earliest  and  most  frequent  are  the  so-called  carjjojjedal  spasms. 
The  thumbs  are  drawn  into  the  palms  and  the  fingers  extended  in  various 
directions.  The  great  toe  is  adducted  and  drawn  upward,  and  the  other  toes 
spasmodically  flexed.  Sometimes  the  hands  are  bent  upon  the  forearm  and  the 
forearm  upon  the  arm.  The  dorsum  of  the  foot  may  be  drawn  up  firmly 
against  the  shin.  The  ocular  nerves  also  become  involved  very  soon,  as 
shown  by  the  rolling  up  of  the  eyes.  Clonic  spasms  occur  only  when  a 
general  eclamptic  seizure  supervenes,  which,  according  to  Henoch,  is  not  so 
infrequent. 

The  disease  is  apyretic.  When  fever  does  set  in  it  generally  depends  upon 
some  intercurrent  affection.  Symptoms  of  dyspepsia  are  almost  always  present: 
eructations,  flatulence,  constipation,  clay-colored  stools  ;  very  rarely  diarrhoea 
or  vomiting. 

In  older  children — i.  e.  after  the  third  year — the  tendency  to  laryngeal 
spasm  is  markedly  lessened.  This  may  be  accounted  for  upon  the  ground  that 
they  have  arrived  at  a  period  of  greater  digestive  power,  when  the  problem  of 
nutrition  is  very  much  simplified,  and  also  one  of  greater  stability  of  the  nervous 
system.  The  paroxysms,  when  they  occur  at  this  later  period,  are  much  less 
severe,  probably  for  the  reasons  above  mentioned,  and  the  further  reason  that 
the  larynx  at  this  age  has  grown  wider  and  the  cartilages  have  become  firmer. 
When  these  children  feel  the  respiration  becoming  impeded  they  grow  fretful 
and  want  to  lie  down.  The  face  becomes  pale,  never  cyanotic  or  dusky  red. 
The  whistling  or  crowing  sounds  are  not  very  marked  or  do  not  occur  at  all, 
and  the  only  complaint  is  of  a  tightness  about  the  throat  and  an  inability  to 
swallow.  The  voice  is  feeble  and  speech  labored.  The  cramp  lasts  at  longest 
but  a  few  seconds,  and  when  it  is  over  the  child  is  as  cheerful  and  apparently  as 
well  as  before. 

Course  and  Duration. — The  course  of  the  disease  is  rather  irregular.  It 
may  set  in  with  great  intensity,  the  paroxysms  being  very  severe  and  recurring 
at  short  intervals  ;  again,  it  may  begin  in  a  very  mild  fashion,  a  few  rather  mild 
paroxysms  recurring  at  longer  intervals,  with  periods  of  entire  freedom  of  from 
ten  to  twelve  days.  Usually,  however,  it  runs  a  circuit  of  aggravation,  climax, 
and  diminution.  Until  the  climax  is  reached  seven  to  eight  weeks  may  elapse. 
There  is  also  considerable  tendency  to  relapse  :  even  after  an  interval  of 
months  of  entire  freedom,  under  the  influence  of  exposure,  of  an  inflammatory 
attack  of  some  part  of  the  respiratory  tract,  or  of  a  fit  of  indigestion,  the  spasm 
may  reappear,  and  with  greater  intensity  than  characterized  it  previously.  The 
duration  of  the  disease  is  rather  uncertain :  the  first  attack  may  prove  fatal ; 


862    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

it  mav  prove  fatal  in  a  feAv  hours  or  it  may  last  for  months.  Flesh  avers  that 
since  he  has  recognized  the  time  nature  of  the  disease  he  has  been  able  to  effect 
marked  improvement  in  all  his  cases  in  a  very  short  time,  and  cites  a  case 
which  was  discharged  well  at  the  end  of  a  month. 

Complications. — The  complications  that  may  occur  in  the  course  of  a  case 
of  laryngismus  are  many.  When  the  disease  is  of  great  severity,  transuda- 
tions between  the  membranes  of  the  brain,  into  the  ventricles,  may  occur,  or 
already  existing  effusions  (of  rachitic  origin)  may  be  dangerously  increased. 
We  may  have  effusion  of  blood  between  the  membranes  or  upon  the  Ijrain 
itself 

Whooping  cough  is  a  dangerous  complication.  Catai'rhs  of  the  larynx, 
trachea,  and  bronchial  tubes  have  been  already  mentioned.  Inflammatory 
affections  of  the  lungs  may  supervene  ;  during  their  continuance  the  spasm 
is  generally  much  weaker  or  ceases  altogether. 

The  most  frequent  complications  are  entero-colitis  and  eclampsia. 

Diagnosis. — In  uncomplicated  cases  the  diagnosis  is  readily  made.  The 
suddenness  of  the  seizure,  the  brief  duration  of  the  apnoea,  the  intervals  of 
perfectly  undisturbed  normal  respiration,  the  absence  of  fever,  of  cough,  of 
change  of  voice,  are  features  so  distinctive  that  it  is  not  possible  to  mistake 
the  disease  for  croup,  oedema  of  the  glottis,  or  other  organic  disease  of  the 
larynx.  The  only  disease  with  which  it  could  possibly  be  confounded  is  spas- 
modic laryngitis  (pseudo-croup),  but  spasmodic  laryngitis  has  so  different  a 
clinical  history  that  the  differential  diagnosis  is  not  difficult.  From  bilateral 
paralysis  of  the  glottis-dilators  it  is  readily  distinguished  by  the  absence  of 
the  constant  and  marked  dyspnoea  Avhich  attends  that  condition.  If  there 
should  be  any  doubt  it  can  be  readily  solved  by  a  laryngoscopic  examination. 

In  complicated  cases,  especially  where  eclampsia  follows  in  the  wake  of 
laryngismus,  the  diagnosis  may  be  more  difficult,  likewise  in  those  cases  where 
a  catarrhal  affection  of  the  larynx  and  trachea  has  supervened  ;  however,  a  his- 
tory of  the  case  from  its  onset  will  very  soon  enable  us  to  arrive  at  a  correct 
conclusion. 

Prognosis. — The  prognosis  should  always  be  a  guarded  one,  even  in  the 
very  mild  cases.  Older  statistics  show  a  great  fatality.  Of  289  cases  observed 
by  Reid,  115  ended  fatally.  Rilliet  and  Barthez  had  9  cases  with  8  deaths ; 
Herard,  7  cases  with  6  deaths.  Henoch,  however,  has  had  a  more  favorable 
experience  :  he  says  that  the  majority  of  the  cases  recover.  Flesh  reports 
that  in  the  last  twelve  years  he  has  lost  but  two  cases. 

Of  course  much  will  depend  in  any  case  upon  the  character  of  the  surround- 
ings of  the  child,  the  severity  of  the  paroxysm,  the  degree  of  impairment  of 
the  general  health,  and  the  intelligence  of  the  parents.  In  children  past  thirty 
months  a  favorable  prognosis  can  generally  be  made. 

Treatment. — This  can  best  be  considered  under  two  heads :  I.  The  tem- 
porary relief  of  the  spasm.  II.  The  cure  of  the  underlying  pathological 
condition. 

I.  From  the  brief  duration  of  the  spasm  tlie  physician  is  but  rarelv  present 
when  it  occurs:  and  only  accidentally,  or  if  the  paroxysms  recur  at  short  inter- 
vals, may  he  happen  to  Avitness  it.  The  treatment,  therefore,  for  the  temporary 
relief  of  the  spasm  lies  mainly  in  the  hands  of  the  mother  or  nurse,  and  she 
should  be  properly  instructed.  In  light  cases  it  is  not  necessary  to  intervene 
at  all ;  only  when  the  paroxysm  is  of  longer  duration  or  when  it  is  made  up  of 
a  series  of  attacks  should  measures  for  its  arrest  be  instituted.  The  tongue 
should  be  looked  after  to  see  that  it  is  not  curled  back  over  the  laryngeal 
orifice,  as  occasionally  happens.    A  large  evacuating  enema  should  be  oriven  at 


LARYNGISMUS  STRIDULUS.  863 

once.  The  child  should  be  placed  in  a  semirecumbent  position,  all  clothing 
loosened,  and  an  abundance  of  fresh  air  provided.  Cold  Avater  may  be  splashed 
into  the  face  and  upon  the  chest,  or  sinapisms  applied  to  the  back  of  the  neck 
and  to  various  parts  of  the  chest  to  excite  respiration.  A  piece  of  ice  wrapped 
in  a  cloth  and  applied  over  the  epigastrium  and  lower  part  of  the  sternum  has 
occasionally  proved  effective.  Ammonia  or  ether  may  be  held  to  the  nose. 
Chloroform  inhalations,  recommended  by  Simpson,  West,  and  others,  are  not 
regarded  with  much  favor,  probably  for  the  reason  that  it  is  a  dangerous 
remedy  to  leave  in  the  hands  of  laymen,  and  for  the  further  reason  that  when 
the  respiration  is  completely  arrested  it  can  do  no  good.  Morphia  is  highly 
spoken  of  by  Henoch.  It  is  given  until  drowsiness  is  produced,  then  stopped. 
A  rectal  injection  of  chloral  hydrate,  gr.  v,  in  milk  of  asafoetida,  fjij,  w^ill 
very  frequently  prove  effective.  Pressure  on  the  pneumogastric  nerve,  on 
the  carotid  arteries,  is  recommended.  The  fauces  may  be  tickled  with  the 
finger  or  with  a  feather  until  emesis  results.  Morrell  Mackenzie  recommends 
putting  a  pinch  of  snuff  into  the  child's  nose  to  produce  sneezing. 

If  the  paroxysm  be  of  great  severity,  cyanosis  marked,  and  apnoea  persist- 
ent, the  child  may  be  placed  in  a  warm  bath  (temperature  95°  F.),  whilst  cold 
water  is  dashed  from  a  height  upon  the  head  and  face ;  or  the  child's  feet  can 
be  placed  in  a  hot  mustard  foot-bath  and  a  cold  compress  applied  to  the  head. 
If  the  apparatus  be  at  haiid,  the  application  of  a  strong  induction  current  to 
the  phrenic  nerve,  or  of  a  galvanic  current  to  vertebrse  and  thorax  or  over 
vertebrae  and  larynx,  may  prove  beneficial.  If  the  danger  be  imminent,  intu- 
bation should  immediately  be  resorted  to ;  if  that  alone  prove  ineffective,  air 
can  be  blown  into  the  lungs  through  the  tube  and  expiration  promoted  by 
pressure  on  the  sides  of  the  thorax.      Tracheotomy  is  not  in  favor. 

Flesh,  who  has  had  a  large  experience,  deprecates,  as  a  rule,  all  interfer- 
ence with  the  child,  with  the  exception  of  the  evacuating  enema.  He  asserts 
that  all  the  other  various  measures  resorted  to  are  not  only  not  beneficial, 
but  positively  injurious. 

As  soon  as  the  child  can  swallow  the  best  remedy  to  be  administered  is 
musk,  as  tincture,  in  doses  of  10—15  drops,  or  after  the  following  formula 
(Mackenzie) : 

I^.  Moschi gr.  iss. 

Sacchari  albi 

Pulv.  acacise aa  gr.  ij . 

Syr.  aurantii  florum TTlxx. 

•  Aquse adf^j. — M. 

Sig.  For  one  dose,  to  be  given  every  two  hours. 

Tincture  of  castor  and  tincture  of  valerian  are  also  recommended. 

In  the  interval,  to  prevent  recurrence,  or  at  least  to  modify  the  severity  and 
frequency  of  the  paroxysms,  numerous  remedies  have  been  recommended : 
musk,  castor,  valerian,  bromide  of  potassium,  bromide  of  sodium,  and  chloral 
hydrate  are  the  most  effective.  The  selection  of  the  remedy  will  depend  in 
a  great  measure  upon  the  condition  of  the  child ;  in  feeble  children  chloral 
hydrate  should  rather  be  avoided ;  in  dyspeptic  cases  the  bromide  of  sodium 
will  be  preferred.  Scarification  or  lancing  of  the  gums  is  of  no  benefit,  and 
therefore  unnecessary. 

Care  must  be  had  that  the  child  be  not  vexed  or  irritated,  especially  for  the 
first  forty-eight  hours  after  instituting  treatment ;  its  wishes  should  be  com- 
plied with  and  its  whims  humored.      Some  friendly  face  should  be  with  the 


864    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

child  when  it  goes  to  sleep,  and  more  particularly  when  it  is  about  to  wake  up, 
so  as  to  avoid  all  fright.  Proper  attention  must  be  paid  to  the  ventilation  of 
the  room  and  to  all  other  hygienic  requirements.  The  child  must  be  taken 
out  into  the  fresh  air  whenever  the  Aveather  permits  ;  the  experience  of  Robert- 
son in  this  respect  has  been  already  referred  to. 

II.  The  principal  point  to  be  kept  in  view  is  undoubtedly  the  cure  of  the 
underlying  pathological  condition.  All  authors  agree  that  the  diet  must  be 
strictly  regulated  and  all  farinaceous  food  prohibited.  All  aliment  must  be  given 
in  fluid  form,  as  thin  as  water.  The  only  articles  permitted  are  milk  and  beef 
tea.  If  the  child  be  at  the  breast  and  the  supply  be  ample,  no  other  food  must 
be  given.  If  bottle-fed,  the  bottle  must  be  put  aside  and  the  child  fed  with  a 
spoon  or  feeding-cup.  The  milk  must,  at  first,  be  diluted  one  half  with  water. 
It  is  of  the  greatest  importance  that  the  number  of  meals  and  the  intervals  at 
which  they  are  given  be  properly  regulated. 

In  children  under  four  months  six  meals  per  day  at  intervals  of  three  hours 
are  allowed ;  over  that  age,  only  five  meals  per  day  are  given.  If  possible, 
nothing  should  be  given  in  the  night ;  if  the  child  wake  up  and  cry  for  its 
accustomed  food,  a  little  water  can  be  given  it,  and  after  a  while  it  will  fall 
asleep  again,  and  thus  in  two  or  three  nights  the  habit  of  taking  food  at  night 
may  be  broken  up.  As  to  quantity,  at  the  outset  not  more  than  one  half  of  the 
normal  quantity,  according  to  the  child's  age,  should  be  given  at  one  feeding.  As 
the  digestion  improves,  as  shown  by  the  improved  character  of  the  stools,  the 
milk  is  diluted  but  one-third,  and  the  quantity  gradually  increased,  until  the 
child  gets  about  the  full  quantity  for  its  age.  When  the  stools  have  become 
normal  and  have  continued  so  for  some  time,  Flesh  recommends,  for  children 
over  six  months  old,  the  addition  to  the  beef  tea  of  a  small  quantity  of  boiled 
lean  beef  finely  chopped,  and  claims  for  it  great  restorative  powers.  After 
there  has  been  no  recurrence  of  the  stridor  for  weeks,  and  not  till  then,  a  lit- 
tle zwieback  or  dry  roll  may  be  allowed ;  at  first  but  very  little,  and  if  well 
borne  gradually  increased.  No  solid  food  must  be  given  till  after  the  child  has 
passed  its  second  year. 

The  remedies  employed  in  conjunction  with  this  treatment  are,  in  rachitic 
cases,  cod-liver  oil  and  phosphorus.  Of  the  latter  agent  Baginski  says  that  in 
some  cases  it  has  proved  remarkably  effective,  inhibiting  the  paroxysms  even 
before  any  effect  upon  the  rachitis  was  noted.  Where  marked  ansemia  exists 
some  preparation  of  iron  is  indicated.  For  enlarged  glands  the  syrup  of  the 
iodide  of  iron  or  iodide  of  iron  and  manganese  must  be  prescribed. 

Local  causes  must  be  properly  attended  to  ;  complications  must  be  treated 
according  to  their  nature. 


FOREIGN  BODIES  IN  THE  LARYNX,  TRACHEA, 

AND  BRONCHI. 


By  JOHX  B.  DEAVER,  M.  D., 

Philadelphia. 


The  entrance  of  a  foreign  body  into  the  larynx  or  any  of  the  more  remote 
portions  of  the  air-passages  is,  fortunately,  a  condition  of  somewhat  rare  occur- 
rence. When  such  entrance  does  happen,  it  is,  in  the  majority  of  instances, 
by  way  of  the  mouth,  but  it  may  also  occur  through  penetration  of  the  walls 
of  the  larynx  or  trachea.  The  infrequency  of  such  accidental  lodgements  as 
may  occur  through  the  normal  opening  of  the  larynx  is  directly  due  to  the 
rapidity  with  which  the  orifice  is  closed  by  the  epiglottis. 

A  foreign  body  having,  however,  entered  the  cavity  of  the  larynx,  it  is  very 
likely  to  have  its  downward  progress  arrested  by  the  apposition  of  the  contig- 
uous borders  of  the  aryteno-epiglottidean  folds  and  the  true  vocal  cords,  and  to 
be  expelled  from  this  position  by  the  cough  which  its  presence  excites.  On  the 
contrary,  it  may,  owing  to  relaxation  of  the  vocal  cords,  pass  through  the  glottis, 
and  into  the  trachea  or  one  or  other  of  the  bronchi.  It  is  rather  exceptional 
for  a  foreign  substance  to  enter  the  larynx  during  deglutition,  except  where 
there  is  paralysis  of  the  gustatory  muscles,  such  as  may  follow  diphtheria,  or 
where,  as  the  result  of  ulceration,  there  is  a  partial  or  complete  destruction  of 
the  epiglottis.  Strong  inspiratory  efforts  while  feeding  or  while  the  mouth 
contains  any  substance  are  most  frequently  responsible  for  the  entrance  of  par- 
ticles of  food  or  other  material  into  the  larynx.  A  sudden  attempt  to  breathe, 
laugh,  or  speak,  a  sneeze,  or  a  sudden  blow,  all  favor  the  occurrence  of  such 
an  accident  through  relaxation  of  the  muscles. 

The  amount  of  obstruction  occasioned  by  the  entranqe  of  a  foreign  body 
into  the  air-passages  depends  upon  the  character  as  well  as  the  size  of  the 
object.  If  of  organic  nature,  such  as  a  bean,  pea,  or  grain  of  corn,  the 
obstruction  will  be  progressive,  owing  to  swelling  through  absorption  of 
moisture.  Of  inorganic  materials,  the  most  frequently  met  with  are  pins, 
needles,   buttons,   coins,   and  teeth. 

The  situation  and  mobility  of  the  foreign  body  are  dependent  upon  its 
general  characteristics,  such  as  its  shape,  size,  and  weight,  and  the  amount 
of  force  with  which  it  enters.  Statistics  show  that  the  most  common  location 
is  in  the  trachea,  next  in  the  larynx,  and  lastly,  in  the  right  bronchus.  The 
right  bronchus  is  more  commonly  the  seat  of  obstruction  than  the  left,  for 
the  reason  that  it  is  the  larger  and  arises  higher,  and  that  the  septum  at  the 
point  of  bifurcation  inclines  to  the  left. 

Symptoms. — The  symptoms  excited  by  the  entrance  of  a  foreign  body 
into  the  air-passages  are — violent  convulsive  cough,  a  sense  of  suffocation,  fear 
of  impending  death,  and  pronounced  dyspnoea.  If  the  body  is  retained 
but  does  not  entirely  occlude  the  passage-way,  these  symptoms  recur  with  less- 

55  865 


866    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ened  severity  in  the  form  of  a  short,  harsh  cough  attended  with  pain  referred 
to  the  lower  part  of  the  neck,  and  increased  expectoration,  which  may  or  may 
not  be  bloody.  If  the  position  of  the  foreign  body  is  changed  by  respiration, 
the  symptoms  recur  at  shorter  intervals.  The  body  not  being  expelled  with 
the  subsidence  of  the  symptoms  is  an  evidence  of  impaction.  A  foreign  body 
which  has  been  lodged  in  the  air-passage  for  a  considerable  period  may  sud- 
denly give  rise  to  symptoms  of  obstruction  due  to  displacement  from  the  seat 
of  impaction.  The  symptoms  excited  by  the  presence  of  an  irregular,  angular, 
or  sharply-pointed  mass  are  always  more  severe;  the  cough  is  increased, 
the  interval  between  the  spasmodic  attacks  is  shortened,  and  the  pain  is  more 
commonly  referred  to  the  larynx.  In  addition  to  these  symptoms  there  are 
evidences  of  inflammatory  disturbance,  such  as  elevation  of  temperature,  in- 
creased pulse-rate,  increased  secretion  and  expectoration,  and  dyspnoea  with  pain 
and  tenderness  over  the  seat  of  lodgement.  Symptoms  suggestive  of  incipient 
pulmonary  tuberculosis  consequent  upon  the  presence  of  an  unsuspected  and 
impacted  body  have  suddenly  abated  upon  the  expulsion  or  removal  of 
the  same.  In  case  of  impaction,  constant  pain,  generally  located  in  the  upper 
part  of  the  chest,  or  a  dragging  sensation  referred,  to  either  side  of  the 
chest,  coupled  with  the  above  symptoms,  may  aid  in  locating  the  body. 
There  may  be  also  huskiness  of  the  voice,  stridulous  breathing,  and  a  cough 
resulting  from  deep  inspiration,  which  may  be  accompanied  by  mucous  or 
muco-purulent  expectoration.  If  a  bronchus  be  entirely  occluded,  the  lung  of 
the  corresponding  side  may  collapse,  in  which  case  the  normal  respiratory  phe- 
nomena will  be  absent.  As  a  result  of  the  extension  of  the  inflammation  by 
contiguity,  the  lungs  may  become  involved,  and  the  character  of  the  expecto- 
rated material  will  be  changed,  becoming  darker  and  more  offensive.  Paroxysms 
of  cough,  night-sweats,  loss  of  sleep,  and  great  depression  will  follow  and  death 
from  exhaustion  probably  I'esult.  When  the  foreign  body  is  smooth,  rounded, 
and  movable,  but  little  inconvenience  may  be  experienced  from  its  presence, 
and  if  in  the  person  of  a  child  old  enough  to  describe  his  sensations,  he  may 
complain  simply  of  a  feeling  of  something  moving  in  the  windpipe. 

Diagnosis. — The  character  of  the  symptoms  and  a  careful  inquiry  into  the 
history  of  the  case  will  materially  assist  in  forming  a  diagnosis.  In  the  absence 
of  any  history  of  the  entrance  of  a  foreign  body,  the  abrupt  onset  of  symptoms 
of  suffocation  in  a  child  previously  well  is  sufficiently  significant  to  suggest 
the  character  of  the  obstruction.  Acute  laryngitis  and  croup  are  conditions 
which  may  simulate  to  some  extent  obstruction  by  a  foreign  body,  and  may  call 
for  careful  examination  in  making  a  diagnosis.  In  the  case  of  a  foreign  body 
the  voice  is  not  necessarily  changed  unless  the  offending  substance  be  located  in 
the  larynx,  in  which  case  there  is  aphonia ;  in  croup  the  voice  is  harsh  and 
high-pitched.  In  croup  or  acute  laryngitis  there  is  stridulous  breathing,  which 
becomes  more  marked  as  the  case  advances  ;  this  is  not  true  of  a  foreign  body. 
In  the  latter  case,  the  respiratory  embarrassment  is  more  pronounced  on  expira- 
tion, while  in  croup  the  difficulty  occurs  on  inspiration. 

To  distinguish  obstruction  by  a  foreign  body  in  the  air-passage  from  one 
in  the  pharynx  or  oesophagus,  it  will  suffice  to  make  a  digital  examination  of 
the  pharynx  or  an  exploration  of  the  oesophagus  with  the  oesophageal  bougie. 
In  a  case  of  impaction  of  a  partial  plate  of  artificial  teeth  in  the  commencement 
of  the  oesophagus,  where  I  was  obliged  to  perform  oesophagotomy  for  its  removal, 
the  symptoms  were  believed  to  be  due  to  its  presence  in  the  larynx.  The  intro- 
duction of  an  oesophageal  bougie  immediately  cleared  up  the  doubt  as  to  loca- 
tion and  position  in  this  particular  case.  As  symptoms  of  respiratory  em- 
barrassment and  the   expectoration  of  muco-purulent  material  were  present, 


FOREIGN  BODIES  IN  LARYNX  AND    TRACHEA.         867 

it  was  found  at  the  autopsy  that  an  opening  into  the  larynx  had  occurred  as 
the  result  of  ulcerative  perforation. 

While  oedema  of  the  glottis  may  result  from  the  presence  of  a  foreign  body, 
yet  it  may  arise  as  an  independent  condition,  following  injury  to  the  larynx,  or 
the  swallowing  of  chemical  irritants  of  any  kind,  or  it  may  accompany 
tubercular,  syphilitic,  or  some  other  form  of  ulceration.  The  diagnosis 
between  foreign  body  and  oedema  of  the  glottis  rests  largely  on  the  history 
of  the  case  and  upon  digital  examination,  by  which  is  detected  swelling  of 
either  the  epiglottis,  the  glottis,  or  of  both  as  the  case  may  be.  Further, 
as  mentioned  before,  the  respiratory  embarrassment  in  foreign  body  is  more 
marked  on  expiration,  while  in  oedema  of  the  glottis,  if  seen  early,  the 
embarrassment  occurs  on  inspiration  only,  and  in  the  later  stages  during 
both  inspiration  and  expiration. 

Laryngeal  obstruction  associated  with  lymphatic  enlargement  of  the  deep 
chain  of  cervical  glands  gives  rise  to  a  series  of  symptoms,  the  onset  of  which 
are  gradual,  and  consist  in  the  presence  of  a  tumor  of  slow  growth,  with  some 
constitutional  evidence  of  a  tubercular  diathesis.  The  symptoms  of  apparent 
obstruction  in  this  class  of  cases  are  not  due  so  much  to  pressure  upon  the  air- 
passage  as  upon  the  laryngeal  nerves. 

The  advantages  to  be  derived  from  a  laryngoscopic  examination  in  children 
are  practically  nil,  unless  ansesthesia  be  employed,  and  even  under  these  con- 
ditions may  prove  unsatisfactory.  The  urgency  of  the  symptoms  in  the  case 
of  a  foreign  body  would  contraindicate  an  examination  of  this  kind  in  the 
majority  of  cases,  because  the  manipulation  necessary  to  accomplish  it  would 
be  attended  by  more  risk  than  the  operation  for  removal.  In  those  cases 
where  the  immediate  symptoms  of  obstruction  subside  consequent  upon  the 
impaction  or  the  lodgement  of  the  body,  an  examination  may  be  attempted. 
Auscultation  may  be  of  value  in  locating  the  position  of  the  mass,  which,  if 
in  the  larynx,  may  create  rough  sounds  synchronous  with  respiration.  In  con- 
nection with  the  other  symptoms  of  obstruction,  if  in  the  trachea,  the  body  may 
be  detected  moving  with  respiration,  and  even  heard  to  strike  against  the  wall 
of  the  windpipe,  while,  if  in  a  bronchus  or  one  of  the  bronchial  tubes,  the 
normal  vesicular  murmur  upon  the  corresponding  side  is  absent  or  modified. 

Prognosis. — The  presence  of  a  foreign  body  in  the  air-passages  subjects 
the  patient  to  great  danger.  For  the  first  seventy-two  hours  at  least  the 
greatest  danger  is  from  suffocation,  as  the  body  is  liable  to  be  forced  into  the 
larynx  and  cause  total  obstruction.  Thereafter  the  risk  is  from  haemorrhage, 
inflammation,  ulceration  or  abscess,  septicaemia,  and  death  from  exhaustion. 
When  the  substance  becomes  impacted  in  a  bronchial  tube  the  irritation 
excited  by  its  presence  may  involve  the  parenchyma  of  the  lung,  causing  a 
local  pneumonia  which  is  sometimes  followed  by  pulmonary  abscess.  Other 
organs  may  become  involved  through  the  extension  of  inflammation  by  con- 
tiguity of  tissue — namely,  the  pericardium,   the  pleura,   and  the  liver. 

Treatment. — All  cases  of  foreign  body  in  the  air-passages  giving  rise  to 
urgent  symptoms  call  for  prompt  and,  in  most  instances,  radical  treatment. 
Nature  alone  should  not  be  depended  upon  to  expel  the  offending  mass ; 
neither  should  delay  be  encouraged  in  the  event  of  the  subsidence  of  the  symp- 
toms, granting  that  there  be  no  doubt  as  to  its  presence.  To  induce  vomiting 
by  the  administration  of  emetics  or  by  mechanical  means,  is  fraught  with,  to 
say  the  least,  some  risk,  and  may  cause  obstruction  by  impaction  in  the  glottis. 
If  emetics  be  employed,  everything  necessary  for  immediate  operation  should 
be  in  readiness.  The  practice  of  inverting  the  patient  and  employing  succus- 
sion  with  the  hope  of  dislodging  the  body  should  be  practised  only  under 


868  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

exceptional  circumstances,  and  resorted  to  only  when  no  other  means  are  at 
hand.  This  form  of  treatment,  like  that  by  emetics,  is  open  to  the  objection  of 
danger  from  immediate  suffocation.  The  class  of  cases  in  which  either  of  these 
means  is  most  likely  to  prove  successful  is  where  the  obstruction  is  due  to  lodge- 
ment of  the  mass  in  the  pharynx  or  oesophagus.  Here,  however,  if  the  body 
cannot  be  extracted  through  the  mouth  or  forced  into  the  stomach  by  the  intro- 
duction of  an  oesophageal  bougie,  it  is  not  likely  that  emesis  or  inversion  and 
succussion  will  succeed  in  dislodging  it. 

The  diagnosis  of  the  presence  of  a  foreign  body  having  been  established, 
the  advisability  of  immediately  opening  the  windpipe,  in  the  event  of 
extraction  through  the  mouth  not  being  feasible,  I  believe  cannot  be  too 
strongly  urged,  as  the  imminent  risk  of  suffocation  is  thus  removed  and 
the  safety  of  the  patient  increased.  For  if  the  body  is  not  expelled  after  the 
windpipe  has  been  opened,  impending  suffocation  is  relieved.  During  the 
time  necessarily  consumed  in  opening  the  windpipe  the  respirations,  which  are 
already  embarrassed,  may  cease.  Should  this  occur,  the  operation  is  to  be 
hastily  completed  and  artificial  respiration  resorted  to.  If  possible,  an  anaes- 
thetic, preferably  chloroform,  should  be  administered  to  prevent  pain  and  allay 
spasm.  With  the  child  anaesthetized  the  surgeon  works  to  a  better  advantage, 
both  to  himself  and  to  his  patient.  If  time  is  not  a  factor,  the  interval 
between  the  paroxysms  of  dyspnoea  is  the  most  favorable  for  operation,  as  in 
this  period  the  child  is  comparatively  comfortable,  and  the  operator  can  work 
without  undue  haste.  The  mere  opening  of  the  windpipe  does  not  entail  much 
risk  if  performed  during  the  period  of  calm ;  in  fact,  less  than  when  done  for- 
other  conditions.  With  the  extraction  of  the  foreign  body  the  chief  source  of 
danger  is  removed,  and  if  done  early  the  necessity  for  the  introduction  of  a 
tracheal  tube  may  not  be  called  for,  thus  simplifying  the  case,  and  lessening, 
particularly,  the  chances  of  post-operative  pneumonia. 

On  the  location  of  the  foreign  body  depends  the  choice  of  operation.  If 
diagnosed  as  occupying  the  larynx,  laryngotomy  is  advisable  on  account  of  its 
simplicity,  the  rapidity  with  which  it  can  be  performed,  and  its  aff"ording  a 
more  thorough  command  of  the  interior  of  the  larynx.  If  the  body  is  too 
large  to  be  extracted  through  this  opening,  which  may  be  the  case  in  very 
young  children,  the  space  may  be  enlarged  by  cutting  the  cricoid  cartilage, 
and,  if  necessary,  prolonging  it  into  the  trachea,  making  a  laryngo-trache- 
otomy.  The  entrance  of  air  through  this  opening  may  cause  the  body  to  be 
expelled  upon  expiration  through  either  the  incision  or  the  mouth.  If  the 
mass  is  supposed  to  be  located  in  the  upper  part  of  the  trachea  the  high  opera- 
tion is  preferable,  Avhile  if  situated  lower  down  in  the  trachea  or  in  a  bronchus 
the  lower  operation  will  be  necessary.  Occasionally  the  foreign  body,  if  sharply 
pointed  and  impacted,  may  be  detected  from  without,  and  then  an  incision  may 
be  carried  directly  down  upon  it. 

In  performing  any  operation  on  the  air-passages  the  child  should  be  brought 
under  the  eff"ect  of  the  anaesthetic  before  being  placed  in  the  customary  position. 
A  free  incision  should  be  made  in  the  median  line  of  the  neck,  and  the 
trachea  or  the  crico-thyroid  membrane  exposed,  as  the  case  may  be,  by  care- 
fully dissecting  down  upon  it.  The  mistake  which  I  think  is  often  made  is 
that  of  too  small  an  incision  through  the  skin  and  fasciae.  A  free  incision  not 
only  affords  more  room,  but  gives  the  operator  a  better  opportunity  of  recog- 
nizing the  anatomical  landmarks,  and  of  completing  the  .operation  with 
rapidity  and  safety.  In  the  high  operation  of  tracheotomy  the  middle  lobe 
(isthmus)  of  the  thyroid  gland  is  to  be  displaced  downward  or  divided 
between  two  ligatures.    In  the  low  operation  the  anomalous  position  sometimes 


FOREIGN  BODIES  IN  LARYNX  AND    TRACHEA.        869 

held  by  the  vessels  must  be  borne  in  mind ;  also  the  difficulty  which  may  be 
experienced  in  dealing  with  the  thyroid  plexus  of  veins.  Upon  the  exposure 
and  division  of  the  tracheal  fascia  (the  last  layer  of  the  structures  overlying 
the  trachea)  air  enters  between  it  and  the  trachea,  giving  rise  to  an  emphy- 
sematous condition  by  which  is  occasioned  a  sound  not  unlike  the  entrance  of 
air  into  the  trachea  when  opened,  and  this  may  mislead  the  operator.  A  free 
incision  should  also  be  made  into  the  trachea,  thus  allowing  the  entrance  of  a 
large  volume  of  air,  which  favors  the  expulsion  of  the  body.  Immediately 
upon  opening  the  trachea  there  escapes  a  frothy  mucus  or  a  muco-purulent 
secretion,  depending  upon  the  length  of  time  the  foreign  body  has  been  pres- 
ent. The  tracheal  wound  should  be  retracted,  when,  if  the  body  is  not  seen 
or  expelled,  an  attempt  to  favor  its  expulsion  should  be  made  by  exciting 
cough  by  irritating  the  lining  membrane  with  a  feather  or  a  camel's-hair  brush. 
If  the  body  be  not  expelled  by  either  of  these  means,  an  attempt  to  locate 
and  to  extract  it  should  be  made.  Should  this  fail,  inversion  and  succussion 
may  be  resorted  to,  this  practice  not  being  objectionable  after  the  windpipe  has 
been  opened.  The  finger,  with  well-smoothed  nail,  undoubtedly  offers  the 
best  means  of  locating  the  foreign  body  when  the  size  of  the  windpipe  is  suf- 
ficient. The  sensation  communicated  to  it  is  far  more  accurate  than  that 
obtained  through  the  medium  of  an  instrument.  When  this  manner  of  pro- 
cedure is  not  feasible,  the  location  of  the  foreign  body  may  be  attempted  by 
the  introduction  of  an  English  catheter  without  the  stylet,  a  tracheal  probe, 
or  the  curved  laryngeal  forceps.  The  body  having  been  located,  its  extrac- 
tion with  a  pair  of  laryngeal  forceps  should  follow ;  when  it  holds  a  transverse 
position  in  the  air-passage,  a  blunt  hook  may  facilitate  its  removal. 

If  the  foreign  body  be  retained,  despite  all  efforts  for  its  removal,  a 
tracheal  tube  should  not  be  introduced,  but  the  wound  in  the  trachea  is  to 
be  kept  widely  open  by  retractors  retained  in  position ;  or  the  edges  of  the 
tracheal  wound,  including  the  skin  and  fascia,  may  be  transfixed  by  sutures, 
the  ends  of  which  are  left  long  and  tied  at  the  back  of  the  neck.  During 
this  time  the  patient  must  be-  constantly  watched,  so  that  if  the  body 
appears  at  the  bottom  of  the  wound,  it  can  be  removed.  A  foreign  body 
in  the  larynx  too  large  to  be  extracted  through  the  wound  made  in  the  crico- 
thyroid membrane  or  the  windpipe  may  call  for  partial  or  complete  division 
of  the  thyroid  cartilage  (thyroidotomy).  The  propriety  of  introducing  a 
tracheal  tube  after  operation  will  depend  upon  the  amount  of  injury  the  larynx 
or  trachea  has  sustained.  When  the  operation  is  completed  without  the  intro- 
duction of   a  tube,  I  should  advise  against  suturing  the  trachea. 

If  the  foreign  body  occupies  a  bronchus,  its  extraction  can  only  be  safely 
accomplished  by  means  of  low  tracheotomy,  and  the  subsequent  use  of  Dur- 
ham's flexible  laryngeal  forceps  or  a  stout  flexible  wire  bent  in  the  shape  of 
a  blunt  hook.  The  hope  of  opening  a  bronchus  through  the  chest-Avall,  as  a 
preliminary  to  extraction,  has  been  clearly  demonstrated  by  experiments  upon 
animals  to  be  both  a  useless  and  a  fatal  procedure,  especially  in  the  light  of  the 
cases  where  a  foreign  body  has  been  expelled  from  a  bronchus  several  days  after 
the  operation  of  tracheotomy. 


TRACHEOTOMY. 

By  henry  R.  WHARTON,  M.  D., 

Philadelphia. 


The  operation  of  tracheotomy  consists  in  opening  the  trachea  by  an  incis- 
ion through  the  tissues  in  the  anterior  region  of  the  neck,  as  nearly  as  possi- 
ble in  the  middle  line,  and  is  a  surgical  procedure  which  is  adapted  for  the 
relief  of  dyspnoea  due  to  laryngeal  or  tracheal  obstruction.  The  operation 
may  be  required  to  relieve  the  dyspnoea  dependent  upon  membranous  or  diph- 
theritic laryngjtis,  or  oedema  of  the  mucous  membrane  of  the  larynx  or  trachea 
from  inflammation  due  to  burns  or  scalds,  or  to  the  inhalation  of  irritating 
gases,  or  the  swallowing  of  corrosive  liquids.  The  operation  may  be  indicated 
to  relieve  dyspnoea  arising  from  growths  in  the  larynx  or  trachea;  from  growths 
external  to  these  organs,  but  causing  pressure  upon  them  ;  and  it  may  also  be 
required  for  the  removal  of  foreign  bodies  from  the  larynx  or  trachea,  as  well 
as  for  the  relief  of  dyspnoea  due  to  their  presence.  Tracheotomy  may  also  be 
called  for  in  cases  of  fracture  or  laceration  of  the  larynx  or  in  cases  of  spasm 
of  the  glottis.  The  indication  for  operation  in  all  of  these  cases  is  a  form  of 
obstructive  dyspnoea  which  threatens  life. 

The  most  reliable  symptoms  of  tracheal  or  laryngeal  obstruction  are  reces- 
sion of  the  anterior  and  lower  portion  of  the  chest-walls,  forcible  retraction  of 
the  tissues  of  the  epigastrium  and  of  the  suprasternal  notch,  and  of  the  supra- 
clavicular and  intercostal  spaces  during  inspiration.  Where  these  symptoms 
are  marked  there  exists  some  serious  mechanical  obstruction  to  the  entrance  of 
air  into  the  lungs.  A  child  suffering  from  well-marked  obstructive  dyspnoea 
has  more  or  less  suppression  of  the  voice,  and  presents  lividity  of  the  lips,  blue- 
ness  of  the  finger-tips,  and,  as  the  dyspnoea  increases,  becomes  restless  and 
cannot  breathe  in  a  recumbent  posture,  is  unable  to  sleep,  sits  up  in  bed, 
clutches  at  his  throat  as  if  to  remove  the  offending  substance,  and  presents  a  pic- 
ture of  distress  which,  when  it  has  once  been  observed,  cannot  well  be  forgotten. 
By  the  change  of  position  the  auxiliary  muscles  of  respiration  are  brought  into 
play ;  and  the  restlessness  and  inability  to  sleep,  except  at  short  intervals,  are 
explained  by  the  well-known  fact  that  in  normal  sleep  the  action  of  the  dia- 
phragm is  diminished,  but,  when  obstructive  dyspnoea  is  present,  its  action  is 
exaggerated,  so  that  sleep  is  impossible.  A  mistake  should  not  be  made  in 
confounding  labored  breathing,  which  is  always  present  in  cases  in  which  there 
exists  mechanical  obstruction  to  the  entrance  of  air  into  the  lungs,  with  fre- 
quent breathing,  which  depends  upon  diminished  air-capacity  of  the  lungs.  I 
call  special  attention  to  this  symptom — labored  breathing — as  I  am  frequently 
called  to  see  cases  to  perform  tracheotomy  where  the  mistake  is  made  in  con- 
founding these  two  forms  of  dyspnoea. 

The  operation  of  tracheotomy  is  considered  by  some  surgeons  a  minor,  by 
others  a  major  operation;  but  my  own  experience  leads  me  to  consider  it  a 
delicate  and  anxious  one,  for  the  condition  calling  for  its  performance  is  one 
870 


TBA  CHEO  TOMY.  871 

which  involves  a  vital  function ;  and,  although  the  operator  may  often  be  sur- 
prised at  the  facility  with  which  the  trachea  is  exposed  and  opened,  yet  in 
other  cases  presenting  apparently  similar  conditions  he  may  at  each  step  be 
met  with  difficulties  which  render  it  a  most  formidable  surgical  procedure.  I 
think  Mr.  Marsh  places  the  operation  in  its  proper  position  when  he  says 
that  tracheotomy  should  be  regarded  as  a  delicate  operation  which  requires 
coolness  and  caution  in  its  performance,  rather  than  one  which  is  very  difficult 
or  dangerous.  I  am  decidedly  of  the  opinion  that  in  this  operation  coolness 
in  the  operator  is  a  matter  of  the  first  importance,  and  that,  in  spite  of  the 
alarming  symptoms  that  may  be  presented,  the  judicious  surgeon  will  not 
allow  himself  to  be  unduly  hurried  in  its  performance,  bearing  in  mind  the  fact 
that  in  cases  of  obstructive  dyspnoea,  except  in  certain  very  rare  instances, 
death  comes  on  slowly,  that  there  is  generally  more  time  than  at  first  appears, 
and  that  precipitated  action  at  the  beginning  of  the  operation  may  cause 
much  time  to  be  lost  before  its  completion.  Tracheotomy  is  most  frequently 
called  for  in  young  children,  and  in  this  class  of  patients  certain  anatomical 
conditions  are  present,  such  as  shortness  of  the  neck,  abundance  of  adipose 
tissue,  great  vascularity  of  the  parts,  a  relatively  larger  size  of  the  isthmus 
of  the  thyroid  gland,  and  the  possible  presence  of  the  thymus  gland;  all 
these  conditions  render  the  trachea  difficult  to  expose  and  open. 

The  time  at  which  tracheotomy  should  be  performed  in  cases  of  obstruc- 
tive dyspnoea  is  a  point  upon  which  there  exists  some  diversity  of  opinion. 
Some  operators  insist  that  it  should  be  undertaken  as  soon  as  the  dyspnoea  is 
well  marked,  while  others  postpone  surgical  interference  until  the  symptoms 
have  become  so  urgent  as  speedily  to  threaten  life.  I  am  of  the  opinion 
that  the  operation  should  not  be  performed  until  the  dyspnoea  is  marked  and 
increasing,  unless  it  be  due  to  the  presence  of  a  foreign  body  or  a  growth 
in  the  air-passages,  or  to  an  injury  of  the  larynx  or  trachea,  under  which  cir- 
cumstances there  is  no  reason  to  delay.  In  cases  of  dyspnoea  due  to  mem- 
branous laryngitis  or  inflammatory  conditions  of  the  larynx  or  trachea,  I  think 
the  surgeon  should  be  largely  guided  as  to  the  proper  time  for  interference  by 
the  urgency  of  the  dyspnoea  and  the  constitutional  condition  of  the  patient. 
When  a  patient  presents  the  marked  symptoms  of  dyspnoea  which  have  been 
previously  pointed  out,  and  in  addition  exhibits  extreme  restlessness  and  ina- 
bility to  sleep,  I  think  nothing  is  to  be  gained  by  delaying  the  procedure,  for  I 
have  never  seen  such  cases  recover  without  operative  interference.  If,  how- 
ever, he  can  sleep  for  a  few  minutes  at  short  intervals,  although  the  symp- 
toms of  obstruction  are  present — I  am  in  favor  of  postponing  the  operation, 
since  under  such  circumstances  I  have  seen  very  urgent  cases  recover  without 
tracheotomy. 

Another  question  on  which  the  surgeon  is  consulted  is  the  advisability  of 
performing  tracheotomy  in  very  advanced  cases.  Here,  if  an  examination  of 
the  patient  shows  that  he  is  not  dying  of  cardiac  failure  and  auscultation  of 
the  chest  reveals  the  fact  that  air  is  entering  the  lungs,  even  though  there  may 
be  evidence  of  extension  of  the  membrane  into  the  bronchial  tubes,  I  consider 
that  the  urgency  of  the  symptoms  presented  certainly  demands  the  performance 
of  the  operation  ;  for  in  a  number  of  these  most  unpromising  cases,  where  the 
patients  have  been  apparently  moribund  at  the  time  of  operation,  I  have  seen 
recovery  follow.  The  operation  usually  prolongs  life  even  if  it  does  not  save 
it,  and  generally  prevents  the  patient  from  dying  by  a  most  distressing  form 
of  death — strangulation — for  in  my  experience  death  from  recurrent  obstruc- 
tion after  tracheotomy  is  comparatively  rare,  the  majority  of  cases  perishing 
from  pneumonia,  from  heart  failure,  or  from  general  adynamia.     Many  cases 


872  AMI:IiICA^^  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  croup  are  unquestionably  allowed  to  die  without  operation  where,  possibly, 
tracheotomy  might  have  averted  the  fatal  issue;  for  there  is,  unfortunately, 
among  the  people  a  tendency  to  attribute  death,  if  it  results  after  the  operation, 
to  the  surgical^  procedure  itself,  and  not  to  the  disease  which  necessitated  its 
performance.  It  is  often  diiEcult  for  this  reason  to  obtain  the  consent  of  parents 
to  have  the  operation  performed  upon  their  children,  but  this  opposition  may 
generally  be  overcome  by  a  candid  statement  as  to  what  may  be  accomplished 
by  the  procedure.  I  think  there  is  also  among  the  profession  too  much  tend- 
ency to  look  upon  tracheotomy  as  a  last  resort,  and  after  it  has  been  performed 
to  relax  the  local  and  constitutional  treatment  of  the  case  ;  but  this  is  mani- 
festly unwise,  for  the  operation  simply  fulfils  one  of  the  indications  in  the  treat- 
ment— viz.  to  remedy  the  imperfect  air-supply ;  and  it  does  not  supplant 
previous  appropriate  constitutional  or  local  measures.  It  may  be  laid  down  as 
a  safe  rule  of  practice  that  tracheotomy  is  indicated  in  all  cases  of  persistent 
and  increasing  dyspnoea  due  to  mechanical  obstruction  of  the  larynx  or  adja- 
cent parts  of  the  trachea. 

Anatomy  of  the  Anterior  Region  of  the  Neck. 

In  the  operation  of  tracheotomy  it  is  essential  that  the  operator  should  bear 
in  mind  the  anatomical  structure  of  the  anterior  region  of  the  neck.  In  cut- 
ting down  upon  the  trachea  in  the  middle  line  of  the  neck  from  the  cricoid 
cartilage  to  the  sternum,  as  soon  as  the  skin  has  been  divided  the  siqierficial 
fascia  is  exposed,  and  beneath  this  is  the  deep  cervical  fascia,  w^hich  encloses 
the  sterno-hyoid  and  sterno-thyroid  muscles.  The  veins  of  the  neck  are  most 
important  in  their  relation  to  tracheotomy,  because  they  are  often  irregular  in 
distribution,  and  from  the  fact  that  in  all  forms  of  pulmonary  obstruction 
they  become  greatly  distended,  and  injuries  to  them  may  be  followed  by  very 
profuse  haemorrhage.  Upon  opening  the  superficial  fascia  a  large  superficial 
venous  branch,  the  siq^erficial  anterior  jugular  vein,  may  be  met  with,  or  there 
may  be  two  veins  running  parallel  Avith  the  trachea  on  each  side  of  the  median 
line,  which  communicate  by  a  large  transverse  branch  at  the  lower  part  of  the 
neck  ;  they  are  usually  placed  one  on  each  side  of  the  median  line  ;  one  may 
be  larger  than  the  other,  or  one  may  cross  the  median  line  and  empty  into  its 
fellow.  A  large  plexus  of  veins  also  surrounds  the  thyroid  isthmus,  opening 
above  into  the  superior  thyroid  and  below^  into  the  inferior  thyroid  vein.  The 
innominate  vein  on  the  left  side  occasionally  rises  above  the  level  of  the  ster- 
num, and  has  been  exposed  and  injured  during  the  operation  of  tracheotomy. 
The  sterno-hyoid  and  sterno-tJii/roid  muscles  are  most  important  landmarks  in 
this  operation.  At  their  upper  attachment  they  are  not  quite  in  contact,  and 
as  they  descend  the  neck  they  are  further  separated  ;  the  space  between  them, 
which  occupies  the  median  line  of  the  neck,  is  a  most  important  guide  to  the 
operator. 

The  arteries  of  the  neck  which  are  of  most  importance  in  the  operation  are 
the  crico-thyroid  artery,  a  branch  of  the  superior  thyroid,  and  the  thyroidea  irua, 
an  irregular  branch  from  the  aortic  arch  or  from  the  innominate.  In  children 
the  innominate  artery  occasionally  rises  into  the  pretracheal  space,  and  this 
vessel  was  once  exposed  by  Lucke  below  the  isthmus  of  the  thyroid  in  per- 
forming tracheotomy.  The  isth7nus  of  the  thyroid  gland  is  a  very  important 
structure  in  the  operation  of  tracheotomy,  and  varies  much  in  size  in  different 
individuals.  It  is  generally  largely  developed  in  children,  often  covering  the 
second  or  third  rings  of  the  trachea,  and  in  some  cases  extending  higher  and 
covering  the  cricoid  cartilage.      The  thymus  gland,  in  children  under  two  years 


TBA  CHEO  TOMY.  8  73 

of  age,  may  be  exposed  in  opening  the  trachea  below  the  isthmus  of  the  thyroid 
gland  ;  I  have  myself  seen  it  present  in  a  number  of  cases  in  young  children. 
The  trachea  begins  at  the  lower  border  of  the  cricoid  cartilage  and  terminates 
opposite  the  fourth  dorsal  vertebra,  although  its  surgical  limit  is  the  upper 
border  of  the  sternum.  It  is  most  superficial  near  the  cricoid  cartilage,  is  sur- 
rounded by  loose  cellular  tissue  or  the  tracheal  fascia,  and  is  more  movable  in 
children  than  in  adults.  Its  size  varies  in  different  individuals  of  the  same 
age,  being  larger  in  male  than  in  female  children.  The  diameter  of  the  trachea 
under  eighteen  months  of  age  is  about  4  mm.  ;  from  two  to  four  years,  6  mm. ; 
from  eight  to  twelve  years,  10  mm. 

Tracheotomy  in  Diphtheritic  or  Membranous  Laryngitis. 

In  children  suffering  from  membranous  or  diphtheritic  laryngitis  obstruc- 
tive dyspnoea  is  most  common ;  and  it  is  in  this  class  of  cases  that  the  surgeon 
is  most  frequently  called  upon  to  perform  tracheotomy. 

Indications  for  Operation. — In  diphtheritic  or  membranous  laryngitis  the 
symptom  calling  for  operative  interference  is  a  form  of  obstructive  dyspnoea 
characterized  by  suppression  of  the  voice,  great  difficulty  in  inspiration, 
lividity  of  the  lips,  depression  of  the  suprasternal  and  supraclavicular  spaces, 
sinking  of  the  lower  part  of  the  chest,  inability  to  breathe  in  the  recumbent 
posture,  great  restlessness,  and  inability  to  sleep.  These  symptoms  being 
present  and  increasing,  I  think  that  the  operation  of  tracheotomy  is  urgently 
indicated. 

Prognosis  of  Tracheotomy  in  Diphtheritic  or  Membranous  Laryn- 
gitis.— It  is  to  be  expected  that  the  prognosis  under  the  above  conditions  is 
more  unfavorable  than  in  cases  where  the  operation  is  undertaken  for  the  relief 
of  dyspnoea  due  to  simple  inflammatory  affections  of  the  larynx  or  to  the  presence 
of  foreign  bodies  in  the  air-passages.  This  is  not  remarkable  when  we  con- 
sider the  fact  that,  in  addition  to  the  local  condition  of  the  larynx  or  trachea 
which  necessitates  the  surgical  interference,  there  exists  a  most  grave  consti- 
tutional disease  which  is  very  fatal  in  childhood,  even  in  cases  where  no  symp- 
toms of  obstructive  dyspnoea  are  developed.  An  examination  of  large  collec- 
tions of  recorded  cases  best  shows  the  results  following  tracheotomy  in  this  class 
of  cases.  Cohen,  in  the  study  of  5000  tracheotomies  for  croup  and  diphtheria, 
found  that  about  1  case  in  4  recovered  after  the  operation.  Krbnlein  reports 
504  similar  cases,  with  29.2  per  cent,  of  recoveries.  Chaym,  in  1000  trache- 
otomies, gives  the  proportion  of  recoveries  as  about  1  in  4.  Mastin,  in  a  col- 
lection of  863  tracheotomies  for  diphtheritic  croup  in  the  United  States,  shows 
that  the  recoveries  were  about  26  per  cent.  At  the  Children's  Hospital  of 
Philadelphia  the  percentage  of  recoveries  in  all  cases  of  croup  operated  upon  to 
the  present  time  has  been  about  43  per  cent.  Lovett  and  Munroe,  in  a  col- 
lection of  21,853  tracheotomies  for  diphtheria  and  croup,  drawn  from  all 
sources,  show  that  there  were  6135  recoveries  and  15,552  deaths,  or  about 
28  per  cent,  of  recoveries.  The  statistics  of  individual  operators  are  often  more 
favorable  in  a  limited  number  of  cases,  some  being  able  to  show  more  than 
50  per  cent,  of  recoveries  ;  but  such  statistics  are  manifestly  unreliable,  as  addi- 
tional cases  would  probably  very  markedly  diminish  the  proportion  of  successes. 
In  a  series  of  5  tracheotomies  for  diphtheritic  laryngitis  I  have  had  4  re- 
coveries, while  in  6  operations  preceding  this  series  the  result  was  uniformly 
fatal.  In  15  tracheotomies  recently  performed  at  the  Children's  Hospital  there 
were  8  recoveries — a  result  which  even  the  most  enthusiastic  advocate  of  the 
operation  could  not  hope  to  sustain  with  additional  cases.     In  recent  years  it 


874  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

seems  the  results  of  tracheotomv  for  diphtheritic  laryngitis  have  been  more 
favorable,  depending  possibly  upon  better  judgment  as  to  the  time  of  the 
operation  and  the  greater  care  which  is  exercised  in  the  details  of  after-treat- 
ment, as  well  as  upon  the  improved  constitutional  treatment  of  the  disease. 
By  comparison  of  a  large  number  of  operations  for  diphtheritic  or  membranous 
laryngitis,  it  will  be  seen  that  the  proportion  of  recoveries  is  very  similar ;  that 
is,  about  1  recovery  in  every  4  cases. 

Age  in  the  Prognosis. — The  age  of  the  patient  is  a  very  important  factor 
in  the  prognosis.  In  infants  and  very  young  children  recoveries  are  not  very 
numerous  after  the  operation,  yet  there  have  been  enough  successful  cases  to 
show  that  age  alone  is  not  a  contra-indication  to  tracheotomy  in  this  class  of 
patients.  A  successful  case  is  reported  by  Scoutetten  in  an  infant  of  six  weeks, 
one  at  two  months  by  Steinmeyer,  at  three  months  by  Annandale,  at  five  months 
by  Croft,  at  six  months  by  Kisler ;  and  from  this  age  to  two  years  a  number  of 
successful  results  have  been  reported.  Krbnlein,  in  85  cases  of  tracheotomy  in 
children  under  two  years  of  age,  reports  11  recoveries.  Chaym,  in  997  cases 
in  children  two  years  of  age  and  under,  found  that  only  15.5  per  cent,  recovered. 
Archambault,  of  the  Children's  Hospital  of  Paris,  presents  some  statistics  bear- 
ing upon  the  results  of  this  operation  at  different  ages : 

Of  976  cases  in  children  from  1  to  3  years  of  age,  104  recovered. 

"    822     "      "         "         "     3  "  4  *   "     "      "  175         " 

"    736     "      "         "         "     4  '*  5      "     "      "  174         " 

"    497     "      "         "         "     5  "  6      "     "      "  148         " 

"    547     "      "         "       over  6  years  of  age,  198 

It  will  be  seen  from  these  facts  that  very  early  age  affects  the  prognosis  unfavor- 
ably, but  it  also  must  be  borne  in  mind  that  the  disease  for  which  the  operation 
is  performed  is  itself  more  fatal  in  infants  and  young  children. 

Instruments  Required  for  Tracheotomy. — In  an  emergency  tracheotomy 
may  be  performed  with  very  few  implements,  but  if  the  surgeon  has  the  choice 
he  will  find  it  convenient  to  have  the  following  instruments  at  hand : 

2  iSmall  scalpels,  1  Pair  of  tracheal  forceps, 
1  Short  grooved  director,  Tracheal  dilator, 

1  Tenaculum,  Tracheotomv-tubes  and  tapes, 

3  Aneurism  needles,  which  may  be  used         Flexible  catheter, 

as  retractors,  Ligatures, 

1  Pair  of  artery  forceps,  Needles, 

4  Haemostatic  forceps,  Feathers, 

2  Pairs  of  dissecting  forceps,  Sponges, 
1  Sharp-pointed  tenotome,  Sutures. 

The  scalpel  should  be  small  and  narrow  in  the  blade,  so  that  it  shall  obscure 
as  little  as  possible  the  operator's  view  of  the  wound.  The  grooved  director 
should  be  shorter  and  slightly  broader  than  the  one  generally  used  (Fig.  1), 
and  it  should  have  a  bevelled  extremity,  which  allows  it  to  pass  with  ease 
through  the  different  layers  of  tissue.  The  ordinary  director  is  usually  too 
long  to  use  Avith  satisfaction  in  the  short  necks  of  children. 

Haemostatic  forceps  are  most  useful  to  temporarily  secure  vessels  which 
bleed  profusely ;  they  may  also  be  useful  in  clamping  the  isthmus  of  the  thy- 
roid gland  on  either  side,  where  it  is  to  be  divided  to  expose  the  trachea  under 
similar  circumstances. 

Tracheal  forceps  may  also  be  of  great  use  after  the  trachea  has  been  opened 
or  the  tube  has  been  introduced,  (Fig.  2),  to  remove  loose  shreds  of  membrane. 


TRA  CHEO  TOMY. 


875 


Fig.  1. 


A  sharp-pointed  tenotome  is  the  knife  I  prefer  in  opening  the  trachea ;  its  sharp 
point  enables  it  to  be  thrust  easily  into  the  trachea,  and  its  short 
cutting  surface  and  narrowness  of  blade  are  additional  advantages, 
as  they  enable  the  operator  to  see  exactly  where  he  is  cutting.  Of 
tracheal  dilators,  either  Golding-Bird's  (Fig.  3)  or  Trousseau's 
(Fig.  4)  are  the  best  forms.  They  can  be  slipped  into  the  tracheal 
wound,  and  thus  its  edges  can  be  held  apart  until  the  trachea  is 
cleared  of  membrane  before  the  tube  is  introduced.  Golding-Bird's 
dilator,  which  is  a  self-retaining  one,  is,  I  think,  a  very  valuable 
instrument.  Tracheal  dilators  may  be  improvised  from  bent  hair- 
pins or  pieces  of  wire,  which  may  serve  the  purpose  when  ordinary 
dilators  cannot  be  obtained.  Silk  or  silver  sutures  may  also  be 
passed  through  the  edges  of  the  tracheal  wound  and  used  as  dila- 
tors. Soft  or  pliable  feathers  may  be  introduced  into  the  trachea 
or  larynx  to  remove  mucus  or  membrane  with  little  risk  or  injury 
to  the  parts.  The  best  feathers  for  this  purpose  I  have  found 
to  be  the  tail  feathers  of  the  turkey. 

Tracheotomy-tuhes. — Tubes  of  various  sizes  should  be  at  hand; 
and  it  is  well  to  remember  that  the  best  tracheotomy-tube  is  one 
which  fits  the  trachea  neatly  and  inflicts  the  least  possible  injury 
upon  it.  To  ensure  this,  the  part  of  the  tube  within  the  trachea 
should  lie  exactly  in  the  axis  of  the  trachea,  and  its  free  extremity 
should  be  capable  of  as  little  movement  as  possible.  The  instru- 
ment now  in  general  use  is  a  quarter-circle  tube,  which  is  made  of 
silver  and  consists  of  two  tubes — an  outer  one  which  is  attached  to 
a  movable  collar  which  fits  to  a  shield,  to  which  tapes  are  fastened  to  secure  it  in 
position,  and  a  movable  inner  tube  which  closely  fits  the  outer  tube.     The  mov- 


Author's  Tra- 
cheotomy 
Director. 


Fig.  2. 


Fig.  3. 


Tracheal  Forceps. 


Golding-Bird's    Trach- 
eal Dilator. 


able  collar,  which  allows  the  tracheal  portion  of  the  tube  to  change  its  position 
during  the  movements  of  the  trachea  and  neck,  was  suggested  by  M.  Roger, 
and  is  a  modification  which  has  ensured  both  comfort  and  safety  in  the  wearing 
of  this  instrument.  I  usually  employ  a  tracheotomy-tube  which  is  of  the  same 
calibre  throughout,  and  does  not  taper  toward  the  lower  extremity,  as  is  the 
case  with  many  of  those  sold  in  the  shops.  I  also  prefer  the  non-fenestrated 
tube ;  the  ordinary  instrument  usually  has  a  fenestra  in  the  outer  tube,  but  I 
have  never  been  able  to  see  any  advantage  in  this,  as  it  is  generally  placed 
at  such  a  position  that  it  is  not  continuous  with  the  tracheal  canal  when  the 
tube  is  in  position  ;  and  I  think  its  presence  is  even  a  decided  disadvantage, 
as  it  may  be  difficult  to  introduce  the  inner  tube  by  the  bulging  of  the 
tissues  into  it.  The  tube  which  I  have  found  most  satisfactory  is  the  quar- 
ter-circle tracheotomy-tube  made  of  silver,  as  above  described,  and  pro- 
vided with  a  fenestrated  guide,  which  materially  facilitates  its  introduction 
(Fig.  6). 


876   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDBEN. 

To  diminish  the  risk  of  erosion  of  the  trachea  or  mucous  membrane  many 
other  forms  of  tracheal  tube  have   been  devised,   notably  those  of  Durham, 

_^  Fig.  5. 

Fig.  4. 


Trousseau's  Tracheal  Dilator. 

Cohen  s  Tracheotfimy-tube,  with  fenes- 
trated guide. 

Parker,  Morant,  and  Baker.  The  latter  has  devised  and  used  flexible  tubes 
made  of  vulcanized  red  rubber.  Professor  Little  recommends  a  non-fenestrated 
tube  constructed  of  aluminium,  which  has  the  advantage  of  great  lightness. 
Tracheotomy-tubes  constructed  of  hard  rubber  have  also  been  recommended  by 
some  surgeons,  but  in  my  experience  they  are  too  bulky  and  are  not  adapted 
for  use  in  recent  cases,  though  they  may  be  employed  with  advantage  in  cases 
where  the  tube  has  to  be  Avorn  for  a  long  time. 

The  size  of  the  tracheotomy-tube  to  be  employed  in  an  individual  case  is 
a  matter  of  some  importance,  as  the  calibre  of  the  trachea  varies  with  the 
age  and  sex  of  the  patient,  being  smaller  in  female  children  than  in  males 
of  the  same  age.  The  safest  rule  of  practice  is  to  introduce  a  tube  which  fits 
the  trachea  comfortably.  I  usually  find  that  a  No.  2  tracheotomy-tube  fulfils 
this  condition  in  children  under  two  years  of  age;  in  those  from  two  to  four 
years  of  age  a  No.  3  or  4  will  usually  be  found  satisfactory.  The  fear  of  in- 
jury to  the  trachea  by  the  continued  presence  of  a  tube  has  caused  some  sur- 
geons to  substitute  for  it  a  tracheal  dilator  made  of  wire;  such  devices  have 
been  suggested  by  Watson,  Bigelow,  and  Packard.  The  latter  surgeon  has 
constructed  such  a  dilator  which  is  self-retaining  and  has  somewhat  the  mechan- 
ism of  the  eye-speculum.  Experience  with  the  use  of  these  substitutes  has 
been  very  limited,  and  I  am  inclined  to  think  they  will  prove  only  of  value  for 
temporary  use. 

Choice  of  Operation. — There  are  two  points  at  which  the  trachea  may  be 
opened,  constituting  respectively  the  high  and  low  operations.  In  the  high 
operation  the  trachea  is  opened  above  the  isthmus  of  the  thyroid  gland,  and  in 
the  low  operation  the  opening  is  made  below  this  structure.  The  high  opera- 
tion is  generally  selected  in  children,  because  at  this  point  the  trachea  is  most 
superficial,  and  for  this  reason  is  more  readily  exposed  and  opened.  In  the  high 
operation  the  cricoid  cartilage  is  frequently  divided  Avith  the  upper  rings  of  the 
trachea.  The  low  operation  cannot  be  executed  so  rapidly,  and  is  certainly 
much  more  difficult  in  its  performance,  because  of  the  relatively  greater  depth 
of  the  trachea,  the  large  size  and  number  of  veins  exposed,  and  the  proximity 
to  the  large  arterial  trunks.  In  young  childi-en  the  extreme  shortness  of 
the  neck  sometimes  prevents  the  satisfactory  adjustment  of  the  tracheotomy- 
tube  when  the  low  operation  is  performed.  I  call  to  mind  the  case  of  a  young 
child  in  Avhom  I  did  a  low  operation,  where  the  lower  extremity  of  the  tube 
came  in  contact  Avith  the  bifurcation  of  the  trachea,  and  it  was  only  after 
I  had  the  tube  shortened  that  the  child  could  wear  it  with  comfort.  Many 
operators  prefer  the  low  operation :   Cohen  expresses  himself  decidedly  in  its 


hd 


TBA  CHEO  TOMY.  877 

favor  in  case  tlie  tube  is  to  be  worn  for  a  long  time  or  where  the  operation 
is  done  for  a  foreign  body  impacted  in  the  bronchus.  I  am  myself  decidedly 
in  favor  of  the  high  operation  in  cases  of  diphtheritic  or  membranous  laryngitis 
when  the  tube  is  to  be  worn  only  for  a  short  time,  and  I  would  therefore 
recommend  those  who  have  had  little  experience  with  the  procedure  to  employ 
the  high  operation,  on  account  of  the  greater  ease  and  safety  of  its  perform- 
ance, save  in  the  exceptional  conditions  referred  to  by  Cohen. 

Position  of  the  Patient  for  Tracheotomy. — In  the  operation  of  trache- 
otomy it  is  a  matter  of  the  first  importance  that  the  patient  be  placed  in  such 
a  position  that  the  neck  shall  be  brought  into  the  greatest  prominence,  to 
render  the  trachea  more  superficial  and  give  the  greatest  amount  of  space 
between  the  sternum  and  the  chin ;  and  it  is  surprising  with  how  much  more 
ease  the  operation  will  be  accomplished  if  the  patient  be  placed  in  this  posi- 
tion. The  most  satisfactory  exposure  of  the  neck  may  generally  be  obtained 
by  laying  the  child  upon  his  back  upon  a  firm  table  and  placing  beneath  the 
shoulders  a  small  round  cushion  or  an  empty  wine-bottle  or  an  ordinary 
wooden  roller-pin  wrapped  in  several  towels  (Plate  XVIII).  In  this  position 
the  head  is  allowed  to  drop  down,  coming  in  contact  with  the  table ;  the  trachea 
is  pushed  upward,  and  becomes  more  prominent,  and  the  anterior  portion  of 
the  neck  is  more  accessible  to  the  surgeon.  The  nurse  or  an  assistant  should 
secure  the  head  by  applying  the  hands  to  its  lateral  aspects,  thus  preventing 
the  child  from  moving  it  during  the  operation,  and  an  assistant  should  also 
control  the  movements  of  the  body  and  arms  of  the  child  by  holding  them 
firmly  against  the  table.  This  is  much  better  than  securing  the  arms  by 
pinning  a  binder  around  the  chest,  and  does  not  restrict  the  already  embar- 
rassed respiratory  movements.  The  same  result  may  be  obtained  by  drop- 
ping the  child's  head  over  the  edge  of  the  table  and  having  it  held  in  this 
position. 

Use  of  Anaesthetics  in  Tracheotomy. — As  to  the  use  of  anaesthetics 
in  the  operation  there  is  much  difference  of  opinion  among  surgeons :  many 
operators  of  large  experience  express  themselves  as  decidedly  opposed  to  the 
use  of  an  anaesthetic  on  the  ground  that  it  is  unnecessary  and  its  employment 
increases  the  danger  of  the  operation.  On  the  other  hand,  manv  surgeons  of 
equally  large  experience  commend  anaesthesia,  not  only  as  facilitating  the  ope- 
ration, but  also  as  not  interfering  with  the  success  of  the  procedure.  My  own 
experience  leads  me  to  agree  with  the  former  class  of  surgeons,  and  I  think 
there  is  a  growing  tendency  to  discard  the  use  of  anaesthetics  in  this  operation. 
In  operating  in  cases  of  diphtheritic  or  membranous  laryngitis,  I  never  use  an 
anaesthetic.  I  have  seen  cases,  which  were  breathing  fairly  well  before  its 
administration,  after  its  use  suddenly  become  so  much  obstructed  that  the 
operation  had  to  be  much  hurried,  and  the  trachea  opened  rapidly  even  before 
it  was  thoroughly  exposed — a  procedure  which  is  always  attended  with  danger. 
The  unfortunate  cases  in  which  I  have  seen  death  occur  during  the  operation 
have  generally  been  those  in  Avhich  an  anaesthetic  had  been  used,  and  in  which 
the  above-named  complication  occurred,  necessitating  the  hurried  opening  of 
the  trachea,  often  followed  by  profuse  haemorrhage.  Tracheotomy  itself  is  not 
painful  when  the  dyspnoea  is  well  marked,  and  after  the  incision  in  the  skin  is 
made  little  pain  is  experienced  in  the  subsequent  steps  of  the  operation.  In 
this  connection  I  mention  the  observation  made  by  Brown-S^quard  that  an  incis- 
ion of  the  tissues  of  the  anterior  region  of  the  neck  causes  anaesthesia  of  the 
surrounding  parts,  and  hence  it  is  only  the  first  incision  which  gives  rise  to  pain 
in  tracheotomy.  Mr.  Hewitt  in  a  recent  paper  very  well  explains  the  danger 
in  the  use  of  an  anaesthetic  in  cases  of  obstructive  dyspnoea.     He  says  that 


878  AMEBIC  AN  TEXT-BOOK  OF  DISEASES  OF  CHILDBEN. 

"in  such  cases  cyanosis  is  kept  at  bay,  not  only  by  compensatory  increase  in 
the  activity  of  the  nerve-centres  which  preside  over  normal  respiratory  move- 
ments, but  also  by  the  co-operation  of  the  centres  which  preside  over  muscles 
which  take  little  or  no  share  in  ordinary  breathing.  During  ordinary  sleep 
the  activity  of  the  diaphragm  is  lessened,  the  centres  which  preside  over  it 
enjoying  comparative  rest;  while  in  obstructed  dyspnoea  the  patient  to  a 
greater  extent  depends  upon  the  increased  action  of  the  diaphragm,  so  that 
natural  sleep  is  generally  impossible  except  at  short  intervals.  These  vicarious 
centres  will  certainly  fall  victims  to  the  anaesthetic  sooner  than  the  automatic 
or  superior  centres.  The  anaesthetic  will  not  therefore  respect  vicarious  func- 
tion, and  the  muscles  will  become  paralyzed  in  the  usual  sequence,  and  the 
patients  will  become  more  embarrassed  in  their  breathing  or  the  breathing 
will  cease  altogether." 

If  an  anaesthetic  be  used,  chloroform  is  probably  preferable  to  ether,  as  it 
is  not  so  apt  to  cause  vomiting,  and  it  may  be  used  with  safety  in  operating  at 
night,  when  close  approximation  of  a  light  may  become  necessary. 

The  Operation  of  Tracheotomy. — The  child  being  placed  in  the  position 
described,  the  head  steadied,  and  the  movements  of  the  body  controlled  by 
assistants,  the  operator  should  take  his  position  either  on  the  right  side  of  the 
patient,  or,  as  I  prefer,  at  the  head  of  the  patient,  for  in  this  position  it  is 
easy  to  keep  the  incision  exactly  in  the  median  line  of  the  neck.  The  surgeon 
then  should  make  himself  familiar  with  the  landmarks  of  the  neck  ;  and  having 
located  the  position  of  the  cricoid  cartilage  with  the  finger,  he  makes  an 
incision  in  the  median  line  two  or  two  and  a  half  inches  in  length,  the  position 
of  the  cricoid  cartilage  being  the  middle  point.  There  is  no  disadvantage  in 
a  long  incision,  which  gives  the  operator  a  good  view  of  the  tissues  through 
which  he  is  to  pass ;  there  are  many  disadvantages  in  a  too  short  incision. 

The  first  incision  should  divide  the  skin  and  expose  the  superficial  fascia ;  upon 
exposing  this  the  operator  will  occasionally  see  parallel  with  or  directly  under 
the  line  of  incision  a  large  vein  lying  in  the  superficial  fascia,  the  superficial 
anterior  jugular  vein.  This  should  be  displaced,  and  next  the  fascia  should  be 
picked  up  with  forceps,  nicked  with  the  point  of  a  knife,  raised  upon  a  director, 
and  divided  freely.  In  the  early  steps  of  the  operation  the  surgeon  should  take 
care  to  see  that  the  wound  is  kept  directly  in  the  median  line  of  the  neck,  for 
this  is  the  line  of  safety,  and  he  should  be  careful  also,  as  the  wound  increases 
in  depth,  not  to  make  the  incisions  so  short  that  it  becomes  funnel-shaped,  so 
that  a  suflScient  space  of  the  trachea  cannot  be  exposed  to  view.  When  the 
deep  fascia  is  reached,  it  should  be  picked  up  and  divided  upon  a  director,  and 
any  large  veins  in  the  line  of  the  wound  should  be  carefully  displaced,  or,  if 
this  be  impossible,  should  be  clamped  by  haemostatic  forceps  or  ligatured 
on  each  side  and  then  divided  between  the  forceps  or  ligatures.  The  operator 
should  next  search,  having  the  wound  well  sponged,  for  the  muscular  space 
between  the  sterno-hyoid  and  sterno-thyroid  muscles :  this  can  generally  be 
found  without  difficulty,  and  the  muscles  should  then  be  separated  with  a 
director  or  the  handle  of  a  knife,  and  the  isthmus  of  the  thyroid  gland  will  be 
exposed.  The  muscles  should  then  be  hehl  aside  with  retractors  placed  one  on 
each  side,  the  aneurism  needles  previously  mentioned  serving  well  for  this 
purpose. 

In  regard  to  the  use  of  retractors  at  this  point,  a  caution  is  not  out  of 
place  :  the  operator  should  place  them  himself  and  allow  the  assistant  to  hold 
them.  I  once  almost  lost  a  case  in  which,  after  exposure  of  the  trachea, 
while  I  had  turned  aside  to  pick  up  a  knife,  my  assistant  replaced  one  retractor 
which  had  slipped ;  in  doing  so  the  movable  trachea  was  caught  in  the  grasp 


TJRA  GHEO  TOMY.  879 

of  the  retractor  and  drawn  to  one  side,  completely  shutting  off  respiration. 
When  I  attempted  to  find  the  trachea  to  open  it,  I  could  simply  feel  the 
anterior  surface  of  the  vertebrae  at  the  bottom  of  the  wound,  and  it  was  only 
when  I  lifted  the  retractor  and  allowed  the  trachea  to  spring  back  to  its 
normal  position  that  I  was  able  to  open  it.  Other  operators  have  had  the  same 
experience.  Mr.  Durham  mentions  a  case,  and  Mr.  Howard  Marsh  also  one,  in 
which  the  trachea  and  great  vessels  were  held  aside  by  an  assistant  until  the 
surgeon  had  exposed  the  cervical  vertebrae.  It  is  well  for  the  operator  to  con- 
stantly explore  the  wound  with  his  finger,  to  locate  exactly  the  position  of  the 
trachea,  and  to  ascertain  the  presence  of  any  anomalous  arterial  branch. 

The  isthmus  of  the  thyroid  gland  being  exposed,  it  is  generally  found  sur- 
rounded by  a  venous  plexus,  and  occupies  a  position  over  the  first  three  tracheal 
rings,  or  it  may  extend  even  higher  and  cover  the  cricoid  cartilage.  At  this 
point  of  the  operation  the  surgeon  may  find  that  the  isthmus  of  the  thyroid 
gland,  if  large,  bulges  up  and  fills  the  Avhole  Avound,  and  he  should  endeavor  to 
displace  it  either  upward  or  doAvnward ;  this  it  is  often  possible  to  do  without 
difficulty.  But  should  it  be  found  firmly  fixed,  and  the  trachea  cannot  be  ex- 
posed either  above  or  below  it,  it  may  be  cut  through  after  being  ligatured  or 
clamped  on  each  side  to  prevent  haemorrhage.  A  procedure  recommended  by 
Bose,  which  I  have  employed  with  advantage  in  several  cases,  may  also  be 
made  use  of — namely,  a  transverse  incision  is  made  across  the  cricoid  cartilage 
to  divide  the  layer  of  cervical  fascia  by  Avhich  the  isthmus  is  bound  down,  and 
a  director  is  then  passed  in,  and  the  isthmus  is  displaced  doAvnward  without 
difficulty.  After  displacing  the  isthmus  of  the  thyroid  gland  upward  or  down- 
ward, as  the  case  may  be,  the  trachea,  yellowish-white  in  appearance,  covered 
by  its  fascia,  should  be  exposed.  This  fascia  should  be  torn  through  with  a 
director  or  the  handle  of  a  knife,  so  as  to  bare  the  surface  of  the  trachea.  On 
this  point  all  authorities  agree — namely,  the  importance  of  thoroughly  clear- 
ing the  trachea  of  its  fascia  before  opening  it,  as  by  so  doing  it  is  easier  to 
incise  it  and  to  introduce  the  tracheotomy-tube.  In  breaking  up  this  fascia 
the  operator  can  feel  it  crepitate  under  the  finger  from  the  suction  of  air  drawn 
in  with  each  inspiratory  movement. 

When  the  surgeon  has  the  trachea  exposed,  he  may  then  take  time  to  see 
that  the  wound  is  free  from  haemorrhage,  and  may  replace  the  retractors  so  as 
to  expose  as  large  a  portion  of  the  trachea  as  possible ;  for,  be  the  case  ever  so 
urgent,  he  now  feels  assured  that  he  can  open  the  trachea  in  a  moment  if  the 
breathing  should  cease.  The  trachea  should  next  be  fixed  with  the  point  of  a 
tenaculum  introduced  a  little  to  one  side  of  the  median  line ;  and  an  incision 
made  in  the  median  line  from  below  upward  for  a  distance  of  half  to  three- 
fourths  of  an  inch.  Some  surgeons  object  to  the  use  of  a  tenaculum  to  fix  the 
trachea,  as  it  arrests  respiratory  movements,  but  prefer  to  use  the  tip  of  the 
finger  as  a  guide  to  steady  the  trachea  before  it  is  incised.  I  always  use  the 
tenaculum  in  this  way,  and  see  no  disadvantage  in  its  use  if  the  trachea  is  not 
fixed  for  too  long  a  time  before  the  opening  is  made.  The  operator  may  find  it 
of  advantage,  especially  in  cases  where  the  trachea  is  deeply  situated,  after 
fixing  it  with  a  tenaculum,  to  lift  it  slightly  from  its  bed,  thereby  bringing  it 
more  prominently  into  view  and  making  it  more  superficial  in  the  wound,  thus 
facilitating  its  safe  incision. 

I  prefer  in  opening  the  trachea  to  employ  a  sharp-pointed  tenotomy  knife: 
the  sharp  point  allows  it  easily  to  be  thrust  into  the  trachea,  and  the  narrow 
blade  obscures  the  operator's  vieAv  of  the  wound  to  the  least  possible  extent. 
The  knife  should  not  be  introduced  so  deeply  into  the  trachea  that  the  posterior 
wall  or  the  oesophagus  may  be  injured:  both  of  these  accidents  have  occurred  by 


880  AMERICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 

a  too  deep  thrust  of  the  blade.  The  operator  should  also  be  careful  not  to  make 
a  too  superficial  incision,  which  might  divide  only  the  trachea  and  the  mucous 
membrane,  while  the  false  membrane,  if  it  be  present,  is  not  divided;  aiid 
the  cavity  of  the  trachea  therefore  not  opened :  under  such  circumstances, 
if  the  tracheotomy-tube  is  hurriedly  introduced,  it  may  pass  between  the 
trachea-wall  and  the  false  membrane,  and  no  relief  from  the  dyspnoea  will  be 
obtained.  I  have  seen  this  accident  occur  and  death  result  from  it.  I  have 
already  spoken  of  the  importance  of  keeping  in  the  median  line  in  exposing  the 
trachea,  and  I  think  it  of  equal  importance  to  have  the  incision  into  the  trachea 
itself  in  the  median  line,  for  these  wounds  are  said  to  heal  more  promptly ;  and, 
if  the  wound  be  made  to  either  side  of  the  median  line  of  the  trachea,  the  tube 
does  not  fit  Avell.  and  its  lower  extremity  may  cause  damage  to  the  lateral 
aspect  of  the  trachea.  It  is  often  a  matter  of  great  difiiculty  to  introduce  the 
tracheotomy-tube  in  a  case  where  the  tracheal  incision  is  far  out  of  the  median 
line;  and  if  this  is  found  to  be  the  case,  I  think  it  is  wiser  to  make  a  second 
incision  in  the  median  line,  disregarding  the  previous  one,  which  generally  heals 
without  difficulty. 

As  soon  as  the  trachea  is  opened  there  is  usually  thrown  from  the  wound, 
with  the  first  expiratory  effort,  mucus  or  false  membrane:  this  should  be  wiped 
away  with  a  sponge,  and  the  tracheal  dilator  introduced.  It  is  well  to  remem- 
ber that  the  tenaculum  should  not  be  removed  until  the  tracheal  dilator  or 
tracheotomy-tube  is  placed  in  position,  as  it  is  often  difficult  to  introduce  either 
of  them  into  the  movable  trachea  after  the  tenaculum  has  been  removed.  It 
is  not  unusual,  after  the  trachea  has  been  opened,  to  have  a  sudden  arrest  of 
respiration ;  the  entrance  of  a  large  body  of  air,  according  to  Cohen,  seems,  as 
it  were,  to  surprise  the  lungs.  This  is  apt  to  produce  great  alarm  to  one  not 
familiar  with  the  circumstance,  as  it  looks  like  a  cessation  of  breathing ;  it  is 
especially  trying  to  the  operator  when  he  is  about  to  congratulate  himself  upon 
the  completion  of  an  anxious  operation.  This  arrest  of  respiration  is  usually 
only  momentary,  and  if  the  child's  face  and  chest  be  slapped  with  a  wet  towel, 
or  artificial  respiration  be  employed,  normal  respiratory  movements  will  soon 
be  re-established. 

The  trachea  being  opened  and  the  tracheal  dilator  being  introduced,  any 
membrane  which  appears  at  the  wound  .should  be  removed  with  a  sponge  or 
forceps,  and  the  trachea  should  be  explored  both  above  and  below  the  wound 
for  the  presence  of  false  membrane,  which  should  be  removed  with  forceps,  a 
feather,  or  a  camels-hair  brush.  This  removal  of  membrane  from  the  trachea 
has  been  urgently  insisted  upon  by  Pilcher.  Parker,  and  others:  and  I  think 
that  it  is  largely  owing  to  the  great  care  which  is  exercised  in  this  particular 
that  the  results  of  tracheotomy  in  diphtheritic  cases  in  the  last  few  years  has 
been  so  much  more  encouraging. 

Mouth-suction  of  the  wound,  which  has  been  frequently  employed  by  sur- 
geons to  restore  respiratory  movements  and  clear  the  trachea  of  membrane,  has 
been  so  often  followed  by  disastrous  results  that  it  cannot  be  too  strongly  con- 
demned. This  procedure  is  no  more  efficient  in  removing  membrane  or  re-es- 
tablishing respiration  than  the  use  of  the  forceps,  brush,  or  feather,  or  the 
employment  of  artificial  respiration  made  in  the  ordinary  manner.  For  the 
purpose  of  clearing  the  trachea  Parker  has  devised  a  tracheal  aspirator,  which 
consists  of  a  glass  or  celluloid  cylinder  three  or  four  inches  in  length  by  three- 
quarters  of  an  inch  in  diameter,  to  the  one  extremity  of  which  is  attached  a 
flexible  tube  and  to  the  other  an  India-rubber  tube  with  a  mouth  piece  at  the 
end.  The  cylinder  may  be  packed  with  antiseptic  cotton,  which  will  act  as  a 
filter  and  prevent  any  infected  material  from  reaching  the  operator's  mouth.    A 


TRACHEOIOMY.  881 

flexible  catheter  may  be  employed  for  the  same  purpose  with  good  results.  The 
membrane  is  usually  loosely  attached,  and  can  be  removed  with  forceps  or  a 
flexible  feather,  particularly  if  a  little  of  Parker's  soda  solution  be  brought  in 
contact  with  the  inner  surface  of  the  trachea.  The  peroxide  of  hydrogen  may 
also  be  employed  with  satisfaction  for  the  same  purpose. 

After  removing  the  membrane,  Mr.  Watson  Cheyne  recommends  that  the 
raw  surface  be  touched  with  a  solution  of  bichloride  of  mercury  1 :  500 ;  he 
also  introduces  into  the  trachea  or  larynx  above  the  tube  strips  of  lint  sat- 
urated with  a  solution  of  bichloride  of  mercury  1 :  2000,  and  washes  the  wound 
with  a  similar  solution  of  1 :  500. 

Having  cleared  the  trachea  of  membrane,  the  tracheotomy-tube  should  be 
introduced.  This  can  be  accomplished  without  difiiculty  if  a  fenestrated  guide 
be  employed,  and  if  the  wound  in  the  trachea  has  been  made  in  the  median 
line ;  the  tube  is  secured  in  position  by  the  tapes  attached  to  the  shield,  which 
are  tied  around  the  neck.  The  tapes  should  be  firmly  tied  by  several  knots, 
so  that  there  may  be  no  possibility  of  the  child  untying  them  when  not  watched 
by  the  attendant,  as  in  such  an  event  the  tube  may  become  displaced  when 
there  is  no  one  at  hand  competent  to  replace  it.  These  knots  should  be  tied 
on  either  one  or  other  side  of  the  neck,  and  not  posteriorly,  where  their  pres- 
ence would  cause  the  child  discomfort  as  he  rests  upon  his  back. 

The  immediate  results  of  the  opei'ation  are,  as  a  rule,  most  encouraging : 
the  patient,  who  previously  exhibited  the  most  distressing  symptoms  by  reason 
of  his  extreme  dyspnoea,  now  becomes  quiet;  the  color  improves,  the  respi- 
ration becomes  natural,  and  it  is  not  an  unusual  occurrence  to  have  him  fall 
into  a  quiet  sleep  before  he  is  removed  from  the  operating  table  to  his  bed. 

Complications  at  the  Time  of  Operation. — The  principal  complication  at 
the  time  of  operation  is  haemorrhage,  which  may  be  either  arterial  or  venous. 
Haemorrhage  should  be  prevented  by  great  care  in  avoiding  the  wounding  of 
any  vessels  of  considerable  size  :  if  their  injury  is  unavoidable,  they  should  be 
immediately  ligatured,  or,  if  the  case  is  too  urgent  to  admit  of  delay,  they 
should  be  secured  by  haemostatic  forceps,  and  after  the  trachea  has  been  opened 
they  can  be  permanently  secured  by  ligatures. 

Sudden  Arrest  of  Respiration. — Cessation  of  the  respiratory  act  during 
the  operation  is  a  most  dangerous  symptom,  and  one  which  calls  for  prompt 
action  on  the  part  of  the  operator.  The  surgeon's  duty  under  the  circumstance 
is  to  open  the  trachea  as  rapidly  as  possible — -even  through  a  pool  of  blood,  as 
described  by  Mr.  Durham — introduce  the  tracheal  dilator,  and  make  artificial 
respiration :  by  such  prompt  action  many  cases  may  be  saved,  and  bleeding 
vessels  may  be  ligatured  or  secured  by  forceps  after  the  trachea  is  opened.  Mr. 
Durham  very  wisely  says  that  in  those  reported  cases  in  which  much  blood  is 
lost  during  the  operation,  and  which  are  abandoned  before  opening  the 
trachea  because  of  the  cessation  of  respiration,  death  is  not  the  result  of 
haemorrhage,  but  of  failure  to  complete  the  operation.  Blood  in  the  tra- 
chea after  the  operation  may  seriously  embarrass  the  breathing,  but  if  the 
tracheal  dilator  is  introduced,  it  may  be  removed  by  the  use  of  a  brush  or 
feather. 

After-Treatment  of  Cases  of  Tracheotomy. — The  operation  of  trache- 
otomy relieves  the  patient  of  the  immediate  danger  of  death  by  strangulation,  yet 
there  still  exist  the  same  indications  for  local  and  constitutional  treatment  as 
wei'e  present  before  it.  This  fact  is  often  overlooked  by  physicians,  who,  ob- 
serving the  improved  condition  of  the  patient  after  the  operation,  are  too  apt  to 
relax  their  eiforts  in  this  direction.  I  knoAV  of  no  cases  in  which  a  successful 
issue  more  directly  depends  upon  care  and  watchfulness  in  their  after-treatment 

56 


882  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

than  those  in  which  tracheotomy  has  been  performed  to  relieve  the  obstructive 
dyspnoea  consequent  upon  diphtheritic  or  membranous  laryngitis.  The  patient 
should  be  under  the  charge  of  an  attendant  or  nurse  who  is  skilled  in  the 
management  of  such  cases,  and  is  able  to  recognize  and  meet  such  complica- 
tions as  may  arise.  After  the  operation  the  patient  should  be  placed  in  a  room 
free  from  draughts,  with  a  temperature  of  70°  to  75°  F.,  and  the  air  of  the 
room  should  be  rendered  moist  and  warm  by  a  vapor  of  steam.  At  the  Chil- 
dren's Hospital  of  Philadelphia  there  is  an  apartment  especially  arranged  for 
the  treatment  of  cases  after  tracheotomy ;  it  is  fitted  with  a  steam  apparatus, 
by  means  of  which  in  a  few  minutes  it  can  be  filled  with  a  vapor  of  steam  and 
maintained  at  an  even  temperature.  I  think  the  large  number  of  successful 
results  of  the  operation  at  that  institution  is  greatly  due  to  this  feature  of  the 
after-treatment.  In  private  practice  it  is  difiicult  to  obtain  these  conditions, 
and  as  a  substitute  a  framework  may  be  fastened  over  the  bed,  over  which 
sheets  can  be  stretched,  forming  a  tent ;  under  this  water  may  be  kept  boiling 
in  a  pan  or  vessel,  or  lime  can  be  slaked ;  the  vapor  from  the  latter  Cohen  con- 
siders one  of  the  most  efficient  solvents  of  the  false  membrane.  A  steam  or 
hand  atomizer  should  be  used  at  frequent  intervals,  the  spray  being  directed 
over  the  opening  in  the  tracheotomy-tube.  I  have  found  great  advantage 
from  the  use  of  Parker's  soda  solution,   which  is  as  follows : 

^.  Sodii  carbonatis 3J-3ij- 

Glycerini fsij. 

Aquse q.  s.  ad  f5vj. — M. 

To  this  solution  a  small  quantity  of  carbolic  acid  may  be  added,  without  in  any 
way  afi"ecting  its  solvent  action  on  the  false  membrane  or  mucus.  I  am  so 
firmly  convinced  of  the  utility  of  this  solution  that  in  all  cases  I  have  it  con- 
stantly used  in  the  steam  or  hand  atomizer,  and  also  have  it  introduced  into  the 
tracheal  tube  by  means  of  a  feather  or  brush.  The  use  of  the  steam  spray  and 
the  soda  solution  is  especially  important  in  cases  in  which  there  is  little  tend- 
ency to  expectorate  mucus  or  false  membrane — dry  cases — or  in  those  in  which 
the  inner  tube  is  found  clogged  with  inspissated  mucus  or  membrane.  Peroxide 
of  hydrogen  in  15-volume  solution,  either  used  in  full  strength  or  diluted 
to  one-half,  one-third,  or  one-fourth,  is  also  used  with  advantage  in  these  cases. 
It  has  a  decided  action  upon  the  membrane,  and  it  may  be  applied  with  a  brush, 
feather,  or  spray.  It  is  a  good  omen  if  the  child  coughs  or  expectorates  false 
membrane  after  the  tracheotomy-tube  is  introduced,  for  moist  cases  in  which 
these  conditions  obtain,  as  a  rule,  are  much  more  fiivorable  than  dry  cases  or 
those  in  which  there  is  little  tendency  to  expectoration.  This  clinical  observa- 
tion was,  as  far  as  I  know,  first  made  by  Cohen  some  years  ago,  and  I  have 
since  personally  seen  numerous  instances  Avhich  attested  its  accuracy.  In  a 
series  of  cases  reported  by  Lovett  and  Monroe  all  those  in  which  thei'e  was 
suppression  of  the  discharge  from  the  tracheotomy-tube,  which  were  classed  as 
dry  cases,  terminated  fatally.  My  own  experience  has  been  the  same,  with  one 
exception.  This  was  in  the  case  of  a  girl  three  years  of  age,  who  was  admitted 
to  the  Children's  Hospital  in  September,  1887,  with  extreme  dyspnoea  from 
diphtheritic  laryngitis.  I  performed  tracheotomy :  when  the  trachea  was  opened 
there  was  no  expectoration,  and  it  seemed  to  be  a  typical  dr}'  case  ;  an  unfavor- 
able prognosis  was  accordingly  given.  This  condition  continued  for  fourteen 
hours,  when,  under  the  persistent  use  of  steam  spray  and  soda  solution,  and 
frequent  moistening  of  the  trachea  through  the  tube  by  means  of  a  feather 
dipped  in  the  soda  solution,  the  child  began  to  expectorate  mucus  and  shreds 


TRACHEOTOMY.  883 

of  membrane,  and  continued  to  do  so  for  several  days.  She  finally  recovered, 
the  tube  being  removed  on  the  tenth  day. 

Oare  of  the  Tracheotomy-tiihe. — The  nurse  or  attendant  having  charge  of 
the  case  should  remove  the  inner  tube  of  the  tracheotomy-tube  every  hour  or 
half  hour  for  the  first  twenty-four  hours,  and  after  this  time  at  less  frequent 
intervals,  and  thoroughly  cleanse  it  with  a  feather  or  brush  dipped  in  soda  solu- 
tion, removing  any  membrane  or  mucus  which  adheres  to  its  inner  surface. 
She  must  be  cautioned  not  to  allow  the  inner  tube  to  remain  out  more  than  a 
few  minutes  at  a  time,  for  I  have  seen  cases  in  which  it  was  carelessly  allowed 
to  remain  out  for  several  hours,  where,  owing  to  the  tendency  of  the  mucus  to 
become  inspissated  in  the  outer  tube,  it  could  not  be  reintroduced  and  the  outer 
tube  had  to  be  removed  from  the  wound  and  cleaned  before  it  could  be  re- 
placed. The  nurse  should  also  be  instructed  to  introduce  a  soft  feather  moist- 
ened with  soda  solution  into  the  tube  every  half  hour,  if  the  case  be  one  in 
which  there  is  little  discharge  from  the  tube ;  if  there  is  membrane  or  mucus 
loose  in  the  trachea  or  tube,  as  evidenced  by  noisy  respiration,  this  manipula- 
tion will  facilitate  its  removal.  If  a  portion  of  membrane  becomes  impacted 
in  the  tube,  its  presence  will  be  shown  by  more  or  less  marked  dyspnoea ;  this 
can  generally  be  relieved  by  removing  the  inner  tube  and  cleansing  it.  If  the 
membrane  is  in  the  trachea  below  the  tube,  it  may  be  extracted  by  means  of  a 
feather  or  the  curved  tracheal  forceps.  If  all  these  means  fail  and  the  breath- 
ing becomes  more  embarrassed,  the  surgeon  should  remove  the  tracheotomy- 
tube,  introduce  the  tracheal  dilator,  and  search  for  and  remove  the  obstructing 
membrane,  after  the  removal  of  which  the  tube  should  be  replaced. 

Changing  the  Tracheotomy-tuhe. — If  no  indication  exists  for  removing  the 
tracheotomy-tube  earlier,  it  should  be  removed  on  the  third  or  fourth  day  and 
replaced  by  a  fresh  one.  At  this  time  the  surgeon  may  take  the  opportunity  of 
testing  the  breathing  capacity  through  the  larynx  by  placing  a  pad  of  moist 
lint  over  the  wound  in  the  neck  ;  if  the  child  breathes  comfortably  without  the 
tube,  it  may  be  kept  out  of  the  wound  for  a  few  minutes  while  it  is  being 
cleansed  and  fresh  tapes  attached,  or  a  fresh  tube  may  be  prepared,  and  it 
should  then  be  inti'oduced.  There  is  usually  little  difficulty  experienced  in 
introducing  a  tube  at  this  time,  for  the  tissues  in  the  region  of  the  wound  have 
become  glued  together  by  inflammatory  lymph,  leaving  a  sinus  leading  down  to 
the  wound  in  the  trachea.  If  there  is  not  any  special  indication  for  its  removal, 
the  tube  need  not  be  again  changed  for  two  or  three  days ;  and  at  this  time  it 
can  be  left  out  of  the  trachea  for  a  longer  period  if  the  child  breathes  comfort- 
ably without  it  and  there  is  evidence  that  air  passes  freely  through  the  larynx. 
I  consider  it  a  good  plan  to  permit  the  nurse  or  attendant  to  introduce  the  tube 
under  the  surgeon's  direction,  so  that  in  the  event  of  its  accidental  displace- 
ment or  necessary  removal  on  account  of  obstruction  by  membrane,  she  will 
have  learned  the  way  into  the  trachea  and  will  feel  confident  of  her  ability  to 
replace  it.  It  is  often  well,  as  the  case  progresses,  to  close  the  opening  in  the 
tube  by  a  cork,  which  may  be  kept  in  place  for  a  short  time,  and  thus  test  the 
permeability  of  the  respiratory  tract  above  the  wound. 

Permanent  Removal  of  the  Tracheotomy-tuhe. — When  it  is  found  that  the 
child  can  breathe  comfortably  with  the  tube  stopped,  showing  that  air  is  passing 
through  the  larynx,  it  is  advisable  to  attempt  the  permanent  removal  of  the 
tube.  The  permanent  removal  of  the  tube  is  most  important  if  there  is  no 
further  indication  for  its  use,  for  its  presence  may  set  up  tracheitis,  which  is 
evidenced  by  the  profuse  discharge  of  glairy  mucus  ;  and  it  is  a  well-estab- 
lished fact  that  tracheotomy-tubes  which  are  retained  for  a  long  time  are,  in 
many  cases,  finally  removed  with  the  greatest  difficulty. 


884  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

It  is  difficult  to  fix  a  definite  time  for  the  permanent  removal  of  the  trache- 
otomy-tube in  all  cases,  as  the  procedure  depends  largely  upon  the  state  of  the 
patient  and  upon  the  local  condition  of  the  trachea  and  larynx.  I  have  seen 
tubes  permanently  removed  as  earl}^  as  the  third  and  as  late  as  the  sixtieth  day, 
and  there  are  numerous  recorded  cases  in  which  it  has  been  impossible  to  remove 
them  for  months  or  even  years.  In  cases  of  tracheotomy  for  diphtheritic  or  mem- 
branous laryngitis  I  think  the  tube  can  usually  be  removed  permanently  from 
the  eighth  to  the  fifteenth  day.  The  wound,  after  the  removal  of  the  trache- 
otomy-tube, contracts  rapidly,  but  for  a  few  days  the  breathing  is  carried  on 
through  both  the  wound  and  the  nose  and  mouth.  Usually  from  the  fifth  to 
the  eighth  dav  after  the  removal  of  the  tube  the  wound  is  so  far  healed  that  no 
air  passes  through  it.  The  superficial  wound  may  be  dressed  with  a  piece  of 
lint  spread  with  boracic  ointment,  and  held  in  position  by  a  strip  of  adhesive 
plaster  until  it  is  completely  healed. 

Too  much  care  cannot  be  exercised  in  the  thorough  cleansing  of  tracheot- 
omy-tubes Avhich  have  been  used.  Before  they  are  employed  in  other  cases 
they  should  be  boiled  in  soda  solution  for  fifteen  minutes,  and  then  dried  and 
polished. 

Feeding  of  Patients  after  Tracheotomy. — It  is  the  general  experience  of 
surgeons  that  children  wearing  tracheotomy-tubes  take  their  nourishment  well 
and  have  no  difliculty  in  swalloAving  fluids,  so  that  they  can  be  given  a  milk 
diet  or  one  of  semi-solids,  or  even  one  of  solids  if,  for  any  reason,  the  latter  is 
considered  desirable.  It  is  also  important  to  remember  that  such  cases  should 
be  given  the  most  nutritious  diet ;  if  the  appetite  fails  or  the  child  refuses  to 
take  a  sufficient  quantity  of  nourishment,  alcohol  in  some  form  should  be 
administered,  and  rectal  feeding  or  the  injection  of  fluids  into  the  stomach  by 
means  of  an  oesophageal  tube  should  be  resorted  to.  Regurgitation  of  fluids 
through  the  tube  or  wound  sometimes  occurs  a  few  days  after  the  operation, 
OAving  to  paralysis  of  the  muscles  of  the  palate  ;  under  such  circumstances  the 
patient  should  first  be  given  a  diet-of  semi-solids,  and  if  this  be  regurgitated 
through  the  tube,  the  nourishment  should  be  given  by  means  of  the  oesophageal 
tube,  and  rectal  feeding  should  be  employed  at  the  same  time.  If  the  diet  is 
restricted  to  semi-solids  or  solids,  the  thirst  may  be  allayed  by  allowing  the 
patient  to  swallow  small  pieces  of  ice,  or  by  the  use  of  enemata  of  water ;  care 
should  be  taken  that  small  quantities  only  are  given  at  a  time.  Regurgitation 
of  fluids  through  the  tube  or  wound  is  not  a  favorable  symptom  ;  but  an  un- 
favorable pi'ognosis  should  not  be  given  from  this  symptom  alone,  as  I  have 
seen  a  number  of  cases  in  which  this  complication  existed  both  before  and  after 
the  removal  of  the  tube,  but  in  which,  by  careful  feeding,  recovery  followed. 

Causes  of  Death  after  Tracheotomy. — After  the  operation  of  tracheot- 
omy many  cases  do  well  for  a  time  and  then  terminate  fatally  from  septicaemia, 
from  diphtheritic  poisoning,  from  pneumonia,  from  heart-clot,  from  recurrent 
obstruction  due  to  extension  of  the  membrane  below  the  seat  of  the  operation 
into  the  trachea  and  bronchial  tubes,  and  from  diphtheritic  paralysis.  Death 
from  any  of  the  above  causes,  except  recurrent  obstruction,  is  usually  devoid  of 
the  signs  of  suffering,  and  the  operation  may  be  credited  with  prolonging  life 
and  rendering  the  mode  of  death  much  less  distressing.  Many  cases  die  of 
heart-clot  or  pneumonia,  and  it  is  a  question  whether  deaths  from  this  compli- 
cation are  more  frequent  after  tracheotomy  than  in  cases  of  diphtheria  in  which 
the  operation  has  not  been  performed.  In  diphtheritic  cases  the  open  wound 
exposes  a  surface  for  the  absorption  of  the  poisons,  as  is  seen  by  the  occasional 
development  on  the  wound  of  diphtheritic  membrane,  and  in  this  way  the  ope- 
ration may  be  said  to  introduce  a  small  additional  element  of  danger ;  but  it  is  a 


TBA  CHEO  TOMY.  885 

comparatively  insignificant  one,  and  is  not  to  be  compared  Tvitli  the  immediately 
dangerous  symptom  for  the  relief  of  which  it  was  undertaken. 

Croup  supervening  upon  the  exanthemata  is  not,  as  a  rule,  amenable  to 
tracheotomy,  according  to  Cohen.  Lovett  and  Munroe  mention  17  cases  in 
which  tracheotomy  was  performed  during  the  course  of  some  one  of  the  exan- 
themata; 10  of  these,  in  which  croup  complicated  measles,  gave  5  recoveries; 
in  the  other  7  cases,  in  Avhich  croup  complicated  whooping-cough,  mumps,  or 
scarlet  fever,  the  operation  failed  to  save  life.  I  have  had  1  successful  result 
out  of  3  tracheotomies  performed  for  croup  complicating  measles  in  a  very  fatal 
epidemic  of  this  disease  in  the  Children's  Home  in  Philadelphia.  My  own 
experience  with  this  class  of  cases  has  been  such  that  I  do  not  refuse  to  operate 
if  the  symptoms  calling  for  operation  exist. 

Complications  after  Tracheotomy. — Diphtheritic  infection  of  the  ivoimd 
is  a  complication  which  is  occasionally  seen  after  tracheotomy  for  diphtheritic 
laryngitis,  and  it  is  one  which  is  not  necessarily  fatal,  although  it  adds  some- 
what to  the  gravity  of  the  case,  for  I  have  seen  patients  recover  in  whom  this 
condition  was  well  developed.  In  the  treatment  the  local  application  to  the 
wound  of  1  part  of  hydrochloric  acid  to  2  parts  of  glycerin  has  been  followed 
by  good  results.  Peroxide  of  hydrogen  may  also  be  applied  to  the  surface  of 
the  wound,  or  the  membrane  may  be  scraped  away  with  a  curette,  and  the  sur- 
face then  swabbed  with  a  solution  of  bichloride  of  mercury  1 :  500.  Diph- 
theritic infection  of  the  wound  should  not  be  confounded  with  sloughing  of 
the  wound,  with  a  discharge  of  thin,  offensive  pus — a  condition  which  is  some- 
times seen  in  poorly-nourished  and  weak  children. 

Injiammatory  oedema  of  the  neck  is  apt  to  occur  in  ill-nourished  children, 
and  it  is  only  a  source  of  danger  when  it  becomes  well  marked ;  for  in  the 
majority  of  cases  of  tracheotomy  it  exists  in  the  immediate  neighborhood  of 
the  wound  to  a  limited  extent.  It  may,  however,  involve  the  tissues  of  the 
neck  to  such  an  extent  that  the  tube  is  lifted  out  of  the  tracheal  wound  by  the 
swelling  of  the  tissues,  and  dyspnoea  occurs,  in  which  event  a  longer  tube  should 
be  introduced.  The  treatment  of  this  complication  consists  in  the  application 
of  lead-water  and  laudanum  to  the  inflamed  area,  and  if  there  is  evidence  of 
diffused  abscess  a  free  incision  should  be  made  at  the  earliest  opportunity. 

Erysipelas  also  may  attack  the  tracheotomy  wound ;  it  is  generally  super- 
ficial, but  may  involve  the  deeper  pai'ts.  The  treatment  is  the  same  as  for  ery- 
sipelas complicating  other  wounds. 

Secondary  hcemorrhage  is  a  rare  complication  after  tracheotomy,  but  may 
arise  from  vessels  divided  or  injured  during  the  operation,  or  from  ulcerative 
perforation  of  the  trachea  from  pressure  of  the  lower  extremity  of  a  badly- 
fitting  tracheotomy-tube,  causing  erosion  of  some  of  the  great  vessels  of  the 
neck.  I  have  seen  two  cases  in  which  death  resulted  from  haemorrhage  after 
the  operation:  in  one  case  a  profuse  consecutive  haemorrhage  occurred  six 
hours  after  the  operation,  and  speedily  proved  fatal.  I  assisted  in  the  opera- 
tion in  this  case,  and  althouo-h  there  was  free  venous  heemorrhao-e  at  the 
time,  it  was  thoroughly  controlled  before  the  tracheotomy-tube  was  intro- 
duced ;  and  the  unfortunate  result,  in  my  mind,  can  be  accounted  for  only  by 
the  displacement  of  one  of  the  several  ligatures  which  had  been  applied  to 
the  injured  vessels.  The  other  was  that  of  an  infant  six  months  old,  in  whom, 
at  the  time  of  the  operation,  there  was  free  venous  bleeding,  which  was  con- 
trolled by  ligatures.  In  this  case  on  the  sixth  day  profuse  haemorrhage 
took  place  from  the  tracheotomy  wound  and  tube,  and  rapidly  proved  fatal. 
M.  d'Heilly  reports  a  fatal  case  in  a  child  in  whom  hgemorrhage  arose  from  an 
ulceration  of  the  trachea,  which  had  extended  to  the  innominate  artery,  and  was 


886  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

caused  by  the  end  of  the  tracheotomy-tube.  Dr.  Hutton  reports  a  similar  case 
in  which  death  occurred  from  haemorrhage ;  and  several  other  cases,  in  which 
the  innominate  artery  was  opened  in  the  same  manner,  have  been  recorded. 
If  the  bleeding  arises  from  smaller  vessels,  it  is  often  possible  to  control  it  by 
the  application  of  ligatures  or  b}^  the  use  of  the  galvano-cautery ;  but  haemor- 
rhage from  the  innominate  artery  is  so  profuse  that  it  has  always  rapidly 
proved  fatal  before  any  attempt  could  be  made  to  control  it. 

Surgical  emphysema,  starting  from  the  region  of  the  wound,  is  occasionally 
met  with  after  tracheotomy :  the  presence  of  air  in  the  tissues  is  explained  by 
the  fact  that  during  the  violent  inspiratory  efforts  in  obstruction  of  the  larynx 
there  is  more  or  less  of  a  vacuum  produced  in  the  chest,  and  the  air  is  sucked 
into  the  cellular  tissues  of  the  neck  and  diifused  throughout  the  tissues  gener- 
allv.  It  is  said  to  be  more  common  after  tracheotomies  in  which  the  incision 
in  the  treachea  is  not  in  the  median  line  and  does  not  correspond  with  the  wound 
in  the  soft  parts  in  front  of  the  trachea.  A  moderate  amount  of  emphysema  in 
the  immediate  neighborhood  of  the  wound  is  not  uncommon,  but  sometimes  the 
condition  is  developed  to  such  an  extent  that  the  cellular  tissues  of  the  neck, 
face,  ai*ms,  chest,  and  abdomen  become  greatly  distended  with  air.  I  once  saw 
a  case  in  which  these  parts  were  all  involved,  and  the  crepitation  of  the  air  in 
the  cellular  tissue  at  the  ends  of  the  fingers  could  be  distinctly  felt.  In  this 
case  there  was  also  recurrent  dyspnoea,  which  was  probably  due  to  mediastinal 
emphysema.  Champneys  has  reported  28  cases  in  which  autopsies  had  been 
made  after  tracheotomy,  in  which  the  operation  was  performed  for  diphtheritic 
laryngitis.  In  16  of  these  cases  emphysema  of  the  mediastinum  was  present. 
This  condition  has  also  been  found  in  patients  dying  from  diphtheria  in  whom 
tracheotomy  had  not  been  performed.  Emphysema,  when  developed  to  a 
moderate  extent,  seems  to  do  no  harm,  as  the  air  is  usually  quickly  absorbed  ; 
but  Avhen  it  becomes  general  and  the  mediastinum  is  involved,  marked  dyspnoea 
is  apt  to  develop  and  the  prognosis  is  extremely  grave. 

Granulations  about  the  tracheal  Avound  occur  in  certain  cases  where  there 
seems  to  be  a  peculiar  hypersensitive  condition  of  the  mucous  membrane  of  the 
trachea.  These  granulations  are  most  commonly  seen  in  cases  where  tubes  have 
been  worn  for  a  long  time,  and  are  often  one  cause  of  difficulty  in  their 
permanent  removal.  The  presence  of  granulations  may  be  suspected  if  the 
child  coughs  up  blood-stained  secretions  after  the  tube  has  been  changed. 
"Withdrawal  of  the  tube  and  inspection  of  the  wound  will  often  disclose  the 
presence  of  granulations  attached  to  the  edges  of  the  tracheal  wound  or  grow- 
ing from  the  trachea  in  the  region  of  the  wound.  The  treatment  of  this  con- 
dition consists  in  the  application  of  a  30-grain  solution  of  nitrate  of  silver ;  or 
they  may  be  touched  with  a  solid  stick  of  nitrate  of  silver;  or  the  wound  may 
be  freely  exposed  by  the  introduction  of  a  tracheal  dilator,  and  the  granula- 
tions seized  with  forceps  and  removed  with  scissors,  or  scraped  away  with  a 
curette. 

Ulceration  of  the  trachea  may  arise  from  improperly-shaped  or  badly-fitting 
tracheotomy-tubes  ;  it  may  be  suspected  when  the  tube,  if  a  silver  one,  becomes 
blackened,  and  there  are  fetor  of  the  breath  and  expectoration  of  purulent 
and  blood-stained  discharge.  This  complication  is  not  so  apt  to  occur  at  the 
present  time  under  the  use  of  the  improved  tracheotomy-tubes  which  are  now 
employed.  The  treatment  of  this  condition  consists  in  first  removing  the  badly- 
fitting  tube  and  replacing  it  by  a  properly-fitting  one.  and,  further,  in  the  appli- 
cation to  the  ulcerated  surface  of  a  10-grain  solution  of  nitrate  of  silver. 

DiflBculties  in  the  Permanent  Removal  of  the  Tracheotomy-tube. — In 
the  great  majority  of  cases  the  tracheotondy-tube  can  be  permanently  dispensed 


TBA  GHEO  TOMY.  887 

with  in  from  eight  to  fifteen  days,  yet  there  are  occasionally  met  instances  in 
which  this  cannot  be  accomplished  for  months  or  even  years ;  a  few  cases  have 
been  recorded  in  which  its  final  removal  was  never  satisfactorily  accomplished. 
The  difiiculty  of  the  permanent  removal  of  the  tracheotomy-tube  is  due,  in  some 
cases,  to  mechanical  causes,  such  as  the  growth  of  granulations  in  the  trachea 
or  wound  or  in  the  larynx,  inflammatory  hypertrophy  of  the  vocal  cords, 
adhesion  between  the  cords,  paralysis  of  the  posterior  crico-arytenoid  muscles, 
spasm  of  the  glottis,  or  stenosis  of  the  trachea  at  the  seat  of  operation.  Dr, 
Emil  Kohl,  in  an  exhaustive  article  upon  this  subject,  mentions,  as  also  causes 
of  delay  or  difiiculty  in  removing  the  tracheotomy-tube,  prolonged  diphtheria, 
re-formation  of  the  diphtheritic  membrane,  changes  in  the  shape  of  the  trachea 
or  larynx  from  the  operation  or  from  the  wearing  of  the  tube,  and  relaxations 
of  the  anterior  wall  of  the  trachea.  Where  the  difiiculty  in  the  permanent 
removal  of  the  tube  is  due  to  the  presence  of  granulations  in  the  trachea  or 
larynx,  after  their  removal  by  some  of  the  methods  before  mentioned  the  phy- 
sician is  usually  able  to  dispense  with  the  tube.  Where  stenosis  of  the  trachea 
or  larynx  exists  and  prevents  the  permanent  removal  of  the  tube,  the  parts 
may  be  gradually  dilated  by  the  use  of  bougies,  or,  better,  by  the  introduction 
of  an  intubation-tube  after  the  removal  of  the  tracheotomy-tube:  the  wound  in 
the  neck  can  then  be  plugged  with  a  nipple  attached  to  a  shield  (Fig.  6),  or  with 

Fig.  7. 
Fig.  6.  '^- ^f\ 


Obturator  for  Tracheotomy  Wound. 

Obturator  for  Tracheotomy 
Wound. 

an  instrument  shown  in  Fig.  7,  to  keep  the  wound  from  healing  until  it  is  cer- 
tain that  there  will  be  no  necessity  for  the  reintroduction  of  the  tracheotomy- 
tube.  The  intubation-tube  may  be  worn  for  some  days  or  weeks,  and  then  re- 
moved, and  if  the  breathing  is  satisfactorily  carried  on  with  the  wound  in  the 
neck  plugged,  as  above  described,  the  shield  with  the  nipple  may  be  removed, 
and  the  wound  be  allowed  to  heal.  By  this  method  of  treatment  I  have 
been  able  to  finally  remove  tracheotomy-tubes  which  had  been  worn  for  a  long 
time.  I  have  had  recently  under  my  care  a  child  of  eighteen  months  of  age 
in  whom  I  was  only  able  to  remove  the  tracheotomy-tube  permanently  after 
sixty  days  by  the  use  of  an  intubation-tube  and  obturator;  and  another  case 
where  a  patient  was  finally  able  to  dispense  with  a  tube  after  having  worn 
it  for  four  years.  In  young  children  I  have  seen  difiiculty  in  the  permanent 
removal  of  the  tube  from  the  fact  that  the  trachea  is  very  flexible,  and  from 
the  fact  that  the  wound  in  the  soft  parts  in  healing  had  become  attached  to 
the  tracheal  wound,  and  in  inspiration  assumed  a  valvular  form,  allowing 
little  air  to  enter  the  trachea. 

If  the  tracheotomy-tube  is  removed  before  the  larynx  is  clear,  or  while  there 
is  irregular  action  of  the  laryngeal  muscles,  dyspnoea  soon  becomes  marked  and 
necessitates  its  reintroduction.  This  can  best  be  overcome  by  removing  the 
tube  from  time  to  time,  and  trying  to  induce  the  child  to  learn  again  to  breathe 


888    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

through  the  larynx,  or  by  introducing  the  intubation-tube  for  a  time,  and  keep- 
ing the  tracheal  wound  from  healing  until  the  breathing  is  again  satisfactorily 
accomplished  through  the  larynx. 

Mr.  Thomas  Smith  has  shown  that  tracheotomy  is  apt  to  cause  undue  irri- 
tability and  disorderly  action  of  the  muscles  of  the  glottis,  so  as  to  interrupt 
their  usual  rhythm.  Cohen  says  that  the  explanation  of  this  phenomenon 
resides  in  the  fact  that  the  laryngeal  muscles  have  lost  their  habit  of  contract- 
ing harmoniously  with  the  needs  of  respiration,  the  patients  being  somewhat 
in  the  condition  of  those  with  paralysis  of  the  vocal  cords.  Some  pa- 
tients can  breathe  comfortably  without  the  tracheotomy-tube  except  during 
sleep.  In  explanation  of  these  cases  Mr.  Thomas  Smith  suggests  that  the 
influence  of  the  will  may  be  necessary  to  regulate  and  secure  due  action  of 
these  muscles,  the  perfection  of  whose  movements  has  been  impaired,  and 
that  on  this  account  inspii-ation  through  the  larynx  during  sleep  is  impos- 
sible. 

Mental  agitation  plays  an  important  part  in  preventing  the  removal  of  the 
tube  in  many  cases,  for  we  often  see  children  who  can  breathe  comfortably 
through  the  larynx  when  the  tube  is  plugged,  but  who,  when  it  has  been 
removed  and  the  tracheal  wound  has  been  closed  with  a  pad  or  obturator, 
exhibit  great  mental  agitation  and  develop  such  alarming  symptoms  of  dyspnoea 
that  the  reintroduction  of  the  tube  becomes  necessary.  It  is  remarkable  to 
observe  how  even  a  young  child  soon  learns  to  depend  upon  the  presence  of  the 
tube  for  breathing,  and  how  he  will  resist  its  removal ;  he  will  often  get  into 
such  a  rage  if  it  is  withdrawn,  that  the  rhythmical  respiratory  action  may 
become  so  seriously  embarrassed  as  to  require  its  immediate  replacing.  Cases 
have  been  recorded  Avhere,  even  after  the  wound  had  healed,  children  could 
breathe  comfortably  only  by  having  the  tracheotomy-tube  tied  around  the 
neck.  Stevenson  has  made  the  observation  that  fright,  upon  the  removal 
of  the  tracheotomy-tube  in  children,  produces  a  nervous,  excitable  condition, 
irregular  respiration,  and  sobbing,  seeming  to  induce  spasm  of  the  glottis. 
The  permanent  removal  of  the  tube,  if  there  be  no  mechanical  difficulty 
present,  can  usually,  in  most  cases,  be  finally  accomplished  by  gaining  the 
confidence  of  the  child,  and  by  patience  and  perseverance  in  withdrawing  the 
tube  at  intervals  of  gradually  increasing  length. 

Post-tracheotomic  Vegetations. — Under  this  title  there  have  been 
described  veo;etations  or  (granulations  Avhich  occur  in  the  trachea  after  the 
wound  has  cicatrized.  These  growths  are  more  apt  to  occur  in  male  children, 
and  appear  fifteen  days  to  a  month  after  the  wound  has  healed.  The  most 
marked  symptoms  of  this  affection  are  embarrassed  respiration  with  progres- 
sive dyspnoea.  The  first  case  of  this  kind  was  reported  by  Gigon,  aud  since 
that  time  fourteen  cases  have  been  collected  by  Ross.  Denger  reported  a  case 
which  died  two  weeks  after  the  wound  had  healed,  and  in  which  an  autopsy 
revealed  a  tumor  of  granular  tissue  in  the  trachea  at  the  seat  of  the  trache- 
otomy wound.  The  treatment  of  these  growths  consists  in  again  performing 
tracheotomy,  exposing  them,  and  removing  them  with  scissors  or  knife, 
cauterizing  their  bases,  and  introducing  the  tracheotomy-tube ;  if,  after  a  short 
time,  they  show  no  tendency  to  recur,  'the  tube  should  be  removed  and  the 
wound  allowed  to  heal. 

Tracheotomy  without  Tubes. — Some  surgeons,  recognizing  the  amount 
of  attention  which  patients  require  while  wearing  tracheotomy-tubes,  and 
possibly  over-estimating  the  dangers  in  their  use  and  the  difficulty  which 
is  sometimes  experienced  in  their  final  removal,  have  recommended  and  prac- 
tised the  operation  of  tracheotomy  without  the  use  of  the  tube.     Dr.  Martin 


TBA  CHEO  TOMY. 

has  reported  several  cases  in  which  he  dispensed  with  the  tracheotomy-tube, 
the  edges  of  the  tracheal  wound  being  fastened  to  the  skin  by  sutures. 
Other  surgeons  have  recommended  the  removal  of  a  small  portion  of  the 
trachea  on  each  side  of  the  incision  when  no  tube  is  to  be  used.  I  think 
there  is  little  danger  in  the  use  of  the  tracheotomy-tubes  which  are  now 
employed,  if  the  precaution  be  taken  to  see  that  they  fit  the  trachea  well. 
The  objection  that  more  care  is  required  in  the  after-treatment  of  the  case 
while  wearing  the  tube  is  not  a  valid  one,  as  it  seems  to  me  that  an  equal 
amount  of  attention  is  required  whether  the  tracheotomy-tube  be  used  or 
dispensed  with.  The  removal  of  a  triangular  portion  of  the  trachea  from 
each  edge  of  the  wound  I  do  not  recommend,  as  stenosis  of  the  trachea  at  the 
point  of  operation  is  apt  to  result.  The  number  of  cases  in  which  the  use  of  a 
tracheotomy-tube  has  been  entirely  dispensed  with  has  been  so  small  that  we 
cannot  yet  fairly  judge  of  the  value  of  the  procedure.  Personally,  I  am 
decidedly  of  opinion  that  the  use  of  a  well-fitting  tube  is  a  most  important 
factor  in  a  case  of  tracheotomy,  and  as  such  would  most  strongly  recommend 
its   employment. 

Thermo-cautery  in  Tracheotomy. — The  dread  of  haemorrhage  has  led 
certain  surgeons  to  substitute  a  thermo-cautery  knife  for  the  scalpel  in  the 
operation  of  tracheotomy.  In  1870,  Amussat  first  employed  the  galvano-cau- 
tery  in  tracheotomy,  and  this  method  also  has  been  employed  by  Verneuil, 
Krishaber,  and  others. 

Rapid  Tracheotomy. — Fear  of  troublesome  hemorrhage  has  not  deterred 
some  surgeons  from  recommending  a  rapid  tracheotomy  by  a  single  cut.  Saint- 
Germain  claims  to  have  performed  a  number  of  such  operations  without  a  single 
serious  accident.  Mr.  Durham  has  recommended  a  rapid  tracheotomy,  which  he 
performs  in  the  following  manner :  The  surgeon  stands  upon  the  right  side  of  the 
patient,  and  places  his  forefinger  on  the  left  side  of  the  trachea  and  his  thumb 
on  the  other  side,  so  as  to  include  between  them  the  spot  at  which  the  trachea 
is  to  be  opened.  Firm  pressure  is  made,  and  the  trachea  can  be  felt  between 
the  thumb  and  finger ;  the  safety  of  the  great  vessels  is  ensured,  as  they  are 
outside  of  the  line  of  incision.  By  a  succession  of  careful  incisions  the  operator 
cuts  down  on  the  trachea,  and  when  it  is  exposed  he  may  open  it  directly 
or  fix  it  with  a  tenaculum  before  opening  it.  Mr.  Durham  claims  to  have 
operated  on  a  number  of  cases  without  any  untoward  results.  This  rapid 
method  of  performing  tracheotomy  has  not  been  very  generally  employed,  and 
I  cannot  appreciate  its  superiority  over  the  slower  and  safer  method  of  dissect- 
ing carefully  down  to  the  trachea  and  opening  it,  except  in  certain  rare  cases 
of  great  urgency.  I  therefore  am  of  the  opinion  that  rapid  tracheotomy  will 
never  supersede  the  latter  operation,  which  has  the  advantage  of  enabling  the 
surgeon  to  recognize  and  avoid  structures  the  wounding  of  which  would  be 
dangerous. 

Condition  of  Patients  after  Recovery  from  Tracheotomy. — The  con- 
dition of  patients  after  recovery  from  tracheotomy  performed  for  diphtheritic  or 
membranous  laryngitis  is  a  matter  of  great  interest.  As  far  as  my  personal 
observation  goes,  the  voice  in  these  cases  seems  to  be  unimpaired,  and  they  do 
not  seem  to  be  more  liable  to  laryngeal  affections  than  those  in  whom  recovery 
has  occurred  without  operative  interference.  The  rare  occurrence  of  post- 
tracheotomy  vegetations  has  been  already  referred  to.  Drs.  Lovett  and  Munroe 
have  made  some  very  valuable  observations  bearing  upon  this  subject:  in  56 
cases  where  tracheotomy  had  been  performed  more  than  a  year  previously, 
which  they  investigated  with  reference  to  the  effect  of  the  operation  upon  the 
voice  and  general  health  of  the  patient,  53  were  in  good  health,  and  none  of 


890  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

them  had  had  a  second  attack  sufficient  to  call  for  surgical  aid.  The  voice  was 
clear  in  all  but  4  cases  ;  6  patients  were  liable  to  sore  throat;  6  were  not  in 
20od  health.  1  having  phthisis,  but  without  any  laryngeal  symptoms,  1  had 
I  hoarse  and  croupy  voice,  and  the  third  was  a  delicate  boy  who  was  con- 


stantly ill. 


INTUBATION  OF  THE  LARYNX. 

By  HENKY  E.  WHABTON,  M,  D., 

Phlladelphia. 


IxTUBATiox  OF  THE  Laeyxx  is  an  operation  by  Avhicli  a  metallic  tube  is 
passed  through  the  mouth  into  the  larynx  for  the  relief  of  dyspnoea  resulting 
from  laryngeal  stenosis.  This  procedure  for  the  relief  of  dyspnoea  depending 
upon  croup  was  first  employed  by  Bouchut  of  Paris  in  1858,  He  used  a  hollow 
metallic  cylinder  about  an  inch  in  length,  which  was  pressed  into  the  larvnx 
and  allowed  to  remain,  and  had  attached  to  it  a  silken  thread  to  facilitate  its 
removal  and  to  prevent  its  passing  down  into  the  trachea.  Although,  as  far 
as  known,  this  was  the  first  formal  method  of  treating  dyspnoea  in  cases  of 
croup  by  the  introduction  of  a  metallic  tube  into  the  larynx,  the  procedure  of 
introducing  a  tube  into  the  larynx  to  relieve  dyspnoea  arising  from  other 
causes,  known  as  catheterization  of  the  larynx,  had  been  employed  by  many 
surgeons  before  this  time.  The  results  of  Bouchut's  cases  were  not  sufficiently 
satisfactory  to  recommend  its  general  adoption,  and  the  procedure  fell  into  dis- 
use. Dr.  Joseph  O'Dwyer  of  Xew  York,  in  1880,  after  numerous  experiments 
upon  dead  subjects  in  the  autopsy-room  of  the  !New  York  Foundling  Asylum, 
finally  reintroduced  this  operation  as  a  means  of  dealing  with  dyspnoea  result- 
ing from  laryngeal  stenosis.  Numerous  modifications  of  the  tube  were  made, 
and  it  is  due  to  the  patient  and  careful  work  of  O'Dwyer  that  the  operation 
has  become  recognized  by  the  profession  as  a  legitimate  procedure  in  the  treat- 
ment of  the  symptoms  arising  from  laryngeal  obstruction.  The  operation  of 
intubation  of  the  larynx,  which  has  been  employed  in  many  thousands  of  cases 
in  this  country  and  abroad,  has  now  taken  its  place  with  tracheotomy  as  a  well- 
recognized  surgical  procedure  in  the  treatment  of  obstructive  dyspnoea. 

Indications  for  Intubation. — The  indications  for  intubation  of  the  larynx 
in  cases  of  diphtheritic  or  membranous  croup  are  similar  to  those  which  are 
recognized  as  indications  for  the  operation  of  tracheotomy  in  the  same  affec- 
tion— namely,  labored  breathing,  retraction  of  the  lower  ribs  and  supracla- 
vicular spaces,  retraction  of  the  tissues  of  the  suprasternal  notch,  cyanosis,  rest- 
lessness, inability  to  sleep,  or,  in  other  words,  marked  symptoms  of  obstructive 
dyspnoea. 

Prognosis  in  Intubation. — An  examination  of  large  numbers  of  reported 
cases  of  intubation  of  the  larynx  shows  that  the  number  of  recoveries  follow- 
ing the  operation  is  very  similar  to  the  number  following  tracheotomy.  Ball, 
in  a  collection  of  4217  cases  of  intubation  gathered  from  American  and  Euro- 
pean sources,  found  that  there  were  1285  recoveries,  or  about  30.4  per  cent. 
Ball  also  presents  some  statistics  bearing  upon  the  age  of  the  patients.  In  a 
total  number  of  1540  cases,  tabulated  according  to  age,  there  were  474  recov- 
eries, or  30.7  per  cent.  The  percentage  of  recoveries  at  each  age  is  shown 
in  the  followincr  table  : 


891 


892     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


60  cases  under  1  year  of  age,  11  recoveries,  or  18.3  per  cent. 


253 

(( 

2  years  of 

age,  48 

(( 

or  19.0 

306 

u 

3 

67 

(( 

or  21.9 

326 

u 

4 

98 

K 

or  30.0 

231 

« 

5 

93 

a 

or  40.0 

127 

(( 

6 

48 

" 

or  37.8 

83 

u 

7 

37 

If 

or  44.5 

80 

" 

8 

41 

u 

or  51.2 

26 

(( 

9 

13 

(( 

or  50.0 

23 

« 

10 

7 

(( 

or  80.0 

7 

li 

11 

3 

(( 

or  42.8 

7 

11 

12         " 

4 

11 

or  57.1 

11 

li 

ovei 

12         " 

4 

a 

or  36.3 

From  the  above  table  it  will  be  seen  that  intubation  gives  better  results  than 
tracheotomy  in  the  first  and  second  years  of  life  ;  from  this  age  the  difference 
between  the  two  operations,  as  far  as  recoveries  go,  is  not  very  marked.  It 
must  be  remembered,  however,  that  the  statistics  of  intubation  as  compared 
with  tracheotomy  are  not  entirely  to  be  relied  upon,  for  many  operators  per- 
form intubation  at  a  time  when  the  dyspnoea  is  not  extremely  urgent,  whereas 
the  same  operator  would  hesitate  to  recommend  tracheotomy  ;  so  that  it  is  prob- 
able that  many  of  the  milder  cases  are  intubated,  whereas  many  of  the  very 
urgent  ones  are  reserved  for  tracheotomy. 

Instruments  required  for  Intubation. — Instruments  required  for  intu- 
bation are : 

Intubation-tubes  of  various  sizes. 

An  introducer. 

An  extractor. 

A  mouth-gag. 

A  gauge. 

Fine  braided  silk. 


The  intubation-tubes  (Fig.  1)  for  children  are  usually  six  in  number,  of 
diflFerent  sizes,  adapted  to  children  from  one  to  twelve  years  of  age.     The  tube 


Fig.  1. 


The  Intubation-tube  and  Introducer. 


now  generally  employed  consists  of  a  metal  cylinder  which  bulges  near  its 
centre,  and  is  provided  with  a  collar  or  head  to  rest  upon  the  false  vocal  cords  ; 
it  is  irregularly  quadrangular,  one  angle  resting  between  the  arytenoid  car- 
tilages, and  its  opposite  angle  bevelled  so  as  to  better  allow  of  the  closure  of 
the  epiglottis  over  the  aperture  of  the  tube ;  the  tubes  are  gold-plated,  and 
each  is  provided  with  an  obturator,  which  has  a  blunt  extremity.  Just  below 
the  head  the  tube  is  of  small  diameter  to  avoid  injurious  pressure  on  the  vocal 


INTUBATION    OF    THE   LABYNX. 


893 


cords.  About  midway  the  wall  of  the  tube  is  increased  to  its  greatest  diame- 
ter, which  bulging  serves  to  maintain  it  in  position  during  coughing  and 
increases  the  weight  to  be  expelled.  Through  the  edge  of  the  collar  on  each 
tube  there  is  a  small  perforation  through 

which  the  strand  of  fine  braided  silk  is  Fig.  2. 

passed,  which  serves  to  remove  the  tube 
if  in  its  introduction  it  should  be  passed 
into  the  pharynx  or  oesophagus  instead 
of  the  larynx,  or  if  from  sudden  ob- 
struction it  has  to  be  hurriedly  with- 
drawn. 

The  introducer  (Fig.  1)  consists  of 
a  handle  and  a  staff  which  is  curved 
to  a  right  angle  at  its  extremity,  which  has  a  screw  that  attaches  it  to  the 

Fig.  3. 


Mouth-gag. 


The  Extractor. 


Fig.  4. 


obturator,  and  a  sliding  gear  for  detaching  the  obturator  from  the  tube  when 
it  is  placed  in  the  larynx. 

Mouth-gags  of  various  kinds  may  be  used :  the  one  generally  supplied 
with  intubation  sets  is  that  shown  in  Fig.  2,  which  is  a  self-retain- 
ing instrument. 

The  extractor  is  also  curved  on  a  right  angle,  and  has  at  its 
extremity  a  small  forceps  with  duckbill  blades,  which  are  made  to 
separate  and  apply  themselves  to  the  interior  surface  of  the  tube 
with  sufficient  firmness  to  withdraw  it  (Fig.  3). 

The  gauge  is  to  determine  from  the  age  of  the  child  the  size  of 
the  tube  to  be  employed  (Fig.  4). 

Preparations  for  Intubation. — It  is  important  that  the  fol- 
lowing preparations  should  be  made,  so  that  the  actual  introduc- 
tion of  the  intubation-tube  may  occupy  as  little  time  as  possible, 
for  it  should  be  remembered  that  when  the  intubation-tube  enters 
the  larynx  breathing  is  arrested  until  the  obturator  is  removed,  and 
therefore  everything  should  be  in  readiness  and  all  manipulations 
should  be  as  rapid  as  consistent  with  accuracy.  The  time  usually 
required  after  the  mouth-gag  has  been  adjusted  for  the  introduc- 
tion of  the  intubation-tube  and  withdrawal  of  the  obturator  is  from 
five  to  ten  seconds. 

Before  attempting  to  introduce  an  intubation-tube  the  surgeon 
should  select  a  tube  of  suitable  size  for  the  age  of  the  patient,  and 
should  have  a  strand  of  fine  braided  silk  about  two  feet  in  length 
passed  through  the  eyelet  and  secured  with  a  knot.  Having 
attached  the  tube  by  means  of  the  obturator  to  the  introducer,  he  should  next 
see  that  it  can  be  freed  from  the  obturator  by  working  the  trigger.     The  mouth- 


Gauge. 


894     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

gag  should  also  be  examined  to  see  that  it  is  in  proper  working  order,  and  this, 
with  the  tube  and  introducer,  should  be  placed  in  a  basin  of  warm  water.  The 
surgeon  should  next  protect  the  index  finger  of  the  left  hand,  which  is  to  be 
passed  into  the  mouth  of  the  patient,  by  wrapping  it  for  an  inch  or  an  inch  and 
a  half  in  the  region  of  the  second  joint  with  rubber  or  adhesive  plaster,  or  a 
metal  shield  may  be  employed.  This  is  an  important  precaution  to  prevent  the 
patient  from  biting  the  finger  in  case  the  mouth-gag  should  slip,  for  a  bite  from 
the  teeth,  which  are  often  very  foul  in  these  cases,  is  liable  to  be  followed  by 
serious  consequences :  a  case  has  been  recorded  of  a  fatal  result  following  such 
an  injury  received  while  performing  intubation. 

Position  of  Patient  for  Intubation. — The  child  should  be  taken  upon 
the  lap  of  the  nurse  and  Avrapped  in  a  blanket,  which  should  swathe  it  from 
the  neck  to  the  heels,  and  the  nurse  should  grasp  the  child's  elbows  outside  of 
the  blanket  and  hold  them  firmly,  but  should  not  press  them  against  the  chest 
in  such  a  way  as  to  embarrass  the  respiratory  movements  ;  at  the  same  time  the 
legs  of  the  patient  are  secured  by  being  held  between  the  knees  of  the  nurse. 
The  head  of  the  patient  should  next  be  secured  by  being  held  between  the 
open  hands  of  the  assistant  placed  upon  the  sides  of  the  head  and  cheeks ;  the 
left  hand  of  the  assistant  may  also  be  used  in  steadying  the  mouth-gag  after  it 
has  been  introduced  (Plate  XIX). 

The  patient  should  be  held  straight,  and  should  not  be  allowed  to  lean 
back  so  as  to  get  out  of  the  operator's  reach.  Xorthrup  Avell  describes  the 
proper  position  of  the  child  for  intubation  when  he  says :  "  The  position  of 
the  child  should  be  as  though  it  hung  from  the  top  of  the  head."  This  is  un- 
questionably the  best  position  in  which  to  place  the  child  for  intubation,  but 
it  is  possible  to  introduce  the  tube  with  the  child  in  the  recumbent  posture  : 
this  I  have  done  on  several  occasions  when,  from  the  condition  of  the  circula- 
tion. I  did  not  think  it  advisable  to  lift  the  child  to  a  sitting  posture  ;  and  in 
the  Boston  City  Hospital,  Dr.  Lovett  reports  that  intubation  has  also  been  per- 
formed in  a  number  of  cases  with  the  patient  supine ;  but  under  ordinary  cir- 
cumstances the  position  described  above  will  be  found  most  convenient. 

Operation  of  Intubation. —  The  child  being  held  as  described  above, 
facing  the  surgeon,  who  sits  upon  a  chair  within  easy  reach  of  the  patient, 
the  assistant  fixes  the  head,  and  the  surgeon  opens  the  mouth  and  introduces 
the  blades  of  the  mouth-gag  between  the  molar  teeth  on  the  left  side ;  the 
blades  are  next  opened  by  compressing  the  handles  of  the  gag,  and  the  assist- 
ant should  then  hold  the  gag  steady  with  the  fingers  of  the  left  hand.  Chil- 
dren often  strugj^le  at  this  time  and  resist  the  introduction  of  the  mouth-orao; ; 
hence  it  is  better  to  open  the  jaws  with  the  handle  of  a  spoon  introduced  between 
them,  even  with  the  exercise  of  some  force,  and  to  introduce  the  gag.  than  to 
allow  the  child  to  become  exhausted  by  struggling  against  ineffectual  attempts 
to  introduce  it  without  the  use  of  force.  When  the  mouth  has  been  opened 
the  surgeon  passes  the  index  finger  of  the  left  hand  into  the  pharynx  and  feels 
for  the  epiglottis,  which  is  hooked  forward  by  the  end  of  the  finger.  The  tube 
attached  to  the  introducer  is  next  passed  into  the  mouth  and  carried  back  to  the 
pharynx,  the  operator  being  careful  to  see  that  it  hugs  the  base  of  the  tongue 
in  the  middle  line,  that  the  handle  is  depressed  well  upon  the  childs  chest,  and 
that  the  silken  thread  is  free.  When  the  extremity  of  the  tube  comes  in  contact 
with  the  end  of  the  finger  holding  the  epiglottis,  the  handle  should  be  raised 
as  it  engages  in  the  larynx  and  descends  into  this  organ  ;  and  as  it  is  pushed 
downward  into  place  the  finger  is  placed  upon  the  head  of  the  tube  to  fix  it  and 
prevent  its  being  withdrawn  with  the  obturator  :  the  trigger  is  next  pressed,  and 
the  introducer  and  obturator  are  drawn  from  the  mouth  by  depressing  the  handle 


PLATE  XIX. 


INTUBATION.    (Inserting  the  Tube.) 


INTUBATION   OF    THE   LABYNX.  895 

upon  the  chest,  and  at  the  same  time  the  tube  should  be  pressed  well  down  into 
the  larynx  with  the  finger  which  rests  upon  its  head.  A  caution  should  here  be 
given  as  to  the  importance  of  using  little  force  in  pressing  the  tube  home  after 
it  engages  in  the  larynx :  no  more  force  should  be  used  than  in  passing  the 
catheter  or  bougie  into  the  urethra ;  and  if  it  is  found  that  the  tube  is  too  large 
to  be  passed  into  the  larynx  without  the  exercise  of  great  force,  it  should  be 
withdrawn  and  a  smaller  one  attached  to  the  instrument  and  introduced.  As 
soon  as  the  obturator  has  been  withdrawn  the  child  makes  a  deep  inspiration  :  at 
the  first  expiratory  effort  there  is  generally  coughed  up  false  membrane  or  muco- 
purulent matter,  and  when  the  tube  has  become  cleared  of  this  the  respiration 
is  usually  satisfactorily  carried  on.  If,  on  the  other  hand,  after  withdrawing 
the  obturator,  the  dyspnoea  is  not  relieved  by  the  expiratory  efforts  of  the  child, 
the  tube  should  be  removed  by  means  of  the  thread  and  examined.  If  its 
canal  is  clear,  showing  that  no  mass  of  membrane  is  occluding  it,  and  the  dys- 
pnoea does  not  decrease,  it  is  pretty  good  evidence  that  the  obstruction  exists 
below  the  point  to  which  the  intubation-tube  extends  :  it  is  therefore  better  to 
make  no  further  attempt  to  introduce  the  intubation-tube,  but  to  perform 
tracheotomy  promptly.  Before  removing  the  mouth-gag  it  is  well  to  intro- 
duce the  index-finger  of  the  left  hand  to  feel  that  the  tube  is  in  place  and  has 
not  been  disturbed  by  the  coughing  efforts. 

The  management  of  the  silken  thread  attached  to  the  tube  is  a  matter  of 
some  importance.  Some  operators,  as  soon  as  the  tube  is  properly  placed,  cut 
the  loop  of  thread,  and,  with  the  finger  resting  upon  the  head  of  the  tube,  pull 
upon  one  end  of  the  loop  and  withdraw  it.  This  is  done  to  relieve  the  irrita- 
tion of  the  fauces  which  the  thread  sometimes  causes,  and  to  prevent  the  child 
seizing  it  and  pulling  out  the  tube.  Other  operators  prefer  to  leave  the  thread 
in  place  for  some  hours  or  days,  securing  the  loop  around  the  ear  so  that  it  can- 
not become  loose ;  and  in  the  event  of  the  tube  becoming  blocked  with  mem- 
brane and  not  being  coughed  out,  it  can  be  removed  by  traction  upon  the 
thread.  To  prevent  the  irritation  of  the  fauces  and  gagging  which  the  thread 
sometimes  causes,  it  may  be  passed  through  the  posterior  nares  and  brought 
out  at  the  anterior  nares,  and  secured  to  the  ear  or  the  face  by  a  strip  of  plas- 
ter. I  usually  leave  the  thread  in  place  for  twelve  or  twenty-four  hours,  bring- 
ing it  out  of  the  mouth  and  attaching  it  by  the  loop  around  the  ear,  and  placing 
a  few  strips  of  adhesive  or  rubber  plaster  over  the  thread  from  the  ear  to  the 
angle  of  the  mouth,  to  prevent  the  child  grasping  it  and  displacing  the  tube. 
Where  it  is  possible,  I  also  pass  the  thread  between  the  molar  or  premolar  teeth 
to  prevent  the  child  from  biting  it  in  two.  When  the  child  shows  a  tendency 
to  grasp  the  thread,  it  is  well  to  enclose  the  hands  in  stockings  and  secure  them 
around  the  wrists. 

It  is  quite  possible  in  introducing  an  intubation-tube  to  pass  it  into  the 
pharynx ;  and  if  this  happens,  as  soon  as  the  obturator  is  withdrawn  the  error 
is  discovered  and  the  tube  should  be  removed  and  reattached  to  the  introducer, 
and  another  attempt  made  to  pass  it  into  the  larynx.  This  error,  I  am  sure, 
often  occurs  in  the  hands  of  inexperienced  operators  by  not  being  careful  to 
hug  the  base  of  the  tongue  closely  with  the  end  of  the  tube,  by  not  keeping 
strictly  in  the  median  line,  and  by  disregarding  the  position  of  the  tip  of  the 
index  finger  of  the  left  hand,  which  is  held  in  contact  with  the  epiglottis  and 
is  a  guide  to  the  opening  of  the  larynx. 

Accidents  during  and  after  Intubation. — It  is  well  for  the  operator  to 
remember  that  certain  accidents  may  occur  during  the  operation  of  intubation, 
such  as  pushing  a  mass  of  membrane  down  into  the  trachea  before  the  tube, 
or  a  too  deep  insertion  of  the  tube,  so  that  its  head  passes  below  the  vocal 


896     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cords :  these  accidents  have  been  reported,  but  I  must  confess  that  I  have  never 
had  a  serious  accident  occur  during  the  operation.  The  pushing  of  a  mass 
of  membrane  down  before  the  tube  is  likely  to  embarrass  the  respiration  so 
seriously  that  in  the  violent  respiratory  efforts  of  the  child  the  tube  is  apt  to 
be  forced  out  of  the  larynx :  if  the  tube  is  not  forced  out,  it  should  be  removed 
by  means  of  the  thread,  and  if  the  respiration  is  still  embarrassed,  tracheotomy 
should  be  resorted  to.  The  accident  of  pushing  the  tube  too  deeply  into  the 
larynx  is  not  likely  to  occur  if  a  proper-sized  and  proper-shaped  tube  is  em- 
ployed. A  tube  which  is  too  small  may  be  easily  forced  between  the  vocal 
cords,  or  may  be  drawn  downward  by  the  inspiratory  efforts  of  the  child.  Should 
this  accident  occur,  the  tube  can  usually  be  removed  by  traction  upon  the  thread, 
and  if  a  subsequent  downward  displacement  occurs  after  the  removal  of  the 
thread,  it  would  be  necessary  to  perform  tracheotomy  for  its  removal.  Several 
instances  have  been  reported  in  which  this  accident  occui'red  and  a  resort  to 
tracheotomy  was  necessary.  In  certain  cases,  after  the  tube  has  been  retained 
for  a  few  days,  it  is  coughed  up,  and  upon  being  replaced  the  same  accident 
occurs:  a  larger  tube  should  then  be  tried,  and  if  it  cannot  be  tolerated  by  the 
larynx,  further  attempts  at  intubation  should  be  desisted  from,  and,  if  dyspnoea 
is  still  marked,  tracheotomy  should  be  resorted  to.  Another  accident  which 
sometimes  occurs  is  the  coughing  up  and  swallowing  of  an  intubation-tube 
which  is  not  attached  to  a  thread.  The  tube  is  usually  passed  through  the  ali- 
mentary canal  without  difficulty,  and  I  know  of  no  fatal  result  following  the 
swallowing  of  an  intubation-tube.  Although  I  have  never  personally  seen  any 
accident  happen  during  the  operation  of  intubation  or  while  the  intubation-tube 
was  in  place.  I  ahvays  have  at  hand  during  the  operation  my  tracheotomy  case, 
so  that  I  can  promptly  open  the  trachea  if  the  indication  exists,  and  would  advise 
all  operators  to  be  similarly  prepared. 

After-treatment  of  Cases  of  Intubation. — Cases  in  which  an  intubation- 
tube  has  been  introduced  require  most  careful  watching  by  a  nurse  who  is  com- 
petent to  meet  any  emergency  that  may  arise.  If  dyspnoea  suddenly  develops 
from  the  obstruction  of  the  tube  by  a  piece  of  membrane  too  large  to  pass,  the 
nurse  should  be  instructed  to  remove  the  tube,  if  the  thread  is  still  attached ; 
or  if  the  thread  has  been  withdrawn  she  should  invert  the  child,  and  by  striking 
over  the  posterior  portion  of  the  chest  she  may  be  able  to  dislodge  the  tube. 
A  case  has  been  recently  reported  in  which  this  manipulation  by  the  nurse 
saved  the  patient's  life.  In  the  after-treatment  of  cases  of  intubation  I  have 
great  faith  in  the  efficacy  of  steam  spray  of  Parker's  soda  solution  (p.  882)  or  a 
spray  of  peroxide  of  hydrogen  for  its  effect  in  dissolving  membrane  and  lique- 
fying the  secretions.  I  usually  have  the  spray  used  every  half  hour,  or  more 
frequently  if  there  is  little  tendency  to  expectoration  ;  in  cases  described  as  dry 
the  use  of  the  spray.  I  think,  is  most  important. 

Feeding  of  Intubation  Cases. — The  most  difficult  portion  of  the  after- 
treatment  of  cases  of  intubation  is  the  satisfactory  feeding  of  the  patient. 
From  the  interference  with  the  act  of  deglutition  caused  by  the  presence  of  the 
tube  and  the  imperfect  action  of  the  epiglottis,  liquid  nourishment  is  apt  to 
pass  into  the  larynx  and  set  up  coughing,  which  interferes  Avith  the  taking  of 
a  sufficient  quantity  of  nourishment.  As  many  cases  in  which  this  operation  is 
employed  require  large  quantities  of  food  from  the  nature  of  the  disease  for 
wiiich  the  operation  is  performed.  I  think  the  difficulty  of  properly  nourishing 
the  patient  constitutes  the  most  serious  objection  to  this  opei-ation.  Children, 
as  a  rule,  while  wearing  an  intubation-tube,  have  difficultv  in  swallowing 
liquids,  but  there  are  occasionally  seen  cases  in  which  liquids  are  swallowed 
without  difficulty ;  therefore  it  is  well  to  make  a  trial  as  to  the  feeding  before 


PLATE  XX. 


METHOD   OF  FEEDING  INFANT  AFTER  INTUBATION,  WITH  THE  HEAD  LOWER 

THAN  THE  BODY. 


INTUBATION   OF    THE  LARYNX.  897 

a  special  diet  is  ordered  for  any  individual  case.  It  is  remarkable  to  observe 
hoTv  some  children  wearing  intubation-tubes  will  learn  to  swallow  with  the 
tube  in  place.  I  have  seen  children  who  at  first  were  unable  to  take  liquid 
nourishment  in  a  few  days  change  their  manner  of  swallowing,  so  that  liquids 
could  be  taken  without  discomfort.  If.  upon  trial,  it  is  found  that  there  is 
difficulty  in  swallowing  liquids,  I  first  order  a  diet  of  semi-solids,  such  as  corn- 
starch, mush,  milk-toast,  rennet,  puddings,  soft-boiled  eggs,  and,  as  jDatients 
soon  experience  thirst,  I  order  for  them  pieces  of  ice  to  be  swallowed,  or  give 
enemata  of  water,  an  ounce  to  an  ounce  and  a  half,  repeated  at  intervals.  In 
young  children,  in  whom  a  milk  diet  is  essential,  it  will  often  be  found  that  the 
child  can  swallow  well  if  fed  from  a  nursing-bottle,  the  head  being  dropped  over 
the  nurse's  lap,  so  that  it  is  lower  than  the  body  (Plate  XX). 

This  useful  expedient  was. suggested  by  Casselberry  of  Chicago,  who  found 
that  with  the  patient  supine  and  the  head  lower  than  the  body  fluids  could  not 
pass  into  the  larynx,  but  would  be  forced  up  the  oesophagus  into  the  stomach. 
If.  however,  all  expedients  fail  as  regards  methods  of  feeding,  as  will  be  found 
in  some  cases,  recourse  must  be  had  to  the  introduction  of  food  by  nutritious 
enemata. 

Removal  of  Intubation-tubes. — The  tube  usually  remains  in  place  for 
some  days,  and  is  often  coughed  out  as  the  swelling  of  the  laryngeal  tissues 
subsides.  If  the  breathing  is  carried  on  satisfactorily,  it  need  not  be  re- 
placed ;  but  it  is  well  to  remember  that  for  a  foAV  days  the  dyspnoea  is  liable 
to  return,  so  that  the  reintroduction  of  the  tube  may  be  necessitated ;  and  the 
surgeon  should  be  within  reach  durino;  this  time.  If  the  tube  has  not  been 
coughed  out  and  the  child's  general  condition  is  improved,  the  temperature 
having  a  tendency  to  reach  the  normal  mark,  at  the  end  of  three  or  four  days 
I  usually  remove  the  tube ;  and  if  there  is  no  return  of  the  dyspnoea  I  do  not 
reintroduce  it,  but  have  the  case  carefully  watched,  for  the  patient  is  not  safe 
from  recurrent  dyspnoea  for  two  or  three  days.  If  dyspnoea  be  present  upon 
the  withdrawal  of  the  tube,  I  replace  it  promptly,  and  do  not  make  another 
attempt  at  its  permanent  removal  for  two  or  three  days.  Usually  in  from  five 
to  ten  days  it  can  be  dispensed  with,  although  I  have  recently  had  a  case  in 
which  the  tube  could  not  be  permanently  removed  until  the  fifteenth  day. 
After  the  expulsion  or  removal  of  the  intubation-tube  I  continue  to  use  the 
soda  spray  for  two  or  three  days,  and  the  child  must  be  carefully  watched,  so 
that  it  is  not  exposed  to  cold.  I  have  noticed  that  in  all  cases  in  which 
recovery  has  followed  intubation  of  the  larynx  there  was  present  a  considerable 
amount  of  hoarseness  of  the  voice  ;  but  this  in  a  foAv  weeks  finally  disappears. 

As  the  same  intubation-tube  may  be  used  in  many  different  cases,  I  think 
it  most  essential  that  eveiy  tube  which  is  used  should  be  thoroughly  sterilized 
as  soon  as  it  is  removed  from  the  patient  by  being  cleansed  and  boiled  for  a 
few  minutes. 

The  removal  of  the  intubation-tube  is,  I  think,  often  more  difficult  than  its 
original  introduction.  The  child  should  be  placed  in  the  same  position  as 
described  for  its  introduction ;  the  mouth-gag  should  be  used  to  separate  the 
jaws ;  the  index  finger  of  the  left  hand,  being  protected,  should  be  passed 
into  the  mouth  and  placed  upon  the  head  of  the  tube ;  the  extractor  should 
then  be  passed  into  the  mouth,  and  Avith  the  finger  on  the  head  of  the  tube  as 
a  guide,  the  blades  should  be  passed  into  the  opening  of  the  tube.  The  tube 
is  grasped  by  pressing  the  lever  which  separates  the  blades,  and,  having  a  firm 
hold  upon  the  tube,  it  is  withdrawn  by  depressing  the  handle  upon  the  chest  of 
the  patient.  It  is  sometimes  difficult  to  pass  the  blades  into  the  opening  in  the 
tube,  and  during  the  withdrawal  the  blades  may  slip,  losing  their  hold  upon  the 

57 


898     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

intubation-tube.  If  tbis  accident  occur,  tbe  tube  can  usually  be  booked  out  of 
tbe  moutb  by  tbe  finger,  wbicb  sbould  follow  it  during  its  Avitbdrawal. 

Intubation  of  tbe  laiynx  bas  added  anotber  very  valuable  surgical  pro- 
cedure to  tbe  treatment  of  dyspnoea  arising  from  dipbtberitic  or  membranous 
laryngitis  and  oedema  or  spasm  of  tbe  glottis,  and,  altbougb  it  does  not 
entirely  supersede  tbe  operation  of  tracbeotomy  in  all  cases,  it  is  now  employed 
in  many  cases  wbere  tracbeotomy  was  formerly  resorted  to.  Cases  wbicb  seem 
to  me  favorable  ones  for  intubation  are  tbose  of  membranous  or  dipbtberitic 
laryngitis,  wbere  tbe  obstruction  comes  on  rapidly,  and  is  probably  largely 
due  to  oedema  of  tbe  mucous  membrane  of  tbe  larynx.  Cbildren  under  two 
years  of  age  are  usually  better  subjects  for  intubation  tban  for  tracbeotomy. 
Intubation  also  seems  well  adapted  for  cases  of  dyspnoea  due  to  oedema  of  tbe 
larynx  from  burns  or  scalds  or  from  tbe  swallowing  of  corrosive  liquids  or  the 
inbalation  of  irritating  gases,  unless  tbere  is  at  tbe  same  time  marked  oedema 
of  the  epiglottis  and  fauces.  Cases  unfavorable  for  intubation  are  those  of  diph- 
theria, in  which  tbere  is  much  swelling  of  the  tonsils  and  fauces,  with  profuse 
deposit  of  membrane  ;  also  those  in  which  the  dyspnoea  comes  on  slowly,  point- 
ing to  a  gradual  deposit  in  tbe  larynx  of  a  well-organized  membrane.  The 
great  advantages  offered  by  intubation  are,  that  tbe  operation  itself  is  com- 
paratively free  from  danger,  it  is  a  bloodless  operation,  and  the  consent  of  the 
parents  for  its  performance  can  usually  be  obtained  without  difficulty ;  tbe 
inspired  air  enters  the  lungs  warm  and  moist ;  and  if  this  operation  fails  to 
relieve  tbe  patient  it  does  not  preclude  a  subsequent  tracheotomy.  Altbougb 
some  statistics  have  been  presented  from  the  Boston  City  Hospital  showing 
that  tbe  prognosis  in  cases  of  tracbeotomy  after  intubation  is  not  favorable, 
my  personal  experience  has  been  different,  for  I  have  resorted  to  tracheotomy 
in  a  number  of  patients  in  whom  a  fair  trial  of  intubation  had  failed  to  relieve 
the  dyspnoea,  and  the  results  following  the  operation  were  in  no  wise  less  satis- 
factory than  those  in  which  tracheotomy  had  primarily  been  performed. 

Intubation  in  Stenosis  of  the  Larynx. — The  introduction  of  an  intuba- 
tion-tube for  the  purpose  of  relieving  chronic  stenosis  of  the  glottis  has  been 
employed  successfully  in  many  cases ;  it  bas  been  proven  that  the  tube  in  these 
cases  can  be  Avorn  for  a  considerable  time  without  barm  or  inconvenience.  It 
bas  been  employed  in  cases  of  chronic  syphilitic  stenosis,  in  cases  where  tbere 
is  difficulty  in  dispensing  with  the  tracheotomy-tube  from  granulations  growing 
in  tbe  region  of  the  tracheal  wound  (see  p.  888),  in  cases  of  cicatricial  stenosis, 
swelling  of  the  mucous  membrane  of  the  larynx  below  tbe  cords,  bilateral 
paralysis  of  the  abductors,  paresis  of  the  cords  from  disease,  or  where  there  is 
dread  of  having  the  tracheotomy-tube  removed.  In  such  cases  tbe  manipula- 
tion for  the  introduction  of  the  intubation-tube  is  similar  to  that  in  acute  cases, 
with  probably  the  difference  that  more  force  is  justifiable  in  tbe  introduction. 
The  tube  sbould  be  changed  at  intervals,  a  larger  size  being  required  from 
time  to  time.  In  chronic  cases  little  difficulty  is  usually  experienced  in  feeding 
the  patients,  as  liquids  are  generally  taken  without  difficulty  after  tbe  first  day 
or  two. 


POST-NATAL  ATELECTASIS. 

By  SAMUEL  S.  ADAMS,  M.  D., 

Washington,  D.  C. 


PosT-XATAL  Atelectasis  is  a  condition  of  the  lung  in  which  the  once- 
inflated  alveoli  become  emptied  and  collapsed  from  partial  or  total  absence  of 
air  in  them.  It  occurs  in  weakly  infants  and  young  children,  and  varies  in 
extent  from  a  few  lobules  to  an  entire  lobe  or  even  a  whole  lung.  It  is 
claimed  by  some  that  it  is  a  common  condition  in  foundlings  and  in  wasted 
infants  who  die  during  the  first  year  of  life. 

Etiology. — The  predisposing  causes  of  post-natal  atelectasis  are  such  as 
weaken  the  constitution,  whether  they  operate  before  birth,  as  inherited 
vices,  such  as  syphilis,  scrofulosis,  malformations,  etc. ;  at  birth,  as  premature 
delivery  or  injuries  received  during  parturition;  or  after  birth,  as  rachitis, 
improper  feeding,  neglect,  exposure,  as  in  foundlings,  unsanitary  habitations, 
and  debilitating  diseases. 

The  exciting  causes  are  such  as  prevent  air  from  entering  the  alveoli,  and 
permit  them  to  collapse  after  the  residual  air  has  been  rarefied,  absorbed,  or 
expelled.  They  may  be  classified  as  intrathoracic  and  extrathoracic.  The 
most  frequent  intrathoracic  cause  is  bronchial  catarrh,  more  especially  of  the 
smaller  subdivisions,  in  which  the  lumen  of  the  tube  is  obstructed  by  the 
resulting  exudation  and  the  ingress  of  air  prevented.  Gairdner  of  Glasgow 
has  explained  the  mechanical  action  of  a  plug  of  mucus  in  a  bronchiole  in 
gradually  diminishing  the  entrance  of  air  to  the  area  supplied  by  it,  and  the 
resulting  collapse  of  the  alveoli.  This  ball-valve  shuts  out  the  air  at  every 
inspiration,  but  allows  the  expulsion  of  that  within  the  alveoli.  If  this  obstruc- 
tion be  not  displaced,  the.  pressure  exerted  by  the  atmosphere  upon  the  thoracic 
walls  and  the  contractile  force  of  the  pulmonary  tissues  cause  the  alveoli  to 
collapse.  It  may  also  be  caused  by  whooping-cough,  the  paroxysms  expelling 
the  residual  air  and  decreasing  the  power  of  the  inspiratory  forces.  Measles  is 
cited  by  some  as  an  etiological  factor,  but  the  more  immediate  cause  is  probably 
the  attendant  bronchial  catarrh.  Effusion  into  the  pleura  or  pericardium  may 
cause  collapse  of  the  pulmonary  alveoli  in  varying  degrees  proportionate  to  the 
pressure  exerted  by  the  fluid  and  the  resistance  of  the  lung.  The  lodgement 
•  of  foreign  bodies,  as  beans,  peas,  seeds,  or  metallic  or  porcelain  substances,  in 
a  bronchus  may  prevent  ingress  of  air  and  lead  to  alveolar  collapse. 

Among  the  extrathoracic  causes  are  spinal  curvature,  deformity  of  the  chest- 
wall,  constricting  clothing,  and  solid  or  fluid  tumors  in  the  abdominal  cavity. 
Any  one  of  these  might  be  sufficient  to  compress  the  lung  to  the  degree  of  col- 
lapse by  diminishing  the  capacity  of  the  thoracic  cavity.  It  may  also  be  of 
cerebral  or  spinal  origin.  Disease  of  the  brain,  cord,  or  nerves  which  paralyzes 
or  over-stimulates  the  respiratory  centres  or  prevents  the  transmission  of  nerve- 
force  may  produce  atelectasis  by  impeding  the  inspiratory  or  increasing  the 


900    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

force  of  the  expiratory  muscles  of  respiration  in  a  weakly  or  rachitic  infant. 
Finally,  it  may  originate  independently  of  affections  of  the  air-passages,  as  from 
the  exhaustion  of  long-continued  illness,  constant  dorsal  decubitus,  diarrhoea, 
or  ileo-colitis. 

Pathology  and  Pathological  Anatomy. — Post-natal  atelectasis,  unlike 
the  congenital  form,  is  a  pathological  condition  in  which  the  expanded  lung- 
alveoli  return  to  the  ante-natal  state,  from  arrest  of  function  owing  to  some 
mechanical  impediment  to  the  ingress  of  air.  The  extent  of  the  collapsed  area 
is  either  circumscribed  or  diffused,  depending  upon  the  calibre  of  the  obstructed 
bronchus.  It  is  usually  situated  at  the  postero-inferior  margin  of  the  lung 
parallel  to  the  spinal  column;  or  it  may  involve  a  whole  lobe  or  a  whole  lung. 
When  it  complicates  bronchial  catarrh,  it  occurs  in  small,  scattered  areas,  cor- 
responding to  the  ramifications  of  the  obstructed  bronchus.  In  pericardial  and 
pleuritic  effusions  of  moderate  extent  the  lower  lobes  are  involved,  but  if  the 
exudation  is  abundant  the  entire  lung  may  be  collapsed  from  compression. 

The  atelectatic  lung-tissue,  being  devoid  of  air,  is  shrunken,  depressed 
below  the  level  of  the  surfice  of  the  lung,  is  of  irregular  outline,  and  dark- 
brown,  violet,  or  reddish-blue  in  color.  On  section  the  collapsed  tissue  appears 
dark-red  and  smooth,  and  a  serous  or  bloody  fluid  exudes  from  it.  From  its 
resemblance  to  flesh  it  is  called  "  carniflcation."  It  is  firm,  dense,  tough, 
without  crepitation,  airless,  and  sinks  in  water.  If  the  collapse  be  recent,  the 
alveoli  can  be  re-inflated  by  removing  the  obstruction  and  blowing  into  the 
bronchial  tube.  If  bronchial  catarrh  be  present,  the  mucous  membrane  is 
swollen,  soft,  and  hypertemic,  and  the  tube  is  filled  with  thick,  tenacious  muco- 
pus  forming  a  complete  plug.  Around  the  affected  areas  are  air-vesicles  in  a 
state  of  compensatory  dilatation.  This  physiological  emphysema  is  only  found 
when  the  child  has  had  sufficient  strength  to  increase  the  inspiratory  efforts, 
and  is  but  rarely  seen  in  the  feeble. 

Symptoms. — The  atelectatic  areas  may  be  so  small,  so  scattered,  or  so 
obscured  by  the  adjacent  compensatory  emphysema  as  to  be  wholly  overlooked, 
although  frequent  and  careful  physical  examinations  may  be  made.  This  is 
especially  true  of  cases  in  which  there  is  no  recession  of  the  chest-wall,  and 
where  the  neighboring  alveoli  are  so  distended  as  to  increase  the  vesicular 
murmur  and  intensify  the  percussion  resonance. 

As  post-natal  atelectasis  usually  happens  to  emaciated  and  puny  infants, 
the  general  symptoms  vary  according  to  the  extent  of  the  lesion.  In  mild 
cases  the  infant  is  indifferent  to  its  surroundino;s,  gives  vent  to  a  whininsj  ex- 
piration,  is  slightly  cyanosed,  and  refuses  its  nourishment ;  but  these  symptoms 
quickly  disappear  upon  the  dislodgement  of  the  occluding  mucus  plug.  In 
severe  cases  restlessness  and  sleeplessness  are  well  marked ;  there  is  evidence 
of  distress  and  exhaustion  depicted  upon  the  face ;  the  features  are  pinched ; 
the  eyeballs  are  sunken  and  Avithout  shimmer,  and  the  livid  eyelids  droop ;  the 
mouth  is  drawn  and  the  lips  are  livid ;  and  the  head  and  face  are  bathed  in  a 
])rofuse,  cold,  clammy  perspiration.  The  tongue  is  dry,  swollen,  and  purple ; 
the  appetite  is  lost,  the  infant  refusing  to  nurse,  suck  the  bottle,  or  take  food 
from  a  spoon  ;  the  bowels  are  normal,  unless  there  be  some  gastro-intestinal 
derangement.  Collapse  is  often  rapid  and  pronounced,  but  is  not  always  fatal. 
There  may  be  convulsions,  in  one  of  which  the  infant  may  die,  though  they 
are  not  necessarily  fatal.  The  pulse  is  accelerated  and  small,  and  its  tension 
decreases  as  the  atelectatic  area  increases.  Cough,  though  not  always  present, 
is  due  to  bronchial  catarrh.  The  integument  is  dusky,  and  becomes  livid  and 
clammy  as  the  disease  progresses.  The  temperature  is  normal  or  subnormal 
even  when  atelectasis  occurs  during  the  course  of  a  febrile  disease. 


POST-NATAL    ATELECTASIS.  901 

Physical  Signs. — It  is  not  surprising  that  this  disease  is  so  frequently 
confounded  with  pneumonia,  when  we  remember  that  its  physical  signs  are 
indicative  of  more  or  less  consolidation  of  lung-tissue,  with  a  catarrhal  inflam- 
mation of  the  bronchial  mucous  membrane.  So  the  physical  signs  vary  with 
the  extent  of  tissue  involved. 

Inspection. — The  nares  dilate  with  the  respiratory  movements,  which  are 
superficial  and  rapid,  varying  from  60  to  90  per  minute,  and  their  normal  ratio 
to  the  pulse  is  lost.  Inspiration  is  slower  and  more  labored  than  expiration, 
and  is  followed  by  a  pause.  Retraction  of  the  chest-wall  varies  with  its  elas- 
ticity and  the  extent  of  the  collapsed  lung  beneath.  If  a  considerable  area  of 
lung  is  involved,  the  chest-wall  yields  to  atmospheric  pressure,  resulting  in 
depression  of  the  supraclavicular  and  intercostal  spaces,  with  a  deep  furrow 
over  the  affected  area.  The  deformities  of  the  chest-wall  are  exaggerated  if 
spinal  curvature  or  rachitis  exists. 

Auseidtation. — The  vesicular  murmur  is  feeble  or  absent  unless  there  is 
compensatory  emphysema  around  the  atelectatic  areas.  Bronchial  respiration 
and  bronchophony  are  present  when  a  large  collapsed  area  surrounds  a  bron- 
chus. When  fine  crepitant  rales  are  present,  they  indicate  an  extension  of  the 
catarrhal  process  to  the  neighboring  bronchioles  and  alveoli. 

Pereussion. — Dulness  is  usually  found  at  the  base  of  the  lung  posteriorly, 
but  is  often  slight  or  entirely  absent,  and  if  the  neighboring  alveoli  are  em- 
physematous the  percussion  resonance  may  be  greatly  exaggerated.  The  dul- 
ness may  extend  upward  parallel  with  the  spinal  column ;  it  may  remain  station- 
ary, or  it  may  be  transient  or  change  with  the  position  of  the  infant.  If  it  is 
due  to  compression  from  a  collection  of  fluid  in  the  pericardial,  pleural,  or 
abdominal  cavity,  the  signs  of  this  causative  factor  may  be  defined. 

If  it  is  coincident  with  bronchial  catarrh,  whooping-cough,  diarrhoea, 
typhoid  fever,  or  any  exhausting  ailment,  the  symptoms  of  the  primary  affec- 
tion will  be  present. 

Duration. — The  duration  of  life  is  uncertain,  and  in  some  infants  it  is 
surprisingly  long.  Some  die  very  early  from  asphyxia  or  in  a  convulsive 
attack,  while  others  linger  for  weeks  or  months  to  die  of  slow  asphyxia  or 
exhaustion. 

Diagnosis. — If  the  atelectasis  is  in  scattered  areas,  it  is  seldom  recognized, 
and  even  if  large  areas  are  involved,  it  may  be  overlooked  unless  frequent  and 
careful  examinations  are  made.  It  is  most  common  in  the  feeble  and  emaciated 
infant,  and  is  directly  caused  by  some  disease  which  impedes  the  respiratory 
movements.  It  frequently  accompanies  broncho-pneumonia,  pertussis,  measles, 
or  some  long-continued  and  exhausting  disease.  The  respirations  are  rapid  and 
shallow,  dyspnoea  is  progressive,  cyanosis  marked,  and  exhaustion  increasing. 
Auscultation  reveals  an  absence  of  vesicular  breathing  and  the  presence  of 
bronchial  respiration  and  bronchophony,  and  there  is  dulness  on  percus- 
sion over  the  affected  area.  A  differential  diagnosis  is  generally  difficult, 
owing  to  the  similarity  of  post-natal  atelectasis  to  other  diseases.  Some  of  the 
physical  signs  of  croupous  or  broncho-pneumonia  are  often  observed  in 
atelectasis,  but  the  characteristic  general  symptoms  of  these  two  diseases  are 
either  indistinct  or  absent.  In  pneumonia  the  temperature  is  high,  and  is 
frequently  accompanied  by  delirium  or  convulsions ;  the  pain  is  acute ;  the 
face  is  flushed  ;  the  skin  is  hot  and  dry ;  there  are  fine  crepitant  rales  and  per- 
cussion dulness  over  a  large  area ;  and  retraction  of  the  chest-wall  during 
inspiration  is  absent.  In  atelectasis  there  is  a  normal  or  subnormal  tempera- 
ture ;  pain  is  absent ;  the  face  is  livid ;  the  skin  is  cold  and  wet ;  r^les  are 


902    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

only  present  when  bronchial  catarrh  exists;  dulness  is  in  small  scattered  areas ; 
and  the  chest-wall  retracts  during  inspiration. 

While  it  is  possible  to  confound  atelectasis  with  acute  miliary  tuberculosis, 
still  there  are  so  many  well-defined  symptoms,  as  the  previous  history,  cough, 
great  fluctuation  of  the  daily  temperature,  emaciation,  and  exhaustion,  which 
precede  the  stage  of  solidification  in  tuberculosis,  that  the  differentiation  should 
be  made  with  a  degree  of  certainty. 

Atelectasis  should  not  be  mistaken  for  pleuritic  effusion,  as  the  absence  of 
bronchial  breathing,  bronchophony,  and  vocal  fremitus,  taken  in  conjunction 
with  the  alteration  of  the  line  of  dulness  with  the  changing  position  of  the 
patient,  will  settle  the  diagnosis.  In  doubtful  cases  aspiration  would  be  the 
determining  factor. 

Prognosis. — The  prognosis  is  always  grave,  and  recovery  is  extremely  rare, 
owing  to  the  low  vitality  of  the  infant.  If  it  complicate  bronchial  catarrh  or 
broncho-pneumonia  in  a  puny,  rachitic  infant,  atelectasis  is  fatal.  Convulsions 
greatly  jeopardize  life.  If  somnolence,  increasing  cyanosis,  superficial  and 
hurried  I'espi rations,  and  refusal  to  take  nourishment  supervene,  the  prognosis 
is  unfavorable  ;  but  if  intelligence  return,  cyanosis  disappear,  the  respirations 
become  stronger  and  deeper,  and  the  child  take  nourishment  liberally,  the 
chances  are  favorable  to  recovery. 

When  complicated  by  whooping-cough,  general  pulmonary  emphysema, 
broncho-pneumonia,  tuberculosis,  or  pleurisy,  it  is  fatal.  When  caused  by 
compression,  as  in  hydro-,  pyo-,  or  pneumo-thorax  or  tumors,  the  prognosis 
depends  upon  the  removal  of  the  cause.  When  dependent  upon  the  presence 
of  a  foreign  body  in  a  bronchus,  recovery  is  conditioned  upon  its  dislodgement. 
It  must  be  remembered,  however,  that  in  some  cases  the  infant  may  recover 
from  the  immediate  effects  of  atelectasis  to  die  later  of  cheesy  pneumonia  or 
phthisis. 

Treatment. — This  being  a  disease  which  is  superinduced  by  the  lack  of  resist- 
ance of  the  enfeebled  infant,  the  prime  factor  in  the  treatment  is  to  improve 
the  general  health  so  as  to  enable  it  to  repel  all  causes  that  depress. the  vitality. 
To  this  end  personal  and  domiciliary  hygiene  should  be  carefully  regulated. 
In  seasonable  weather  the  infant  should  be  taken  in  his  perambulator  into  the 
open  air  ;  removal  into  the  country,  or,  when  practicable,  to  the  mountains  or 
seashore,  is  advisable.  An  occasional  tepid,  alcoholic,  or  moderately  cool 
sponge-bath  will  prove  beneficial.  Sleep  should  be  encouraged  at  stated  times, 
care  being  taken  not  to  permit  too  much.  The  clothing  must  be  of  the  proper 
quality  and  quantity,  and  should  permit  of  the  freest  movements  of  the  chest. 
Very  feeble  infants  may  be  wrapped  in  cotton-wool.  The  domicile  must  be 
scrupulously  healthful  in  having  pure  air  by  free  ventilation  and  the  best  sani- 
tary equipment.     The  temperature  of  the  room  must  be  from  70°  to  75°  F. 

Care  should  be  taken  in  supervising  the  quality  and  quantity  of  the  infant's 
food.  If  the  nursing  infant  has  progressively  emaciated  and  weakened,  the 
mother's  milk  needs  attention.  If  bottle-fed,  the  management  is  even  more 
perplexing,  but  the  proportion  of  albuminoids,  fat,  and  sugar  can  be  changed 
until  a  combination  is  found  that  will  be  digestible  and  nutritious.  Broths  and 
beef-juice  may  prove  valuable  adjuvants  to  the  milk  diet.  If  the  infant  be  too 
weak  to  nurse,  or  even  to  swallow,  oravage  or  stomach-feedinrr  is  indicated. 
W  hen  the  stomach  will  not  retain  food,  the  strength  must  be  sustained  by  con- 
centrated nutritious  enemata. 

There  are  no  specifics  for  the  cure  of  atelectasis,  but  its  different  phenomena 
must  be  met  prompth-  and  energetically.  When  secondary,  the  treatment  must 
be  directed  to  the  primary  affection.    If  a  foreign  body  be  lodged  in  a  bronchus, 


POST-NATAL    ATELECTASIS.  .  903 

its  removal  by  operation  is  recommended.  If  the  obstruction  is  a  plug  of  ropy 
muco-pus,  it  may  be  removed  by  active  emesis  induced  by  teaspoonful  doses  of 
syrup  of  ipecacuanha,  one  or  two  grains  of  the  sulphate  of  copper  dissolved  in 
water,  or  the  hypodermatic  injection  of  apomorphia. 

Cardiac  and  respiratory  depressants,  especially  preparations  of  opium,  must 
be  positively  interdicted,  Avhile  cardiac  and  respiratory  stimulants  must  be 
judiciously  administered.  The  cardiac  stimulants  of  most  importance  are 
strophanthus,  sparteine,  nitro-glycerin,  camphor,  musk,  and  ammonium  car- 
bonate. Brandy,  in  frequently  repeated  doses,  is  one  of  the  most  efficient 
stimulants.  The  force  of  the  respiratory  movements  can  be  increased  by  -gl-g- 
*^  2T0  gi'^^^n  of  atropine  sulphate,  which  stimulates  the  respiratory  centre. 
Compressed  air  or  oxygen  may  be  inhaled,  but  neither  has  proved  to  be  par- 
ticularly beneficial.  Convulsions  must  be  treated  by  hot  mustard  baths  and 
antispasmodics.  Finally,  to  ensure  any  hope  of  success,  the  infant  requires 
the  most  careful  handling,  the  most  rigid  regimen,  and  the  most  judicious 
dosage. 


BRONCHO-PNEUMONIA. 

By  WILLIAM  PEPPER,  M.  D., 

Philadelphia. 


Broncho-pneumonia — also  known  as  catarrhal  pneumonia,  lobular  pneu- 
monia, and  capillary  bronchitis — is  an  inflammatory  disease  of  the  terminal 
bronchioles  and  air-vesicles  of  the  lung,  affecting  scattered  groups  of  lobules. 
Thouo;h  in  the  main  a  catarrhal  inflammation  of  the  bronchioles  and  air-sacs, 
the  interventricular  and  peribronchial  tissues  are  also  involved,  and  the  term 
"catarrhal  pneumonia"  is  therefore  not  altogether  accurate,  nor  are  the  other 
terms  by  -which  it  has  been  designated  wholly  appropriate  in  all  cases.  The 
disease  varies  Avidely  in  its  course  and  duration,  often  proving  fatal  in  a  few 
days,  at  other  times  becoming  a  lingering  chronic  affection,  leading  to  secondary 
changes  or  creating  a  tendency  to  subsequent  tuberculous  infection. 

Etiology. — Broncho-pneumonia  is  in  the  great  majority  of  cases  a  sec- 
ondary disease,  and,  as  a  rule,  bronchitis  is  the  primary  cause.  This  may 
be  either  a  simple  bronchitis  or  that  which  occurs  as  a  pai't  of  infectious 
diseases,  prominent  among  which  are  measles,  wdiooping-cough,  diphtheria, 
influenza,  and  typhoid  fever.  The  manner  in  Avhich  a  bronchitis  affecting  the 
smaller  tubes  might  lead  to  a  broncho-pneumonia  is  readily  appreciated,  but 
will  be  considered  more  minutely  in  the  description  of  the  morbid  anatomy. 
A  most  important  cause  is  tuberculosis  affecting  the  bronchi  and  lungs.  In 
all  cases  of  chronic  phthisis  there  occur  from  time  to  time  attacks  of  localized 
broncho-pneumonia,  from  which  the  patient  recovers,  or  there  may  be  more 
widespread  and  fatal  attacks.  The  primary  focus  of  tuberculosis  is  sometimes 
so  small  as  to  have  escaped  detection,  and  in  such  cases  the  broncho-pneumonia 
is  apt  to  be  looked  upon  as  of  the  ordinary  type.  Broncho-pneumonia  may 
also  arise  without  bronchitis  as  a  primary  disease  of  obscure  origin,  or  as  a 
result  of  inspiration  of  irritants  from  the  mouth,  nose,  or  upper  respiratory 
passages,  and  in  the  new-born  it  may  be  the  result  of  respiration  of  the  liquid 
secretions  of  the  genital  tract  during  birth. 

The  specific  cause  of  the  inflammation  is  probably,  in  most  cases,  the 
pneumococcus  of  Frankel,  but  the  staphylococcus  and  streptococcus  pyogenes, 
the  bacillus  of  Friedlander,  or,  as  we  have  seen,  the  tubercle  bacillus,  may  be 
the  excitant  in  certain  cases. 

Of  the  predisposing  causes  of  catarrhal  pneumonia,  by  far  the  most 
important  is  the  age  of  the  patient.  A  study  of  mortality  statistics  of  young 
children  shows  pneumonia  to  be  second  only  to  infantile  diarrhoea  as  a  cause 
of  death,  and  in  children  under  five  years  it  is  the  lobular  form  of  pneumonia 
which  is  found  in  the  great  majority  of  cases.  It  is  especially  during  primary 
dentition  that  broncho-pneumonia  occurs,  and  most  of  the  fatal  cases  in  par- 
ticular occur  before  the  age  of  tAvo  years.  The  preponderance  of  this  form  of 
pneumonia  during  the  early  years  of  life  is  to  be  explained  partly  by  the 
anatomical  condition  of  the  lungs,  and  partly  by  the  marked  tendency  to 
catarrhal  processes  generally  in  infants. 

904 


BR0NCH0-PNEU3I0NIA.  905 

In  addition  to  age,  malhygienic  surroundings  exercise  a  powerful  influence 
on  the  prevalence  of  the  disease,  and  particularly  is  this  the  case  in  times  of 
epidemics  of  measles,  diphtheria,  and  whooping-cough,  Avhen  children  of  the 
poorer  class  are  especially  exposed  and  are  apt  to  suifer  from  improper  care. 
The  disease  is  most  common  during  the  winter  and  spring,  and  particularly  at 
times  when  the  weather  is  changeable.  Previous  conditions  of  health,  aside 
from  the  infectious  diseases,  exercise  some  influence,  and  children  suff"ering 
with  rickets  or  scrofula  are  prone  to  be  attacked  by  the  disease  in  its  most 
fatal  form. 

Morbid  Anatomy. — As  stated  before,  the  more  important  part  of  the 
pathological  changes  is  the  catarrhal  inflammation  of  the  lining  of  the  smaller 
bronchioles  and  air-vesicles,  the  epithelial  cells  rapidly  desquamating  and 
accumulating  within.  As  a  rule,  the  cells  are  cast  off  singly,  and  lie  inter- 
mingled with  a  smaller  number  of  leucocytes  or  red  corpuscles.  In  more 
rapid  and  virulent  cases  the  epithelial  lining  may  be  detached  in  large  flakes, 
and  sometimes  there  is  considerable  diapedesis  of  red  blood-corpuscles,  giving 
the  section  a  decidedly  hemorrhagic  appearance.  The  latter,  however,  is  rare. 
As  the  disease  continues  the  cellular  desquamation  and  exudation  increase, 
and  at  the  same  time  a  more  or  less  copious  outpouring  of  mucous  secre- 
tion occurs,  until  the  bronchioles  and  air-vesicles  become  completely  filled. 
Beginning  in  the  terminal  bronchi,  the  inflammatory  process  advances, 
and  invades  the  adjacent  air- vesicles  in  several  ways.  In  the  first  place, 
there  is  always  a  direct  extension  of  the  inflammation  to  the  surrounding 
peribronchial  tissues,  which  are  seen  to  be  invaded  by  round  cells  and  to  be 
the  seat  of  active  cellular  proliferation.  The  secondary  peribronchial  inflam- 
mation gradually  spreads  to  the  walls  of  the  adjacent  air-vesicles.  Thus  it  is 
seen  that  the  peribronchial  and  perivesicular  involvements  are  important 
elements  in  the  morbid  anatomy,  and  in  cases  where  the  disease  becomes 
chronic  these  secondary  changes  lead  to  the  induration  processes  characteristic 
of  chronic  broncho-pneumonia.  The  extension  from  the  bronchioles  to  the 
alveoli  is,  however,  also  effected  in  other  ways.  There  may  be  a  continuous 
inflammation  extending  along  the  epithelial  lining,  or  the  irritating  matters 
within  the  tubes  may  be  directly  conveyed  by  the  strong  inspiratory  efforts 
following  a  paroxysm  of  coughing.  These  inspired  substances  may  directly 
excite  vesicular  inflammation,  or  by  obstructing  the  terminal  bronchial  tubes 
may  first  produce  areas  of  collapse  of  the  lung- tissue.  The  occurrence  of 
pulmonary  atelectasis  in  the  course  of  bronchial  catarrh  and  broncho-pneumo- 
nia is  entirely  a  mechanical  result  of  the  obstruction  of  the  tubes.  In  some 
cases  the  obstructing  material  acts  as  a  ball  valve,  permitting  the  air  to  pass 
out,  but  not  re-enter  the  affected  area.  More  frequently  the  expiratory  efforts 
expel  the  air  through  partially  obstructed  tubes,  but  the  weaker  inspiratory 
force  proves  inadequate  to  refill  the  vesicle ;  and  finally,  in  cases  where  there 
has  been  complete  obstruction  of  the  tubes,  the  air  enclosed  within  is  gradually 
absorbed.  In  any  case,  the  vesicular  structure  collapses,  the  blood-vessels 
become  surcharged  with  blood,  and  the  most  favorable  conditions  for  inflamma- 
tory action  are  thus  supplied. 

When  the  disease  begins  to  undergo  resolution  the  cellular  material  within 
the  vesicles  suffers  fatty  degeneration,  and  with  the  mucous  secretion  is 
expectorated  or  absorbed  coincidently  with  resolution  of  the  peribronchial 
inflammation.  In  cases,  however,  in  which  chronic  pneumonia  I'esults,  the 
peribronchial  connective-tissue  hyperplasia  undergoes  fuller  organization,  and 
induration  follows  in  consequence.     The  bronchial  walls  are  thickened,  and 


906  A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

not  rarely  show  fusiform  dilatations,  the  result  of  traction  of  the  newly-formed 
connective  tissue. 

The  macroscopic  appearance  is  highly  characteristic  in  most  cases.  The 
involvement  of  scattered  lobules  of  both  lungs  in  itself  is  a  most  distinctive 
condition,  though  sometimes  by  confluence  a  whole  lobe  may  be  affected.  In 
such  cases  the  distinction  from  croupous  pneumonia  becomes  one  of  great  diffi- 
culty if,  as  sometimes  happens,  the  vesicles  contain  fibrinous  exudate  and  the 
incised  surface  presents  a  granular  appearance.  Even  in  these  cases,  hoAvever, 
it  will  be  noted  that  the  process  is  not  entirely  a  uniform  one,  and  that  there 
is  a  certain  tendency  to  lobular  limitation.  Examination  of  the  pleural  sur- 
face of  the  lung  shows  a  moderate  deposit  of  lymph  over  areas  Avhich  have 
reached  the  periphery.  The  inflamed  lobules  project  slightly  from  the  surface, 
and  have  a  dark-red  or  in  later  stages  a  grayish  appearance,  which  at  once  dis- 
tinguishes them  from  the  depressed,  blue-black,  and  indurated  spots  of  atelec- 
tasis. The  latter  may  be  small  and  lobular  or  more  extensive,  and  they  are 
most  frequently  seen  posteriorly  along  the  spinal  column  or  anteriorly  in  the 
middle  lobe  of  the  rijjht  luns;  or  the  lingula  of  the  left.  In  the  early  stages 
they  may  usuallj^  be  distended  by  inflating  the  lungs  through  a  tube,  but  later, 
as  inflammatory  changes  occur  within  them,  this  becomes  difficult  or  impossible. 
The  incised  surface  of  the  lung  presents  a  similar  picture.  The  distinct  lobular 
invasion  is  again  quite  evident,  and  the  atelectatic  areas  are  recognized  by  the 
same  characters  as  on  the  pleural  surface.  The  lung  is  smooth  and  airless  in 
the  affected  portions,  or  in  rare  cases  may  be  slightly  granular  when  the 
exudate  contains  fibrin.  The  smaller  bronchi  are  distended  with  clear  viscid 
mucus  or  turbid  yellowish  muco-pus.  The  lobules  adjacent  to  the  affected 
ones  are  emphvsematous,  as  are  also  the  anterior  margins  and  the  upper  lobes 
of  the  lungs,  and  occasionally  subpleural  emphysema  may  be  seen.  In  one 
instance  I  found  pneumothorax  resulting  from  rupture  of  the  pleura  in  such  a 
case. 

When  resolution  takes  place,  the  inflamed  lobules  become  lighter  in  color, 
the  exudate  softens,  and  is  finally  removed.  More  rarely  abscess  or  gangrene 
may  result,  or  chronic  broncho-pneumonia  may  occur  in  lingering  cases.  The 
termination  in  cheesy  pneumonia,  of  which  much  was  formerly  written,  is  per- 
haps always  the  expression  of  tubercular  infection,  either  primary  or  consequent 
upon  the  broncho-pneumonia. 

Symptoms. — The  onset  of  broncho-pneumonia  is  rarely  marked  by  decided 
symptoms.  If  the  primary  measles  or  whooping-cough  has  not  been  entirely 
recovered  from,  a  slight  increase  of  the  existing  fever,  Avith  acceleration  of  the 
pulse,  dyspnoea,  and  a  change  of  the  cough  to  a  short  and  hacking  character, 
may  be  the  only  symptoms  to  indicate  beginning  trouble.  In  cases  in  which 
broncho-pneumonia  arises  primarily  the  same  symptoms  follow  an  initiatory 
stage  of  bronchitis.  The  fever  rises  gradually,  reaching  the  maximum  in 
three  or  four  days,  and  is  throughout  the  disease  markedly  irregular,  the 
diurnal  excursions  ranging  from  three  to  four  degrees.  In  ordinary  cases  the 
evening  maxima  are  from  103°  to  104.5°  F.,  but  it  is  not  unusual  to  find 
higher  temperatures,  and  in  one  case  which  recovered  I  have  seen  it  reach  107°. 
The  decline  of  the  temperature,  like  the  ascent,  is  gradual,  and  for  a  long  time 
during  convalescence  ieverishness  may  be  noted  toAvard  evening.  With  in- 
crease of  the  fever  the  pulse-rate  accelerates  to  130  or*140  beats  per  minute, 
and  in  exceptional  cases  a  rate  of  200  may  occur.  Dyspnoea,  however,  is  a 
more  decided  symptom,  the  ratio  between  the  respiration  and  pulse  not  infre- 
quently becoming  1  to  2,  or  even  less  than  2.  The  alae  of  the  nose  dilate 
with  each  inspiratory  effort,  the  base  of  the  chest  sinks  in,  and  the  child  mani- 


BR  ONCHO-PNE  UMONIA . 


907 


fests  by  its  expression  that  pain  is  felt  in  the  side.  When  areas  of  the  lung 
collapse,  there  are  paroxysms  of  more  decided  dyspnoea,  the  expiration  becomes 
more  grunting,  and  duskiness  or  decided  cyanosis  of  the  skin  makes  its  appear- 
ance. The  cough  at  first  is  sharp  and  short,  and  is  attended  by  grimaces  and 
a  cry  of  pain ;  later  it  is  heard  to  be  looser,  and  in  children  over  seven  years 
of  age  there  may  be  muco-purulent  expectoration.     In  younger  children  the 

Fig.  1. 


Chart  of  Temperature,  Pulse  and  Respiration  of  Broncho-pneumonia  in  a  patient  two  years  and  two 

montlis  old;  recovery. 

sputa  are  swallowed.  With  the  fever  and  dyspnoea  there  is  nearly  always  a 
complete  loss  of  appetite,  but  excessive  thirst.  Nursing  infants  are  unable  to 
retain  hold  of  the  nipple  for  more  than  a  moment  or  two  on  account  of  dyspnoea, 
and  older  children  refuse  food  entirely.  The  child  becomes  fretful  and  irritable, 
but  sometimes  the  urgency  of  dyspnoea  may  be  such  that  it  suiFers  itself  to  be 
taken  up  or  examined  without  complaint.  The  general  strength  rapidly 
declines,  and,  as  the  interference  with  respiration  continues,  a  soporose  or 
somnolent  condition  or  complete  stupor  presages  an  early  death  unless  relief 
be  afforded.  Not  infrequently  vomiting  is  present  at  the  onset  or  during  the 
course  of  the  disease,  and  with  diarrhoea  may  still  further  add  to  the  general 
depression  and  the  unfavorable  outlook. 

In  cases  in  which  resolution  occurs  the  symptoms  gradually  ameliorate,  the 
fever  subsides,  and  in  the  course  of  a  few  days  or  a  week  convalescence  is 
established.  In  less  favorable  cases,  after  subsidence  of  the  urgent  symptoms, 
the  disease  may  linger  and  become  chronic,  or  from  the  start  it  may  assume  a 


908  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

clironic  type.  In  such  cases  there  is  persistent,  irreorular  pyrexia,  with  cough, 
dyspnoea,  and  acceleration  of  the  pulse,  and  the  general  health  of  the  patient 
becomes  more  and  more  depressed. 

Physical  Signs. — At  the  inception  of  the  disease  the  physical  signs  of 
bronchitis  affecting  the  smaller  tubes  will  nearly  always  be  present.  At  first 
there  are  heard  on  auscultation  numerous  dry  rules  throughout  both  lungs; 
later,  coarse  moist  rales  nuike  their  appearance,  but  the  pulmonary  resonance 
remains  unaffected.  The  physical  signs  of  the  developed  disease  are  by  no 
means  distinctive.  Defective  expansion  and  an  up-and-down  type  of  breath- 
ing are  manifest,  and  with  each  inspiratory  effort  the  base  of  the  chest  may  be 
seen  to  recede.  At  the  same  time,  careful  percussion  of  the  lateral  and  pos- 
terior portions  of  the  lungs  may  detect  localized  patches  of  dulness,  but  this 
is  by  no  means  constantly  the  case.  In  not  a  few  the  percussion  note  is  hyper- 
resonant,  perhaps  from  associated  emphysema  of  the  unaffected  lobules,  or,  on 
the  other  hand,  the  extent  of  dulness  is  rendered  considerable  by  coexistence 
of  large  areas  of  atelectasis.  Vocal  fremitus  is  slightly  increased  over  the  con- 
solidated areas  when  the  bronchial  tubes  are  not  unduly  filled  with  mucus,  but 
over  the  collapsed  portions  it  is  usually  wholly  absent.  Auscultation  shows  the 
continuation  of  the  preceding  bronchitis,  but  in  addition  to  these  coarser  dry 
and  moist  rales  there  is  also  heard  fine  moist  crackling .  over  the  consolidated 
areas.  These  fine  subcrepitant  rales  are  heard  on  inspiration  and  expiration, 
and  are  perhaps  the  most  suggestive  sign  of  the  disease.  The  breath-sounds 
themselves  vary  widely  with  the  condition  of  the  terminal  bronchi  and  the 
degree  of  distention.  Sometimes  the  sounds  are  weak  and  faintly  blowing,  at 
other  times  harsh  and  clear,  but  only  rarely  do  we  find  the  distinct  bronchial 
breathing  of  croupous  pneumonia.  It  will  be  noted,  then,  that  the  signs  of 
broncho-pneumonia  are  in  no  sense  characteristic  ;  but  when  to  the  rales  of 
bronchitis  there  are  superadded  fine  subcrepitant  rales,  with  harsh  or  somewhat 
blowing  breathing,  and  areas  of  even  indistinct  impairment  of  resonance  at  the 
postero-inferior  portions  of  the  lungs,  the  evidence  is  fairly  clear  as  for  as 
physical  examination  is  concerned. 

Complications  and  Sequels. — As  has  been  said  in  the  description  of  the 
pathological  anatomy,  pulmonary  collapse  is  a  more  or  less  constant  factor  in 
the  disease,  and  is  therefore  hardly  to  be  looked  upon  as  a  complication.  Yet 
in  some  cases  the  extent  of  the  atelectatic  areas  is  so  great,  and  the  attending 
dyspnoea  and  appearance  of  suffocation  so  severe,  as  to  merit  the  place  of  com- 
plicating symptoms.  It  is  in  such  cases  that  the  old  title  "suffocative  catarrh" 
finds  a  not  inapt  application.  Pleurisy,  so  commonly  present  in  slight  degree, 
rarely  becomes  a  troublesome  complication,  though  some  observers,  among  them 
myself,  have  met  with  purulent  effusion.  Abscess  and  gangrene  rarely  follow 
broncho-pneumonia,  but  are  most  apt  to  do  so  in  aspiration  and  deglutition  pneu- 
monias, in  which  the  inflammation  from  the  beginning  may  take  on  a  serious 
character.  Subpleural  emphysema  and  pneumothorax  are  rare  complications. 
The  most  dreaded  sequel  of  broncho-pneumonia  is  tuberculosis.  In  some  of 
the  cases  the  broncho-pneumonia  is  undoubtedly  tubercular  from  the  beginning, 
but  in  any  case  the  vulnerability  of  the  system  is  so  heightened  by  the  attack 
that  subsequent  infection  becomes  an  easy  matter,  and  frequently  occurs.  The 
marked  nervous  symptoms  during  the  course  of  broncho-pneumonia  or  toward 
its  termination  may  suggest  meningitis,  but  it  is  more  probalde  that  in  the 
majority  of  such  cases  the  symptoms  are  due  to  hyperaemia  of  the  meninges  or 
the  toxaemic  state  of  the  patient  rather  than  to  actual  meningitis. 

The  termination  of  protracted  cases  in  chronic  pneumonia  has  been  alluded 
to  before. 


BRONCHO-PNEUMONIA.  909 

Diagnosis. — In  the  first  place,  it  is  essential  to  recognize  the  development 
of  pneumonia  during  acute  bronchitis  at  the  very  earliest  moment.  It  may  be 
suspected  when  there  has  been  a  sudden  increase  of  fever  and  acceleration,  of 
the  pulse  and  respiration,  but  such  might  occur  independently  of  broncho- 
pneumonia. If,  however,  in  addition  to  these  symptoms,  fine  subcrepitant  r^les 
and  blowing  breathing  be  heard,  and  percussion  detects  small  areas  of  impair- 
ment of  resonance,  pneumonia  may  be  diagnosticated  with  considerable  cer- 
tainty. 

The  disease  when  fully  developed  may  readily  be  confounded  with  croupous 
pneumonia  in  cases  in  which  the  confluence  of  lobular  involvement  has  led 
to  a  considerable  area  of  consolidation.  This,  however,  is  rarely  the  case,  and 
even  when  it  does  occur  the  consolidation  is  not  so  definitely  localized  in  one 
lobe,  and  scattered  patches  will  probably  be  found  in  the  other  lung.  In 
ordinary  cases  the  dulness,  the  vocal  fremitus,  and  bronchial  breathing  are  not 
developed  to  nearly  the  degree  which  they  commonly  attain  in  croupous  pneu- 
monia, and  in  typical  cases  there  could  scarcely  be  the  possibility  of  confound- 
ing the  one  disease  with  the  other.  The  difficulty,  however,  of  making  accurate 
physical  examinations  in  young  children  is  often  considerable,  and  in  such 
cases  the  history  of  the  disease  is  of  greatest  assistance.  The  gradual  onset 
and  the  marked  irregularity  of  the  fever,  the  existence  of  a  preceding  bron- 
chitis, and  the  character  of  the  sputa  when  present,  are  in  all  cases  highly 
suggestive  of  broncho-pneumonia,  as  the  abruptness  of  the  attack  and  the 
greater  regularity  of  the  temperature  curve  give  strong  evidence  of  croupous 
pneumonia. 

The  diagnosis  from  pleurisy  with  effusion  presents  little  difficulty,  altogether 
aside  from  the  fact  that  the  latter  disease  is  rare  in  children  under  six  years. 
The  coexistence  of  moderate  pleuritic  effusion  may,  however,  be  difficult  to 
recognize.  In  such  cases  the  decided  dulness  and  the  variation  of  its  outlines 
with  changes  in  the  position  of  the  patient,  and  the  more  distant  and  muffled 
character  of  the  breath-sounds,  may  serve  to  indicate  the  actual  pathological 
conditions ;  but  the  complication  so  rarely  occurs  that  its  recognition  hardly 
merits  further  study.  More  commonly,  plastic  pleurisy  accompanies  broncho- 
pneumonia, and  may  confuse  the  physical  signs,  but  careful  study  of  the  degree 
of  dulness,  compared  with  the  auscultatory  phenomena,  will  in  these  cases 
usually  point  to  the  proper  diagnosis,  and  the  evidence  of  great  pain  in  the  side 
would  still  further  strengthen  this  opinion. 

In  cases  in  which  nervous  symptoms  or  gastro-intestinal  disorders  become 
prominent,  it  may  happen  that  the  underlying  pneumonia  is  wholly  overlooked. 
Such  an  error  can  only  be  avoided  by  a  critical  study  of  the  symptoms  in  every 
case,  particularly  by  close  observation  of  the  rate  of  the  pulse  and  respirations 
and  by  careful  and  repeated  examination. 

Prognosis. — Broncho-pneumonia  is  always  a  most  serious  disease,  the 
mortality  ranging  from  30  to  50  per  cent.,  according  to  the  nature  of  the  cases 
and  the  surrounding  conditions.  It  is  most  fatal  in  children  under  two  years, 
and  the  form  which  occurs  in  the  new-born  from  aspiration  of  irritating  or 
infectious  particles  during  the  transit  through  the  maternal  passages  is  almost 
invaria.bly  fatal.  In  children  over  two  years  of  age  the  mortality  grows  pro- 
gressively less  with  the  age  of  the  patient.  The  cases  which  complicate 
whooping-cough  are  most  apt  to  be  fatal  or  lingering.  Rickets  or  other  debili- 
tating diseases  and  the  occurrence  of  gastric  disturbances,  diarrhoea,  marked 
nervous  symptoms,  and  pyrexia,  all  make  the  prognosis  highly  unfavorable. 

Duration. — The  duration  of  ordinary  cases  is  generally  from  fifteen  to 
twenty -five  days ;  milder  cases  may  terminate  in  a  week  or  ten  days.      Chronic 


910    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

broncho-pneumonia  is  uncertain  in  duration,  ranging  from  a  few  to  many 
months. 

Treatment. — It  is  difficult  to  lay  down  fixed  rules  for  treatment  in  a  disease 
in  which  so  much  depends  upon  the  actual  extent  and  nature  of  the  pathological 
changes  and  upon  the  reaction  of  the  patient. 

In  many  cases  of  bronchitis  or  of  infectious  diseases  attended  with  bron- 
chitis, it  will  be  possible  to  prevent  the  development  of  broncho-pneumonia  by 
careful  attention  to  hygiene  and  by  strict  insistance  upon  every  detail  of  treat- 
ment. It  Avill  be  necessary  in  such  cases  to  maintain  an  even  temperature  of 
70°  or  72°  in  the  sick-room,  to  avoid  all  drafts,  and  to  adapt  the  clothing  of 
the  patient  according  to  his  powers  of  resistance.  In  very  young  children  the 
mouth  should  be  carefully  cleansed  with  some  simple  mouth-wash  like  glycerin 
and  boric-acid  solution,  and  older  children  should  in  addition  be  directed  to 
expectorate  the  sputa. 

When  pneumonia  has  actually  become  established,  the  hygienic  details  of 
the  sick-room  must  be  still  more  strictly  maintained.  The  temperature  of  the 
room  must  be  kept  as  nearly  as  may  be  at  an  even  point,  and  it  is  always  well 
to  have  the  air  moistened  by  allowing  water  to  steam  at  the  hearth  or  over  a 
flame.  In  severe  cases  a  tent  of  sheets  may  be  erected  over  the  bed  and  steam 
from  a  boiler  be  directed  into  it.  A  light  woollen  shirt  should  be  worn,  and 
the  chest  will  require  special  protection.  Formerly  flaxseed  poultices  were  in 
common  use  in  the  treatment  of  pneumonia,  but  they  are  so  apt  to  become  cold 
and  disordered,  and  their  constant  application  is  attended  by  so  much  risk  and 
disturbance  of  the  patient,  that  their  use  is  now  generally  abandoned.  The  best 
protection  is  aff"orded  by  a  jacket  of  cotton  or  wool  batting,  lightly  quilted  and 
covered  on  the  outside  with  oiled  silk.  This  may  be  so  constructed  as  to  be 
easily  applied  and  removed  without  the  slightest  disturbance  of  the  patient, 
and  it  is  so  light  as  to  cause  little  discomfort  by  its  weight.  Practically 
the  same  thing  is  accomplished  by  stitching  cotton  batting  on  the  inside  of  a 
light  merino  shirt,  and  oiled  silk  outside,  but  the  jacket  is  more  convenient.  It 
is  unnecessary  in  ordinary  cases  to  change  the  jacket  oftener  than  every  seven 
or  eight  days.  The  use  of  counter-irritants,  such  as  turpentine  stupes,  mus- 
tard plasters,  and  blisters,  while  occasionally  advisable,  has,  as  a  routine  treat- 
ment, fallen  into  disrepute ;  but  the  repeated  application  of  tincture  of  iodine 
diluted  with  alcohol,  so  as  not  to  prove  too  irritating,  is  often  attended  by  good 
results. 

The  diet  of  the  patient  should  be  at  once  light  and  nutritious,  so  that  the 
digestive  functions  may  be  kept  in  the  best  possible  condition,  and  at  the  same 
time  the  patient's  strength  preserved.  Milk,  gruels,  light  broths,  arrowroot, 
and  egg  albumin  dissolved  in  water  or  milk  answer  the  requirements,  and  are 
the  most  suitable  foods  obtainable.  In  addition  to  proper  regulation  of  the 
diet,  it  is  sometimes  desirable  to  administer  a  mild  laxative  at  the  onset  or  dur- 
ing the  course  of  the  disease  if  constipation  be  present ;  but  it  must  be  remem- 
bered that  gastro-intestinal  irritation  is  apt  to  complicate  the  case,  and  noth- 
ing must  be  done  which  might  invite  its  occurrence.  Minute  doses  of  mercury 
with  bicarbonate  of  sodium  or  Dover's  powder,  or  the  mildest  salines,  may  be 
of  value,  and  in  certain  cases  may  exercise  a  happy  regulating  influence  on  the 
gastro-intestinal  system,  provided  that  free  purgation  is  not  induced. 

For  the  condition  of  the  lungs  themselves  expectorants  are  highly  important. 
During  the  early  stage,  when  bronchitis  is  marked  and  the  sputa  tenacious,  small 
doses  of  ipecacuanha  or  apomorphine,  in  combination  with  alkalies  like  citrate 
of  potassium,  are  useful.  Such  a  combination  as  the  following  is  readily  taken 
by  children,  and  rarely  fails  to  render  the  mucous  secretion  less  tenacious : 


BRONCHO-PNEUMONIA.  911 

^.  Potassii  citratis 3iiss. 

Syr.  ipecac f^ss. 

Syr.  limonis 

Aquae aa  q.  s.  ad  f.liv. — M. 

Sig.   Two  teaspoonfuls  every  three  or  four  hours,  for  a  child  of  five  years. 

A  small  dose  of  apomorphine — a  sixteenth  or  a  twenty-fourth  of  a  grain- 
may  be  added  Avith  advantage  in  case  the  mucus  is  unusually  tenacious. 
Generally,  however,  recourse  must  soon  be  had  to  the  more  stimulating  expec- 
torants. The  ammonium  salts,  the  chloride  and  carbonate,  in  combination 
with  squills  or  senega,  are  the  most  desirable.  In  cases  in  which  depression  is 
marked  the  carbonate  is  preferable  to  the  chloride,  and  when  painful  cough 
is  urgent  minute  doses  of  morphine  or  paregoric  may  be  added  to  the  mixtures. 
Opium,  however,  should  never  be  given  w^ith  such  freedom  as  to  benumb  the 
sensibility,  and  in  the  later  stages  of  the  disease  should  be  avoided  if  possible. 
In  some  cases,  where  the  stomach  is  particularly  irritable,  the  aromatic  spirits 
of  ammonia  may  be  better  retained  than  other  preparations,  and  is  acceptably 
administered  in  combination  with  brandy  or  other  stimulant. 

The  following  combination  is  especially  valuable  for  children,  being 
pleasant  to  take  and  more  stimulating  than  such  as  contain  the  chloride  of 
ammonium : 

!^.  Ammonii  carbonatis gr.  xlviij. 

Pulv.  acacige  et  sacchari aa  q.  s. 

Spt.  lavandulae  comp.    ,    .    • fgij. 

Aquae q.  s.  ad  f^iv. — M. 

Sig.  A  teaspoonful  in  water  every  two  or  three  hours,  for  a  child  five  years  old. 

The  general  strength  of  the  patient,  and  particularly  the  respiratory 
function,  require  special  attention.  To  this  end  quinine  in  small  doses  and 
alcoholic  stimulants  are  highly  beneficial,  but  for  respiratory  and  muscular 
stimulation  no  drug  compares  with  strychnine  in  efficiency.     E.  g. — 


I^.   Quinine  sulph gr.  xxiv 

Strychninae  sulph.  . 
Acid,  muriat.  dil.    . 


Glycerini     . 
Liq.  pepsini 
Sig.  A  teaspoonful  in  water  ever 


.    .    .    .  gtt.  xvj  vel  gtt.  xxxij. 
.    .    .  •.  f^iij. 
q.  s.  ad  fgiv. — M. 
y  three  or  four  hours,  alternating  with  the 


expectorant  remedies,  for  a  child  of  five  years. 

In  cases  where  the  stomach  is  non-retentive  quinine  may  be  given  in  sup- 
positories of  two  or  three  grains  each.  The  use  of  such  expectorant  and  tonic 
treatment  usually  suffices  to  keep  the  bronchi  free  and  to  prevent  the  occurrence 
of  atelectasis ;  but  when  these  unwelcome  accidents  make  their  appearance  and 
suffocating  paroxysms  occur,  active  treatment  must  be  instituted.  The  admin- 
istration of  emetic  doses  of  ipecacuanha,  five  grains  of  the  powder  in  a  little 
syrup,  is  an  old  method  of  treatment  which  serves  admirably  to  clear  the 
respiratory  passages.  In  some  cases  it  may  be  well  to  combine  alum  or  sul- 
phate of  zinc  with  the  ipecacuanha,  but  the  preparations  of  antimony  formerly 
so  commonly  used, are  depressing  agents  which  had  better  be  avoided.  When 
vigorous  emesis  fails  of  the  desired  purpose,  a  warm  bath  or  alternate  hot  and 
cold    douches  may  be  resorted  to,  and  stimulants  given  by  the  mouth  and 


912    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

hypoderraaticallj.  In  all  cases  in  which  the  strength  of  the  child  is  gi*eatly 
affected  it  is  necessaiy  to  change  the  position  from  time  to  time,  so  that  h^^po- 
static  congestion  may  be  avoided. 

Fever  in  catai-rhal  pneumonia  does  not  usually  call  for  active  treatment, 
from  the  fact  that  the  p^a-exia  is  not  constantly  maintained  at  a  high  point, 
but  such  is  not  always  the  case.  In  the  very  early  stages  a  few  doses  of  the 
tincture  of  aconite,  a  half  or  one  drop  repeated  every  hour  or  two,  are  of  dis- 
tinct value ;  and  in  the  later  stages  small  doses  of  antipyrin  or  phenacetin 
exert  a  powerful  influence  on  pyrexia.  The  use  of  either  aconite  or  more 
active  antipyretics  must  always  be  most  cautious,  and  the  first  indication  of 
general  depression  would  call  for  the  immediate  withdrawal  of  the  medicines. 
Unquestionably  the  use  of  hydrotherapic  measures  is  most  valuable  in  controlling 
fever,  in  stimulating  the  general  and  respiratory  tone,  and  in  quieting  the 
nervous  system.  The  patient  may  be  carefully  sponged  with  lukewarm  or 
cold  water  or  wrapped  in  sheets  wrung  out  in  water,  or  he  may  be  placed  in  a 
bath  of  temperature  varying  according  to  the  age.  With  very  young  children 
the  temperature  of  the  water  should  be  near  that  of  the  body,  and  gradually 
cooled  after  the  patient  has  been  placed  in  it ;  in  older  children  the  initial  tem- 
perature may  be  85°  or  80°.  After  removal  from  the  bath  the  skin  should  be 
lightly  dried  with  a  towel  or  woollen  cloth  and  the  patient  wrapped  in  a  blanket. 

Excessive  nervous  symptoms  are  to  a  large  extent  controlled  by  sponging 
or  bathing,  but  in  cases  where  this  is  inadequate  small  doses  of  chloral  may 
be  given  in  enemata,  or  asafoetida  in  5  grain  doses,  may  be  added  to  the  quinine 
suppositories. 

In  more  chronic  cases  the  general  health  and  the  respiratory  action  should 
be  maintained  by  the  closest  attention  to  daily  life  and  by  administration  of 
suitable  tonics. 

During  convalescence  of  acute  cases  renewed  exposure  must  be  avoided, 
and  the  child  should  receive  cod-liver  oil,  arsenic,  iodide  of  iron,  or  other 
tonics ;  and,  if  possible,  a  change  of  climate  is  of  material  advantage. 


CROUPOUS  PNEUMONIA, 

By  WILLIAM  PEPPER,  M.  D., 

Philadelphia. 


Croupous  Pneumonia — designated  also  lobar  pneumonia  and  fibrinous 
pneumonia — is  a  specific  inflammatory  disease  of  the  lungs,  characterized  by 
fibrinous  exudation  into  the  vesicular  structure  and  consolidation  of  the  lung, 
presenting  a  characteristic  clinical  course  and  terminating  by  self-limitation  in 
seven  to  ten  days.  The  croupous  pneumonia  of  children  differs  from  that  of 
adults  only  in  some  of  the  less  important  manifestations,  in  the  situation  of  the 
lesion,  and  in  the  smaller  mortality. 

Etiolog-y. — One  of  the  most  important  causes  of  croupous  pneumonia  is 
exposure  to  cold.  The  history  of  a  large  majority  of  the  cases  will  disclose 
the  fact  that  the  child  has  sufi'ered  chill  from  exposure,  and  the  study  of 
mortality  statistics  shows  that  two-thirds  of  all  cases  occur  during  the  winter 
and  spring.  Cold  cannot,  however,  in  the  light  of  recent  knowledge,  be  looked 
upon  as  the  exciting  cause  of  the  disease,  though  there  are  still  some  who 
maintain  that  a  small  number  of  idiopathic  cases  from  exposure  do  exist. 

Age  is  an  important  factor  in  determining  the  form  of  pneumonia.  The 
croupous  variety,  though  it  does  sometimes  occur  in  infants  at  the  breast,  is 
rare  before  the  age  of  three,  and  in  children  is  most  common  between  five  and 
ten.  On  the  other  hand,  broncho-pneumonia  is  a  prevalent  disease  in  chil- 
dren under  three  or  two,  its  frequency  being  explained  by  the  great  tendency 
to  catarrhal  processes  manifested  in  young  children. 

The  previous  health  of  the  child  is  another  point  in  Avhich  the  croupous 
form  differs  from  broncho-pneumonia.  Unlike  the  latter,  it  affects  children 
who  are  robust  and  in  good  health.  Rilliet  and  Barthez  said  that  in  only 
one-quarter  of  the  cases  was  the  child  in  good  health  before,  but  this  may 
have  arisen  from  confusion  with  broncho-pneumonia,  and  in  the  statistics  of 
private  practice  of  Dr.  J.  F.  Meigs  and  myself  there  were  but  7  of  52  cases 
secondary  to  previous  diseases.  Of  the  diseases  upon  which  croupous  pneu- 
monia may  be  consequent,  pulmonary  tuberculosis,  measles,  whooping-cough, 
influenza,  and  typhoid  fever  may  be  named ;  but  in  all  of  these  in  children 
under  three  years  of  age  broncho-pneumonia  is  more  apt  to  occur  as  the  com- 
plication. 

Malhygienic  influences  may  induce  pneumonia,  either  by  causing  exposure 
or  by  reducing  the  power  of  resistance  in  some  other  manner. 

The  exciting  cause  in  a  great  majority  of  all  cases  is  the  pneumococcus  of 
Frankel.  This  lance-shaped  coccus  usually  occurs  in  pairs  as  a  diplococcus, 
and  is  surrounded  by  a  transparent  capsule.  It  has  been  found  in  a  very  large 
percentage  of  cases  of  croupous  pneumonia,  but  also  in  the  catarrhal  form,  and 
it  seems  to  bear  close  etiological  relations  also  to  cerebro-spinal  fever,  to 
middle-ear  disease,  and  to  endocarditis.  The  pneumococcus  is  a  normal  con- 
stituent of  the  saliva ;  and  it  is  held  that  after  exposure  to  cold  or  similar 

58  913 


914    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

predisposition  the  micro-organism  gains  greater  virulence  or  the  lungs  become 
less  resisting.  There  are,  however,  other  micro-organisms  which  occasionally 
seem  the  causative  agents.  Among  these  the  bacillus  of  Friedlander,  the 
bacillus  of  influenza,  the  streptococcus  pyogenes,  and  staphylococci  are  promi- 
nent. 

The  evidence  in  favor  of  contagiousness  of  pneumonia  of  both  forms  is 
fairlv  convincincr,  though  the  contao-iousness  is  slight.  I  have  seen  a  local 
epidemic  in  a  children's  hospital  in  which  the  disease  crept  from  bed  to  bed 
around  the  ward,  and  similar  instances  are  common  in  the  recent  literature  of 
the  disease. 

Morbid  Anatomy. — The  stages  in  the  morbid  anatomy  are  exactly  the 
same  as  in  the  adult,  but  more  frequently  there  is  a  coexistence  of  the  several 
stages  in  the  child,  so  that  when  one  part  of  the  lung  is  newly  congested 
another  may  show  the  most  advanced  consolidation  or  beginning  resolution. 
The  stages  are  those  of  congestion,  consolidation,  red  and  gray,  and  resolution. 
Durinor  the  first  stage  the  lung  is  swollen  and  red,  and  the  surfiice  of  a  section 
is  smooth  and  moist.  The  fluid  which  flows  from  the  cut  surface  contains  air 
and  is  bloody.  In  the  stage  of  consolidation  the  lung  becomes  solid  or  hepa- 
tized ;  it  is  friable,  so  that  the  finger  easily  tears  through  it,  and  the  surface 
is  granular  and  dry.  The  granular  appearance  is  due  to  the  fibrinous  exudate 
which  fills  up  the  air-vesicles  and  smaller  bronchioles.  Microscopicalb/,  the 
vesicles  are  seen  to  contain  a  fibrin  network  enclosing  leucocytes,  red  corpuscles, 
and  a  few  desquamated  cells  of  the  lining  membrane  of  the  vesicle ;  and  the 
blood-vessels  of  the  intervesicular  septa  are  over-full.  In  the  first  stage  of 
consolidation,  that  of  red  hepatization,  the  number  of  red  corpuscles  is  very 
great,  but  in  the  stage  of  gray  hepatization  they  have  largely  been  removed. 
During  resolution  the  exudate  rapidly  undergoes  softening  and  is  expectorated 
or  absorbed. 

More  rarely,  termination  in  abscess-formation  or  gangrene  results,  or 
chronic  pneumonia  may  follow  as  a  sequel. 

As  in  adults,  croupous  pneumonia  of  children  is  a  lobar  process,  but  it  is 
far  more  frequently  a  bilateral  disease  in  children.  The  lobe  most  frequently 
affected  is  the  lower  lobe  of  the  right  lung,  as  in  adults.  Apex  pneumonia, 
however,  is  as  common  a  disease  in  children  as  it  is  uncommon  in  adults,  and 
some  Avriters  claim  the  right  apex  as  the  more  frequent  seat. 

In  every  case  in  which  the  pneumonic  consolidation  reaches  the  pleural 
surface  of  the  lung  there  is  a  certain  amount  of  plastic  pleurisy.  More  rarely 
efl"usion  of  liquid  occurs,  and  I  have  seen  extensive  empyema  result.  In  some 
cases  there  is  also  a  concomitant  bronchitis.  This  condition  is  occasionally 
found  in  croupous  pneumonia  of  adults,  but  with  not  nearly  so  great  frequency 
as  in  children. 

Symptoms. — The  onset  of  croupous  pneumonia  in  children,  as  in  adults, 
is  usually  abrupt,  but  there  may  be  a  short  prodromal  period  during  which 
the  child  is  drowsy  or  restless  and  chilly,  or  coughs  slightly  and  complains 
of  pain  in  the  side.  As  a  rule,  however,  the  onset  is  decided,  a  paroxysm  of 
vomiting  or  convulsions,  with  rapid  rise  of  temperature,  at  once  calling  attention 
to  the  seriousness  of  the  malady.  Rigor  may  be  present,  but  distinct  chill,  such 
as  is  so  constantly  noted  in  adults,  is  rarely  met  with.  Instead  of  this,  con- 
vulsions and  vomiting,  especially  when  indiscretions  in  diet  have  preceded  the 
onset,  are  very  common  in  young  children.  The  temperature  rises  rapidly, 
and  in  a  few  hours  may  reach  104°  F.  It  continues  during  the  course  of  the 
disease  with  moderate  daily  remissions,  and  declines  at  its  termination  by 
rapid  crisis.     More  rarely  decided  remissions  and  gradual  decline  may  mark 


CROUPOUS  rNEU3IONIA. 


915 


the  case.  With  the  rise  of  temperature  great  rapidity  of  pulse  is  noted,  but 
even  greater  relative  rapidity  of  the  respirations,  and  in  bad  cases  dyspnoea 
is  a  most  urgent  symptom.  The  child  lies  on  the  affected  side,  and  from  time 
to  time  is  seized  with  paroxysms  of  sharp,  short  cough.  In  young  children 
the  grimaces  and  cry  give  evidence  of  the  pain  experienced  during  coughing, 
and  older  children  complain  of  pain  in  the  side  or  abdomen.  Expectoration 
is  rarely  seen  excepting  in  children  over  seven  years,  when  it  may  occur,  and 
presents  the  characteristic  hemorrhagic  or  rusty  character  so  commonly  seen 


Fig.  1. 

DAV  OF  DISEASE 

1 

2 

s 

4 

s 

c. 

7 

% 

9 

m 

11 

If 

13 

14 

1 

m;e 

m;e 

ME 

MiE 

ME 

M   E 

mI 

I  wk 

M    E 

M 

E 

M 

E 

M 

E 

m 

^ 

M 

E 

M 

E 

TEMP 

_ 

-_ 

^ 

\ 

_ 



_ 

"" 

""^ 

~ 

~" 

^---  ~^ 

— 



1 

i 

— ' — 

5  i  1 

if, 

— 

-  — 

— 

— 

— 

— 

— 

— 

— 

— 

— 

4«&- 

^ 

S 

■'    - 

— \ — 

, 

— 

~ 

— 

~ 

~ 

~ 

- 

~ 

— 

~ 

~ 

- 

[i  i 

■40?- 

1 

^... 

1 

1 

+-- 

1-^ 
^ 

^ 

= 

= 

= 

— 

— 

— 

Zl 

— 

— 

= 



+5©^ 

-£-t^ 

— 

-4— 

-— 

-  + 

-h 

]= 

— 1— 

— 

— 

— 

— 

— 

ZI 

— ■ — 

— 

— 

1 

1»+- 

■~ 

'■^ 

■Wb- 

1 — 

T^ 

-■^ 

— ^ — 

— 1 

— 

— 

— 

— 

— 

^5i^ 

-:■<?- 

— 



E 

— 



y 

=^ 

-A— 

. 

— 

\;2 

— 

— 

— 

— 

-&3- 

405- 

— 

^ 

!"■■ 

— 

rz 

-f 

-j^- 

"(T 

1 

.     t 

~ 

= 

= 

^ 

^ 

>3tH 

~U>- 

1  T 

^ 

/  - 

i 

\    \ 

; 

1       . 

~ 

— 

— 

■,t, 

-^64- 

— 

L- 

—J — 

f\ 

^V 

— 1-7 

-  L-Vn 

i^ 

-\~ 

4- 

— 

— 

— 

_ 

-«- 

~ 

— 

— P 

F^ 

-fr 

1 

-  ^— 

_L 

^ 

— — ^ 

— 

— 

n 

— 

■f?9- 

44 

— 

' — 

— 1 — 

1 

— |— 1 

vP 

s 

- 

— 1 — 

' 

-    -T-^. 

— 

/ 

V^ — 

— 

— 1 

— 

— 

— 

4«8- 

— 

_ 

J 

— I— 

4^ 

%. 

JU 

,     .     ,- 

|i_ 

V 







_ 



1- 





= 

~P 

1 
i — TT 

zz 

^_ 

^- 

-rf 

— 

I 

— 

— 

'^- 

h- 

— 

— 

— 

1 

f — 

1 

1 

— 

— j\- 

— 

— 

-^J 

— 

— 

c 

-j-*- 

1  *. 

M^ 

1 

1 

1 

j  ^ 



t\ 

1 

1 

1 

- 

T 

— 

-  cij- 

1    ■   ■•' 

} 

1 

7*^ 

-¥^ 

/ 

/ 

5 

1 

^ 

' — 

— 

--c-r-^ 

f 

w 

:-« 

1 

-• 

■■ 

44H- 



1 

i^ 

■ 

— 

— 

' — 

— 

— 

-{*$- 

1 

T 

c 

— 

- 









^ 

j 



-90- 

C.0 



IZI 

Ij 

, 

~ 

zz 

H 

— 

— ^ 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

-J 

iW- 

~ 

J 

t 

— 



— 

— 

— 

-^ 

— 

— 

— 

- 

— 

— 

— 

— 

— 

-SO- 

= 

= 

= 

= 

= 

= 

^ 

= 

= 

- 

= 

= 

— 

f 

— 

= 

= 

= 

= 

— 

—25- 

-99- 

^ 

~ 

= 

E 

~ 

= 

= 

■ 

— 

— 

— 

^ 

b: 

— 

— 

— 

— 

— 

liNT 

^ 

^ 

~~ 

""■ 

"" 

■»■ 

■  — 

— 

— 

— 

— 

— 

? 

— 

^ 

— 

-ht- 

■9tt- 

— 

— 

— 

— 

— 

— 

1 

— 

— 

— 

— 

— 

^ 

— 

— 

— 

^6- 

^ 

n 

H5(>- 

-44- 

— 1. 

— 























-49- 

■B^ 

— 

— 

— 

~ 

— 



~- 

— 

— 

— 

— 

— 

— 

— 

— 

— 

^ 

^4»- 

■ 

— 

— 

— 

— 

— 





— 

— 

— 

— 

— 

— 

— 

— 

— 

— 



r_^ 

— 

























-^^^ 

1 

ZI 

— 

— 

— 

— 

-  |- 





— 

— 

— 

— 

— 

— 

— 

— 

-T-l 

Chart  of  Temperature  (rectal),  Pulse, 
of  the  left  lung  in  a 


and  Respiration  in 
patient  three  years 


Croupous  Pneumonia  of  the  apex 
old ;  recoTerv. 


in  the  pneumonia  of  adults.  The  child  may  be  restless  and  irritable,  and 
insist  upon  being  constantly  changed  from  the  nurse's  arms  to  the  bed ;  but 
when  the  disease  is  most  severe  and  dyspnoea  is  marked,  complete  apathy  is  apt 
to  be  developed.  The  face  is  flushed,  and  particularly  a  bright  red  spot  may 
be  seen  on  the  cheek  or  region  of  the  zygoma  of  one'^or  both  sides  ;  the  alge 
of  the  nose  dilate  Avith  each  inspiratory  effort ;  herpes  is  often  seen  upon  the 
lips.  ^  The  tongue  is  coated,  the  appetite  is  lost,  and  in  certain  cases  vomiting 
and  diarrhoea  may  persist  throughout  the  disease.  Ordinarily  in  mild  cases, 
when  convulsions  or  delirium  have  been  present  at  the  onset,  they  rapidly  dis- 


916    A3fEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

appear  with  full  development  of  the  disease,  but  in  severe  cases  nervous  symp- 
toms may  take  a  prominent  place  throughout  the  case,  and  in  some  malignant 
forms  death  may  occur  in  convulsion  before  the  appearance  of  the  ordinary 
symptoms  of  the  disease. 

In  bad  cases  as  the  disease  nears  a  fatal  termination  the  respiratory  efforts 
become  more  and  more  rapid  and  irregular ;  the  pulse  becomes  more  rapid 
and  weak ;  duskiness  or  cyanosis  may  develop,  with  increasing  drowsiness  and 
stupor,  and  the  child  may  die  convulsed  or  comatose.  In  favorable  cases  the 
temperature  rapidly  declines  about  the  seventh  to  the  tenth  day,  and  during 
the  early  days  of  convalescence  remains  subnormal.  Coincidently  with  the 
decline  of  temperature  the  dyspnoea  becomes  less  urgent,  the  pulse  gains  in 
force,  the  nervous  symptoms,  if  marked,  soon  disappear,  and  convalescence  pro- 
ceeds. Sometimes,  however,  convalescence  is  rendered  tedious  by  diarrhoea  or 
stomatitis  or  by  tendency  to  slight  recrudescences  of  the  fever. 

Varieties. — Though,  as  a  rule,  the  symptoms  in  croupous  pneumonia  have 
a  typical  and  regular  course,  there  are  occasional  cases  in  which  the  manifes- 
tations are  so  irregular  as  to  warrant  the  description  of  certain  clinical  varie- 
ties :  (1)  Cerebral  pneumonia  is  a  type  in  Avhich  from  the  onset  excessive 
pyrexia  and  nervous  symptoms,  such  as  delirium,  convulsions,  or  coma,  so 
dominate  the  case  that  the  underlying  disease  might  readily  be  overlooked,  and 
the  existence  of  meningitis  be  suspected,  especially  as  cough  and  other  pul- 
monary indications  may  be  wholly  absent.  Such  cases  are  most  frequently 
observed  in  children  debilitated  by  previous  disease,  and  very  often  the  pneu- 
monic changes  affect  the  apex  of  the  lung.  The  relation  of  apical  involve- 
ment to  severity  of  nervous  symptoms  has,  however,  been  greatly  exaggerated. 
(2)  Abdominal  pneumonia  is  a  less  common  variety,  in  which  vomiting  and 
diarrhoea,  with  marked  abdominal  pain,  are  prominent  symptoms.  In  some 
cases  these  may  be  so  decided  as  to  indicate  the  existence  of  gastro-enteritis, 
or,  when  pain  and  abdominal  distention  are  excessive,  of  acute  peritonitis. 
In  a  small  number  of  cases,  especially  of  basal  pneumonia  of  the  right  side, 
jaundice  is  noted,  and  to  such  the  term  "bilious  pneumonia"  has  been 
applied.  (3)  Wandering  pneumonia,  or  j^neumonia  migrans,  bears  so  close 
a  similarity  to  broncho-pneumonia  that  the  distinction  requires  the  greatest 
care.  The  disease  affects  one  portion  of  the  lung  after  another,  and  gives  to 
the  case  an  irregular  and  lingering  nature  quite  unusual  in  the  croupous  form 
of  pneumonia.  By  the  completion  of  the  disease  consolidation  may  have  been 
present  in  every  part  of  the  lung,  but  the  consolidation  is  usually  not  well 
marked. 

Physical  Signs. — The  physical  signs  are  often  less  distinctive  than  in 
adults,  and  it  is  especially  to  be  remembered  that  the  apex  is  almost  as  fre- 
quently the  seat  of  the  disease  as  the  base,  and  that  bilateral  pneumonia  is 
a  much  commoner  condition  in  young  children  than  in  adults.  In  a  typical 
case,  however,  the  signs  are  quite  decided.  The  respiratory  expansion  is  often 
seen  to  be  lessened  on  the  affected  side ;  percussion  and  auscultation  give  evi- 
dence of  the  consolidation  of  the  lung.  Dulness  on  percussion  is  never  so 
decided  as  in  older  persons,  and  sometimes  the  emphysematous  condition  of 
the  lung  surrounding  a  centrally  located  pneumonia  may  cause  the  percussion 
note  to  be  hyper-resonant  or  tympanitic.  In  these  cases  deep  percussion  may 
reveal  the  true  condition  of  things,  or  the  consolidation  may  subsequently 
extend  to  the  surface  of  the  lung.  On  auscultation  the  typical  crepitant  rale 
of  pneumonia  may  be  heard  in  a  minority  of  the  cases,  either  with  ordinary 
breathing  or  during  the  deep  inspiratory  efforts  after  coughing.  In  31  cases 
of  the  late  Dr.  Meigs  and  myself,  the  crepitant  rale  was   heard  in  but  10. 


CBOUPOUS  PNEUMONIA.  917 

Subsequently,  when  consolidation  is  complete,  the  breath-sounds  become 
decidedly  bronchial,  as  we  found  in  46  of  57  cases ;  and  the  vocal  resonance 
and  fi'emitus  may  be  found  increased  over  the  aifected  areas.  The  latter,  how- 
ever, are  untrustworthy  signs  and  difficult  to  determine.  In  children  under 
five  or  six  it  is  not  unusual  to  find  evidences  of  bronchitis  in  addition  to  the 
signs  of  consolidation,  and  coarse  moist  rales  may  persist  throughout  the  case. 
In  any  case  moist  rales  become  prominent  during  resolution  and  give  evidence 
of  the  softening  of  the  exudate. 

The  physical  signs  are  subject  to  wide  variations  in  certain  atypical  cases. 
Thus  the  existence  of  a  large  pleuritic  exudate  of  plastic  nature  would  render 
the  dulness  decided,  without  altering  the  breath-sounds  otherwise  than  by 
muffling  them  to  a  greater  or  less  extent.  In  the  rare  cases  in  which  liquid 
eifusion  occurs  this  condition  becomes  still  more  marked,  and  the  auscultatory 
signs  may  be  completely  obscured.  Wandering  pneumonia  is  apt  to  be  pecu- 
liar, not  only  in  its  migratory  character,  but  also  in  the  incompleteness  of  the 
consolidation,  so  that  but  a  small  area  of  dulness  may  be  detected. 

Complications  and  Sequels. — Pleurisy  is  a  constant  accompaniment  of 
pneumonia  which  reaches  the  surface  of  the  lung,  but  is  usually  of  no  great 
severity.  Effusion  may,  however,  supervene,  and  in  the  pneumonias  of  measles, 
scarlet  fever,  and  typhoid  fever,  purulent  efi"usion  is  occasionally  met  with. 
Pericarditis  may  also  occur,  either  alone  or  following  the  pleuritic  complication. 
The  excessive  nervous  symptoms  of  cerebral  pneumonia  frequently  create  the 
suspicion  of  meningitis,  but  this  does  not  actually  occur  so  frequently  as  the 
symptoms  would  indicate.  In  such  cases  also  hyperpyrexia  becomes  so  decided 
as  to  amount  to  a  complication.  The  occurrence  of  jaundice  has  been  alluded 
to  in  the  reference  to  abdominal  pneumonia.  Xephritis  is  a  complication  met 
with  in  a  certain  proportion  of  cases,  and  one  which  materially  increases  the 
gravity  of  the  disease.  It  is  much  commoner  in  the  pneumonia  of  children 
than  in  that  of  adults.  Abscess  and  gangrene  of  the  lung  are  rare  sequels, 
as  is  also  chronic  indu^'ative  pneumonia. 

Diagnosis. — The  sudden  onset  of  pneumonia  with  vomiting  and  convulsion 
and  high  fever  simulates  very  closely  the  onset  of  scarlatina.  The  distinction 
is,  however,  rarely  difficult  if  the  excessive  rapidity  of  the  pulse,  the  soreness 
of  the  throat,  and  the  early  appearance  of  a  rash  in  scarlet  fever  be  kept  in 
mind,  and  the  physical  examination  for  the  signs  of  pneumonia  be  carefully 
applied. 

When  the  disease  is  fully  developed  it  may  be  extremely  difficult  to  dis- 
tinguish it  from  broncho-pneumonia,  especially  from  cases  of  the  latter  which 
become  lobar  by  confluence.  On  the  other  hand,  a  wandering  type  of  croup- 
ous pneumonia  with  imperfectly  developed  consolidation  may  simulate  an  ordi- 
nary form  of  broncho-pneumonia,  but  the  diagnosis  is  sufficiently  detailed  in 
the  description  of  that  disease.  Acute  meningitis  is  often  suspected  when 
profound  nervous  symptoms  make  their  appearance,  and  indeed  the  latter  may 
obscure  the  underlying  pneumonia.  In  such  cases  only  a  careful  physical 
examination  will  reveal  the  existence  of  pneumonia ;  and.  as  for  a  complicat- 
ing meningitis,  it  must  be  remembered  that  such  is  far  less  common  than 
we  might  suppose  from  the  symptoms.  The  abdominal  type  of  pneumonia  is 
sometimes  mistaken  for  gastro-enteritis,  peritonitis,  or  even  acute  ileus,  and  is 
only  recognized  by  careful  study  of  the  breathing  of  the  patient  and  by  the 
physical  signs. 

Pleurisy  with  effusion  is  distinguished  by  the  decidedly  dull  or  flat  percus- 
sion note  and  the  movable  character  of  this  dulness  ;  by  the  absence  of  breath- 
sounds,  rales,  and  vocal  fremitus ;   and  by  the  milder  character  of  the  symp- 


918    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

toms.  At  its  onset  pain  is  more  severe  than  in  pneumonia,  but  fever  and  the 
general  depression  of  the  child  are  decidedly  less  marked. 

Prognosis. — Primary  croupous  pneumonia  of  young  children  is  a  disease 
of  little  gravity  compared  with  the  same  disease  in  adults  or  with  broncho- 
pneumonia of  children.  Of  60  cases,  nearly  one-half  of  them  under  two 
years,  Baginski  lost  but  4.  In  secondary  cases,  however,  the  prognosis  is 
much  more  grave,  and  in  those  dependent  upon  primary  septic  diseases  the 
mortality  is  very  high.  As  a  rule,  marked  dyspnoea,  high  fever,  and  pro- 
nounced nervous  symptoms  are  indications  of  evil  omen  ;  but  common  experience 
has  shown  that  in  this  disease,  of  all  others,  a  favorable  termination  may  fol- 
low the  most  desperate  case.  Complications,  such  as  pleurisy  or  pericarditis 
and  extensive  involvement  of  one  or  both  lungs,  naturally  make  prognosis 
more  unfavorable. 

It  is  to  be  remembered  also  that  croupous  pneumonia  tends  to  relapse,  and 
that  second  attacks  at  remote  periods  are  not  unusual. 

Treatment. — The  seriousness  of  the  disease  requires  that  the  patient  be 
at  once  placed  at  rest  in  bed.  The  room  should  be  kept  at  an  even  tempera- 
ture of  about  68°  to  70°,  and  drafts  must  be  carefully  avoided.  It  is  always 
well  to  protect  the  chest  by  a  jacket  made  of  cotton  batting  lightly  quilted. 
The  food  must  be  light,  but  nutritious  ;  broths,  junket,  and  milk,  as  a  rule, 
prove  most  acceptable.  Sufficient  water  should  be  permitted  to  relieve  thirst. 
The  medicinal  treatment  need  not  generally  be  a  vigorous  one,  care  being  taken, 
however,  that  the  strength  of  the  patient  be  properly  maintained.  In  the  early 
stajjes  small  doses  of  tincture  of  aconite  in  combination  with  the  solution  of 
ammonium  acetate  or  with  sweet  spirits  of  nitre  serve  to  control  the  tempera- 
ture and  to  quiet  excessive  action  of  the  heart.  If,  however,  fever  becomes 
more  decided,  aconite  will  prove  inadequate,  and  recourse  to  stronger  antipyretics 
may  be  necessary ;  but  hydrotherapic  measures  are  more  efficient.  Sponging 
with  cool  water  and  the  cold  pack  or  bath  are  the  safest  and  surest  means  of 
controlling  temperature,  and  when  carefully  used  give  rise  to  no  unpleasant 
consequences.  The  prejudices  on  the  part  of  parents  may,  however,  prevent 
their  use,  in  which  case  small  doses  of  antipyrin  or  phenacetin  become  neces- 
sary. When  cough  and  pain  in  the  side  are  troublesome  symptoms,  opium  may 
be  given  in  quantity  sufficient  to  allay  the  irritation,  guarding  carefully,  how- 
ever, against  excessive  opiate  effect.  In  severe  cases,  where  general  depres- 
sion and  cardiac  weakness  are  marked,  recourse  must  be  had  to  stimulating 
remedies.  Brandy  or  whiskey  may  be  used  in  liberal  quantity,  and  carbonate 
of  ammonium  is  useful  in  cases  in  which  the  cough  is  tight  and  irritating. 
For  the  support  of  the  heart  digitalis  is  unquestionably  the  most  reliable 
remedy,  though  care  must  be  taken  lest  it  prove  disturbing  to  the  stomach. 
In  cases  of  extensive  or  double  pneumonia,  in  which  the  strength  of  the  child 
is  profoundly  affected  and  the  heart  and  respiration  losing  force,  stimulation 
must  be  pushed  to  the  utmost.  In  such  cases  the  hypodermatic  administration 
of  strychnine  and  of  such  diffusible  stimulants  as  ether  and  aromatic  spirits 
of  ammonium  may  help  to  carry  the  child  over  the  crisis,  and  the  inhalation 
of  compressed  air  or  oxygen  may  prove  of  signal  service.  Throughout  the 
disease  the  general  systemic  tone  is  well  maintained  b}'^  the  use  of  quinine  in 
suppositories,  to  which  asafcetida  may  be  added  in  case  nervous  symptoms 
become  pronounced.  If  asafoetida  does  not  suffice,  chloral  by  enema  may  be 
tried,  and  usually  exercises  the  happiest  control. 

Of  late  the  use  of  serum  from  the  blood  of  convalescent  patients  has  been 
advocated,  and  has  seemed  to  effect  a  crisis  in  some  cases,  but  the  time  is  not 
yet  ripe  for  a  definite  expression  on  the  value  of  such  treatment. 


GANGRENE  AND  ABSCESS  OF  THE  LUNG. 


By  henry  JACKSON,  M.  D., 

Boston. 


I.  Gangrene  op  the  Lung. 

Gangrene  of  the  Lung  is  a  necrosis  of  the  pulmonary  tissue,  with 
decomposition  of  the  affected  portion,  due  to  the  invasion  of  the  tissue  by  the 
bacteria  of  putrefaction. 

It  is  important  to  remember  that  gangrene  may  be  closely  simulated  by  a 
post-mortem  putrefactive  softening  of  the  lung,  due  to  the  action  of  the  con- 
tents of  the  stomach.  These  spots  may  be  multiple,  are  dark-greenish  or 
black  in  color,  and  have  a  sour  smell.  This  process  is  identical  with  the  post- 
mortem softening  so  often  found  in  the  stomach  and  oesophagus.  There  is 
rarely  found  a  necrosis  of  the  lung-tissue  without  putrefaction ;  this  form 
usually  occurs  in  small  patches.  The  tissue  is  reddish-brown  in  color  and  easily 
torn,  but  there  is  no  odor,  as  in  true  gangrene  of  the  lung.  It  is  usually  found 
in  patients  suffering  from  diabetes,  and,  so  far  as  I  know,  it  has  not  been  met 
with  in  children. 

Etiology. — Gangrene  of  the  lung  is  not  met  with  as  a  primary  disease, 
but  is  always  secondary  to  some  other  pathological  condition.  It  is  found  in 
two  classes  of  cases  essentially  different :  First,  gangrene  may  result  from  a 
lobar  pneumonia ;  this  occurs  only  in  individuals  whose  general  health  has 
been  seriously  affected,  and  is  especially  common  in  drunkards.  On  account 
of  the  impairment  of  the  circulation,  either  from  local  disease  of  the  arteries 
or  from  extreme  weakness  of  the  heart,  the  inflammatory  exudation  is  not 
absorbed ;  it  becomes  foul  from  the  entrance  of  the  bacteria  of  putrefaction, 
and  gangrene  ensues.  This  form  of  gangrene  is  rare  in  children.  On  the 
other  hand,  gangrene  may  be  the  result  of  wounds  of  the  lung  or  may  follow 
severe  contusion  of  the  chest ;  in  the  latter  instance,  as  Orth  says,  the  process 
probably  results  from  the  decomposition  of  unabsorbed  blood.  Another  class 
of  cases  is  found  where  the  gangrene  is  the  direct  result  of  inoculation  from 
putrefactive  processes  situated  at  a  distance  from  the  lung,  which  is  infected  by 
septic  emboli  through  the  blood-current,  or  from  the  aspiration  of  foul  secre- 
tions from  bronchiectatic  cavities  or  gangrenous  ulceration  in  the  mouth  and 
naso-pharynx. 

Gangrene  of  the  lung  in  children  is  usually  met  with  in  those  of  a  vv^eak 
constitution,  with  poor  circulation,  where  some  local  cause  can  be  found  as  the 
origin  of  the  septic  process.  It  is  rarely  met  with  except  as  an  intercurrent 
disease.  In  16  cases  treated  by  Barthez  and  Rilliet  the  gangrene  was  asso- 
ciated as  a  complication  with  the  following  diseases :  Measles,  3  cases ;  small- 
pox, scarlet  fever,  intestinal  catarrh,  tuberculosis,  each  1  case ;  pulmonary  and 
general  tuberculosis,  3  cases  ;  intestinal  catarrh,  with  collapse,  2  cases  ;  menin- 
gitis, typhoid  fever,  bronchitis,  and  pleuro-pneumonia,  each  1  case. 

919 


920  A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

A  very  considerable  number  of  the  cases  of  gangrene  in  children  are  asso- 
ciated Avith  acute  septic  processes  in  the  middle  ear  or  foul  ulcerations  in  the 
mouth  or  naso-pbarynx.  Several  cases  have  been  reported  where  gangrene  of 
the  lung  has  followed  the  inspiration  of  some  foreign  body.  It  is  especially 
notcAvorthy  that  recovery  appears  to  be  the  rule  in  such  cases  even  after 
extensive  destruction  of  the  lung-tissue  has  occurred,  as  evidenced  by  the 
expectoration  of  large  masses  of  foul  pus  and  the  demonstration  of  cavities 
by  physical  examination.  Small  patches  of  gangrene  are  not  infrequently 
found  in  lungs  Avhich  contain  tuberculous  cavities,  the  gangrene  being  de- 
pendent upon  the  aspiration  of  bits  of  putrid  material  from  these  cavities. 
Again,  it  is  not  an  unusual  accompaniment  of  chronic  bronchitis  with  cavity- 
formation.  The  only  case  of  gangrene  in  a  young  individual  which  has  come 
under  my  observation  was  of  this  character.  A  young  girl  of  eighteen  pre- 
sented herself  at  my  clinic  with  the  history  of  cough  for  several  years ;  she 
was  never  strong.  For  many  months  the  cough  had  been  paroxysmal  in 
character,  and  accompanied  by  the  expectoration  of  large  masses  of  fetid 
sputum.  After  moderate  cough  she  raised  at  once  several  ounces  of  greenish 
fetid  pus ;  the  sputum  contained  man}^  bacteria,  but  no  bacilli  of  tuberculosis. 
Physical  examination  showed  a  pale,  thin  girl ;  chest  long  and  narrow,  shoulders 
rounded.  No  dulness  on  percussion  ;  throughout  both  lungs  numerous  coarse, 
moist  rales.  The  breath  w^as  fetid.  This  case  was  apparently  one  of  chronic 
bronchitis  Avith  large  bronchiectatic  cavities,  as  shoAvn  by  the  sudden  expecto- 
ration of  large  masses  of  sputum. 

In  the  autopsy  records  of  the  Boston  City  Hospital  I  do  not  find  a  case  of 
gangrene  of  the  lung  in  a  child,  though  the  hospital  receives  quite  a  large  num- 
ber of  children  among  its  patients.  I  find  thirteen  cases  of  gangrene  of  the 
lung,  and  the  list  fairly  covers  the  varying  conditions  in  which  gangrene  may 
occur:  Four  cases  of  acute  fibrinous  pneumonia  Avith  gangrene :  1st.  A  drunkard 
aged  fifty-four,  Avith  delirium  tremens  and  pneumonia  of  both  upper  lobes; 
2d.  A  AAoman  aged  thirty-five,  acute  abscess  in  peritoneal  cavity  and  acute 
suppurative  perihepatitis ;  3d.  A  Avoman  aged  tAventy-eight,  much  reduced  by 
chronic  empyema  of  eight  months'  duration ;  4th.  A  man  of  thirty-six,  habits 
not  given,  etiology  obscure.  Three  cases  of  tuberculosis  Avith  gangrene :  1st. 
A  man  of  thirty-eight,  chronic  nephritis,  chronic  endarteritis ;  2d.  A  Avoman 
aged  seventy,  acute  broncho-pneumonia,  bed-sores,  and  fracture  of  the  thigh  ; 
3d.  A  man  aged  fifty,  putrid  bronchitis,  cough  for  many  years,  emaciated, 
recent  abscess  in  the  throat.  Tavo  cases  associated  Avith  surgical  operations  : 
1st.  A  man  aged  forty-five,  drunkard,  syphilis,  stricture  of  long  standing,  with 
urethral  tears ;  2d.  Old  man,  operated  upon  for  cancer  of  the  tongue,  inha- 
lation pneumonia,  and  gangrene  of  the  lung,  Avith  gangrenous  pyo-pneumothorax. 
Two  cases  of  injury  to  the  head,  Avith  inhalation  pneumonia,  both  old.  One 
case  of  typhoid  fever  in  a  drunkard,  Avith  broncho-pneumonia.  One  case,  a  man 
aged  tAventy-seven,  who  had  a  gangrenous  abscess  of  the  lung  and  gangrenous 
pleurisy.  These  cases  are  collected  from  a  large  number  of  autopsies  Avhich 
include  many  cases  of  tuberculosis  of  the  lungs  and  pneumonia.  The  only 
case  in  Avhich  there  Avas  not  some  previous  local  or  constitutional  disease  ex- 
planatory of  the  gangrene  is  the  last  one  mentioned. 

Gangrene  of  the  lung  is,  at  any  age,  a  rare  disease,  and,  except  in  a  fcAV 
cases  AA'here  it  follows  acute  pneumonia,  is  usually  met  Avith  in  individuals  of 
weak  constitution  in  Avhom  some  septic  process  oifers  a  point  of  origin  for  septic 
emboli  Avhich  may  be  carried  to  the  lung.  It  is  interesting  to  study  the  autop- 
sies made  on  cases  of  diphtheria  at  the  Boston  City  Hospital  as  bearing  upon 
the  etiology  of  gangrene.     In  26  cases  in  a  continuous  series,  19,  or  73  per 


GANGRENE   AND    ABSCESS    OF   THE   L  UNG.  921 

cent.,  had  some  aiFection  of  the  lungs :  of  these  cases,  14,  or  50  per  cent.,  had 
acute  catarrhal  pneumonia ;  5  had  atelectasis.  One  of  the  cases  of  atelectasis 
had  also  a  small  abscess.  None  of  these  19  cases  presented  evidence  of  gan- 
grene of  the  lungs.  As  all  these  cases  of  pneumonia  occurred  in  individuals 
with  a  serious  local  septic  condition,  it  is  evident  that  gangrene  of  the  lung  is 
rare,  even  in  septic  cases,  unless  the  resistant  power  of  the  pulmonary  tissue  is 
impaired  by  a  previously-existent  general  feebleness  of  the  individual.  In  other 
words,  the  pulmonary  circulation  is  so  favorable  that  an  acute  inflammatory 
process  does  not  tend  to  become  gangrenous  simply  because  the  immediately 
exciting  cause  of  the  inflammation  is  a  septic  material. 

A  few  cases  of  D-ang-rene  of  the  lunsr  have  been  observed  in  which  careful 
examination  failed  to  elicit  any  reasonable  explanation  of  the  etiology.  Such 
a  case  is  reported  by  Holt.  A  child  three  years  of  age,  who  had  not  been 
sick  except  for  an  attack  of  bronchitis  two  years  before,  was  suddenly  taken 
ill ;  the  disease  ran  its  course  with  signs  of  acute  pneumonia  and  bronchitis ; 
death  in  two  weeks.  Autopsy  showed  right-sided  pleurisy  with  gangrene  of 
two-thirds  of  the  rio-ht  lower  lobe. 

Pathology. — Gangrene  of  the  lung  may  be  met  with  as  a  diff"used  or  a 
circumscribed  process.  The  circumscribed  form  occurs  more  frequently  in 
children ;  small  patches  are  found  scattered  through  the  lungs ;  they  are 
greenish  or  black  in  color,  the  tissue  is  softened,  easily  broken  down,  and  has 
a  most  intensely  fetid  odor.  Surrounding  the  patches  of  gangrene  there  is 
usually  an  area  of  acute  inflammation,  comparable  to  the  line  of  demarcation 
Avhich  surrounds  a  slough.  It  is  usual  to  find,  in  one  or  more  of  these  areas 
of  gangrene,  cavities  which  contain  a  foul,  dirty  material  composed  of  broken- 
down  lung-tissue,  while  the  walls  of  the  cavities  themselves  are  shreddy. 
When  the  primary  lesion  is  in  the  upper  part  of  the  lung,  numerous  areas 
of  gangrene  are  found  in  the  lower  lobes,  due  to  the  inspiration  of  small 
bits  of  necrotic  tissue.  Microscopical  examination  of  the  contents  of  such 
gangrenous  areas  shows  the  presence  of  bits  of  elastic  tissue  of  the  lung, 
numerous  cells  exhibiting  fatty  degeneration,  and  immense  numbers  of  bac- 
teria of  many  kinds ;  fat-crystals  and  globules  of  free  fat  are  also  met  with  in 
abundance.  No  specific  bacteria  have  been  found  in  cases  of  gangrene  of  the 
lung ;  the  bacteria  belong  to  the  various  species  which  are  the  etiological 
factors  in  ordinary  putrefactive  processes.  Streng  describes  two  cases  of 
gangrene  of  the  lung  in  which  he  found  infusoria.  The  infusoria  were  cells 
about  the  size  of  a  white  blood-globule  :  they  had  cilia  and  were  capable  of 
active  motion. 

When  the  gangrenous  area,  in  its  extension,  reaches  the  pleural  surface, 
there  results  a  gangrenous  pleurisy,  which  may  become  encapsulated  by  the 
formation  of  adhesions.  This  formation  of  an  encapsulated  pleurisy  gives  at 
times  an  impca'tant  hint  for  treatment,  making  it  possible  in  suitable  cases  to 
open  the  lung  by  free  incision  and  drain  a  gangrenous  cavity  without  causing 
a  general  pleurisy.  It  is  not  unusual  that  during  the  progress  of  the  disease 
small  blood-vessels  are  eroded,  thus  crivins;  rise  to  haemorrhage  of  srreater  or 
less  severity. 

Symptoms. — In  many  cases  the  symptoms  of  the  gangrene  are  masked  by 
the  more  prominent  symptoms  of  the  primary  disease,  and  the  gangrene  is  only 
discovered  at  autopsy :  this  is  especially  true  of  children,  in  whom  expecto- 
ration is  rare.  Loss  of  flesh  and  strength  is  rapid ;  the  complexion  is  pale, 
gray  ;  sweating  is  a  prominent  sign.  The  temperature  is  irregular,  much  more 
intermittent  than  in  pneumonia:  the  course  of  the  temperature  may  be  an  im- 
portant guide  in  the  difl"erential  diagnosis  between  an  acute  pneumonia  and  a 


922  AJIBBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

diffused  gangrenous  affection  of  a  large  part  of  the  lung,  where  the  physical 
signs  point  to  consolidation  of  a  large  area  of  lung-tissue.  The  pulse  is  rapid 
and  feeble.  Physical  examination  yields  varying  results  according  to  the  area 
of  the  diseased  tissue :  Ave  may  find  only  the  evidence  of  a  bronchitis,  but  if 

Fig.  1. 


ve: 

ME  me:me1me;me:|me: 

ME 

ME  ME 

ME 

JME.ME 

ME 

M  EtVlE 

m'eI 

F 

I07O 

loeo 

loa  c 

104  0 
103  <^ 
103° 
JOIO 
100° 
090 

08  c 
07° 

PuJj.. 

1 

1 

: 

; 

] 

1 

- 

1 

1 

\ 

1 

/ 

1 

( 

1 

' 

1 

1 

H 

f 

A 

/ 

/ 

1 

/ 

( 

/ 

1 

/ 

/ 

r 

4 

f 

f 

/ 

f 

I 

1 

7 

-r 

1 

1 

1 

1 1 

V 

1 

f 

1 

\ 

1 

1 

! 

■ 

1 

1 

1 

1 

1 

2 

3 

4 

5 

e 

7 

8 

0 

10 

" 

12 

13 

14 

16 

16 

/^ 

P^ 

loo 

110 

108 

106 

lOO 

^ 

/^ 

9^ 

1.^ 

*9 

/><?■ 

<2^> 

/3t> 

/JO 

i£J 

zo 

»o 

^ 

26 

»5 

^ 

3S' 

^.' 

■30 

do' 

30 

A5 

95 

60 

60 

Temperature  Chart  of  Gangrene  of  the  Lung  following  operation 
for  cancer  of  tongue— adult  patient. 

the  area  of  gangrene  is  large  we  find  dulness  due  to  consolidation.  "Where  large 
areas  have  been  destroyed  by  the  gangrenous  process  we  may  find,  after  cough 
with  expectoration,  amphoric  respiration  and  a  high-pitched  tvmpanitic  note, 
indicating  the  presence  of  a  cavity.  The  breath  is  exceedingly  foul  and  has  a 
peculiar  fetid,  sickening  odor:  it  is  important  to  bear  in  mind  that  a  local 
gangrenous  process  in  the  mouth  may  give  rise  to  an  odor  almost  as  disagreeable 
as  that  of  gangrene  of  the  lung.  Caries  of  the  nasal  bones  with  retained  secre- 
tion, ozgena,  gives  an  odor  even  more  similar  to  that  of  gangrene  of  the  lung.  If 
there  be  expectoration,  the  sputum  is  dark  greenish-yellow  and  very  fetid :  it 
may  be  large  in  amount,  even  in  quite  young  children,  as  the  gangrene  causes 
the  formation  of  large  cavities,  which  are  usuallv  emptied  at  irregular  intervals. 
An  important  diagnostic  sign  is  haemoptysis,  Avhich  is  of  especial  value  in  chil- 
dren, since  Avith  them,  in  other  diseases,  this  symptom  is  rare.  Kohts  records 
the  case  of  a  child  of  three  years  Avho,  after  an  excision  of  the  hip-joint,  spat 
up  four  or  five  tablespoonfuls  of  blood,  and  soon  became  very  weak,  had  exceed- 
ingly foul  breath,  and  died  in  a  fcAv  Aveeks  after  the  onset  of  the  unfavorable 
symptoms. 

Prog-nosis. — The  prognosis  in  gangrene  due  to  septic  emboli  or  inhalation 
pneunionia  is  almost  necessarily  fatal.  It  is  about  equally  bad  in  gangrene 
folloAving  pneumonia,  as  it  is  only  met  with  in  children  previously  much  re- 
duced.     Several  cases  have  been  reported  of  recovery  from  gangrene  which 


GANGRENE  AND   ABSCESS    OF   THE  LUNG.  923 

had  followed  the  swallowing  of  a  foreign  bodj.  Kohts  describes  such  a  case 
which  occurred  in  his  own  practice.  A  girl  of  six  years  swallowed  a  bit  of 
bone :  eight  weeks  later  she  had  excessive  cough  with  foul  expectoration  and 
fever.  Ten  months  later  she  coughed  up  the  foreign  body,  and  finally,  after  a 
year,  was  completely  restored  to  health. 

Treatment. — The  first  indication  is  to  sustain  the  strength  by  giving  the 
greatest  possible  amount  of  food ;  stimulants  may  be  pushed  to  an  extreme 
degree.  Small  doses  of  strychnia  are  at  times  useful  in  asthenic  forms  of 
pneumonia  as  seen  in  diphtheria,  and  may  be  tried  in  gangrene.  This  drug 
acts  as  a  stimulant  to  both  the  circulation  and  respiration.  Direct  cardiac  stim- 
ulants, like  tincture  of  strophanthus  or  of  digitalis,  are  indicated  if  the  pulse 
be  weak  and  rapid.  Where  there  is  fair  reason  to  suppose  that  the  gangrene  is 
circumscribed  and  not  of  very  large  extent,  incision  of  the  lung  is  admissible : 
this  surgical  procedure  is,  however,  limited  to  cases  that  are  free  from  general 
septicaemia;  that  is,  practically,  to  cases  of  gangrene  dependent  upon  the 
swallowing  of  a  foreign  body.  If  there  be  a  pyo-pneumothorax,  free  incision 
of  the  pleural  cavity  is  always  indicated.  If  the  child  is  old  enough  to  inhale, 
sprays  of  creasote  or  turpentine  should  be  used,  as  these  modify  the  odor  of  the 
breath,  and  may  aid  in  hastening  a  curative  process. 

n.  Abscess  of  the  Lung. 

Abscess  of  the  lung,  like  gangrene,  may  be  an  occasional  sequel  of  acute  lobar 
pneumonia  in  children.  In  such  cases  physical  examination  shows  an  absence 
of  the  usual  signs  of  resolution  after  the  subsidence  of  the  fever.  There  ensues 
an  irregular  rise  and  fall  of  the  temperature,  the  pulse  becomes  rapid,  and  there 
is  a  progressive  loss  of  flesh  and  strength.  It  is  not  unusual  that  a  large 
amount  of  pus  may  be  raised  when  the  abscess  breaks  into  a  bronchus ;  after 
the  expectoration  of  such  a  quantity  of  pus  there  is  often  found  amphoric  respi- 
ration. The  abscess  often  extends  to  the  pleural  surface,  and  finally  breaks 
through  into  the  pleural  cavity.  As  the  process  is  more  chronic,  pleural  adhe- 
sions are  more  likely  to  occur  than  in  gangrene  of  the  lung ;  so  that  when  the 
abscess  breaks  we  have  an  encapsulated  pleural  abscess.  Rarely,  a  neglected 
empyema  may  break  into  the  lung  and  give  rise  to  a  pulmonary  abscess  instead 
of  forcing  its  way  outward  through  the  skin. 

The  prognosis,  in  abscess  of  the  lung,  though  serious,  is  not  so  absolutely 
unfavorable  as  in  gangrene. 

As  to  the  general  treatment,  the  same  course  may  be  followed  as  outlined  in 
gangrene.  This  condition  offers  a  better  opportunity  for  surgical  interference 
than  does  gangrene  :  we  do  not  have  the  general  septic  condition  to  contend  with. 
Before  making  a  free  incision  into  the  lung  the  diagnosis  should  be  confirmed 
by  an  aspirating  needle,  and  incision  should  be  made  at  the  point  where  the  pus 
is  withdrawn. 


BROIS^CHITIS. 

By  WALTER  S.  CHRISTOPHER,  M.  D., 

Chicago. 


Broxciiitis  is  an  inflammation  of  the  bronchial  mucous  membrane.  On 
account  of  the  great  number  of  independent  causes  capable  of  producing 
this  condition,  it  should   be  regarded  as  a  symptom    rather  than   a  disease. 

Bronchitis  may  be  classified  fi-om  several  standpoints.  With  reference  to 
the  parts  of  the  bronchial  tree  affected,  it  may  be  classified  as  large  tube,  small 
tube,  and  capillary  bronchitis.  Under  the  first  category  tracheitis  should  be 
included.  Capillary  bronchitis,  referring  to  the  inflammatory  condition  of  the 
smallest  bronchioles,  is  probably  always  associated  with  broncho-pneumonia  and 
does  not  exist  as  a  distinct  entity.  The  term,  therefore,  is  an  unfortunate  one, 
and  should  not  be  used;  indeed,  any  general  classification  of  bronchitis  with 
reference  to  the  anatomical  distribution  of  the  bronchial  tubes  is  misleading 
and  often  erroneous. 

As  to  duration,  bronchitis  is  classified  as  acute,  chronic,  and  recurrent. 
From  the  standpoint  of  origin  it  is  denominated  ^jrimary  or  idiopathic,  and 
secondary  or  symptomatic.  It  is  doubtful  if  bronchitis  ever  occurs  as  a 
primary  disorder,  an  opinion  which  Sutton  has  also  expressed,  although  it  must 
be  admitted  that  it  is  not  always  possible  to  clinically  determine  the  antece- 
dent conditions.  As  to  intensity,  it  is  convenient  to  adopt  the  division  into 
mild  and  severe  cases. 

Etiology. — The  etiological  factors  Avhich  lead  to  the  production  of  bron- 
chitis are  exceedingly  varied,  and  the  consideration  of  them  is  one  of  the  most 
important  factors  in  the  study  of  this  subject.  Much  light  is  thrown  upon  the 
nature  of  bronchitis  by  grouping  together  the  various  elements  which  go  to 
produce  the  disease  in  its  different  forms.  Bronchitis  is  a  constant  symptom 
in  most  of  the  exanthemata  and  in  some  other  of  the  acute  infectious  diseases, 
produced  no  doubt  by  a  direct  action  of  the  particular  poisons  present.  Prom- 
inent among  diseases  of  this  type  are  pertussis  and  measles.  Typhoid  fever  is 
invariably  accompanied  by  some  bronchial  catarrh,  and,  Avhile  in  the  adult  this 
symptom  is  frequently  so  slight  as  to  be  practically  unnoticed,  it  is  by  no  means 
so  in  children,  and  the  younger  the  child  the  more  important  does  the  symptom 
become.  As  seen  in  the  West,  a  disease  which  seems  to  be  typhoid  fever,  and  is 
so  admitted  by  many  practitioners,  is  characterized  by  the  great  predominance 
of  the  bronchial  symptoms;  and  there  can  be  but  little  doubt  that  some  cases  of 
so-called  idiopathic  bronchitis  in  infants,  some  of  Avhich  have  advanced  even  to 
the  stage  of  broncho-pneumonia,  are  manifestations  of  typhoid  fever.  While 
bronchitis  is  one  of  the  usual  symptoms  of  influenza,  not  infrequently  it  is  the 
most  important  and  most  striking;  particularly  is  this  true  of  infants.  During 
the  prevalence  of  influenza,  cases  of  bronchitis  are  seen  that  cannot  be  referred 
positively  to  this  infection,  but  which  probably  are  manifestations  of  it.  Rubella, 
rather  less  frequently  than  measles,  has  bronchial  catarrh  as  a  symptom.     In 

924 


BRONCHITIS,  925 

scarlet  fever  bronchial  catarrh  rarely  occurs,  but  the  possibility  of  its  occurrence 
in  this  disease  should  not  be  overlooked.  Pulmonary  tuberculosis  is  a  common 
cause  of  bronchitis  in  infants.  Septicaemia,  or  wound  infection,  occasionally  has 
bronchitis  as  one  of  its  numerous  symptoms.  Another  toxic  influence  of  great 
practical  importance  is  to  be  found  in  infection  from  the  intestine.  Several  years 
ago  Sevestre  called  attention  to  cases  of  broncho-pneumonia  accompanied  by 
putrid  diarrhoea,  from  which  he  inferred  that  the  cause  of  the  pneumonia  was  to 
be  found  in  the  infection  from  the  putrid  contents  of  the  bowel.  Later,  his  pupil, 
Le  Sage,  determined  in  the  lungs  of  such  cases  the  presence  of  the  bacillus  coli 
communis.  More  recently,  similar  cases  have  been  investigated  by  his  pupils, 
Gastou  and  Renard,  who  did  not  find  the  coli  bacillus  uniformly,  but  occa- 
sionally the  pneuniococcus,  a  staphylococcus,  and  an  encapsulated  bacillus. 
While  there  is  no  positive  research  going  to  show  that  a  similar  condition 
obtains  in  the  case  of  bronchitis,  there  is  clinical  evidence  which  confirms  the 
idea  that  some  cases  of  bronchitis  are  due  to  infection  or  poisoning  from  the 
intestine.  That  poisoning  by  a  chemical  agent  alone  is  capable  of  inducing 
the  anatomical  conditions  of  acute  bronchitis  has  been  shown  very  conclusively 
by  Hamilton,  who  describes  the  appearances  found  in  the  bronchial  tubes  of  a 
healthy  man  dead  of  opium-poisoning,  and  proves  quite  conclusively  that  the 
appearances  found  were  due  to  the  opium-poisoning  exclusively.  The  condi- 
tions were  exactly  those  produced  at  the  beginning  of  acute  bronchitis.  In 
Bright's  disease  the  bronchitis  which  occasionally  occurs  is  no  doubt  a  toxic 
symptom,  although  in  some  instances,  particularly  in  the  acute  Bright's  disease 
of  children,  it  is  an  evidence  of  pulmonary  oedema. 

In  infants  and  young  children  innutrition  plays  a  most  important  r61e  in 
the  production  of  bronchitis.  It  is  frequently  asserted  that  dentition  is  a  cause 
of  bronchitis.  The  coexistence  of  dentition  and  bronchitis  is  no  doubt  true ; 
the  recurrence  of  bronchitis  in  certain  children  Avith  the  proruption  of  each 
tooth  likewise  is  to  be  admitted ;  but  in  the  cases  Avhicli  have  fallen  under  my 
own  observation  there  has  invariably  been  a  demonstrable  degree  of  innutrition, 
and  to  this  factor,  rather  than  to  the  dentition,  should  be  ascribed  the  occurrence 
of  the  disease.  In  the  presence  of  some  nutritional  deficiencies,  other  physio- 
logical conditions,  no  less  trifling  than  dentition,  may  be  capable  of  exciting  a 
bronchitis.  The  particular  form  of  innutrition  present  is  usually  shown  to  be 
rickets — that  is  to  say,  a  fat-starvation,  characterized  by  profuse  sweating  about 
the  head,  by  delayed  dentition,  by  restlessness  at  night,  and  later  by  the  bony 
changes.  No  doubt  exposure  to  cold  becomes  active  as  an  etiological  factor  in 
those  whose  nutrition  is  below  par,  but  it  is  more  than  doubtful  that  exposure 
to  cold  alone  is  capable  of  inducing  the  condition  of  bronchitis.  Nevertheless, 
it  must  be  admitted  that  bronchitis  occurs  much  more  frequently  during  the 
cold  and  damp  periods  of  the  year  than  during  the  dry  and  warm  seasons. 

Inhalations  of  irritating  gases  and  the  accidental  introduction  of  foreign 
bodies  into  the  bronchi  are  capable  of  producing  acute  bronchitis  in  a  purely 
mechanical  way.  Obstructive  heart  lesions,  by  interfering  with  the  pulmonary 
circulation,  may  likewise  lead  to  oedema  and  some  of  the  changes  of  the  milder 
form  of  bronchitis.  Chronic  bronchitis,  once  established,  is  capable  by  its 
mere  presence  of  being  the  starting-point  of  subsequent  acute  attacks  ;  indeed, 
any  form  of  lung  degeneration,  as  has  been  pointed  out  by  Sutton,  is  capable 
of  inducing  attacks  of  bronchitis. 

Probably  the  most  important  cause  of  recurrent  bronchitis  is  the  presence 
of  enlarged  bronchial  glands.  And  when  it  is  remembered  that  any  acute 
bronchitis,  no  matter  how  trifling,  may  lead  to  the  enlargement  of  these  glands, 
and  that  acute  bronchitis,  in  one  form  or  another,  is  probably  in  children  the 


926    A3IERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN, 

commonest  of  all  pathological  manifestations,  the  importance  of  broncho-adenitis 
as  a  cause  of  recurrent  bronchial  catarrh,  and,  indeed,  as  an  independent  affec- 
tion, is  at  once  apparent.  It  is  not  at  all  uncommon  to  find  children  suffering 
through  several  winters  Avith  attacks  of  bronchitis  recurring  at  short  intervals, 
and  in  almost  every  instance  it  can  be  found  upon  investigation  that  enlarge- 
ment of  the  bronchial  glands  is  at  the  root  of  the  trouble.  Many  cases  classed 
as  phthisis  pulmonalis  in  younger  children  are  instances  of  broncho-adenitis. 
It  must  also  be  noted  that  bronchitis  may  be  secondary  to  a  local  extension 
downward  of  any  form  of  laryngeal  inflammation. 

From  the  wide  variety  of  factors  concerned  in  the  production  of  bronchitis 
it  is  hardly  to  be  expected  that  a  micro-organism  should  be  found  as  a  specific 
cause  of  this  condition ;  nevertheless,  E.  F.  Griin  has  noted  in  cases  of  bron- 
chitis produced  by  various  causes,  measles,  whooping-cough,  etc.,  a  bacillus 
which  he  regards  as  the  specific  cause  of  the  catarrh. 

Morbid  Anatomy. — A  very  careful  stud}^  of  the  anatomical  changes  occur- 
ring in  bronchitis  lias  been  made  by  Hamilton,^  whose  work  has  been  referred 
to  freely  in  the  preparation  of  the  fallowing  outline.  The  anatomical  changes 
in  acute  bronchitis  have  been  found  to  be  identical,  irrespective  of  the  cause. 
The  bronchial  mucous  membrane  throughout  is  not  uniformly  affected,  but  the 
inflammation  is  found  distributed  either  generally,  in  patches  of  greater  or  less 
extent,  or  limited  principally  to  one  lung  or  even  a  part  of  one  lung.  The 
trouble  may  be  limited  .to  the  tubes  of  large  calibre  or  may  extend  into  the 
smaller  tubes.  The  tendency  to  extend  into  the  smaller  tubes  is  more  marked 
in  children  than  in  adults,  and  particularly  is  this  true  of  infants.  Inasmuch  as 
the  accumulation  of  the  catarrhal  products  in  the  smaller  tubes  adds  a  gravity 
of  its  own  to  the  situation,  it  is  well  to  emphasize  this  peculiar  tendency  of  the 
trouble  in  those  of  tender  age. 

On  section  of  the  lung  a  muco-purulent  discharge  is  seen  to  ooze  from  the 
bronchi,  and  by  squeezing  the  lung  the  same  material  is  forced  out  of  the 
smaller  tubes.  To  the  eye  the  surface  of  the  mucous  membrane  appears  con- 
gested and  vessels  are  seen  ramifying  on  the  surface.  According  to  Hamilton, 
the  first  microscopic  change  consists  in  the  "  relaxation  and  distention  of  the 
abundant  plexus  of  blood-vessels  ramifying  in  the  inner  fibrous  coat  imme- 
diately beneath  the  basement  membrane — that  is  to  say,  of  the  branches  of  the 
bronchial  artery."  Immediately  following  this  the  basement  membrane  becomes 
thickened  and  oedematous  and  is  thrown  into  folds.  By  the  end  of  twenty  or 
thirty  hours  the  columnar  epithelium  becomes  loosened  and  desquamates  in 
patches.  The  cast-off  epithelium  becomes  one  of  the  elements  of  the  catarrhal 
secretion,  but  as  these  cells  are  not  reproduced  until  after  the  process  ceases, 
they  are  only  found  in  the  expectoration  during  the  early  stages.  During  this 
period  the  bronchial  secretion  is  diminished  and  the  accompanying  cough  is 
spoken  of  as  "tight."  The  cells  of  the  deeper  layers  of  the  epithelium  nearly 
all  remain  attached  to  the  basement  membrane,  and  w-hen  freed  from  the  over- 
lying columnar  epithelium  proliferate  actively,  and  give  off  into  the  bronchial 
secretion  an  abundant  mass  of  small  round  cells.  The  secretion  is  further  made 
up  of  the  material  poured  out  by  the  mucous  glands.  These  elements  partake 
of  the  general  activity.  Their  secreting  cells  become  greatly  distended  with 
mucus,  and,  breaking  down,  pour  out  an  abundance  of  this  material  into  the 
bronchial  tubes. 

Throughout  the  whole  process,  according  to  Hamilton,  the  basement  mem- 
brane remains  intact,  except  in  so  far  as  it  becomes  thickened,  and  forms  a 
barrier  between  the  inner  epithelial  elements  and  the  outer  fibrous,  muscular, 
*  The  Pathology  of  Bronchitis,  etc.  London,  1883. 


BRONCHITIS.  927 

and  lymphatic  elements.  Beneath  the  basement  membrane  the  inner  fibrous 
coat  of  the  bronchus  becomes  thoroughly  infiltrated  with  small  cells,  and,  as 
these  cells  cannot  pass  inwardly  because  of  the  basement  membrane,  they 
make  their  way  outwai'dly  and  infiltrate  the  muscularis  and  the  outer  fibrous 
coat.  Beyond  this  infiltration  the  muscularis  and  the  outer  fibrous  coat  are 
not  involved  if  the  process  ceases  in  the  acute  stage.  The  cellular  infiltration 
continues  outwardly,  involving  the  interlobular  septa  and  even  reaching  the 
pleura.  Hamilton  notes  that  the  lymphatic  glands  at  the  root  of  the  lung,  the 
bronchial  glands,  are  invariably  involved  in  the  process  and  become  enlarged. 
This  harmonizes  with  clinical  experience.  Particularly  in  infants  and  young 
children  does  this  change  take  place.  There  is  no  one  item  in  the  morbid 
anatomy  of  bronchitis  which  is  of  greater  consequence  than  this.  It  is  im- 
portant to  note  that  enlargement  of  the  bronchial  glands  occurs  in  every  case 
of  bronchitis ;  that  in  sharp  attacks  or  after  repeated  attacks  the  enlargement 
becomes  considerable ;  and  that  the  enlargement  is  not  always  tuberculous,  but 
may  become  so.  A  considerable  enlargement  of  the  bronchial  glands  is  not 
infrequently  mistaken  for  pulmonary  phthisis.  As  has  already  been  noted, 
broncho-adenitis  is  a  potent  factor  in  the  further  production  of  bronchitis,  and 
should  always  be  suspected  in  the  presence  of  recurrent  or  chronic  bronchitis. 
It  is  furthermore  important  in  that  it  leads  to  the  establishment  of  anaemia  and 
to  delayed  convalescence,  for,  as  Rachford  has  shown,  disease  of  the  lymphatic 
system  is  a  potent  factor  in  the  production  of  chronic  anaemia  in  children,  with 
resulting  malnutrition. 

When  an  acute  bronchitis  has  run  its  course  and  is  about  to  terminate  in 
resolution,  the  vascular  congestion  and  the  epithelial  activity  ceases,  the  muco- 
purulent secretion  grows  less,  and  finally  the  columnar  epithelium  is  redeveloped 
over  the  denuded  spots  from  the  now  less  active  epithelium  beneath. 

During  the  course  of  bronchitis  it  sometimes  happens  that  atelectasis  or 
collapse  of  lobules  occurs.  The  amount  and  distribution  of  collapse  varies 
very  greatly.  It  is  usually  associated  with  emphysema  and  with  broncho-pneu- 
monia, which  supervene  under  the  same  conditions  as  favor  the  occurrence  of 
atelectasis.     Broncho-pneumonia  is  the  most  serious  termination  of  bronchitis. 

Chronic  bronchitis  may  result  from  the  acute  form  or  follow  obstructive 
heart  lesions,  or  it  may  be  produced  by  the  inhalation  of  foreign  matter.  When 
the  acute  form  fails  to  undergo  resolution,  the  small  cell  infiltration  of  the 
fibrous  coats  continues,  and  results  in  an  enormous  thickening  of  the  whole 
bronchus.  This  thickening  causes  a  diminution  in  the  calibre  of  the  tube,  and 
further  leads  to  atrophy  and  absorption  of  the  muscularis  and  cartilages.  The 
diminished  elasticity  of  the  bronchia  then  favors  the  formation  of  fusiform 
dilatations.  If  the  infiltration  goes  on,  the  formation  of  fibrous  tissue,  so-called 
interstitial  pneumonia,  ensues.  The  subsequent  contraction  of  this  tissue,  par- 
ticularly that  which  has  been  formed  in  the  interlobular  septa,  draws  out  the 
bronchial  walls  in  places,  leaving  irregular  dilatations  of  the  tubes.  This  con- 
dition, known  as  bronchiectasis,  is  a  potent  factor  in  the  causation  of  subsequent 
acute  attacks.  Among  the  lesions  of  chronic  bronchitis  atelectasis  and  emphy- 
sema are  always  found. 

Symptoms. — Acute  bronchitis  varies  in  its  severity  from  an  exceedingly 
mild  to  an  exceedingly  severe  type.  The  character  of  its  onset  is  largely  deter- 
mined by  the  causes  which  lead  to  it.  In  the  milder  forms  the  onset  may  be 
rather  insidious,  but  sometimes  it  commences  sharply  with  feelings  of  malaise, 
some  elevation  of  temperature,  cough,  soreness  of  the  chest,  and  at  times  with 
catarrh  of  other  mucous  surfaces,  as  those  of  the  larynx,  the  throat,  and  the 
nose.     In  this  form  none  of  the  symptoms  become  severe,  although  the  cough 


928    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

may  be  somewhat  disti-essing.  The  fever  does  not  reach  a  point  to  attract 
attention,  and,  if  the  child  be  young,  expectoration  does  not  occur.  Such  an 
attack  usually  lasts  three  or  four  days,  but  may  be  prolonged,  according  to 
the  cause  which  has  produced  it,  for  several  Aveeks. 

In  the  earliest  stages  of  bronchitis  the  cough  is  dry  and  rasping,  and  indi- 
vidual paroxysms  are  apt  to  be  prolonged.  The  secretion  at  first  is  scanty,  but 
after  twenty-four  to  thirty-six  hours  becomes  freer.  It  is  removed  from  the 
bronchial  tubes  by  the  act  of  coughing,  but  in  the  case  of  infants  and  young 
children  it  is  not  expectorated  ;  indeed,  it  is  with  great  difficulty  that  infants 
can  remove  the  secretion  from  the  bronchial  tubes  into  the  mouth,  and  when 
once  in  the  mouth  it  is  swallowed  and  not  expectorated.  Expectoration  is  an 
art  which  has  to  be  acquired,  and  usually  is  not  learned  until  the  sixth  or 
seventh  year  of  life.  A  cough  Avhich  is  sufficiently  severe  to  cause  expulsion 
of  bronchial  secretion  from  the  mouth  in  children  who  have  not  yet  acquired 
the  art  of  expectorating  is  usually  whooping-cough.  The  swallowed  secretion 
occasionally  produces  some  disturbance  of  the  large  bowel,  and  may  be  associ- 
ated with  mucous  diarrhoea,  but  the  mucus  in  the  movements,  while  in  part 
originally  secreted  in  the  bronchial  tubes,  is  also  in  part  formed  in  the  intestine 
itself.  It  is  to  be  noted  in  this  connection  that  a  mucous  diarrhoea  may  be 
induced  on  the  one  hand  by  a  bronchitis,  and  on  the  other  hand  a  bronchitis 
may  be  produced  as  the  result  of  a  diarrhoea,  or  at  least  as  the  result  of  a  putrid 
condition  of  the  intestinal  contents.  In  milder  cases  of  bronchitis  the  respira- 
tion is  not  particularly  hurried ;  in  young  infants,  however,  it  becomes  quite 
rapid  even  in  mild  cases.  In  the  severer  forms  of  bronchitis,  where  there  is 
much  thickening  of  the  bronchial  mucous  membrane  and  great  difficulty  in 
the  removal  of  the  bronchial  secretion,  and  a  corresponding  interference  with 
aeration,  the  respirations  become  correspondingly  rapid.  But  the  difficult 
respiration  of  acute  bronchitis  cannot  always  be  attributed  to  mechanical  occlu- 
sion of  the  bronchial  tubes,  for  not  infrequently  great  dyspnoea  will  be  present, 
and  disappear  suddenly  without  a  corresponding  removal  of  mucus  from  the 
bronchi.  Difficulty  of  respiration  is  manifested  in  several  Avays :  First,  by  an 
increase  in  the  rate  of  respiration  ;  second,  by  dyspnoea  ;  third,  by  special  forms 
of  dyspnoea,  particularly  the  grunting  expiration.  When  dyspnoea  is  present 
the  alae  of  the  nose  dilate  on  inspiration,  and  if  the  dyspnoea  be  due  to  mechan- 
ical causes,  the  tissues  above  the  sternum  and  the  soft  parts  along  the  insertion 
of  the  diaphragm  sink  in  during  inspiration.  These  symptoms,  which  usually 
are  diagnostic  of  broncho-pneumonia,  may  be  occasionally  found  in  cases  in 
which  the  evidences  of  pneumonia  are  not  altogether  clear  and  in  which  only 
bronchitis  can  be  made  out.  But,  inasmuch  as  they  not  infrequently  disappear 
quite  suddenly  in  a  manner  that  seems  impossible  in  broncho-pneumonia,  it  is 
justifiable  to  assume  that  they  are  indeed  the  result  of  a  bronchitis  pure  and 
simple.  Even  in  broncho-pneumonia  the  dyspnoea  is  at  times  entirely  out  of 
proportion  to  the  amount  of  lung-tissue  invaded,  and  cannot  be  explained 
entirely  by  the  mechanical  obstruction  to  the  aeration  of  the  blood.  It  is 
simpler  to  suppose  that  such  are  cases  of  toxiemia,  in  which  the  dyspnoea  is 
itself  a  toxic  manifestation,  in  part  at  least. 

In  severe  forms  of  bronchitis  the  respiration  may  become  exceedingly  rapid, 
but  the  pulse,  while  frequent,  may  not  be  increased  in  proportion  to  the  respira- 
tion. The  temperature  varies  greatly  in  different  cases,  but  usually  there  is 
some  elevation.  It  is  hard  to  believe,  however,  that  bronchitis,  of  itself,  neces- 
sarily causes  an  elevation  of  temperature,  and  it  is  more  than  likely  that  the 
associated  pyrexia  is  a  distinct  and  co-ordinate  symptom  produced  by  the  same 
factors  which  cause  the  bronchial  catarrh.     No  definite  temperature  curve  can 


BRONCHITIS.  929 

be  ascribed  to  bronchitis ;  it  follows  the  other  conditions  present,  and  in  the 
severer  forms  runs  hish. 

The  facies  of  severe  bronchitis  resembles  that  of  broncho-pneumonia  ;  that 
is  to  say,  the  countenance  is  anxious,  the  alge  of  the  nose  dilate,  the  lips  may 
become  cyanotic,  and  in  general  the  countenance  indicates  distress.  Under 
such  conditions  it  is  perhaps  true  that  broncho-pneumonia  is  usually  present  to 
a  greater  or  less  degree,  but  this  is  certainly  not  always  the  case,  as  this  facies 
is  sometimes  found  in  bronchitis  which  has  invaded  only  the  larger  tubes. 
Nevertheless,  the  prognosis,  whether  broncho-pneumonia  be  found  upon  physical 
examination  or  not,  is  grave  in  accordance  with  the  facies  just  described. 

Nervous  symptoms  are  often  very  marked  in  the  severer  forms.  Great  rest- 
lessness occurs  not  oidy  as  a  result  of  the  difficulty  of  respiration,  but  also  as  a 
toxic  symptom.  Ataxic  features  are  occasionally  noticeable,  and  drowsiness 
deepening  into  coma  is  at  times  seen.  A  toxic  or  so-called  febrile  dyspnoea 
is  often  met  with  ;  that  is  to  say,  a  dyspnoea  which  is  out  of  proportion  to  the 
mechanical  conditions  present,  and  apparently  due  to  the  same  or  a  coincident 
cause  as  that  producing  the  fever.  The  grunting  expiration,  noted  above,  is 
often  of  this  type ;  it  usually  occurs  when  the  rate  of  respiration  is  not  greatly 
increased,  and,  while  present  during  the  waking  hours,  disappears  during  sleep. 
The  bronchitis  which  is  caused  by  the  putrefaction  of  bowel-contents  is  essen- 
tially toxic.  Often  mild,  it  may  be  very  severe  and  accompanied  by  great 
acceleration  of  respiration,  by  dyspnoea,  and  by  marked  head  symptoms.  An 
uncomplicated  case  of  this  kind  is  relieved  by  the  action  of  a  suitable  purga- 
tive, the  most  marked  symptoms  disappearing  at  once,  leaving  no  doubt  of  the 
toxic  origin. 

The  cough  which  accompanies  enlargement  of  the  bronchial  glands  is 
usually  dry  and  harassing,  and  often  assumes  a  croupy  character.  Not  infre- 
quently, however,  the  accompanying  bronchitis  is  severe,  and  may  continue  for 
weeks  or  even  months  with  a  profuse  bronchial  secretion,  showing  little  or  no 
tendency  to  recovery.  This  is  but  one  phase  of  the  condition  which  Dr.  B.  K. 
Rachford^  designates  by  the  term  "scrofulous  bronchitis."  He  describes  it  as 
follows  :  "  It  is,  as  a  rule,  recurrent,  coming  on  during  the  cold  and  disagreeable 
winter  months  and  disappearing  during  the  summer  months.  It  is  characterized 
by  marked  ansemia,  and  as  a  rule  by  other  well-known  signs  of  scrofula,  such 
as  enlarged  external  lymphatics,  chronic  coryza,  etc.  In  these  cases  of  scrof- 
ulous bronchitis  there  may  be  extensive  tubercular  disease  of  the  deep-seated 
lymphatics  of  the  abdomen  or  chest,  without  any  evidence  whatever  of  external 
scrofulosis.  In  such  cases  the  well-marked  anaemia  and  the  possible  family 
history  of  tuberculosis  will  be  of  material  aid  in  diagnosis." 

This  form  is  very  often  mistaken  for  pulmonary  tuberculosis,  but  it  may 
extend  over  a  very  prolonged  period  without  the  production  of  pulmonary 
phthisis,  although  it  tends  to  that  termination.  The  prognosis  is  about  the 
same  as  in  other  forms  of  glandular  tuberculosis. 

Bronchitis  is  accompanied  by  a  great  variety  of  symptoms  referable  to  other 
organs  and  variable,  inasmuch  as  the  associated  features  are  determined  by  the 
particular  causes  which  produce  the  bronchitis,  and  necessarily  must  vary  with 
them. 

Chronic  bronchitis  in  children  does  not  diifer  sufficiently  from  the  same 
condition  in  adults,  either  in  its  symptoms  or  treatment,  to  require  separate 
consideration. 

Prognosis. — Prognosis  as  to  duration  should  be  guarded,  as  it  depends 
upon  the  cause  which  has  produced  the  disease.     Those  cases  which  we  are  com- 

^  Personal  communication. 
59 


930    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

pelled  to  recognize  clinically  as  idiopathic  bronchitis  usually,  when  mild,  termi- 
nate in  three  or  four  days,  and  even  when  severe  rarely  last  more  than  a  week 
or  ten  days.  A  bronchitis  which  is  caused  by  typhoid  fever  will  last  from  ten 
days  to  three  weeks,  and  disappear  with  the  disease  which  it  accompanies.  In 
the  case  of  pertussis  the  bronchitis  may  be  prolonged  quite  indefinitely.  In 
measles,  while  it  may  disappear  in  four  or  five  days,  it  not  infrequently  lasts 
several  weeks.  Bronchitis  of  purely  intestinal  origin,  usually  disappears  imme- 
diately upon  the  removal  of  the  bowel-contents. 

Prognosis  as  to  severity  is  determined  by  a  number  of  factors,  but  ordinarily 
it  is  good.  It  is  customary  to  say  that  the  prognosis  in  bronchitis  of  the  larger 
tubes  is  more  favorable  than  in  bronchitis  of  the  smaller  tubes,  and  in  general 
this  is  true,  but  by  no  means  is  it  always  so,  as  some  of  the  most  severe  attacks, 
so  far  as  fever,  depression,  and  other  nervous  symptoms  go,  are  those  in  which 
the  large  tubes  only  are  affected.  The  age  of  the  patient  is  always  an  important 
element  in  the  prognosis.  The  infant  with  bronchitis  is  to  be  regarded  as  always 
in  danger,  as  broncho-pneumonia  may  readily  supervene.  The  exciting  causes 
of  the  attack  must  also  be  taken  into  consideration.  Bronchitis  symptomatic 
of  a  general  infection,  such  as  measles,  is  very  likely  to  be  commensurate  with 
the  other  symptoms  so  far  as  severity  is  concerned.  The  presence  of  enlarged 
bronchial  glands  is  to  be  taken  as  indicating  a  prolongation  or  recurrence  of  the 
trouble,  and  as  paving  the  way  for  a  possible  termination  in  pulmonary  phthisis. 
The  condition  of  the  child's  nutrition  determines  to  a  very  considerable  degree 
the  severity  of  an  attack.  Where  the  nutrition  is  below  par,  particularly 
where  rickets  is  well  marked,  the  disease  is  apt  to  prove  vei'y  severe,  and  to 
take  upon  itself  suddenly  severe  nervous  symptoms  or  to  lead  to  the  develop- 
ment of  broncho-pneumonia.  Marasmus  and  great  weakness  from  any  cause, 
interfering  with  the  prompt  expulsion  from  the  tubes  of  the  accumulating 
secretions,  are  conditions  unfavorable  to  the  satisfactory  progress  of  the  case. 
The  cough  per  se  is  of  but  little  aid  in  prognosis.  It  may  be  very  severe  in 
children  who  are  evidently  but  slightly  ill,  and,  again,  may  be  nearly  absent 
in  children  who  are  in  great  danger.  The  character  of  the  respiration  is  of 
more  importance  from  a  prognostic  standpoint.  Whenever  it  becomes  rapid, 
or  its  rhythm  is  interfered  with,  or  the  grunting  expiration  appears,  or  dyspnoea 
manifests  itself,  the  prognosis  should  be  guarded.  With  improvement  of  the 
respiration  in  rate  and  rhythm  a  more  favorable  prognosis  may  be  made.  The 
temperature  is  often  an  important  guide :  the  higher  the  temperature,  other 
things  being  equal,  the  graver  the  prognosis ;  the  lower  the  temperature,  the 
better  the  outlook.  With  a  pulse  that  tends  to  irregularity  irrespective  of  the 
temperature  and  respiration-rate,  the  prognosis  is  not  favorable.  But  more 
important  than  all  these  sj^mptoms  is  the  condition  of  the  brain,  delirium  in 
any  of  its  forms  having  its  usual  grave  significance.  Intense  cardiac  depres- 
sion, and  sleeplessness,  or,  on  the  other  hand,  somnolence,  all  are  indicative  of 
severe  and  threatening  conditions. 

Diagnosis. — The  diagnosis  involves  the  recognition  of  the  existence  of 
the  bronchial  catarrh  itself,  and  the  determination,  so  far  as  possible,  of  the 
etiological  factors.  The  existence  of  bronchitis  is  ordinarily  recognized  with- 
out any  difficulty.  The  history  of  cough,  with  bronchial  secretion  of  recent 
origin,  is  usually  enough  to  establish  the  diagnosis.  An  examination  of  the 
chest,  which  should  always  be  made,  will  decide.  In  the  earlier  stages,  before 
the  secretion  has  become  established,  sibilant  and  sonorous  rales  are  heard.  Not 
infrequently,  however,  these  rales  are  very  scanty,  and  not  always  heard  on 
both  sides  of  the  chest.  Later  the  rales  become  moist  and  more  numerous. 
When  the  smaller  tubes  are  invaded,  small  and  even  subcrepitant  rales  are 


BRONCHITIS.  931 

heard.  At  no  time  in  an  uncomplicated  bronchitis  is  there  any  modification 
of  the  percussion  note. 

The  severer  forms  are  to  be  differentiated  from  pneumonia.  This  can  only 
be  done  by  the  detection  of  the  consolidated  pneumonic  area  by  percussion  and 
auscultation.  The  consolidated  area  is  expected  to  show  dulness  on  percussion, 
and  bronchophony  and  bronchial  breathing  on  auscultation.  But  when  the 
area  is  small  and  centrally  located,  these  signs  cannot  always  be  made  out. 
Fortunately,  it  is  not  of  the  highest  importance  to  determine  these  conditions 
exactly,  because  the  prognosis  and  treatment  will  not  be  essentially  modified  by 
the  presence  of  a  small  area  of  pneumonic  consolidation. 

Pleural  effusion,  whether  serous  or  purulent,  does  not  always  present 
specific  symptoms  indicating  its  nature,  but  is  often  shown  only  by  a  cough 
which  may  readily  be  mistaken  for  that  of  bronchitis.  The  physical  exami- 
nation will  always  differentiate  these  conditions. 

The  presence  of  bronchitis  being  once  established,  the  search  for  the 
etiological  factors  begins.  The  existence  of  one  of  the  exanthemata  as  a 
causative  factor  is  usually  readily  made  out  by  the  history  and  appearance 
of  the  child.  Pertussis,  however,  is  difiicult  to  determine  before  the  occur- 
rence of  the  convulsive  stage.  It  may  be  suspected,  however,  if  the  cough  be 
very  severe  and  the  disease  be  prevalent.  Influenza  usually  presents  its  neural- 
gic and  other  nervous  features.  The  character  of  the  stools  should  always  be 
carefully  inquired  into,  and  if  there  be  any  suspicion  of  putridity  of  the 
bowel-contents,  the  fact  should  be  noted  as  a  possible  factor  in  the  case.  The 
condition  of  the  nutrition  should  be  carefully  studied,  particularly  in  infants, 
and  if  the  history  shows  the  occurrence  of  profuse  sweating,  especially  about 
the  head  at  night,  with  great  restlessness  and  a  tendency  to  lie  uncovered, 
if  there  be  beading  of  the  ribs,  recurrent  bronchial  attacks  during  dentition, 
and  occasional  laryngismus  stridulus,  rickets  is  to  be  diagnosticated. 

Treatment. — The  treatment  of  bronchitis  includes  attention  to  the  local 
conditions  in  the  chest,  to  the  general  constitutional  disturbance,  and  to  the 
removal,  as  far  as  possible,  of  the  causative  factors.  It  is  not  convenient, 
however,  to  divide  the  description  of  the  treatment  with  strict  reference  to 
these  three  factors,  but  rather  to  consider  the  matter  somewhat  in  the  order  in 
which  the  various  steps  are  undertaken  in  actual  practice. 

The  very  mildest  cases  require  no  treatment  whatever,  but  they  should 
always  be  watched,  particularly  in  infants,  so  that  interference  may  be  made 
as  soon  as  necessary. 

It  is  good  practice  to  commence  the  treatment  of  every  case  of  bronchitis 
in  infants  and  young  children  with  the  use  of  a  laxative,  the  reason  for  this 
being  that  the  intestinal  tract  of  the  infant  so  commonly  contains  putrid  faeces 
which  do  not  always  manifest  themselves  by  special  signs.  In  older  children 
some  signs  of  bowel  disturbance  may  be  waited  for,  but  in  severe  cases  the 
character  of  the  bowel-contents  should  always  be  investigated  by  the  aid  of 
purgatives.  Besides  their  action  on  the  bowels,  purgatives  deplete  the  liver  and 
prepare  that  organ  to  receive  some  of  the  blood  which  has  been  determined  to 
the  bronchi.     The  most  available  laxatives  are  castor  oil  and  calomel. 

Calomel,  which  is  preferable  in  the  infant,  should  be  administered  in  three 
doses,  of  one  grain  each,  at  intervals  of  four  or  five  hours.  When  putrid  faeces 
are  found,  all  animal  food  should  be  prohibited  for  one  or  two  days,  and  such 
intestinal  antiseptics  as  naphthaline  and  salol  administered. 

Expectorants  are  often  of  great  service  in  the  earlier  stages  of  bronchitis, 
but,  as  a  rule,  they  are  abused.  Their  sole  use  is  to  cause  an  increase  in  the 
bronchial  secretion.     When  the  secretion  is  scanty,  and  the  rales  few  and  dry, 


932    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  the  cough,  in  consequence,  frequent  and  harassing,  expectorants  afford 
relief.  But  when  the  secretion  has  become  thoroughly  established,  and  auscul- 
tation shows  the  rales  to  be  abundant  nnd  moist,  then  expectorants  are  of 
no  further  use,  and  it  is  better  to  withhold  them.  The  best  expectorants 
are  ammonium  chloride  and  potassium  iodide.  The  following  formula  may  be 
employed  for  an  infant  from  three  to  six  months  of  age : 

^.  Ammon.  chlorid gr.  xvj. 

Syr.  tolutan 

Aq.  destillat da  fij. — M. 

Sig.   One  teaspoonful  in  a  little  water  every  two  or  three  hours. 

Ipecacuanha  is  widely  used.  It  is  of  peculiar  value  because,  besides  increas- 
ing secretion,  it  tends  to  dilate  the  cutaneous  capillaries.  When  the  secre- 
tion is  excessive  and  the  efforts  at  coughing  inadequate  to  remove  the  ac- 
cumulation, emesis  affords  much  relief.  For  this  purpose  ipecacuanha  is 
valuable. 

The  modern  coal-tar  antipyretics  have  a  marked  effect  in  bronchitis.  They 
appear  to  act  almost  as  specifics,  diminishing  the  amount  of  secretion,  lessening 
the  severity  and  frequency  of  the  cough,  and  relieving  pain,  without  acting 
like  opium  in  simply  covering  up  symptoms.  Of  these,  the  safest  probably  is 
phenacetin.  For  an  infant  from  six  months  to  two  years  of  age  the  follow- 
ing: formula  will  be  found  useful : 

!^.  Phenacetin gr.  xii-xxiv. 

Caffeine g^- j~y- — •^• 

Div.  in  chart.  No.  xii. 
Sig.  -Give  one  powder  every  four  hours. 

The  smaller  dose  may  be  used  at  six  months  and  the  larger  at  two  years. 
For  younger  infants  the  dose  should  be  reduced,  and  for  older  children  slightly 
increased.  These  powders  are  advantageously  alternated  with  the  calomel 
powders  given  at  first.  Here,  as  elsewhere,  phenacetin  should  be  used  cau- 
tiously, withheld  entirely  from  weakly  children,  and  never  continued  over  a 
long  period.  » 

In  severer  cases  the  inhalation  of  antiseptic  vapors  seems  at  times  to  be 
useful.  For  this  purpose  it  is  convenient  to  evaporate  turpentine  or  oil  of 
eucalyptus  from  a  water-bath  in  the  patient's  room. 

Particularly  in  the  bronchitis  of  infants  and  young  children  is  the  cough 
salutary,  and  it  should  be  laid  down  as  a  cardinal  rule  that  no  effort  should  be 
"made  to  smother  it.  Narcotics  and  antispasmodics  distinctly  increase  the  tend- 
ency to  pneumonia.  But  it  is  not  always  possible  to  dispense  entirely  with 
the  use  of  opium.  In  some  very  severe  cases,  where  there  is  great  restlessness, 
a  single  full  dose  of  opium  to  produce  sleep  is  occasionally  necessary.  Used 
in  this  way,  the  best  results  to  the  patient  are  obtained  Avith  a  minimum  of 
danger. 

Certain  means  very  commonly  employed  in  the  treatment  of  bronchitis  and 
pneumonia  have  for  their  object  the  relief  of  internal  congestion  by  the  pro- 
duction of  a  dilatation  of  the  cutaneous  capillai'ies.  These  are  the  poultice 
jacket,  the  cotton  and  oiled  silk  jacket,  local  counter-irritation,  and  the  inter- 
nal use  of  sweet  spirits  of  nitre,  alcohol,  and  aconite.  Redness  of  the  chest- 
wall  is  readily  obtained  by  thorough  friction  with  camphorated  oil  or  an  oint- 
ment of  turpentine  and  lard.     It  is  rarely  necessary  to  use  mustard.     The 


BRONCHITIS.  933 

agent  selected  should  be  well  rubbed  on  twice  each  day,  and  the  redness  main- 
tained by  the  use  of  the  poultice  jacket  or  the  jacket  of  cotton  batting  and  oiled 
silk.  When  poultices  are  used,  two  should  be  made — a  smaller  one  to  lie  upon  the 
front  of  the  chest,  and  a  larger  and  heavier  one  to  cover  the  back  and  sides  of 
the  chest  and  lap  over  the  front  poultice.  As  their  object  is  to  keep  the 
skin  red,  they  must  be  as  warm  as  can  be  borne,  and  changed  often  enough  to 
prevent  cooling.  The  advantage  of  two  poultices  is  to  be  found  in  the  chang- 
ing. The  one  at  the  back  does  not  cool  as  rapidly  as  the  front,  which  must  be 
the  thinner,  so  as  to  embarrass  the  respiration  as  little  as  possible.  Hence  the 
front  poultice  requires  changing  oftener  than  the  back.  Poultices  which  are 
allowed  to  become  cold  constitute  an  element  of  danger,  and  therefore  should 
not  be  used  on  patients  when  the  nursing  is  inferior.  They  are  disadvantageous 
also  to  very  weak  children,  to  whom  their  weight  is  a  burden.  When  properly 
employed  their  action  is  of  the  greatest  service,  and  they  should  always  be 
used  in  properly  selected  severe  cases.  As  a  substitute  for  the  poultice  the 
chest  may  be  enveloped  in  a  thick  layer  of  cotton  batting,  and  this  covered 
with  oiled  silk.  This  dressing,  Avhile  inferior  to  poultices,  is  yet  so  convenient 
a.nd  so  serviceable  that  it  should  always  be  employed,  in  conjunction  with 
camphorated  oil,  even  in  quite  mild  cases. 

The  principal  utility  of  alcohol  in  bronchitis  has  seemed  to  the  writer  to  be 
due  to  its  power  of  relaxing  the  cutaneous  capillaries.  For  this  purpose  it  is 
best  administered  in  rather  small  doses  at  frequent  intervals,  and  in  the  shape 
of  whiskey  or  some  light,  non-astringent  wine.  Sweet  spirits  of  nitre,  so 
commonly  employed  in  febrile  conditions,  is  often  of  great  service  in  bronchitis, 
particularly  when  there  is  fever.  It  dilates  the  cutaneous  capillaries,  acts  as  a 
diaphoretic,  and  by  its  diuretic  action  no  doubt  assists  in  the  elimination  of 
toxic  principles. 

When  bronchitis  is  produced  by  any  of  the  specific  fevers  the  cause  cannot 
be  directly  removed,  but  treatment  directed  to  the  amelioration  of  the  com- 
plexus  of  febrile  conditions  relieves  the  bronchitis,  as  it  does  the  other  mani- 
festations of  the  poison.  In  those  specific  fevers  which  are  best  treated  by 
the  application  of  cold  the  presence  of  bronchitis  is  not  to  be  regarded  as  a 
contraindication  of  the  means. 

Convalescence  from  bronchitis  is  always  worthy  of  attention,  and  after 
severe  cases,  where  the  bronchial  glands  are  considerably  enlarged,  treatment 
of  this  stage  is  highly  important.  Fortunately,  proper  medical  attention  at 
this  period  produces  excellent  results  and  prevents  much  subsequent  trouble. 

In  the  treatment  of  broncho-adenitis  cod-liver  oil  is  a  most  important  agent. 
It  is  usually  desirable  to  administer  it  plain,  and  by  most  infants  it  is  well 
borne.  Its  use  should  be  continued  for  three  or  four  weeks,  and  even  longer 
if  the  trouble  does  not  yield  readily. 

When  the  bronchial  glands  are  enlarged  a  coexisting  anaemia  will  usually 
require  the  use  of  iron.  This  agent  is  best  administered  as  the  reduced  iron 
or  the  freshly-prepared  saccharated  carbonate  of  iron.  In  either  case  the  dose 
should  be  large.  Reduced  iron  in  5-grain  doses  three  times  a  day  to  a  child 
two  years  old  will  give  better  results  than  smaller  doses.  For  very  young 
infants  iron  is  best  administered  in  the  shape  of  freshly-expressed  beef-juice, 
which  may  be  given  in  teaspoonful  doses  three  times  a  day. 

The  iodides  may  at  times  be  used  advantageously,  and  of  these  the  best  are 
the  syrup  of  hydriodic  acid  and  potassium  iodide.  The  latter  should  be  given 
in  small  doses,  J  grain  to  1  grain,  three  times  a  day,  and  well  diluted.  The 
Byrup  of  the  iodide  of  iron  is  rather  disappointing  in  its  action. 

It  is  often   desirable  to  use  creasote  or  guaiacol,    particularly  where  the 


934    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

glandular  enlargement  is  very  pronounced  and  general  tuberculous  infection  is 
feared.     The  following  is  a  convenient  formula  for  a  creasote  emulsion  : 

'Sf.  Creasoti  (beechwood)       fsj- 

Pulv.  acaciae gr.  xv. 

Aq.  dest KTLxlv. 

Glycerini q.  s.  ad  f  3ss. — M. 

Sig.  Four  to  eight  drops  in  port  wine  three  times  a  day. 

Ordinarily  it  is  not  desirable  to  commence  treatment  of  the  broncho-adeni- 
tis along  these  lines  until  after  the  subsidence  of  the  acute  attack  of 
bronchitis.  Cases  presenting  nutritional  deficiencies  call  for  treatment  both 
during  and  after  the  attack.  In  most  instances  the  innutrition  in  infants  is 
due  to  rickets,  and  cod-liver  oil  and  iron  act  almost  as  specifics.  Salt  baths 
and  out-door  exercise  are  also  valuable,  and  should   never  be  omitted. 

In  older  children,  the  subjects  of  scrofulous  bronchitis,  the  underlying 
nutritional  deficiencies  particularly  call  for  treatment.  In  these  cases  cod-liver 
oil,  iron,  and  iodine,  while  of  service,  are  often  disappointing,  and  do  not 
yield  the  satisfactory  results  obtained  by  their  use  in  less  severe  cases,  where 
enlargement  of  the  bronchial  glands  constitutes  the  principal  departure  from 
the  normal.  In  the  severer  cases  of  this  type  relief  can  only  be  obtained  by 
removal  to  a  warm  climate  or  to  the  sea-shore.  In  the  experience  of  the 
writer  the  Florida  coast  has  aflForded  great  relief  to  such  patients. 


PLEURISY  AND  EMPYEMA. 

By  HEXBY  KOPLIK,  M.  D., 

New  York. 


Pleurisy,  or  pleuritis,  occurs  in  infancy  and  childhood  usually  as  a  second- 
ary, and  rarely  as  a  primary,  disease.  There  are  certain  forms  in  which  the 
pleura  is  inflamed  without  any  appreciable  exudate ;  such  are  called  chy  or 
fibrinous  pleurisies.  Other  forms  combine  the  above  with  an  exudate  of 
fluid — serous,  sero-purulent,  or  purulent — into  the  pleural  cavity.  These  forms 
are  called  pleurisy  u'itJi  effusion,  or  sometimes,  less  accurately,  subacute 
pleurisy.  When  the  exudate  has  a  sero-purulent  character  or  is  visibly  puru- 
lent, the  pleurisies  have  been  called  empyema.  Empyema  in  this  article  will, 
for  the  sake  of  uniformity,  be  called  puruleiit  or  suppurative  jjleurisy,  while 
those  pleurisies  which  have  a  protracted  course  and  are  due  to  neoplasms  will 
be  referred  to  only. 

Frequency. — Pleurisy  is  a  common  disease  of  infancy  and  childhood. 
The  greatest  number  of  cases  occur  before  the  fifth  year  of  life  (Simmonds). 
The  succeeding  five  years  (five  to  ten  years)  show  the  next  greatest  frequency. 
Our  statistics  upon  pleurisy  in  childhood  are  incomplete,  for  the  reason  that 
authors  have  not  unreservedly  exposed  their  material  for  criticism.  Only 
favorite  methods  have  been  published,  to  the  exclusion  of  unfavorable  results. 
This  has  caused  much  confusion.  Israel  has  tabulated  206  cases,  of  which  59 
were  purulent  (29  per  cent.).  Mackey  gives  purulent  cases  in  children  40  per 
cent,  as  against  5  per  cent,  of  the  whole  number  in  adults.  In  240  cases  140 
were  boys  (Simmonds).  On  the  other  hand,  Hofmokl,  who  has  a  great  pedia- 
tric surgical  practice  in  Vienna,  tabulates  60  cases,  of  which  42  were  females. 
Thus,  combining  both  statistics,  the  boys  would  still  show  the  greater 
frequency. 

The  left  side  is  more  frequently  the  seat  of  disease.  Of  175  cases  collected 
by  Simmonds,  103  were  on  the  left  side,  whereas  of  the  60  tabulated  by 
Hofinokl,  33  were  on  the  left  side. 

Pleurisy  is  generally  a  unilateral  disease.  Of  175  cases,  only  7  were  bi- 
lateral (Simmonds).  This  is  fortunate  in  infancy  and  childhood,  where  exudates 
reach  a  large  amount  in  a  very  shoi-t  time.  With  these  youthful  patients 
the  natural  resiliency  of  the  chest  combines  with  others  factors  to  make  even 
enormous  exudates  comparatively  well  borne,  as  contrasted  with  a  similar  con- 
dition in  later  life.  In  the  adult  the  resistant  chest-wall  tends  to  cause  greater 
pressure-eff'ects  and  displacements  of  important  viscera. 

Pathology. — The  pleura  is  a  connective-tissue  structure,  made  up  of  elastic 
fibres  in  a  fibrillar  membrane,  containing  branched  connective-tissue  cells  and 
covered  with  a  layer  of  flat  epithelium,  called,  in  this  membrane,  endothelium. 
In  inflammations  of  the  pleura  which  are  not  dependent  upon  and  accompanied 
by  a  neoplastic  growth  (tubercle  or  carcinoma),  the  changes  take  place  at  the 
surface.     The  most  frequent  pleurisies  are  those  acute  processes  which  invari- 

935 


936    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ably  accompany  the  several  forms  of  acute  pulmonitis.  They  occasion  but  few 
symptoms  per  se,  and  only  in  the  event  of  a  fatal  termination  of  the  primary 
pulmonary  disease  do  they  come  to  the  autopsy  table.  In  these  forms  of 
pleurisy  the  changes  may  be  so  trifling  as  to  be  indicated  only  by  a  slight 
injection  of  the  surface  of  the  pulmonary  pleura  and  a  loss  of  its  characteristic 
lustre.  Here  and  there  a  few  fibrinous  threads  or  adhesions  may  be  found 
coursing  over  the  surface  of  the  membrane  or  running  from  the  costal  to 
the  pulmonary  pleura.  This  is  the  so-called  dry  pleurisy,  pleuritis  sicca. 
In  other  cases  there  is  a  more  extensive  formation  of  fibrin,  which  becomes  dif- 
fused over  the  whole  surface  of  both  the  pulmonary  and  costal  pleura ;  and 
this  formation  may  become  so  marked  as  to  cause  a  distinct  thickening  of  both 
these  surfaces.  In  some  forms  in  children  the  amount  of  fluid  is  small  com- 
pared with  the  immense  thickening  of  the  pleuree.  Some  writers  have  main- 
tained that  in  these  fibrinous  exudates  the  primitive  endothelium  may  be  found 
upon  the  original  pleural  surface,  beneath  the  exudative  product ;  others,  that 
the  fibrinous  exudation  is  coated  with  the  original  endothelium  (Delafield). 
The  pleura  itself  may  be  but  little  altered,  the  only  change  being  that  its 
lymph-spaces  and  blood-vessels  are  dilated,  and  there  may  be  a  diapedesis  of 
leucocytes. 

In  other  forms  of  pleurisy  the  fibrinous  exudation  at  the  surface  is  also 
combined  with  a  serous  exudate  into  the  cavity  of  the  pleura.  This  serum  is 
variable  in  amount :  it  usually  contains  leucocytes,  in  many  cases  bacteria,  as 
will  be  shoAvn  later.  It  may  be  quite  clear,  turbid,  or  opaque,  yellow  or 
greenish  in  color  and  creamy  or  thin  in  consistency.  In  acute  processes  in 
children  large  masses  of  fibrin  may  be  found  floating  free  in  the  cavity  of  the 
pleura  (metapneumonic  cases).  In  many  instances  the  adhesions  are  so  great 
as  to  bind  down  the  lung  at  various  places,  thus  enclosing  the  exudate  in 
quasi-capsular  formations.  Even  in  acute  cases  the  fibrinous  coating  on  the 
surface  of  the  pulmonary  and  costal  pleura  contains  newly-formed  blood-ves- 
sels. Hiemorrhages  into  the  pleural  cavity  may  rarely  occur  as  a  part  of 
such  conditions  as  scurvy  and  true  morbus  Werlhofii,  and  then  the  serous  or 
purulent  exudate  becomes  a  so-called  haemorrhagic  one. 

In  some  cases  the  fibrinous  coating  on  the  pulmonary  pleura  may  be  so 
thick  as  to  seriously  impair  the  function  of  the  lung.  In  children,  however, 
this  is  not  common,  except  as  a  sequence  of  tubercular  processes ;  so  that 
a  marked  pleurisy,  suppurative  or  fibro-serous,  may  be  followed  by  a  complete 
restitutio  ad  integrum.  It  is  rare  that  in  acute  processes  the  lung  is  in  any 
way  compromised.  It  is  only  in  prolonged,  unrelieved  pleurisy  that  this  occurs, 
and  thus  there  may  be  perforation  of  the  exudate  with  erosion  of  the  pulmon- 
ary or  costal  pleura,  (pleuritis  necessitatis).  Small  purulent  exudates,  unrecog- 
nized during  the  illness,  may  thus  perforate  after  all  fever  has  ceased  and  the 
patient  is  apparently  well. 

In  tubercular  inflammation  of  the  pleura,  besides  the  production  of  fibrin, 
serum,  clear  or  hsemorrhagic,  and  pus,  there  may  be  considerable  thickening 
of  the  costal  and  pulmonary  pleura,  caused  by  the  inflammatory  exudate, 
which,  as  well  as  the  pleura,  is  infiltrated  with  tubercle.  In  these  cases  the 
serous  or  purulent  effusion  may  be  encapsuled  by  adhesions,  while  the  lung  is 
crippled  and  bound  down  by  layers  of  inflammatory  tissue.  In  these  forms 
of  pleurisy  the  anatomical  changes  are  progressive.  In  acute  fibrinous  pleurisy 
the  exudative  products  on  the  surface  of  tlie  pleura  are  organized  into  new  con- 
nective tissue  or  partly  disappear,  but  the  pleura  is  restored  to  its  original 
condition.  Again,  absorption  takes  place  in  those  cases  where  the  exudate  does 
not  demand  artificial  relief.     In  children  the  adhesions  form  an  important  part 


PLEURISY  AND   EMPYEMA.  937 

of  the  process  in  acute  pleuritis,  while  in  other  forms  the  pleura  may  remain 
permanently  thickened  by  the  formation  of  a  surface  layer  of  new  connective 
tissue,  which  may  persist  through  life.  There  are  non-tubercular  forms  of 
pleurisy  where,  after  the  acute  process  has  run  its  course,  the  pleura  remains 
thickened  by  newly-formed  connective  tissue  ;  and  this  not  only  involves  the 
pleural  tissue  proper,  but  also  continues  to  extend  and  involve,  through  the 
lymph-vessels,  the  interlobular  tissue  of  the  lung  itself,  causing  a  species  of 
cirrhotic  changes.  In  these  cases,  which  are  prolonged,  the  lung-tissue  is 
seriously  compromised. 

In  the  exudates  of  the  pleura  there  is  a  constant  interchange  of  fluids 
through  the  vessels  of  this  membrane  (Gerhardt).  Drugs  may  find  their  way 
from  the  general  circulation  into  the  pleuritic  fluid.  Iodine  and  salicylic  acid 
have  thus  been  found.  Moreover,  the  amount  of  leucocytes,  red  blood-cells, 
and  endothelial  cells  in  the  exudate  is  constantly  varying,  so  that  a  serous 
eff'usion  may  result  from  a  haemorrhagic  one,  and  an  opaque  purulent  from  a 
serous. 

The  amount  of  fluid  efiused  in  children  is  usually  considerable,  and  may 
reach  1000  or  2000  c.cm.  (Simmonds).  Hofmokl  in  several  cases  evacuated 
as  much  as  2000  to  5000  c.cm. 

The  chemical  composition  of  pleural  exudates  may  be  of  clinical  interest. 
The  specific  gravity  varies  from  1028  to  1032  (Bartels,  quoted  by  Gerhardt). 
Some  authors  have  attempted  to  formulate  prognostic  signs  from  the  specific 
gravity  of  the  pleural  exudate,  but  few  would  accept  such  a  line  of  thought  to- 

The  amount  of  albumin  varies  from  0.06-2.68  per  cent,  in  non-inflam- 
matory to  2.40-6.90  per  cent,  in  inflammatory  exudates  ;  extractives  and 
salts  in  non-inflammatory  exudates,  1.08  percent.,  in  inflammatory,  1.18  per 
cent.  ;  the  chlorides  average  0.67  per  cent,  in  both.  Among  the  foreign  sub- 
stances, urea,  uric  acid,  leucin,  tyrosin,  glucose,  glycogen,  cholesterin,  xanthin, 
and  medicinal  agents  have,  at  various  times,  been  found,  proving  that  the  fluid 
in  the  pleural  cavity  is  in  direct  touch  with  the  general  circulation  and  lymph- 
atic system. 

Etiolog-y. — Primary  pleurisy,  occurring  without  any  exciting  cause  in  the 
chest  or  elsewhere,  is  rare  in  children.  There  are  numbers  of  cases  in  which 
an  acute  eff'usion  of  inflammatory  character  takes  place  without  any  previous 
symptoms  of  illness  or  external  exciting  causes.  Our  data  upon  this  very 
interesting  and  important  question  are  still  incomplete.  Such  a  case  came 
under  the  notice  of  the  author  in  a  boy  aged  six  years,  in  whom  a  pleural  effu- 
sion was  present  for  a  week  without  any  previous  symptoms.  The  liquid  was 
serous  in  character,  and  did  not  contain  any  micro-organisms.  There  was  no 
tubercular  lung  disease  and  no  history  of  other  illness.  In  these  clinical  cases 
the  etiology  is  very  obscure.  The  author  has  elsewhere  published  cases  of 
infants  where  illness  began  acutely,  nothing  having  been  found  except  a  ton- 
sillitis follicularis.  The  chest  showed  no  pneumonia  or  pleurisy  at  first. 
Within  a  week,  however,  a  purulent  effusion  was  found  in  the  chest.  In  these 
cases  it  is  impossible,  inasmuch  as  recovery  takes  place,  to  establish  the 
primary  cause.  In  those  cases  which  come  to  the  autopsy  table  after  the 
disease  has  existed  a  long  time  the  pulmonary  changes  are  no  more  conclusive. 

Primary  pleuritis,  if  it  does  occur  in  children,  must  be  rare.  There  are  so 
many  avenues  of  infection  that  to  satisfactorily  exclude  all  these  has  as  yet  not 
been  possible.  Pleuritis  in  infancy  and  childhood  is  therefore  mostly  second- 
ary to  diseases  of  the  lungs.  All  acute  forms  of  pneumonitis — lobar  pneu- 
monia and  broncho-pneumonia — may  give  rise  to  pleuritis.     The  greatest  num- 


938    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

ber  of  cases  has  been  traced  to  this  cause.  Of  84  cases  of  pleuritis  tabulated 
bj  Simmonds  as  occurring  in  children,  31  were  caused  primarily  by  pneumonia 
(meta-pneumonic  pleurisy). 

The  infectious  diseases,  measles,  scarlet  fever,  pertussis,  typhus,  typhoid, 
diphtheria,  forms  of  tonsillitis,  retro-pharj^ngeal  or  mediastinal  abscess,  may 
precede  and  directly  cause  an  attack  of  pleurisy.  In  these  cases  a  pneumonitis 
generally  precedes  the  pleurisy  or  is  present  at  the  same  time.  Such  a  pleurisy 
is  to  be  classed  under  the  heading  of  complications.  It  may  be  serous  or 
purulent,  but  is  generally  microbic  in  origin,  as  will  be  shown  later.  In  the 
new-born  the  class  of  cases  included  under  the  heading  of  septico-pysemia  are 
sometimes  complicated  by  a  pleuritis,  usually  suppurative  and  of  a  progressive, 
fatal  type.  In  these  instances  the  pleuritis  is  simply  caused  by  the  same 
microbic  agent,  which  enters  at  the  umbilicus  or  elsewhere.  Such  cases  have 
been  published  by  the  author.  The  acute  bone  diseases,  such  as  osteomyelitis, 
may  be  complicated  by  purulent  pleurisy ;  so  also  may  septic  wounds  in  any 
distant  portion  of  the  body,  as  the  foot  (Koplik). 

Tubercular  disease  of  the  lung  or  tuberculosis  elsewhere ;  echinococcus 
(Simmonds)  or  abscess  of  the  liver  ;  any  abscesses  in  the  mediastinum  ;  forms  of 
endocarditis ;  and  abscesses  in  the  abdominal  cavity  or  involving  any  of  the 
viscera, — may  cause  pleuritis.  A  case  of  perityphlitis  in  the  author's  practice, 
in  a  girl  eight  years  old,  after  running  an  acute  course  was  followed  by  chronic 
peritonitis  with  multiple  abscess-formations  in  the  abdominal  cavity,  and  was 
later  complicated  by  pleuritis  on  the  right  side.  As  no  autopsy  was  allowed,  it 
was  impossible  here  to  trace  a  direct  connection,  but  such  has  been  done  by 
other  authors. 

^  In  many  cases  of  pleuritis,  as  in  other  diseases,  it  is  possible  to  find  as  the 
only  exciting  cause  an  exposure  to  cold  or  dampness.  This  has  occurred  so 
often,  and  with  such  apparent  connection,  that  most  authors  look  upon  cold 
and  dampness  as  undoubtedly  exciting  toward  any  pulmonary  or  pleural 
inflammation.  At  least  they  are  not  without  influence.  A  reduction  of  con- 
stitutional resistance  by  these  agents  opens  the  avenues  for  the  activity  of  well- 
known  exciting  agents  (microbic). 

Traumatism  of  all  kinds,  even  without  a  lesion  of  the  external  surface,  may 
act  like  cold  in  exciting  pleurisy.  Compression  of  the  chest-wall  or  a  blow 
may  not  directly  cause  it,  but  certainly  many  cases  follow  so  closely  upon  such 
accidents  that  an  intimate  connection  seems  to  be  the  inevitable  deduction. 

It  is  conceded  upon  all  sides  that  there  are  evanescent  forms  of  pneumonia 
in  children  lasting  only  a  few  days.  It  is  easy  to  conceive  that  a  pleuritis 
may  have  been  preceded  by  such  a  pneumonia,  the  symptoms  of  the  primary 
disease  being  masked  by  those  of  the  main  condition,  the  effusion  in  the  chest. 

The  etiology  of  pleuris}^  has  been  greatly  elucidated,  in  recent  years,  by 
the  bacteriological  studies  of  Weichselbamn,  Fraenkel,  Ehrlich,  and  Thue. 
These  authors  have  busied  themselves  Avith  the  study  of  pleuritic  exudates  and 
their  relationship  to  processes  which  affect  the  lung.  They  directed  their  atten- 
tion to  the  adult  cases.  In  1891  the  author  made  a  series  of  bacterioscopic 
studies  in  children,  which,  with  certain  peculiar  exceptions,  bring  the  pleurisies 
of  children  much  into  the  line  of  those  of  the  adult  as  to  causation.  We  know 
that  when  the  lungs  are  the  seat  of  bronchitis,  broncho-pneumonia,  or  lobar 
pneumonia,  a  number  of  micro-organisms  play  an  important  role  during  the 
course  of  the  inflammatory  processes.  Thue,  in  a  series  of  studies,  established 
beyond  question  that  these  micro-organisms  (notably  the  diplococcus  pneu- 
monipe)  can  be  found  not  only  in  the  lung-structures,  but  especially  in  the 
lymph-spaces  of  the  tissue  of  the  pleura  and  on  the  surface  of  the  pleura  itself, 


I 


PLEURISY  AND   EMPYEMA.  939 

even  in  most  evanescent  inflammatory  reactions  of  that  structure.  This  once 
accepted,  it  is  easy  to  explain  how  micro-organisms,  which  are  "per  se  capable 
of  exciting  suppuration,  Avhen  they  once  gain  the  surface  of  the  pleura  will 
cause  inflammatory  response  of  that  structure.  Such  is,  in  fact,  the  case.  If 
we  examine  the  acute  pleuritic  exudates  in  children,  we  find  they  resolve  them- 
selves into  groups.  The  most  interesting  group  is  that  in  which  the  eff'usion, 
whether  serous  (clear)  or  purulent  and  full  of  fibrin  clots  and  flocculi  (sup- 
purative), shows  the  presence  of  the  diplococcus  pneumonise  of  Fraenkel  or 
the  streptococcus  lanceolatus.  This  micro-organism  is  the  accepted  exciting 
factor  of  both  lobar  (Fraenkel)  and  lobular  pneumonia  (Weichselbaum).  It  is 
found  in  both  serous  and  purulent  exudates  (meta-pneumonic  pleurisies),  and 
this  in  pure  culture.  So  constant  is  this  that  we  can  group  such  pleurisies  by 
themselves,  and  both  clinically  and  bacteriologically  accept  the  diplococcus  as 
the  connecting  link  between  the  process  in  the  lung  and  the  pleuritic  inflam- 
mation. It  is  not  always  possible  to  trace  clinically  the  pneumonia  and  pleurisy 
in  sequence,  for  in  many  of  these  cases  the  pneumonia  is  so  slight  as  to  play 
but  a  secondary  clinical  role.  In  other  cases  the  direct  clinical  sequence  of 
pneumonia  followed  by  pleurisy  can  be  satisfactorily  established. 

In  another  group  of  cases  the  pleuritic  eff'usion,  if  examined  bacterioscop- 
ically,  is  found  to  contain  staphylococcus  pyogenes  aureus,  and  in  other  cases 
the  streptococcus  pyogenes.  The  exact  etiological  role  played  by  these  micro- 
organisms is  not  very  apparent.  It  is  true  we  can  justly  conclude  that  by 
their  presence  in  the  pleural  cavity  they  have  been  direct  excitants  of  the 
pleuritic  inflammatory  reaction.  It  is  not  clear,  however,  how  they  gain 
access  to  the  pleural  cavity,  and  whether  the  pleuritis  was  preceded  by,  or  was 
concomitant  with,  some  form  of  pneumonitis.  These  organisms  are  found  in 
the  lungs  during  a  lobar  or  broncho-pneumonia.  In  certain  forms  of  broncho- 
pneumonia following  or  complicating  the  infectious  diseases,  the  streptococcus 
pyogenes  is  found  as  a  chief  exciting  factor  of  the  pneumonitis.  This  has 
been  well  established  by  Babes,  Prudden,  and  Northrup.  But  there  is  a  class 
of  pleurisies  in  children  which  are  not  secondary  to  the  acute  infectious  diseases, 
and  in  these  the  staphylococcus  and  streptococcus  have  been  found  (Koplik). 
The  most  probable  conclusion  in  such  cases  is  that  there  may  have  been  some 
element,  such  as  an  exposure  or  traumatism,  which  favored  the  invasion  of 
the  pleura  through  the  lungs.  In  many  cases  we  could  assume,  in  spite  of 
the  absence  of  the  streptococcus  lanceolatus  or  Fraenkel's  diplococcus,  that  i 
broncho-pneumonia  might  have  existed,  and  the  staphylococcus  or  ordinary 
streptococcus,  which  always  exists  in  these  cases  in  the  lung  as  a  mixed  infec- 
tion, may  have  gained  access  to  the  pleural  cavity  to  the  exclusion  of  the 
primary  excitant,  the  diplococcus  pneumoniae. 

In  many  pleuritic  effusions,  both  serous  and  purulent,  the  most  careful 
examination  of  the  exudate  fails  to  give  any  microbic  elements,  and  in  these 
we  are  left  to  surmise  the  etiology.  The  serum  and  pus  of  such  cases  have 
been  injected  into  animals  without  arriving  at  any  satisfactory  conclusion.  It 
is  possible  that  a  proportion  of  these  cases  are  tubercular,  but  it  would  be  a 
very  extreme  view  to  assume  that  all  those  cases  of  pleuritic  efiusion  in  which 
no  micro-organisms  are  found  are  tubercular.  For  this  is  at  variance  with 
clinical  experience.  Many  of  these  negative  exudates  have  been  assumed  to 
be  due  to  acute  primary  pleurisies  brought  about  by  cold,  exposure,  or  trauma. 
The  clinical  regularity  with  which  an  exposure  or  traumatism  can  be  shown  to 
have  been  followed  by  pleurisy  leads  us  to  assume  that,  though  of  itself  it  may 
not  be  able  to  produce  inflammation  of  a  structure,  it  can  so  devitalize  a 
part  or  organ  as  to  make  the  latter  a  ready  prey  to  the  action  of  microbic 


940  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

agents.  On  the  other  hand,  we  know  that  in  the  healthy  individual  the  upper 
air-passages  are  the  seat  of  micro-organisms  which,  isolated  from  their  habitat, 
are  pathogenic  (the  streptococcus  of  sputum).  Yet  in  the  healthy  unexposed 
individual  these  micro-orgranisms  are  harmless.  We  thus  have  that  class  of 
pleurisies  in  which  the  staphylococcus  of  various  kinds  and  the  chain  coccus 
have  been  found,  as  well  as  part  of  the  class  in  which  no  micro-organisms  have 
been  established,  as  still  to  be  more  satisfactorily  elucidated. 

The  question  of  primary  pleurisy  in  children  is  also  very  difficult  to  ap- 
proach. We  know  of  pleurisies  Avhich,  clinically,  are  very  acute  in  onset,  and 
in  which  the  effusion  Avitliin  twenty-four  hours  reaches  such  an  extreme  gross 
quantity  as  to  cause  by  its  presence  alone  quite  serious  symptoms.  In  these 
cases  the  effusion  may  be  serous,  or  it  may  from  the  outset  be  purulent.  In 
many  of  them  no  previous  history  of  lung  trouble  or  any  traumatism  or 
exposure  has  preceded.  These  are  the  cases  which  have  been  described  as 
acute  lorimary  pleurisy.  While  allowing  the  former  classification  to  stand,  the 
writer  must  express  his  conviction  that  future  work  will  reveal  some  primary 
etiological  factor  outside  the  pleura  itself.  The  pleural  cavitj^  is  such  an 
isolated  space,  much  like  the  joints,  that  it  is  difficult,  in  the  light  of  our 
present  knowledge,  to  conceive  of  its  primary  inflammatory  reaction  similar 
to  that  taking  place  in  the  lung  in  pneumonitis. 

In  the  septic  pleurisies  the  micro-organism  Avhich  has  been  found  in  children 
is  the  streptococcus,  probably  the  streptococcus  pyogenes  (Koplik).  In  the 
tubercular  pleurisies,  whether  the  effusion  be  serous  or  purulent,  the  tubercle 
bacillus  can  be  found,  but  only  with  great  difficulty.  In  many  cases,  as  has 
been  shown  by  Ehrlich,  it  is  absent.  In  the  pm-ulent  exudates  the  staphy- 
lococcus and  streptococcus  may  be  found  as  mixed  infections,  or  they  may  be 
absent. 

Symptoms. — There  are  two  distinct  sets  of  cases  in  children :  those  with 
an  acute  and  those  with  an  insidious  onset.  If  the  invasion  be  acute,  Ave  have  a 
picture  which  differs  but  little  from  the  onset  of  a  pneumonia,  and  as  in  the 
majoi'ity  of  cases  such  a  pulmonary  process  is  coexistent,  it  is  easily  seen  how 
the  symptoms  of  one  condition  may  be  masked  by  the  other.  A  chill  is 
the  rule  only  in  older  children,  while  in  infants  cerebral  symptoms,  convul- 
sions, or  stupor  may  usher  in  the  disease.  The  fever  is  quite  high — 103°  to 
105°  F. ;  and  the  pulse  very  much  increased — to  140,  sometimes  180  beats. 
There  is  marked  dyspnoea,  and  even  in  infants  the  face  has  an  anxious  expres- 
sion. The  urine  is  diminished,  and  in  the  course  of  a  few  days  we  have  all 
the  symptoms — dryness  of  tongue,  loss  of  appetite,  and  prostration — which 
accompany  any  acute  disease  with  fever.  The  cough,  which  may  be  present 
from  the  beginning,  is  distressing,  for  the  infant  cries  whenever  it  coughs; 
but,  as  is  the  rule  in  infants  and  children  of  all  ages,  there  is  no  expecto- 
ration. After  the  acute  symptoms  have  subsided  a  slight  elevation  of  temper- 
ature may  persist,  with  a  remittent  curve,  sometimes  only  about  one-half 
degree  above  the  normal,  with  an  evening  rise  of  one  or  two  degrees,  but  never 
quite  reaching  the  normal.  This,  with  dyspnoea  and  pain,  though  less  than  at 
first,  and  more  infrequent  cough,  continues  the  clinical  picture  during  the  sub- 
acute stage.  The  effects  of  the  illness  are  shown  by  pallor  instead  of  the 
febrile  flush  of  the  onset,  and,  if  the  case  continue  without  relief,  even  for  two 
or  three  weeks,  by  marked  emaciation,  especially  in  those  patients  suffering 
from  a  purulent  exudate. 

In  the  other  class  of  cases  the  onset  is  more  insidious.  The  ch'ld  may  have 
at  first  a  marked  febrile  movement  for  a  few  hours,  and  as  this  passes  away  it 
is  apt  to  disarm  suspicion.     The  child  is  not  quite  well ;  it  has  a  remittez': 


PLEURISY  AND    EMPYEMA.  941 

curve  of  febrile  movement,  and,  if  older,  will  complain  of  occasional  pain  in 
the  side.  The  cough  may  be  so  slight  as  to  be  unnoticed.  Yet  the  increasing 
pallor,  languor,  and  evident  illness  will  bring  the  patient  to  the  physician,  who 
will  not  suspect  a  pleurisy  unless  a  systematic  physical  examination  reveal  fluid 
in  the  chest. 

The  fever  is,  in  most  acute  cases,  high  in  the  beginning,  and,  though  it  is 
not  uniformly  so  from  day  to  day,  it  still  reaches  in  some  cases  a  maximum  of 
105°,  and  then  may  remit  a  degree  or  two.  When  pleurisy  is  accompanied  by 
pneumonia,  the  temperature,  as  in  this  disease,  continues  uniformly  high,  103° 
-105°  F.,  until  the  eighth,  ninth,  tenth,  or  thirteenth  day,  when  a  fall  will 
occur  with  an  attempt  at  crisis.  At  this  period  the  axillary  temperature 
may  reach  99°-99.5°,  but  it  will  not  fall  to  the  normal  level.  In  the 
following  days,  should  the  pleurisy  continue,  as  in  most  of  these  cases  it  does, 
the  curve  begins  to  rise  gradually  to  101°  or  102°,  and  will  remit  in  the  morn- 
ing. These  cases  are  quite  characteristic.  In  dry  pleurisy  without  effusion 
there  is  scarcely  any  fever. 

The  pulse  is  accelerated,  being  sometimes  as  high  as  180,  and  especially 
so  in  paroxysms  of  coughing.  The  tension  vaides,  but  in  children  the  heart, 
though  pressed  upon  by  effusion,  generally  is  equal. to  the  new  condition  in  the 
chest.  It  is  only  in  fat,  flabby  children  and  those  suffering  from  dyscrasiae 
that,  with  a  rapidity  and  threadiness  of  pulse,  even  from  the  outset,  we  notice 
instead  of  the  usual  flushed  appearance  a  pallor  of  the  skin  and  a  cyanosis  of 
the  mucous  surfaces,  as  of  the  lips. 

Dyspnoea  is  generally  the  most  apparent  symptom  in  children.  The  dilated 
nostrils  and  the  drawing  inward  of  the  infrasternal  region  both  indicate  a  disturb- 
ance of*  the  respiratory  function.  When  the  chest  is  touched,  pain  is  evinced 
by  uneasiness  and  greater  dyspnoea.  The  mother  will  say  that  the  child  cries 
when  taken  hold  of  under  the  arms  in  the  usual  way.  The  babe  will  favor  the 
side  affected  by  lying  upon  it,  and  suckling  the  left  breast,  if  the  right  side  be 
the  seat  of  trouble  (Henoch).  Older  children  will  sometimes  indicate  the 
portion  of  the  chest  in  which  the  pain  is  located  ;  in  other  cases  they  will 
mislead  by  indicating  the  epigastrium  or  abdomen  as  the  seat  of  pain  (diaphrag- 
matic pleurisy). 

The  cerebral  symptoms  not  only  mislead,  but  may  puzzle  the  physician  for 
days,  until  the  effusion  becomes  large  enough  to  detect.  These  symptoms 
resemble  those  in  pneumonia — convulsions,  somnolence,  vomiting,  in  older 
children  cephalalgia  and  epileptiform  seizures. 

Physical  Signs. — Inspection  of  the  chest  in  children  who  suffer  from  any 
form  of  pleurisy,  Avhether  effusion  be  present  or  not,  reveals  a  lack  of  movement 
on  the  affected  side.  This  is  quite  apparent  in  even  very  young  infants,  and 
is  in  striking  contrast  to  the  motion  of  the  opposite  side  in  all  the  various 
grades  of  dyspnoea  which  may  be  present  in  individual  cases.  If  there  be  a 
quantity  of  exudation  or  fluid  in  the  chest,  there  is,  in  addition  to  lack  of 
motion,  a  very  marked  bulging  of  the  affected  side.  By  this  is  meant  bulging 
as  a  whole.  The  individual  intercostal  spaces  do  not  always  bulge  in  infants. 
On  the  contrary,  the  chest  may  be  full  of  fluid,  and  a  retraction  of  the  spaces, 
increasing  on  inspiration,  may  exist.  It  is  of  little  practical  value  to  calcu- 
late the  amount  of  increase  in  circumference  of  the  affected  side.  This  will 
vary  with  the  amount  of  fluid  present. 

Palpation  reveals  but  little  if  the  form  of  pleurisy  be  dry  and  the  effusion 
slight.  On  the  other  hand,  if  the  effusion  be  considerable,  a  most  valuable 
sign  is  furnished  by  the  complete  absence  of  vocal  fremitus  in  older  children. 
In  infants  the  absence  of  the  cry-fremitus  gives  evidence  of  the  same  con- 


942    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

dition.  This  is  one  of  the  most  constant  signs  of  pleurisy  with  effusion  in 
children,  where,  above  all  other  things,  the  physical  signs  to  be  detailed  are 
constantly  varying.  It  has  been  the  practice  of  the  author  to  rely  largely  upon 
fremitus  and  a  certain  resistance  to  percussion,  which  will  be  noted  later,  in 
deciding  upon  the  presence  of  an  effusion.  If  the  healthy  side  be  the  seat  of 
bronchitis,  a  peculiar  rale-fremitus  may  be  felt  on  this  side,  but  this  is  only 
of  negative  interest. 

Percussion. — The  percussion-note  over  thickened  pleura  is  dull ;  over  fluid, 
flat.  But,  as  has  been  hinted,  in  children  these  signs  show  the  most  marked 
variation.  There  is  nothing  characteristic  in  the  signs  obtained  by  percussion. 
The  chest  in  an  infant  is  so  resilient  that  much  depends  upon  the  force  used  and 
the  skill  of  the  examiner  to  bring  out  the  requisite  note.  A  layer  of  fluid  may 
exist  between  the  lung  and  the  chest-wall,  and  skilful  percussion  will  reveal 
tlulness,  while  more  forcible  percussion  brings  out  the  pulmonary  note  of  the 
underlying  lung.  If  the  chest  be  filled  with  fluid,  the  note  will  be  flat ;  and 
this  is  another  reliable  sign.  In  chests  where  the  fluid  fills  out  the  lower  por- 
tion of  the  pleural  cavity  the  pulmonary  resonance  will  be  obtained  above, 
while  below  there  Avill  be  noted  dulness  varying  to  flatness,  depending  upon  the 
thickness  of  the  layer  of  fluid  between  the  lung  and  the  percussing  finger. 
The  resistance  to  the  percussing  finger  is  jwculiarh/  wooden  in  character, 
especially  in  children.  The  resonance  upon  the  unaffected  side  of  the  chest 
is  increased,  and  sometimes  tympanitic. 

Auscultation  may  reveal  rales  or  friction-sounds,  bronchial  voice,  and  bron- 
chial breathing,  or  all  these  may  be  absent,  the  breathing  being  simply  puerile 
and  the  voice  but  little  changed.  Xothing  is  so  deceptive  as  the  auscultatory 
signs  in  pleurisy.  If  no  effusion  be  present,  we  hear  friction-sounds  in  children 
resembling  for  the  most  part  the  fine  crepitations  of  pneumonia,  and  even  when 
the  chest  is  full  of  fluid  these  crepitations  may  be  quite  loud.  These  may 
be  confined  to  small  areas  in  dry  pleurisy,  or  in  pleurisy  with  effusion  may 
be  diffused  over  the  whole  chest.  This  is  what  tends  to  confuse  the  examiner. 
The  voice  in  dry  pleurisy  is  not  changed.  In  pleurisy  with  all  varieties  of  effu- 
sion the  voice  may  be  normal,  even  when  the  chest  is  full  of  fluid.  Again,  as 
stated,  it  may  be  bronchophonic.  The  breathing  may  be  heard  above  the 
level  of  fluid,  and  be  diminished,  absent,  or  bronchial,  below.  Again,  breath- 
ing may  be  heard  with  equal  distinctness  over  a  side  which  is  full  of  fluid, 
as  over  the  unaffected  side.  In  most  cases  we  must  rely  mainly  upon  fremitus 
and  percussion. 

In  children  sometimes,  though  rarely,  the  fluid  will  not  appear  in  front  of 
the  chest,  though  it  exists  over  the  whole  side  posteriorly.  The  lung  seems  to 
have  been  pushed  up  and  forward,  instead  of  against  the  spinal  column.  In 
such  cases  increased  respiratory  murmur  and  tympanitic  resonance  will  be 
obtained  over  the  apex  of  the  lung  in  front. 

It  is  quite  common  to  see  the  routine  remark  that  displacements  of 
viscera,  notably  of  the  liver  and  heart,  are  common  in  children  suffering 
from  pleurisy  with  effusion.  This  is  not  strictly  true.  In  young  children, 
where  the  chest  is  very  easily  expanded  by  the  accumulated  fluid,  the  effu- 
sion must  be  exceedingly  large  before  downward  displacement  of  the  liver 
w^ill  be  appreciated.  Older  childi-en  also  may  carry  large  amounts  of  fluid 
without  marked  displacement  of  the  liver,  though  it  can,  in  some  cases,  be 
distinctly  noted.  In  younger  children  effusion  upon  the  left  side  may  displace 
the  apex  of  the  heart  toward  the  sternum,  but  this  is  not  apt  to  occur,  except 
as  the  result  of  very  large  effusion.  In  the  adult  the  displacement  of  the  liver 
in  right  pleurisy,  and  of  the   heart   in  left,  is  quite  a  constant  sign. 


PLEURISY  AND   EMPYEMA.  943 

In  conclusion,  the  author  would  lay  stress  upon  the  immobility,  bulging  of 
the  affected  side  as  a  whole,  lack  of  fremitus,  and  flatness,  combined  with  a  pecu- 
liar resistance  to  the  percussing  finger,  as  the  leading  reliable  signs  of  acute 
chest  effusion,  which  may  be  corroborated  by  change  in  the  voice  and  breath- 
sounds.  In  children,  as  in  adults,  the  effusion  of  pleurisy  accumulates  in  the 
most  dependent  part  of  the  thorax,  behind,  adjacent  to  the  vertebral  column. 
In  children  100  grammes  of  effusion  can  be  thus  discovered  by  percussion  at 
the  lower  and  inner  portion  of  the  chest-wall,  adjacent  to  the  spine  (Gerhardt ; 
Piorry).  Accumulation  of  the  fluid  takes  place  thus  in  an  oblique  area, 
growing  deepest  toward  the  median  and  tapering  at  the  axillary  line.  Small 
effusions  in  meta-pneumonic  pleurisies  may  be  encapsuled  and  give  a  localized 
area  of  dulness  or  flatness.  In  tubercular  pleurisies  this  is  also  very  often 
the  case.  In  infants  and  young  children  the  fine  distinctions  of  change  of 
position  of  small  exudates  can  hardly  be  made  out,  as  in  the  adult,  on  account 
of  the  restlessness  of  the  patient. 

Diagnosis. — The  diagnosis  of  pleuritis  in  children  is  not  difficult  in  the 
majority  of  cases,  but  there  is  a  percentage  in  which  care  must  be  exercised 
before  diagnosis  can  be  positive.  Dry  pleurisy  is  diagnosed  by  the  presence 
of  pain  and  the  phj'sical  signs  of  local  dulness  and  friction-rales.  Localized 
encapsulated  pleurisies  must  be  diagnosed  by  the  circumscribed  dulness  or 
flatness  and  the  change  of  fremitus  over  a  circumscribed  area,  with  perhaps  a 
change  in  the  voice  and  respiratory  sounds. 

If  an  effusion  be  of  considerable  size,  the  diagnosis  is  difficult  when  the 
layer  of  fluid  is  so  thin  as  not  to  mask  the  pulmonary  resonance  and  give  only 
dulness ;  but  even  here  the  fremitus  will  be  absent.  In  marked  effusion  the 
complete  loss  of  fremitus,  immobility  of  the  affected  side,  and  flatness,  with  a 
certain  wooden  resistance  to  the  percussing  finger,  are  quite  characteristic.  It 
is  well  not  to  rely  too  much  upon  vocal  resonance  or  respiratory  murmur.  In 
order  that  an  effusion  may  not  be  overlooked,  it  is  important  to  think  of  the  pos- 
sibility of  its  existence  in  every  case,  and  to  exclude  it  only  after  careful  exami- 
nation. It  is  of  little  moment  if  a  delay  of  twenty-four  or  forty-eight  hours 
occur  when  the  symptoms  are  not  of  a  pressing  character.  But  every  practi- 
tioner sees  cases  in  which  fluid  must  have  been  present  for  weeks  without  being 
recognized.  In  children  the  exudate  at  a  very  early  period,  even  from  the 
onset,  is  likely  to  be  purulent,  and  it  can  be  easily  seen  how  important  it  is  to 
discover  the  character  of  an  exudate  as  soon  as  possible.  Aside  from  pressure 
effects,  the  presence  of  a  purulent  exudate  is  dangerous  on  account  of  its 
tendency  to  burrow  inward  toward  the  lung,  eroding  the  pleura,  or  to  rupture 
externally. 

If  there  be  doubt  as  to  the  presence  of  fluid  or  as  to  its  nature,  these 
facts  should  be  determined  as  soon  as  possible.  For  this  purpose  a  hypo- 
dermic exploring  needle  should  be  used  in  the  following  manner  :  The  mother 
holds  the  babe  in  her  arms  in  the  usual  way,  the  posterior  part  of  the  chest 
is  bared,  and  the  area  of  most  complete  dulness  or  flatness  is  determined.  This 
part  is  first  washed  carefully  with  alcohol,  and  then  with  corrosive  sublimate 
(1  :  5000).  A  long  exploring  needle,  a  little  larger  than  the  ordinary  hypoder- 
mic needle,  but  stronger  and  stouter,  having  been  attached  to  a  well-cleansed 
hypodermic  syringe,  is  rapidly  driven  into  one  of  the  intercostal  spaces,  the 
higher  the  better.  On  the  right  side,  where  the  liver  will  present  itself  to  the 
entering  point  of  the  needle  if  too  low,  the  puncture  should  not  be  lower  than 
the  eighth  space,  in  line  with  the  angle  of  the  scapula.  The  chief  point,  how- 
ever, is  to  enter  at  the  area  of  greatest  dulness  or  flatness.  Having  pushed  in 
the  needle  about  one-half  an  inch,  the  piston  of  the  syringe  should  be  drawn. 


944    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  whole  operation  should  be  rapidly  done,  and  the  mother  should  be  warned 
to  hold  the  child  firmly,  for  any  sudden  movement  might  cause  the  needle  to 
impinge  against  the  rib  and  break  off — an  accident  which  has  occurred.  This 
little  operation  should  be  over  before  the  child  has  ceased  to  experience  the 
pain  of  the  entry  of  the  needle.  If  no  fluid  be  found  the  needle  is  rapidly 
withdrawn  and  a  piece  of  rubber  plaster  placed  over  the  point  of  puncture. 
The  author  has  never  had  an  accident  in  many  such  operations,  and  it  requires 
but  ordinary  cleanliness  and  care.  It  secures  to  the  patient  the  benefit  of  an 
absolute  diagnosis. 

Sometimes  we  may  be  absolutely  certain  of  fluid,  and  yet  be  unable  to 
prove  it  with  the  needle.  In  such  cases  the  needle  has  entered  an  adhesion  of 
the  pleura,  and  at  the  next  sitting,  if  still  in  doubt  of  the  diagnosis,  the  needle 
should  be  entered  at  another  point.  It  is  unwise  after  inserting  the  needle  to 
thrust  it  up  and  down  the  chest-wall  or  pleural  space.  In  this  way  the  lung 
may  be  wounded,  and  emphysema,  haemorrhage,  or  irreparable  injury  be  caused. 
While  the  needle  is  in  the  chest  it  should  be  held  so  lightly  that  any  sudden 
unexpected  movement  on  the  part  of  the  child  will  not  afford  leverage  to  the 
needle  against  the  rib,  for  if  this  occur  the  needle  is  apt  to  break.  When  fluid 
is  obtained  its  character  should  be  carefully  determined,  and  the  presence  and 
significance  of  contained  bacteria  should  be  investigated.  The  busy  practi- 
tioner may  not  have  time  to  do  this,  but  the  author  has  devised  a  very  simple 
bulb '  for  the  withdrawal  and  transportation  of  such  fluids. 

As  far  as  prognosis  and  even  treatment  are  concerned,  it  is  of  self-evident 
importance  to  determine  as  early  as  possible  whether  an  exudate  is  pneumonic, 
tubercular,  or  doubtful.  The  presence  of  chain  cocci,  staphylococci,  or  the 
diplococcus  pneumoniae  in  a  serous  exudate  will  prepare  the  physician  for  the 
advent  of  a  purulent  effusion,  and  the  practical  knowledge  thus  gained  may  be 
of  vital  importance  to  the  patients  future  happiness. 

In  the  presence  of  a  suspected  effusion  it  was  previously,  and  still  is  among 
some,  the  custom  to  temporize.  It  was  argued  that  an  exploring  needle  wjis 
likely  to  cause  a  serous  fluid  to  become  purulent  through  the  entrance  of  air 
or  some  few  micro-organisms.  But  the  most  ordinary  cleanliness  will  render 
this  almost  impossible.  The  author  doubts  very  much  if  an  effusion  was  ever 
changed  in  character  by  careful  h^^podermic  exploration.  A  slight  amount  of 
air,  or  a  few  staphylococci,  if  through  some  carelessness  introduced  into  a 
serous  exudate  on  the  point  of  a  needle,  can  scarcely  change  the  character 
of  fluid  filling  the  chest.  The  serous  portion  of  exudates,  like  those  in  joints, 
hydroceles,  etc.,  is  actually  capable  of  annihilating  the  life  of  micro-organisms 
in  fixed  ratio  (Buchner ;  Prudden).  Moreover,  serous  effusions,  formerly 
thought  to  turn  purulent  through  some  accident,  are  really  purulent  and  con- 
tain the  microbic  element  of  pus  from  the  outset,  although  they  appear  serous 
to  the  eye.  While  advocating  caution,  the  author  recommends  a .  fearless 
resort  to  so  valuable  a  guide  as  the  hypodermic  exploring  syringe. 

The  tubercular  cases  alone  offer  the  greatest  difficulties  of  diagnosis,  for, 
as  has  already  been  shown,  some  serous  and  purulent  exudates  which  contain 
no  micro-organisms  may  be  tubercular,  as  may  even  those  that  contain 
staphylococci  or  streptococci.  But,  fortunately,  in  children  tubercular  pleurisies 
are  not  the  most  common  forms.  Hgemorrhagic  pleuritic  exudates  are  very 
rare  in  children.  They  are  generally  caused  by  grave  disease — tuberculosis, 
sarcoma,  carcinoma,  or  morbus  Werlhofii. 

The  cases  of  pneumonia  which  are  complicated  with  pleurisy  are  the  most 
trying  to  the  practitioner.     Here  on  the  eighth,  ninth,  tenth,  or  thirteenth  day 

'  American  Journal  of  the  Medical  Sciences,  1892. 


PLEURISY  AND   EMPYEMA.  945 

no  complete  crisis  takes  place.  The  temperature  falls  to  within  even  one-half 
of  a  degree  of  the  normal  in  the  axilla,  but  dulness  persists  in  the  lower  part 
of  the  chest  or  flatness  appears  over  its  whole  extent.  This  condition  is  fre- 
quently mistaken  for  so-called  unresolved  pneumonia. 

Prognosis. — In  children  the  prognosis  in  pleuritis  is  good.  In  the  form 
occurring  after  pneumonia  or  that  caused  by  the  staphylococcus  or  streptococ- 
cus (non-septic),  with  effusion  into  the  chest,  recovery  is  rapid  as  soon  as  the 
fluid  is  evacuated,  and  much  depends  upon  early  diagnosis.  In  suppurative 
pleurisy,  if  allowed  to  remain  unrelieved  the  pus  will  burrow,  usually  exter- 
nally. The  effusion  then  may  infiltrate  the  soft  tissues  of  the  thorax,  after 
eroding  the  pleura,  and  point  as  an  abscess  at  the  side  anteriorly  or  posteriorly. 
Sometimes  such  an  exudate,  when  on  the  left  side,  may  receive  an  impulse 
from  the  heart,  and  thus  is  occasioned  the  so-called  pulsating  pleurisy.  Such 
effusions  have  been  mistaken  for  aneurisms,  but  lack  of  expansile  pulsation 
and  the  history  of  the  case  will  guide  in  the  diagnosis.  The  tumor  disappears 
when  the  chest  is  aspirated.  If  the  pulmonary  pleura  becomes  eroded  by  a  pur- 
ulent exudate,  the  perforation  takes  place  into  the  lung,  and  the  pus  is  more  or 
less  quickly  expectorated.  Even  in  such  cases,  though  unrelieved  by  any 
additional  measure,  recovery  has  taken  place,  as  in  a  case  elsewhere  recorded 
by  the  author.  Tubercular  pleurisies  do  not  recover  completely  in  children; 
fistulous  suppurating  cavities  with  retraction  of  the  chest  result.  In  some 
cases  the  pleurisy  has  been  so  extensive  as  to  cause  retraction  of  the  lung,  its 
utility  being  impaired  by  the  binding  of  thick  pleural  plates,  which  leave 
behind  a  large  suppurating  pleural  sac.  The  septic  cases  are,  as  a  rule,  fatal, 
though  in  fortunate  instances  recovery  takes  place. 

Hofmokl  treated  by  resection  60  cases,  in  which  recovery  was  complete 
in  26.  Twenty-eight  cases  were  fatal ;  13  of  these  were  tubercular,  6  were 
complicated  with  pneumonia,  3  died  through  pericarditis,  3  with  peritonitis,  1 
with  amyloid  degeneration  of  the  organs,  1  with  heart  failure,  and  1  with  neo- 
plasm. These  cases  were  evidently  more  unfavorable,  as  to  general  character 
of  the  pleuritis,  than  is  common. 

Complications. — The  most  dangerous  complication  of  pleuritis  is  peri- 
carditis, which  in  most  cases  is  fatal.  The  occurrence  of  lobar  or  lobular 
pneumonia  as  a  complication  has  been  dilated  upon  elsewhere.  The  septic  cases 
may  be  complicated  by  endocarditis  or  suppuration  of  other  serous  surfaces, 
such  as  the  peritoneum  or  that  of  the  joints.  Gangrene  of  the  lung  may  cause 
severe  putrid  inflammatory  reaction  of  the  pleura,  and  thus  the  pleural  cavity 
may  contain  gases  with  purulent  exudation  (pyopneumothorax).  In  these  cases 
a  peculiar  physical  sign,  known  as  the  succussion  sound,  may  be  elicited  by 
shaking  the  patient. 

Sudden  death  from  heart  failure  may  occur,  but  this  must  be  rare.  The 
right  heart,  however,  may  become  weakened  to  such  an  extent  as  to  allow 
the  formation  of  thrombi,  and  their  entry  into  the  circulation  may  cause  sudden 
death. 

Contraction  and  retraction  of  the  chest-wall  always  follow,  to  a  certain 
extent,  in  those  forms  of  pleuritis  which  have  been  left  to  nature.  Many  of 
the  deformities  of  the  chest  observed  later  in  life  are  due  to  pleuritis  in  child- 
hood. 

The  perforation  of  an  empyema  into  the  lung,  with  its  evacuation  through 
a  bronchus,  has  already  been  referred  to  as  having  rather  a  favorable  prog- 
nosis, even  when  not  relieved  by  operation.  As  a  rule,  however,  such  cases 
are  best  treated  by  external  incision,  although  evacuation  may  be  expected 
by  the  bronchus.  Again,  perforation  may  take  place  through  the  chest-wall ; 
fill 


946   AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

here  a  large  boggy  infiltration  of  the  tissues  of  the  chest  or  adjacent  abdominal 
wall  takes  place,  constituting  the  condition  known  as  emi^yema  necessitatis. 

Treatment. — It  is  diflficult  to  formulate  methods  of  treatment  of  pleuritis, 
a  disease  in  which  the  successful  issue  depends  greatly  upon  judgment  founded 
upon  experience.  Those  cases  of  pleuritis  in  which  the  process  is  circumscribed, 
and  in  which  the  effusion  in  the  pleural  cavity  is  but  slight,  have  pain  as  the 
main  symptom.  The  fever  is  generally  marked,  and  requires,  as  a  rule,  but  ordi- 
nary methods.  In  children  the  pain  is  best  relieved  by  some  mild  opiate,  like 
Dover's  powder  in  proportionate  dosage,  or  in  combination  with  phenacetin  and 
salol.  The  latter  has  the  advantage  of  controlling  to  a  degree  the  febrile  move- 
ment. The  author  has  seen  but  little  advantage  from  the  time-honored  appli- 
cation of  iodine  to  the  chest,  nor  has  he  seen  much  result  from  the  internal 
administration  of  the  iodide  of  potassium.  The  latter  is  apt  to  disturb  the 
stomach,  which  at  this  time  has  largely  to  be  depended  upon  to  maintain 
nutrition.  The  author  would  also  advise  against  the  use  of  external  blisters  of 
all  kinds,  if  for  no  other  reason  than  the  unnecessary  pain  which  these  agents 
cause,  and  from  the  danger  of  infection  in  a  weakened  constitution  if  the  skin 
be  broken. 

When  there  is  a  moderate  effusion  of  a  serous  character,  even  though  this 
effusion  contain  micro-organisms,  yet  if  there  is  still  no  tendency  to  turbidity, 
it  is  quite  proper  to  make  an  attempt  to  favor  absorption.  Therefore,  without 
weakening  the  patient,  care  should  be  taken  that  the  bowels  are  freely  opened 
from  day  to  day,  while  the  strength  of  the  heart  must  be  maintained.  The 
most  useful  combination  of  druors  in  these  cases  is  one  of  dio:italis  and  calomel. 
There  is  undoubtedly  a  very  firm  foundation  for  the  belief  that  activity  of  the 
kidneys  will  diminish  a  pleural  effusion  which  is  not  due  to  renal  or  cardiac 
disease.  The  fluid  extract  of  digitalis  should  be  used,  in  proportionate  dosage, 
in  a  separate  mixture,  whereas  the  calomel  may  be  used  in  powder  form.  The 
author  generally  gives  both  together.  The  supporting  effect  of  digitalis  upon 
the  circulation  is  aided  by  the  diuretic  effect  of  the  calomel.  Large  doses  of  the 
latter  drug  are  unnecessary;  small  doses  should  be  used  at  first  and  increased, 
given  at  three-hour  intervals.  Salivation,  or  even  dosage  to  its  limit,  is 
injurious. 

Where  the  chest  is  full  of  an  exudate  which  is  quite  clear,  but  which  causes 
few  symptoms  of  pressure,  absorption  may  be  hastened  by  aspiration  of  a 
small  quantity  to  begin  Avith,  trusting  to  drugs  and  nature  for  the  rest.  In 
children  this  is  rarely  necessary,  so  quickly  does  the  circulation,  if  supported, 
respond  to  the  demands  made  upon  it.  There  are  cases  of  pleurisy  in  which 
a  clear  serous  exudate  of  a  pneumonic  character  may  increase  so  rapidly  and 
cause  such  dangerous  dyspnoea  and  pressure  effects,  that  within  a  short  space 
of  time  it  may  be  necessary  to  relieve  the  patient  by  aspiration.  Even  when 
aspiration  is  effectually  carried  out.  in  some  cases  reaccumulation  at  once 
occurs.  Such  exudates  are  not  turbid,  but  clear,  and  niay  contain  micro- 
organisms. If  reaccumulation  occur  in  spite  of  diuretics,  the  question  of  a 
radical  procedure  always  presents  itself  The  author  must  support  the  view 
founded  upon  experience,  that  such  cases  can  be  most  effectually  treated  by 
permanent  drainage.  The  operations  which  are  at  our  disposal  for  this  end  will 
be  taken  up  later. 

From  this  it  will  be  seen  that  the  author  regards  aspiration  as  a  palliative 
measure,  after  the  performance  of  which  the  little  patient  must  be  watched  as 
closely  as  before  the  operation.  In  children  aspiration  does  not  bear  the  same 
relative  therapeutic  value  in  pleuritis  that  it  does  in  the  adult.  Its  immediate 
performance  entails  as  much  care,  causes  as  much  anxiety,  as  a  more  radical 


PLEURISY  AND   EMPYEMA.  947 

procedure,  and  with  less  satisfactory  results.  In  most  cases  not  only  does 
reaccumulation  occur,  but  the  eiFusion,  at  first  serous,  becomes  purulent — 
not  because  it  has  been  infected  by  aspiration,  but  rather  through  the  progress 
of  the  pleuritis,  as  previously  explained.  Radical  procedure  may  therefore  be 
required  in  rapidly  reaccumulating  serous  exudates,  causing  pressure  effects, 
whether  these  contain  micro-organisms  or  are  free  from  such. 

In  small  and  large  purulent  exudates  absorption  rarely  occurs  spontaneously. 
To  temporize  with  a  purulent  exudate  is  to  harm  the  patient.  With  purulent 
exudates  we  include  also  those  serous  exudates  which  were  formerly  treated 
expectantly :  they  are  slightly  turbid,  and  contain,  to  the  eye,  a  few  flocculi, 
but,  if  examined  bacteriologically  and  microscopically,  will  be  found  to  contain 
leucocytes  and  micro-organisms.  To  temporize  with  such  so-called  serous  exu- 
dates is  to  be  finally  disappointed  in  finding  them  more  distinctly  purulent 
after  a  short  period.  In  formulating  diagnoses  we  must  remember  also  that 
exudates  which  are  in  part  purulent  tend  to  separate  into  a  serous  layer  above 
and  a  thick  purulent  layer  below.  Our  needle  may  withdraw  serum  from  a 
chest  which  contains  a  fully-developed  purulent  exudate. 

In  the  simple  aspiration  of  the  chest  we  should  be  guided  by  the  case, 
and  with  our  needle  avoid  the  proximity  of  vital  organs.  The  sixth  space 
in  front,  the  seventh  in  the  axillary  line,  and  the  eighth  behind  are  those 
generally  selected.  Yet  sometimes,  fluid  being  low  in  level,  a  change  may  be 
demanded.  The  point  of  the  needle  should  enter  near  the  upper  border  of 
the  rib,  and  should  not  be  passed  too  deeply  into  the  chest  for  fear  of  wound- 
ing the  lung. 

The  operative  procedures  which  may  be  considered  to  be  radical  in  their 
nature,  and  which  now  have  the  confidence  of  clinicians  are — incision,  with 
insertion  of  drainage-tubes ;  siphonage  of  the  pleural  sac ;  excision  of  the 
ribs  with  insertion  of  drains. 

Incision. — This  operation  is  practised  in  the  fifth  space  if  in  front,  in  the 
sixth  in  the  axillary  line,  and  if  behind,  the  ninth  space  is  chosen.  Konig 
advises  the  higher  point.  Behind  and  on  the  right  side  we  consider  the  pres- 
ence of  the  arch  of  the  liver.  The  incision  is  made  near  the  upper  border  of 
the  rib,  5  to  8  cm.  long. 

This  operation  is  popular  with  the  practitioner,  because  it  involves  but 
little  technical  skill,  and  once  the  incision  is  made,  a  drainage-tube  is  easily 
inserted.  In  children,  however,  where  the  intercostal  spaces  are  narrow,  sur- 
geons do  not  look  with  great  favor  upon  simple  incision,  for  the  reason  that  it 
is  difiicult  to  retain  a  tube  of  any  great  size  in  the  wound.  The  opposing  ribs 
are  constantly  pressing  the  sides  of  the  tube  together,  and  in  this  respect  the 
drainage  is  imperfect.  Moreover,  the  constant  movements  of  the  patient  and 
the  chest  are  apt  to  dislodge  the  tube  completely,  and  in  the  intervals  of  dress- 
ing the  wound  the  opening  into  the  pleural  cavity  becomes  distorted,  so  that 
attempts  to  replace  the  tube  give  much  pain  or  even  fail  completely.  Many 
cases  will,  however,  do  well  with  simple  incision  ;  yet  the  fact  remains  that  in 
other  cases  a  secondary  operation,  which  has  for  its  object  the  removal  of  a 
piece  of  rib,  has  to  be  performed  in  order  to  obtain  drainage.  The  author  has 
seen  cases  treated  by  incision,  and  thought  to  have  recovered,  in  which  reac- 
cumulation occurred  after  removal  of  the  tube,  and  necessitated  a  secondary 
resection  of  the  rib. 

Resection. — In  all  cases  of  purulent  exudation  it  saves  much  of  the  strength 
of  the  patient  if  efiicient  drainage  be  obtained  from  the  outset.  This  is  secured 
by  the  operation  of  resection  of  one  of  the  ribs  of  the  affected  side.  In  this  way 
sufficient  space  is  obtained  for  the  insertion  of  a  drain  of  considerable  size,  but 


948    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

this  drain  is  not  pressed  upon  by  the  adjacent  ribs,  and  is  not  generally  dis- 
placed, or,  if  displaced,  is  easily  readjusted. 

The  seventh,  eighth,  ninth,  or  tenth  rib  is  chosen,  as  demanded  by  the  indi- 
vidual peculiarities  of  each  case.  The  skin  incision  is  made  about  10  cm. 
long,  and  4  to  6  cm.  of  the  rib  is  taken  away  with  the  bone  forceps,  after  care- 
fully reflecting  the  periosteum.  The  opening  is  then  made  into  the  pleural 
space — through  the  periosteum,  or  by  a  separate  incision  which  passes  through 
the  intercostal  space  below.  The  latter  saves  the  whole  periosteum  intact,  and 
ensures  reproduction  of  the  bone  without  the  least  deformity.  As  in  simple 
incision,  the  opening  may  be  made  in  the  axillary  or  post-axillary  line,  or 
behind  in  line  with  the  angle  of  the  scapula.  On  the  right  side  the  incision  for 
resection  should  not  be  made  too  low,  as  the  arch  of  the  liver  will  eventually 
interfere  with  the  retention  of  the  drainage-tube.  After  the  rib  has  been 
resected  and  an  opening  made,  some  operators  introduce  the  finger  and  break 
up  adhesions  between  the  lung  and  chest-wall  to  free  any  encapsuled  collections 
of  pus  which  may  be  present.  This  is  to  be  deprecated,  because  in  unskilful 
hands  the  lung  itself  is  apt  to  suffer  injury. 

Irrigation  of  the  cavity  is  not  necessary  either  at  or  after  the  operation. 
Such  a  procedure  may  cause  fatal  syncope,  or,  if  not  attended  with  accident, 
certainly  does  tend  to  prolong  inflammatory  processes  going  on  in  the  chest. 
Moreover,  on  account  of  the  retention  of  some  of  the  irrigating  fluid,  an 
exudate  at  first  of  good  character  may   become  putrid. 

In  those  suppurating  pleurisies  which,  from  various  causes,  such  as  the 
perforation  of  a  gangrenous  or  tubercular  pulmonary  focus,  become  putrid, 
or  have  from  the  first  been  putrid,  irrigation  at  long  intervals  witli 
Thiersch's  solution  or  simple  boric-acid  solution  or  permanganate  of  potash  is 
admissible. 

Resection  of  the  rib  has  of  late  been  confounded  with  Estlander's  operation. 
The  latter  operation  is  one  undertaken  to  secure  retraction  of  tlie  chest-wall 
against  a  crippled  lung,  and  should  not  in  any  way  be  associated  with  the 
comparatively  simple  procedure  of  removing  an  inch  or  so  of  one  rib  to  give 
space  for  the  insertion  of  a  drain  in  ordinary  acute  purulent  pleurisies. 

Though  much  has  been  said  on  the  subject  of  valvular  drains  (Phelps), 
which  prevent  the  entrance  of  air  into  the  pleural  cavity,  and  are  sup- 
posed to  favor  expansion  of  the  lung  while  securing  complete  drainage,  there 
seems  to  be  little  gained  by  their  use.  In  the  ordinary  suppurating  pleurisies 
the  customary  surgical  dressings  seem  to  answer  very  well  in  taking  up  and 
keeping  aseptic  any  purulent  discharge  from  the  pleural  cavity.  The  free 
filtration  of  air  into  the  pleural  sac  is  not  attended  with  any  ill  effects.  It  is 
difficult  to  conceive  how  a  discharge  can  become  putrid  from  the  admission  of 
air  alone  into  the  pleura.  There  must  be  other  elements  present  to  cause  such 
a  bad  result ;  and  these  will  be  found  in  ineffectual  drainage  with  retention  of 
old  discharges  in  the  pleural  sac,  or  in  some  necrotic  focus  adjacent  to  the 
pleura  and  opening  into  it. 

It  was  formerly  customary  to  make  counter-openings  in  the  chest  to  favor 
drainage,  but  this  has  been  found  to  be  undesirable. 

Slphonage. — To  some  the  operation  of  resection  Avill  always  be  a  grave 
procedure,  and  there  lias  been  a  constant  effort  to  find  some  substitute  which 
would  be  more  satisfactory  than  simple  incision,  yet  not  so  complicated  as 
resection.  This  has  resulted  in  perfecting  an  operation  which  depends  on 
the  principle  of  siphonage,  through  negative  pressure,  to  drain  the  pleural 
cavity.  The  Buelau  operation,  to  which  reference  is  made,  consists  of  the 
introduction  of  a  drain  through  an   opening  in  the  intercostal  space  ;    this 


PLEURISY  AND    EMPYEMA.  949 

drain  is  connected  with  tubing  which  empties  into  a  siphon-bottle,  under  the 
surface  of  an  antiseptic  fluid. 

The  operation  requires  (a)  a  trocar  exactly  6  mm.  in  calibre,  fitted  with  a 
cannula ;  (h)  a  new  disinfected  Jacque  catheter,  fitted  accurately  to  the  cannula 
and  passing  through  its  lumen  with  ease,  yet  not  loosely  ;  {e)  attached  to  this 
catheter,  by  means  of  glass  tubing,  a  rubber  tubing  75  cm.  long. 

A  small  incision  is  made  in  the  skin  of  the  intercostal  space,  where  the 
trocar  is  to  enter.  The  trocar  and  cannula  are  then  inserted,  the  trocar  with- 
drawn, and  the  Jacque  catheter,  with  its  blunt  extremity  cut  squarely  off",  is 
introduced  for  about  15  centimetres  into  the  chest.  The  cannula  is  now  with- 
draAvn  over  the  Jacque  catheter,  escape  of  chest-contents  being  for  the  time 
prevented  by  pinching  the  catheter.  The  catheter  is  now  connected  with 
the  tubing,  which  is  led  into  a  bottle  filled  one-third  with  an  antiseptic  fluid. 
The  pleural  exudate  thus  escapes  into  the  bottle  beneath  the  layer  of  anti- 
septic fluid,  and  air  is  prevented  from  entering  the  chest.  Among  the 
advantages  claimed  for  this  operation  by  its  advocates  are  its  simplicity  and 
the  prevention  of  entrance  of  air  into  the  pleural  sac.  The  negative  pressure 
in  the  pleural  sac  is  also  maintained,  and  the  siphonage  favors  expansion  of 
the  lung.  The  siphoning  exudate  is  under  constant  observation  through  the 
glass  tubing  and  bottle,  and  when  recovery  sets  in  its  advent  can  be  noted  by 
the  cessation  of  the  discharge.  There  are  no  dressings  except  the  adhesive 
plaster,  which  retains  the  catheter  in  the  chest.  The  results  of  this  operation, 
especially  with  children,  in  the  hospitals  of  Hamburg  have  been  so  gratifying 
as  to  make  certain  surgeons  there  its  enthusiastic  advocates.  Scheede,  on  the 
other  hand,  fears  that  unruly  children  will  displace  the  tube  in  the  chest.  The 
advocates  of  the  siphon  method  maintain  that  this  is  not  likely  to  happen. 
Their  results  are  certainly  equal  to  those  of  surgeons  using  other  methods,  and 
should  bring  the  operation  into  favorable  notice. 


PULMONARY  EMPHYSEMA. 

By  JOHN  DORNING,  M.  D., 

New  York. 


Pulmonary  Emphysema  is  an  abnormal  accumulation  of  air  -within  the 
vesicles  or  in  the  extravesicular  connective  tissue  of  the  lungs. 

The  varieties  of  this  malady  are — I.  Interstitial,  interlobular,  or  extraves- 
icular emphysema.  II.  Vesicular  or  alveolar  emphysema,  subdivided  into  a, 
compensatory  or  vicarious  emphysema;  h,  substantive,  idiopathic,  or  hyper- 
trophic emphysema.  III.  Atrophic  emphysema.  As  this  last  form  occurs  only 
in  advanced  life,  no  further  allusion  will  be  made  to  it  here. 

I.  Interstitial  Emphysema. — In  this  condition  there  is  an  accumulation 
of  air  in  the  connective  tissue  of  the  lung.  It  is  usually  the  result  of  some 
violent  expiratory  effort,  such  as  would  occur  in  a  severe  case  of  pertussis. 
When  the  escaped  air  extends  beneath  the  pleura,  small  air-bubbles  appear  on 
the  surface  of  the  lung,  showing  the  outlines  of  one  or  more  lobules.  Some- 
times large  bullne  ai'e  seen.  In  unusual  cases  the  air  may  burrow  along  the" 
larger  bronchi  into  the  mediastinum  and  up  into  the  subcutaneous  tissue  of  the 
neck.  Interstitial  emphysema,  as  a  rule,  gives  rise  to  no  symptoms,  and  unless 
it  extend  to  the  neck  is  not  a  serious  malady. 

II.  Vesicular  or  Alveolar  Emphysema. — a.  Compensatory  Emphy- 
sema.— As  the  term  would  imply,  this  is  a  condition  in  which  the  vesicles 
of  one  portion  of  the  lung  are  abnormally  distended  in  consequence  of  the 
crippling  or  non-expansion  of  some  other  part  of  the  organ. 

Etiology. — It  is  this  form  of  emphysema  rather  than  the  substantive  form 
that  is  to  be  observed  in  young  children.  Indeed,  cases  of  typical  substantive 
emphysema  are  extremely  rare  in  early  childhood.  In  the  genesis  of  compen- 
satory emphysema  there  probably  exists  in  most  of  the  cases  as  a  predisposing 
factor  a  defect  in  the  nutrition  of  the  pulmonary  tissue.  Thus  with  the  same 
exciting  causes  in  operation  it  is  much  more  likely  to  occur  in  rachitic  subjects 
than  in  children  whose  nutrition  is  perfect.  The  immediate  causes  include  any 
mechanical  obstruction  to  free  respiration  that  would  give  rise  to  increased 
pressure  within  the  vesicles.  In  protracted  bronchitis,  particularly  when  the 
finer  bronchial  tubes  are  affected,  the  swollen  mucous  membrane  and  the  accu- 
mulation of  viscid  mucus  interfere  with  the  entrance  of  air  into  the  correspond- 
ing lobules,  causing  a  partial  or  complete  atelectasis  of  the  parts  involved. 
This  will  leave  an  unoccupied  space  in  the  chest-cavity  which  becomes  filled 
by  the  hyperdistention  of  adjacent  lobules.  This  is  the  inspiratory  theory. 
Again,  as  is  so  often  observed  in  pertussis,  in  consequence  of  obstruction  to 
the  free  egress  of  air  through  the  glottis  with  extra-violent  expiratory  efforts, 
the  retained  air  is  forced  in  the  direction  of  the  least  resistance,  the  apices  and 
anterior  borders,  causing  an  over-distention  of  the  vesicles  in  these  regions 
— the  expiratory  theory. 

In  the  vicinity  of  solidified  areas  of  lung-tissue,  as  in  pneumonia  or  tuber- 

950 


PULMONARY  EMPHYSEMA.  951 

culosis,  emphysema  is  usually  discernible.  When  one  lung  is  compressed  by 
fluid  in  the  pleural  cavity,  the  other  lung  by  reason  of  its  increased  function 
becomes  over-expanded.  Pleuritic  adhesions  that  prevent  the  normal  expan- 
sion of  the  apex  and  posterior  border  of  the  lung  necessitate  over-distention 
of  other  parts  of  the  organ,  especially  the  anterior  and  inferior  borders. 

In  addition  to  other  complications,  emphysematous  distention  of  parts  of 
the  lungs  is  to  be  found  in  membranous  croup.  In  advanced  rachitis  the  plia- 
bility of  the  ribs  and  costal  cartilages  favors  the  development  of  emphysema  in 
the  anterior  margins  of  the  lungs. 

Inflation  of  the  lungs  in  the  asphyxiated  new-born  child  by  blowing  into 
its  mouth  has  been  said  to  give  rise  to  emphysema.  Such  a  cause  must  be  quite 
exceptional,  judging  from  the  manner  in  which  lungs  that  have  been  removed 
from  the  body  collapse  after  forcible  inflation. 

Pathology. — In  the  majority  of  cases  of  compensatory  emphysema  com- 
plicating acute  bronchitis  and  pertussis  recovery  evidently  takes  place.  In 
these  cases  there  has  undoubtedly  been  simply  a  hyperdistention  of  the  pul- 
monary air-vesicles  without  any  structural  changes  in  their  walls.  The  same 
may  be  said  of  the  inordinate  inflation  of  the  lung  of  the  non-affected  side  in 
acute  pleurisy  with  eff'usion,  where  there  has  been  a  rapid  absorption  of  the 
accumulated  fluid.  .  Where  the  aff"ection  is  associated  with  tuberculous  infiltra- 
tion or  old  pleuritic  adhesions,  dilatation  of  the  air-vesicles,  with  thinning  of 
their  walls  and  other  structural  changes  characteristic  of  substantive  emphysema, 
may  be  found  to  exist.  From  this  we  may  conclude  that  the  longer  the  dura- 
tion of  the  immediate  causes  of  compensatory  emphysema,  the  more  likely  is  a 
true  emphysema  to  develop. 

SjTiiptoras. — A  diagnosis  of  compensatory  emphysema  cannot,  in  most 
instances,  be  made  either  from  the  symptoms  or  by  physical  exploration  of  the 
chest.  In  fact,  there  are  no  distinctive  signs  of  the  affection  unless  consider- 
able of  the  lung  be  involved,  and  its  existence  is  generally  assumed.  Bulging 
of  the  supraclavicular  space  during  the  severe  expiratory  efforts  of  coughing, 
and  a  falling-in  during  inspiration,  have  been  regarded  as  indicative  of  an 
involvement  of  the  apices.  Where  one  side  of  the  chest  is  filled  with  fluid  the 
hyper-resonance  of  the  opposite  side  with  the  exaggerated  vesicular  murmur 
would  suggest  the  belief  that  the  one  lung  is  performing  the  work  of  the  two, 
and  that  the  vesicles  are  abnormally  distended.  If  extensive  pleuritic  adhe- 
sions exist,  a  prolonged  low-pitched  expiratory  murmur  may  be  heard  over 
certain  portions  of  the  lung,  but  especially  at  the  anterior  border.  In  this 
latter  situation  the  same  character  of  respiration  may  be  detected  in  rachitic 
subjects  with  marked  chest-deformity. 

Treatment  will  be  considered  under  Substantive  Emphysema. 

h.  Substantive  Emphysema. — This  is  a  chronic  and  generally  incurable 
malady,  characterized  by  an  abnormal  distention  of  the  pulmonary  vesicles, 
with  structural  changes  in  their  walls. 

Etiology. — Well-marked  substantive  emphysema  in  young  children — that 
is,  under  the  age  of  ten  years — is  extremely  rare.  After  this  age  it  is  occa- 
sionally observed,  but  not  until  adolescence  is  it  encountered  with  any  fre- 
quency. Authorities  diff"er  materially  in  their  views  regarding  the  causation 
and  nature  of  this  disease.  From  the  frequency  with  which  it  is  found  to  run 
in  families  it  would,  in  a  measure,  appear  to  be  of  an  hereditary  nature.  Jack- 
son investigated  28  cases,  and  found  that  18  were  born  of  parents  one  or  the 
other  of  whom  had  suffered  from  emphysema.  Greenhow  collected  42  cases, 
23  of  which  appeared  to  be  of  an  hereditary  tendency.  The  histories  of  many 
cases  of  emphysema  in  the  adult  show  that  there  have  been  frequent  respiratory 


952    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

affections  from  early  life ;  still,  in  other  instances  where  the  disease  has  been 
extensive,  no  account  of  previous  attacks  of  bronchitis  can  be  elicited. 

Increased  air-pressure  within  the  pulmonary  vesicles,  due  to  forced  and 
long-continued  inspiration  or  expiration,  is  by  some  investigators  considered  at 
least  the  exciting,  if  not  the  primary,  cause  of  emphysema. 

According  to  the  inspiratory  theory  of  Laennec  as  modified  by  Hutchin- 
son, Traube,  and  Gairdner,  emphysema  is  a  result  of  bronchial  catarrh.  The 
presence  of  a  tumefied  mucous  membrane  and  viscid  mucus  in  the  bronchioles 
prevents  the  entrance  of  air  into  the  corresponding  lobules,  giving  rise  to  areas 
of  collapse,  and  to  fill  up  the  deficiency  so  caused  the  neighboring  lobules 
become  hvperdistended. 

The  theory  of  expiration  as  maintained  by  Jenner  and  Mendelsohn  would 
seem  to  afford  a  more  adequate  explanation,  than  does  the  inspiratory  theory, 
of  the  part  mechanical  distention  of  the  air-cells  plays  in  the  production  of 
substantive  emphysema.  During  forced  expiratory  efforts  with  a  closed  glot- 
tis, as  occurs  in  violent  attacks  of  coughinor  or  severe  straining:,  the  air  is 
driven  in  the  direction  of  the  least  resistance — namely,  the  apices  and  anterior 
borders  of  the  lungs.  It  is  in  these  situations  that  the  greatest  degree  of  dila- 
tation is  usually  found.  There  are  cases,  however,  where  the  disease  is  diffused 
throughout  the  lung,  without  a  history  of  previous  cough  or  increased 
expiratory  pressure. 

C.  J.  B.  Williams  claimed  there  was  a  fatty  degeneration  of  the  lung-tissue 
that  aided  in  bringing  about  the  pathological  changes  observed  in  emphysema. 
Fatty  matter  has  been  found  in  only  a  small  number  of  cases.  Jenner  taught 
that  the  most  frequent  anatomical  change  in  the  lung  was  fibrous  degeneration 
resulting  from  slight  but  long-continued  congestion. 

Delafield  believes  substantive  emphysema  to  be  a  chronic  inflammation  of 
the  lungs,  a  pneumonia,  and  the  dilatation  of  the  air-vesicles  a  mere  result  of 
this  inflammation,  and  not  the  essential  lesion :  the  inflammation,  he  states,  is 
of  the  same  type  as  that  which  so  often  attacks  the  endocardium,  the  inner 
coat  of  the  arteries,  the  liver,  and  the  kidneys — a  chronic  inflammation  attended 
with  the  production  of  new  fibrous  tissue,  and  at  the  same  time  with  atrophy 
and  disappearance  of  normal  tissue.  It  is  quite  evident  that  increased  air- 
pressure  within  the  vesicles  does  not  exclusively  account  for  the  presence  of 
substantive  emphysema.  Indeed,  it  seems  doubtful  if  it  can  be  considered  as 
anything  more  than  an  exciting  cause  or  as  a^o-ravatino:  the  disease  when  it  has 

111  1  oo  rz 

already  been  established.  We  think  it  may  reasonably  be  inferred  that  chil- 
dren who  suffer  with  frequent  prolonged  attacks  of  bronchitis  are  likely  to 
become  the  subjects  of  emphysema  later  in  life,  not  only  because  of  the  pul- 
monary disturbance  induced  by  the  increased  intralobular  pressure,  but  on 
account  o^"  the  existing  condition  which  predisposes  the  child  to  the  repeated 
bronchial  catarrhs  ;  for  in  such  children  there  is  unquestionably  a  vulnerability 
of  the  tissues  the  outcome  of  some  defect  in  the  nutrition. 

Pathology. — In  the  rare  cases  of  substantive  emphysema  that  occur  in 
early  life  most  of  the  changes  that  are  to  be  observed  in  the  adult  are  present, 
only  in  a  less  degree.  On  opening  the  thorax  the  lungs  do  not  collapse.  They 
have  a  peculiar  cushiony  feel  and  pit  on  pressure.  The  color  is  pale  grayish  or 
yellowish  gray.  The  air-vesicles  present  varying  degrees  of  dilatation.  *  Their 
walls  are  in  some  parts  of  the  lung  thinned,  in  others  thickened.  Coalescence 
of  neighboring  vesicles  and  obliteration  of  the  capillaries  occur  in  some  in- 
stances. The  epithelium  of  the  air-cells  presents  degenerative  changes.  In 
the  bronchial  tubes  may  be  seen  evidence  of  chronic  bronchitis,  with  dilata- 
tion of  the  bronchioles  in  some  advanced  cases.     There  may  be  some  hyper- 


PULMONARY  EMPHYSEMA.  953 

trophy  of  the  right  ventricle,  and  less  frequently  a  secondary  dilatation.  The 
secondary  lesions  of  emphysema  do  not  usually  occur  until  long  after  childhood. 

Symptoms. —  Substantive  emphysema  not  infrequently  is  present  in  the 
adult  without  giving  rise  to  any  subjective  symptoms.  This  being  the  case,  the 
more  abundant  reason  there  is  why,  with  its  less  extensive  development,  it  may 
exist  in  the  young  subject  without  thus  manifesting  its  presence.  When  rational 
symptoms  are  present,  they  resemble,  in  a  milder  form,  with  the  exception  of 
those  dependent  upon  secondary  lesions,  which  are  absent,  those  observed  later 
in  life. 

Dyspnoea  is  probably  the  most  marked  symptom.  At  first  it  may  be  expe- 
rienced only  during  unusual  exercise;  later,  it  becomes  more  constant,  and  is 
aggravated  by  even  slight  exertion,  attacks  of  bronchial  catarrh,  and  by  dis- 
tention of  the  stomach  bv  a  heartv  meal  or  bv  the  accumulation  of  gas  from 
indigestion.  Asthmatic  attacks  are  of  not  infrequent  occurrence.  OfF  and  on 
during  the  winter  there  is  more  or  less  cough. 

Physical  Signs. — Inspection. — The  typical  barrel-shaped  chest  of  emphy- 
sema is  seldom  observed  in  children.  There  may,  however,  be  a  slight  increase 
in  the  antero-posterior  diameter.  This  will  be  more  noticeable  when  associated 
with  rachitic  deformity  of  the  thorax.  Posteriorly,  the  curve  of  the  spine  may 
be  increased,  giving  the  back  a  rounded  appearance.  This  must  not  be  con- 
founded with  rachitic  curvature  of  the  spine.  There  is  some  increased  exer- 
tion in  respiration,  but  the  rigidity  of  the  chest,  due  to  ossification  of  the  costal 
cartilages,  seen  in  advanced  adult  cases  is  absent.  There  may  be  some  retrac- 
tion of  the  upper  abdominal  region,  owing  to  the  powerful  action  of  the  dia- 
phragm on  the  lower  ribs.  Jenner  has  observed  falling  in  of  the  supraclavic- 
ular region  during  inspiration  in  cases  where  the  apices  were  affected.  Fiirst 
considered  expansion  of  this  region  during  severe  cough  as  a  characteristic  sign. 

Palpation  is  negative. 

Percussion. — Pulmonary  resonance  may  remain  unaltered.  In  older  child- 
ren, when  it  is  changed,  it  is  of  a  vesiculo-tympanitic  quality.  In  young  child- 
ren the  great  elasticity  of  the  thoracic  walls  and  the  smallness  of  the  organs 
to  be  examined  favor  the  transmission  of  resonance  from  the  distended  intes- 
tines, so  that,  unless  there  be  Very  marked  distention  of  the  thoi^ax,  sufficient 
to  displace  the  liver  downward,  percussion  will  be  of  little  value.  Thus  it  is 
the  extent,  and  not  the  intensity,  of  the  pulmonary  resonance  that  is  to  be 
considered. 

Auscultation. — The  respiratory  murmur  is  usually  feeble  and  of  a  low  pitch. 
Expiration  is  prolonged.  When  bronchitis  is  present  sonorous,  sibilant,  and 
mucous  rales  are  heard.  The  heart-sounds  are  generally  clear ;  the  second 
sound  may  be  accentuated  in  older  cases. 

Prognosis. — Recovery  from  compensatory  emphysema,  if  the  malady  has 
not  existed  for  too  long  a  time,  may  be  expected.  Perfect  restoration  of  the 
lungs,  however,  w^hen  substantive  emphysema  has  once  become  established,  is 
not  to  be  looked  for.  It  never  of  itself  proves  fatal ;  still,  it  may  be  a  com- 
plicating factor  in  bringing  about  a  fatal  issue.  It  is  claimed  by  some  that  in 
cases  of  short  duration  with  but  limited  involvement  of  the  lung,  under  favor- 
able circumstances  recovery  may  take  place.  Xot  infrequently,  improvement, 
even  to  the  extent  of  an  apparent  cure,  may  be  observed,  but  later  in  life,  in 
most  instances,  it  will  be  found  to  have  been  only  temporary.  At  one  time  it 
was  erroneously  believed  that  emphysema  protected  the  subject  against  tuber- 
culosis. 

Treatment. — In  children  the  treatment  should  be  mainly  prophylactic. 
As  malnutrition  is  evidently  a  predisposing  factor,  everything  pertaining  to  the 


954    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

diet  and  hygiene,  even  from  early  infancy,  should  receive  due  consideration. 
In  this  way  the  exciting  causes  of  the  disease  may  be  prevented,  or,  should 
they  develop,  the  patient  will  be  in  a  better  condition  to  withstand  them. 

When  the  affection  is  present  it  is  infinitely  necessary  that  measures  be 
adopted  toward  the  improvement  of  the  general  health.  The  whole  body 
should  be  protected  by  woollen  underclothing.  The  cold  sponge  bath,  used 
only  to  an  extent  that  will  produce  a  proper  reaction,  is  a  general  tonic  of 
unquestionable  value.  By  maintaining  a  healthful  condition  of  the  skin  it 
lessens  the  liability  to  repeated  bronchial  catarrhs.  An  abundance  of  out-door 
air,  with  exercise  regulated  to  suit  the  physical  endurance  of  the  patient,  is  an 
essential  part  of  the  treatment.  An  equably  dry  climate  with  an  altitude  of 
not  over  a  thousand  feet  is  veiy  desirable.  The  diet  should  be  principally 
nitrogenous.  The  value  of  milk  is  too  well  appreciated  to  need  more  than 
mere  mention.  The  quantity  of  food  taken  at  one  time  should  not  be  great 
enough  to  cause  any  embarrassment  of  the  respiration.  Cod-liver  oil,  particu- 
larly if  rachitis  be  present,  should  be  administered.  When  the  pure  oil  is  given, 
begin  with  small  doses,  five  to  ten  drops  three  times  a  day,  and  increase  grad- 
ually until  a  full  teaspoonful  is  reached.  The  emulsion  of  cod-liver  oil,  either 
simple  or  in  combination  with  malt  extract,  is  in  some  cases  preferable  to  the 
plain  oil. 

In  the  way  of  medicinal  treatment  iron  in  some  form  should  be  used  when 
there  is  any  evidence  of  ansemia.  Of  the  different  preparations,  the  tincture 
of  the  pomate  is  for  children  one  of  the  most  acceptable  both  to  the  palate  and 
the  stomach.  A  child  three  years  of  age  may  be  given  from  five  to  eight 
drops  in  a  little  plain  or  sweetened  water  three  times  a  day ;  at  ten  years,  ten 
to  twenty  drops.  The  citrate  or  the  tincture  of  the  chloride  may  also  be  used. 
In  older  children  either  Basham's  mixture  or  the  ethereal  tincture  of  the  acetate 
of  iron  can  be  recommended. 

Strychnine  has  been  thought  to  possess  some  specific  virtue  in  the  treatment 
of  this  disease.  That  its  action  is  anything  more  than  that  of  a  general  tonic 
seems  doubtful.  Care  should  be  taken  in  prescribing  the  drug  for  young  chil- 
dren. Tincture  of  nux  vomica  is  a  safer  preparation,  and  may  be  administered 
in  from  one-half  to  two-drop  doses  at  six  years  of  age.  Arsenic  in  the  form  of 
Fowler's  solution,  in  from  one-half  to  two-drop  doses  at  eight  years  of  age,  is  a 
general  tonic  of  some  value. 

The  mechanical  treatment  by  compressed  air,  while  valuable  in  certain  cases 
in  the  adult,  is  less  practicable,  and  may  be  positively  harmful,  in  children. 

All  the  exciting  causes  of  compensatory  emphysema  or  those  that  aggra- 
vate the  substantive  form,  if  not  preventible,  should  be  mitigated  as  much  as 
possible. 

For  the  chronic  bronchitis  that  so  often  coexists  with  substantive  emphy- 
sema iodide  of  potassium  is  generally  recognized  as  a  drug  of  great  worth.  In 
many  cases  favorable  results  may  be  obtained  by  combining  it  with  linseed  oil, 
as  follows : 

^.  Potassii  iodidi 3ij. 

01.  lini fgiij. 

Pulv.  acaciae giij. 

01.  gaultheriae gtt.  viij. 

Syrupi flij. 

Aq.  dest q.  s.  adf|vj. — M. 

Ft.  emulsio. 
Sig.  Teaspoonful  three  or  four  times  a  day  at  ten  years  of  age. 


PULMONARY  EMPHYSEMA.  955 

Another  drug  of  marked  excellence  where  there  is  much  bronchial  secretion 
is  terebene.     At  eight  or  ten  years  of  age  it  may  be  given  thus : 

^.  Terebene fgij. 

Tinct.  opii  camph f  §ss. 

01.  menth.  pip gtt.  vj. 

Syr.  acacise q.  s.  ad  f.^iij. — M. 

Sig.  Teaspoonful  every  four  hours. 

The  treatment  of  the  complicating  asthmatic  attacks  will  be  considered  in 
the  article  on  Bronchial  Asthma. 


BRONCHIAL  ASTHMA 

By  JOHN  DORNING,  M.  D., 

New  York. 


Asthma  is  a  peculiarly  distressing  form  of  paroxysmal  dyspnoea,  accom- 
panied  by  wheezing  respiration  and  characterized  by  a  freedom  from  all  mani- 
festations of  the  affection  in  the  intervals  of  the  attacks. 

Etiology. — It  seems  to  be  generally  conceded  by  writers  on  the  subject 
that  those  who  suffer  with  asthma  inherit  a  tendency  to  the  disease.  In  many 
cases  there  is  an  ancestral  history  of  gout  instead  of  asthma.  According  to 
the  statistics  of  Thery  and  Hyde  Salter,  asthma  is  more  common  among  males 
than  females.  It  is  of  frequent  occurrence  during  childhood.  Of  Hyde  Salter's 
225  cases,  71  developed  the  disease  during  the  first  decade.  It  is  said  to  be 
more  common  in  the  upper  than  in  the  lower  walks  of  life.  In  a  certain  class 
of  cases  the  cold  season  seems  to  exert  some  predisposing  influence  on  the 
malady. 

The  exciting  causes  may  be  divided  into  those  which  act  directly  upon 
the  nervous  mechanism  of  the  lungs,  and  those  which  are  reflected  from 
more  remote  parts  or  organs. 

It  is  to  be  borne  in  mind  that  the  exciting  causes  are  only  operative  when 
there  is  a  predisposition  to  the  disease.  In  some  instances  no  definite  ex- 
citing cause  can  be  discovered.  Ursemic,  cardiac,  gouty,  saturnine,  and  mer- 
curial asthma  are  thought  to  be  the  result  of  an  irritation  of  the  respiratory 
centre  in  the  medulla  oblongata  by  vitiated  blood.  Irritation  of  the  pneumo- 
gastric  nerve  along  its  course,  as  by  the  pressure  of  enlarged  bronchial 
glands,  may  give  rise  to  paroxysms  of  asthma.  Eustace  Smith  has  rarely 
failed  to  find  evidence  of  swelling  of  the  bronchial  glands  in  the  cases  he  has 
seen  of  asthma  in  the  child.  The  enlargement  of  these  glands  is  a  result  of 
bronchial  catarrh.  The  asthma  observed  in  the  subjects  of  congenital  syphilis, 
the  so-called  sj^philitic  asthma,  can  very  likely  be  explained  by  a  syphilitic 
enlargement  of  the  bronchial  glands.  Bronchitis,  either  alone  or  associated 
with  emphysema,  is  generally  recognized  as  an  exciting  cause  of  asthma.  Such 
cases  may  be  accounted  for  either  by  a  direct  irritation  of  the  terminal  fila- 
ments of  the  pneumogastric  nerve  or  by  the  concomitant  swelling  of  the  bron- 
chial glands. 

The  inhalation  of  various  irritants,  as  dust,  the  pollen  of  plants,  smoke, 
gases,  certain  vapors,  and  the  emanations  from  certain  animals,  are  well  known 
to  excite  asthmatic  attacks.  In  this  connection  idiosyncrasy  plays  a  prom- 
inent part.  Some  individuals  are  susceptible  to  only  a  few  or  perhaps  but 
one  of  such  irritants,  and  what  will  excite  a  paroxysm  in  one  patient  will 
have  no  influence  on  another.  Thus,  one  patient  cannot  bear  the  perfume 
of  some  particular  flower,  as  the  rose,  Easter  lily,  or  heliotrope  ;  another 
cannot  tolerate  the  presence  of  a  cat,  horse,  or  dog ;  and  a  third  dare  not 

956 


BRONCHIAL   ASTHMA.  957 

encounter  the  air  of  certain  localities.  It  is  a  well-known  fact  that  a  change 
of  residence  may  either  bring  on  the  attacks  or  entirely  prevent  them.  Sudden 
changes  in  the  barometrical  pressure,  with  strong  easterly  or  northerly  winds, 
are  particularly  detrimental  to  some  asthmatics.  Indigestion,  overloading  the 
stomach,  or  the  ingestion  of  certain  articles  of  diet  not  infrequently  precipitates 
a  paroxysm.  In  some  rare  instances  intestinal  worms  are  said  to  be  an  exciting 
factor.  Asthmatic  attacks  may  be  induced  by  polypi  in  the  nose.  Volto- 
lini  of  Breslau  was  the  first  to  direct  attention  to  this  fact,  and  his  observations 
have  been  confirmed  by  later  investigators.  Hypertrophy  of  the  mucous 
membrane  over  the  turbinated  bones  and  nasal  septum  has  been  shown  by 
Daly,  Harrison,  Roe,  Allen,  Hack,  and  others,  to  be  a  source  of  reflex  irrita- 
tion in  provoking  paroxysms  of  asthma,  more  especially  hay  asthma.  Skin 
eruptions,  notably  eczema  and  urticaria,  have  been  included  in  the  category 
of  exciting  causes.  West  has  "  never  known  eczema  to  be  very  extensive  and 
very  long  continued  without  a  marked  liability  to  asthma  being  associated  with 
it."  Cases  have  been  observed  where  asthma  and  eczema  have  coexisted  or 
alternated  with  each  other,  and  the  cure  of  one  has  been  coincident  with  recov- 
ery from  the  other.  It  would  seem  not  unreasonable  to  assume  that  where 
urticaria  or  eczema  and  asthma  coexist  or  alternate  with  each  other,  instead  of 
there  existing  a  reciprocally  etiological  relation  between  the  two,  both  are 
dependent  upon  some  common  cause. 

Pathology. — Thus  far,  no  well-defined  post-mortem  alterations  have  been 
discovered  that  would  place  the  pathology  of  bronchial  asthma,  if  it  really  be 
a  distinct  affection  and  not  merely  a  symptom,  without  the  domain  of  specu- 
lation. There  is  a  number  of  theories  regarding  the  nature  of  this  affection, 
the  most  plausible  of  which  are  : 

1st.  That  it  is  due  to  spasm  of  the  bronchial  muscles — the  most  popular 
theory  at  the  present  time.  This  theory  is  based  upon  the  experiments  of 
Williams  and  Longet,  who,  after  the  discovery  of  muscular  tissue  in  the  walls 
of  the  finer  bronchi  by  Reisseisen,  found  that  electrical  irritation  of  the  lungs 
and  pneumogastric  nerve  produced  contraction  of  the  bronchial  tubes.  Among 
the  advocates  of  this  theory  are  Romberg,  Bergson,  Trousseau,  Hyde  Salter, 
Paul  Bert,  and  Biermer. 

2d.  The  next  theory,  and  one  having  many  supporters,  is  that  the  dyspnoea 
is  due  to  a  sudden  tumefaction  of  the  bronchial  mucous  membrane  with  exuda- 
tion, the  result  of  turgescence  of  its  blood-vessels  caused  by  the  action  of  the 
vaso-motor  nerves  (Weber),  fluctionary  hypersemia  (Traube).  Stoerck  adopted 
this  theory  from  having,  during  the  paroxysm,  observed  with  the  laryngoscopic 
mirror  an  acute  hypersemia  of  the  laryngeal  and  tracheal  mucous  membrane, 
which  disappeared  after  the  attack  had  subsided,  and  he  consequently  inferred 
that  the  same  condition  existed  in  the  smaller  bronchial  tubes. 

3d.  Another  view  regarding  the  nature  of  this  malady  is  that  it  is  depend- 
ent upon  a  catarrh  of  the  bronchioles  (bronchiolitis  exudativa).  This  theory 
is  based  on  the  presence  in  the  sputum  of  certain  peculiar  spiral  structures 
described  by  Curschmann  (Fig.  1). 

Leyden  discovered  in  the  sputum  of  asthmatics  certain  elongated  octahedral 
crystals  (Fig.  1),  which  he  believed,  by  their  irritation  of  the  terminal  nerve- 
filaments  in  the  bronchial  mucous  membrane,  induced  bronchial  spasm.  These 
crystals  have  been  found  in  pneumonic  expectoration,  and  hence,  while  not 
pathognomonic,  they  may  be  of  some  dia,gnostic  value  in  differentiating 
bronchial  asthma  from  other  forms  of  dyspnoea. 

Symptoms. — In  the  majority  of  instances  the  asthmatic  attack  occurs 
without  any  premonition  whatever ;  sometimes,  however,  certain  sensations  are 


958    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

experienced  which  to  those  who  have  previously  suffered  are  pretty  sure  evi- 
dence of  an  approaching  paroxysm.  The  premonitory  symptom  may  be  a 
depression  or  exaltation  of  spirits,  a  chilly  feeling,  a  sense  of  constriction  of 
the  chest  or  throat,  flatulent  distention  of  the  abdomen,  itching  of  the  skin, 

Fig.  1. 

Curschmann's  Spirals  and  Leyden's  Crystals  (Strumpell). 

the  voiding  of  a  large  quantity  of  clear  urine,  or  some  other  functional  dis- 
turbance peculiar  to  the  individual.  Not  infrequently  an  acute  catarrh  of  the 
upper  air-tract  precedes  the  attack. 

The  paroxysm  generally  comes  on  after  the  patient  has  retired  for  the 
night ;  still,  it  may  occur  at  any  hour  of  the  day.  It  commences  with  the 
characteristic  wheezing,  and  soon  the  patient  is  awakened  by  a  distressing  sense 
of  lack  of  breath,  which  becomes  more  and  more  urgent  until  he  is  finally 
compelled  to  assume  a  position  that  will  facilitate  an  easier  entrance  of  air  into 
his  lungs.  He  may  sit  up  in  his  bed  or  in  his  chair,  with  his  hands  grasping 
his  knees,  his  shoulders  elevated,  and  his  head  thrown  backward,  so  that  all 
the  muscles  of  respiration  and  their  auxiliaries  may  act  to  greatest  advantage ; 
or,  he  may  find  greatest  relief  by  kneeling  before  his  cot  or  chair  with  his  head 
resting  on  his  hands  or  a  pillow.  Often  the  desire  for  breath  is  so  pressing 
that  the  sufferer  will  rush  to  an  open  window  in  the  hope  of  obtaining  relief. 
The  face  assumes  an  anxious  expression,  pallid  at  first,  and  as  the  dyspnoea 
increases  changing  to  a  dusky  bluish  hue.  The  eyes  are  prominent  and  have  a 
staring  expression,  the  nostrils  are  widely  dilated,  and  the  mouth  is  partly  open. 
The  skin  becomes  moistened  with  perspiration  as  the  distress  increases.  The 
respiration,  particularly  expiration,  is  noisy  and  wheezing,  and  may  be 
heard  in  the  adjoining  apartment.  Inspiration  is  short  and  jerky,  expiration 
very  much  prolonged.  The  number  of  respirations  is  seldom  much  increased, 
and  may  be  even  less  than  normal.  Speech,  beyond  monosyllables,  is  impossi- 
ble. Notwithstanding  the  laborious  efforts  in  breathing  there  is  merely  an  up- 
and-down  movement  of  the  ribs,  with  but  little  or  no  expansion,  the  thorax 
being  fixed  in  the  position  of  full  inspiration.  The  pulse  is  small,  rapid,  and 
thready  in  proportion  to  the  intensity  of  the  dyspnoea.  There  is  no  elevation 
of  the  temperature.  If  the  attack  be  prolonged,  the  surface  temperature  falls 
below  normal,  the  extremities  become  cold,  clammy,  and  bluish,  and  death 
seems  imminent. 

As  the  paroxysm  subsides  there  is  more  or  less  cough  and  expectoration, 
whether  they  have  previously  existed  or  not.  In  some  cases  the  expectoration 
consists  of  rounded  masses  of  tenacious  mucus ;  in  others  it  is  profuse  and 
watery.  Sometimes  streaks  of  blood  are  found.  In  some  rare  and  severe 
cases  haemoptysis  has  been  known  to  occur. 


BRONCHIAL   ASTHMA.  959 

After  the  paroxysm  there  is  usually  considerable  exhaustion,  and  the  patient 
soon  falls  asleep.  On  awakening,  with  the  exception  of  a  little  soreness  of  the 
respiratory  muscles,  no  discomfort  is  experienced,  and  the  patient  afterward 
enjoys  his  usual  health. 

The  duration  of  the  attack  may  vary  from  a  few  hours  to  several  days,  with 
remissions  and  exacerbations.  The  paroxysms  vary  in  frequency.  They  may 
recur  as  often  as  once  a  week  or  there  may  be  an  interval  of  months  between 
them.  Ordinarily  there  is  no  regularity  in  the  recurrence  of  the  attacks.  A 
periodicity,  however,  is  sometimes  noticed,  and  is  probably  due  to  some  con- 
dition operative  only  at  particular  times. 

Physical  Sigxs. — During  the  paroxysm  inspection  shows  an  expanded  and 
barrel-shaped  thorax,  with  but  little  respiratory  motion.  Inspiration  is  short 
and  quick,  expiration  prolonged  and  violent.  On  percussion  more  or  less 
hyper-resonance  is  obtained:  in  mild  cases  it  is  slight,  but  when  the  attack  is 
severe  and  of  long  duration  it  is  usually  quite  marked.  Auscultation  reveals, 
in  severe  cases,  diminution  or  suppression  of  the  vesicular  murmur. 

In  mild  attacks  the  respiratory  murmur  may  be  exaggerated  and  jerky. 
All  over  the  chest  may  be  heard  an  ever-changing  variety  of  sonorous  and  sib- 
ilant r^les.  They  are  piping,  cooing,  wheezing,  and  often  musical  in  their 
nature.  They  are  louder  during  expiration.  Toward  the  close  of  the  parox- 
ysm moist  rales  are  to  be  heard,  or,  if  bronchial  catarrh  exists,  they  may  be 
detected  from  the  beginning  of  the  attack. 

Prognosis. — Uncomplicated  asthma  is.  per  se,  rarely  if  ever  fatal.  In 
general  the  prognosis  is  better  in  young  subjects  than  in  adults.  Hyde  Salter 
makes  the  statement  that  "in  young  asthmatics  the  tendency  is  almost  invariably 
toward  recovery."  The  prognosis  may  be  said  to  be  favorable  when  the  attacks 
are  dependent  upon  some  removable  cause,  when  mild  and  occurring  at  long 
intervals,  when  there  is  no  hereditary  predisposition,  and  when  there  is  freedom 
from  complications. 

Diagnosis. — The  rational  and  physical  signs  of  an  uncomplicated  paroxysm 
of  asthma  are  so  distinctive  that,  if  properly  appreciated,  there  should  be  little 
or  no  difficulty  in  reaching  a  correct  diagnosis. 

The  affections  which  it  is  thought  may  possibly  be  mistaken  for  bronchial 
asthma  are  the  various  forms  of  obstruction  in  the  upper  air-passages,  as  for- 
eign bodies  in  the  throat:  retro-pharyngeal  abscess;  diphtheritic  and  false 
croup;  oedema  of  the  glottis ;  neoplasms  of  the  larynx ;  spasmodic  contraction 
of  the  adductors  of  the  larynx  or  paralysis  of  the  abductors ;  tracheal  stenosis 
or  foreign  body  in  one  or  the  other  of  the  main  bronchi ;  bronchitis,  pneu- 
monia; emphysema;  pulmonary  oedema;  pleuritic  effusion;  cardiac  disease; 
urgemia,  and  spasm  of  the  diaphragm. 

In  obstructive  dyspnoea  from  any  cause  the  difficulty  in  breathing  is 
during  inspiration,  while  in  asthma  it  is  during  expiration.  There  is  also 
inspiratory  recession  at  the  episternal  notch  and  epigastrium  not  observed 
in  asthma.  In  the  former  there  is  the  absence  of  wheezing  in  the  chest, 
and  the  dyspnoea  is  continuous  instead  of  paroxysmal,  as  in  asthma.  Changes 
in  the  quality  of  the  voice  will  exclude  the  latter  affection.  Examination  of 
the  throat  with  the  finger  or  mirror  will  enable  one  to  determine  the  exact 
nature  of  the  obstruction.  Occlusion  of  a  main  bronchus  will  cause  a 
diminished  intensity  or  absence  of  the  respiratory  murmur  on  the  affected 
side.  The  dyspnoea  of  bronchitis  and  pneumonia  comes  on  gradually  and 
is  attended  with  some  degree  of  fever ;  the  respirations,  particularly  in 
pneumonia,  are  rapid  and  often  short  and  catching.     In  asthma  the  onset  is 


960    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

more  sudden,  there  is  no  elevation  of  temperature,  and  the  respirations  are 
either  but  slightly  or  not  at  all  increased  in  frequency. 

Some  difficulty  may  be  experienced  in  distinguishing  between  emphysema 
and  asthma  on  account  of  their  frequent  coexistence.  Each  may  induce  the 
other.  Emphysema  more  often  exists  without  asthma  than  does  the  latter 
affection  without  some  degree  of  the  former.  In  emphysema  the  dyspnoea  is 
remittent  rather  than  intermittent  as  in  asthma.  It  is  aggravated  by  physical 
excitement,  and  hence  is  more  likely  to  occur  during  the  day  than  at  night.  In 
pulmonary  oedema  the  increased  frequency  of  the  respiration,  with  perhaps 
some  dulness  on  percussion,  the  presence  of  large  and  small  moist  rales  all  over 
the  chest,  the  profuse  and  watery  expectoration,  and  the  absence  of  wheezing 
will  ordinarily  distinguish  it  from  asthma.  In  pleuritic  effusion  the  usual  dul- 
ness on  percussion,  the  limitation  of  the  diminished  respiratory  murmur  to  the 
area  occupied  by  the  fluid,  the  detection  of  aegophony,  and  the  absence  of  the 
characteristic  dry  rales  of  asthma  will  suffice  for  a  diagnosis. 

Cardiac  asthma  is  not  very  common  in  children.  It,  however,  resembles 
bronchial  asthma  in  that  it  may  be  paroxysmal  in  nature,  intense  in  degree, 
and  may  come  on  at  night.  It  generally  follows  cardiac  excitement.  The 
absence  of  the  varied  musical  sounds  in  the  chest  and  of  the  prolonged  expira- 
tion, and  the  presence  of  a  cardiac  lesion  capable  of  inducing  dyspnoea,  will 
be  of  some  assistance  in  distinguishing  the  one  from  the  other. 

Dyspnoea  due  to  uraemia  need  never  be  confounded  with  bronchial  asthma 
if  the  precaution  is  taken  to  examine  the  urine  of  every  case  coming  under 
observation. 

Spasm  of  the  diaphragm  may  be  distinguished  from  asthma  by  the  sudden, 
abrupt  inspiration,  the  hiccough,  and,  after  a  few  seconds,  the  quick,  violent 
expiratory  effort. 

Treatment. — The  treatment  of  asthma  comprises  the  management  of  the 
paroxysm  and  the  treatment  of  the  patient  in  the  intervals  between  the  attacks. 
If  possible,  the  exciting  cause  should  be  discovered  and  removed.  For  instance, 
if  clearly  dependent  upon  an  overloaded  stomach  or  the  presence  of  some  indi- 
gestible substance  in  the  alimentary  canal,  an  emetic  or  an  enema  will  afford 
prompt  relief.  To  relieve  the  patient  during  the  attack,  in  the  absence  of  any 
apparent  and  removable  cause,  it  generally  becomes  necessary  to  have  recourse 
to  some  sedative  or  depressant.  The  numerous  drugs  recommended  vary  so  in 
their  action  upon  different  subjects  that  not  infrequently  a  number  have  to  be 
tried  before  the  one  is  found  that  gives  the  greatest  relief.  The  one  drug  that 
is  most  frequently  successful  in  cutting  short  the  paroxysm  is  morphine  admin- 
istered subcutaneously.  In  young  children,  however,  it  is  rarely  necessary  to 
use  it,  as  some  one  of  the  remedies  to  be  mentioned  will  usually  be  found  to 
be  sufficiently  effective.  In  later  childhood,  if  given,  the  greatest  caution 
should  be  observed,  as  children  are  markedly  susceptible  to  the  toxic  influence 
of  morphine.  To  a  child  ten  years  of  age  from  -^  to  ^^  of  a  grain  of  the  sul- 
phate, combined  with  2-5-0  ^^  ^  grain  of  atropine  sulphate,  may  be  given  hypo- 
dermatically.  Next  to  morphine  in  abating  the  asthmatic  paroxysm  comes 
chloroform.  The  relief  is  speedy,  but  often  only  temporary,  so  that  repeated 
inhalations  are  usually  required.  In  the  writer's  experience  chloral  hydrate  is 
superior  to  chloroform  at  any  period  of  childhood,  in  that  its  effects,  though 
less  prompt,  are  more  lasting.  At  five  years  of  age  5  grains  dissolved  in  at 
least  1  drachm  of  some  simple  menstruum,  may  be  given,  and  repeated  in  forty 
minutes  if  there  be  no  abatement  of  the  dyspnoea.  If  it  cannot  be  taken  by 
the  mouth,  10  to  15  grains  dissolved  in  half  an  ounce  of  water  may  be  injected 
into  the  rectum. 


BRONCHIAL  ASTHMA,  961 

The  fumes  of  nitre-paper  (charta  potassii  nitratis),  a  very  popular  remedy, 
will  often  cut  short  a  mild  attack  and  give  considerable  relief  in  a  severe 
one;  sometimes  it  has  no  effect  at  all.  The  remedy  is  prepared  by  dip- 
ping a  sheet  of  absorbent  paper  into  a  saturated  solution  of  nitrate  of  potas- 
sium and  afterward  drying  it ;  the  dried  paper  is  then  cut  into  pieces  of 
the  required  size  and  is  ready  for  burning.  The  patient  should  be  placed  in  a 
small  room  or  in  some  kind  of  an  extemporized  tent,  so  that  he  can  inhale  the 
fumes  of  the  burning  paper.  It  acts  promptly  if  at  all,  at  first  exciting  some 
cough,  but  in  a  few  minutes  alleviating  the  distress. 

Inhalation  of  the  smoke  of  Datura  stramonium  and  Datura  tatula  is  often 
serviceable.  In  young  subjects  it  must  be  used  with  care,  and  the  inha- 
lation stopped  as  soon  as  the  sight  or  intellect  becomes  confused.  Lobelia  and 
belladonna,  either  separately  or  combined,  are  beneficial  in  some  cases. 

Tobacco,  while  an  excellent  remedy  in  adult  cases,  is  too  powerful  a  depress- 
ant to  be  recommended  in  children.  The  nitrite  of  amyl  and  nitro-glycerin  do 
good,  but  they  have  not  yielded  such  results  as  would  be  expected  from  our 
knowledge  of  their  physiological  action.  If  used  at  all  in  children,  they  must 
be  given  with  due  caution.  Quebracho  and  Grindelia  robusta  have  been  advo- 
cated, but  their  action  is  uncertain. 

Iodide  of  ethyl  is  thought  to  be  efficacious  (Germain  S^e).  Eight  to  twelve 
drops  by  inhalation  is  a  fair  dose  at  eight  years.  Pilocarpine,  ^  to  ^^q-  of  a  grain 
hypodermatically  at  five  years,  has  been  advocated  by  Berkart.  Cofiee  and 
alcohol  are  useful  in  the  adult ;  but  it  is  questionable  if  it  would  be  wise  to 
have  recourse  to  them,  particularly  the  latter,  in  children. 

Intense  niental  emotion,  as  a  sudden  alarm  or  a  pleasurable  surprise,  will 
frequently  at  once  check  an  asthmatic  paroxysm. 

During  the  intervals  of  the  attacks  every  effort  should  be  made  to  discover 
and  remove  the  exciting  cause.  Hypertrophied  turbinated  bodies  should  be 
reduced,  nasal  polypi  extirpated,  adenoid  growths  in  the  naso-pharynx  removed, 
and  catarrh  of  any  part  of  the  respiratory  tract  relieved  by  appropriate  meas- 
ures. Particular  attention  should  be  given  to  the  diet,  especially  when  the 
asthmatic  attacks  bear  any  relation  to  the  state  of  the  digestion.  As  a  rule, 
it  is  best  to  allow  only  a  light  and  easily-digested  supper,  and  that  early  enough 
in  the  evening  to  be  digested  and  passed  from  the  stomach  before  retiring. 

When  there  is  no  apparent  exciting  cause  the  general  condition  of  the 
patient  requires  attention.  The  value  of  an  out-door  life,  in  the  open  country 
if  possible,  the  daily  cold  sponge-bath,  the  protection  of  the  body  by  suitable 
clothing,  and  a  nutritious  diet  in  the  asthmatic  subject  is  too  well  appreciated 
to  require  more  than  mere  mention.  All  those  afi'ections  that  directly  or 
indirectly  cause  enlargement  of  the  bronchial  glands  are  to  be. most  sedulously 
guarded  against.  Cod-liver  oil,  beginning  with  small  doses  and  gradually 
increasing,  should  be  administered  in  most  cases.  Iron  is  frequently  indicated. 
The  tincture  of  the  pomate  of  iron  in  from  5-  to  10-drop  doses  at  five  years  of 
age  is  an  acceptable  and  easily-digested  preparation  for  children.  The  tincture 
of  the  chloride  or  the  syrup  of  the  iodide  may  be  given  if  the  digestion  be  good. 
In  many  cases  arsenic  renders  good  service.  It  is  best  administered  in  the 
form  of  liquor  potassii  arsenitis  (Fowler's  solution),  beginning  at  the  age  of 
five  years  with  1  drop  in  water  three  times  a  day,  and  increasing  gradually  to 
4  or  6  drops.  On  the  supervention  of  toxic  symptoms  the  drug  should  be  dis- 
continued for  a  time. 

Iodide  of  potassium  is  lauded  as  possessing  some  special  beneficial  action  in 
asthma.  If  given  to  the  point  of  tolerance  and  continued  for  a  long  period  of 
time,  it  often  yields  good  results.     In  some  cases,  however,  it  utterly  fails. 

61 


962    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Quinine  and  strychnine  have  their  respective  advocates.  The  former  will  prove 
valuable  where  there  is  a  malarial  complication.  In  small  doses  they  are  both 
tonics. 

Change  of  climate  or  locality  will  relieve  some  patients.  Asthma  is  such  a 
capricious  malady  that  it  would  be  next  to  impossible  to  select  any  particular 
locality  and  guarantee  immunity  from  the  attacks.  Some  city  patients  are 
benefited  by  removal  to  the  country,  those  living  in  the  country  by  going  to 
the  city,  dwellers  at  the  sea-coast  by  a  change  to  the  interior,  and  those  living 
inland  by  a  residence  at  the  sea-board.  The  fact  of  the  matter  is,  each  patient 
must  select  his  own  climate. 


FIBROID  PHTHISIS. 

By  FREDERICK  C.  SHATTUCK,  M.  D., 

Boston. 


This  affection — otherwise  known  as  chronic  pneumonia,  interstitial  pneu- 
monia, cirrhosis  of  the  lung,  or  fibroid  induration  of  the  lung — is  a  process 
not  uniform  in  origin,  generally  unilateral,  very  chronic  in  course,  resulting 
in  the  substitution  of  connective  for  pulmonary  tissue  in  a  more  or  less  con- 
siderable area,  usually  associated  with  bronchial  dilatation,  and  often,  at  some 
period  in  the  case,  with  tuberculosis. 

Etiology. — This  condition — for,  in  the  great  majority  of  cases  at  least,  it 
is  a  condition  rather  than  a  disease — is  not  very  common  at  the  best,  and  is, 
in  its  fully-developed  form,  very  rare  in  children,  though  its  origin  may  date 
back  to  childhood.  Of  30  fatal  cases  with  autopsy  collected  by  Bastian  in 
Reynolds's  System  of  Medicine,  only  2  were  under  fifteen  years  of  age,  3  from 
fifteen  to  twenty,  while  more  than  one-half  of  the  cases  succumbed  between 
twenty  and  forty.  The  age  of  both  children  was  seven  years,  and  one  of 
them  was  reported  by  Sir  D.  Corrigan  in  his  original  paper  on  "  Cirrhosis 
of  the  Lung,"  published  in  1838  in  the  Dublin  Journal.  In  Wilson  Fox's 
great  posthumous  work  on  "Diseases  of  the  Lung  and  Pleura"  will  be  found 
references  to  other  cases  in  children. 

That  the  affection  should  be  rare  in  children  is  not  surprising,  inasmuch  as 
inflammation,  like  nutrition,  in  the  young  is  a  more  active  process  than  in 
adults,  and  is  less  likely  to  lead  to  the  formation  of  organizable  products  than 
in  later  life.  The  power  of  complete  repair  is  also  greater  in  children,  and  in 
them,  if  recovery  takes  place,  it  is  less  likely  to  leave  permanent  or  progressive 
changes  behind.  The  literature  of  the  subject  would  seem  to  show  that  in 
children  pneumonia  and  broncho-pneumonia  are  the  affections  which  are  m(^st 
apt  to  be  followed  by  fibroid  changes  in  the  lung.  Of  the  two,  the  latter  is 
probably  the  more  frequent  antecedent.  That  simple  bronchitis  may  pave  the 
way  to  connective-tissue  growth  seems  probable.  It  is  certain  that  pleurisy 
may  do  so,  though  this  origin  is  probably  more  frequent  in  adults.  The  thick 
false  membranes  may  then  serve  as  the  starting-point  for  a  growth  of  connective 
tissue  into  the  contracted  lung  itself,  while  bronchiectasis  gradually  comes 
about  as  a  result  of  frequent  cough,  and  also  as  a  means  of  equalization  of  the 
atmospheric  pressure  within  and  without  the  chest.  Other  things  being  equal, 
the  older  the  person  the  more  rigid  the  chest-wall  and  the  less  can  it  collapse. 
The  space  which  the  firm  adhesions  prevent  the  lung  from  reoccupying  must 
thus  be  filled  in  a  measure  by  dilatation  of  the  bronchi,  of  some  of  the  air- 
vesicles,  and  even  of  the  blood-vessels  and  lymphatics. 

There  is  another  sequence  of  events  which  is  certainly  more  common  in 
adults,  if  indeed  it  ever  occurs  in  children.  The  arrest  of  an  ordinary  ulcer- 
ating pulmonary  tuberculosis,  with  the  formation  of  abundant  connective-tissue 
growth  in  which  the  bacilli  are,  as  it  were,  bottled  up,  is  here  alluded  to.  The 
writer  has  seen  some  conspicuous  examples  of  this.    The  report  of  one  of  them, 

963 


964    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

with  autopsy,  may  be  found   in  the   Boston  Medical  and  Surgical  Journal, 
1880. 

The  fibroid  phthisis  which  results  from  irritation  by  particles  of  dust,  as 
in  miners,  grinders,  painters,  and  the  like,  is  not  apt  to  be  encountered  in 
children,  and  is  a   bilateral  aifection. 

The  view  is  expressed  by  Striimpell,  Osier,  and  other  recent  writers  that 
most  cases  of  fibroid  phthisis  either  are  or  have  been  tuberculous.  That  this 
is  true  of  some  cases  there  can  be  no  question ;  but  further  investigation  is 
needed  to  enable  us  to  determine  how  large  the  proportion  is,  or  whether, 
indeed,  such  destructive  processes  ever  go  on  without  the  aid  of  the  tubercular 
bacillus.  That  many  of  the  inflammations  of  serous  membranes,  including 
the  pleura,  formerly  believed  to  be  simple  or  due  to  exposure  to  cold,  are  really 
tubercular,  seems  now  to  be  well  established.  And  the  origin  of  some  of  these 
cases  of  fibroid  phthisis  in  pleurisy  has  been  already  alluded  to.  The  dis- 
covery of  the  true  criterion  of  tuberculosis  is  still  too  recent  to  permit  the 
accumulation  of  sufficient  positive  evidence  to  establish  the  relation  of  fibroid 
phthisis  and  pulmonary  tuberculosis.  In  the  older  reports,  if  no  miliary 
tubercles  or  caseous  masses  were  found  after  careful  search,  the  case  was  classed  as 
non-tubercular.  I  have  not  met  with  any  reports  of  thorough  microscopic  ex- 
amination of  these  cases  of  late  years.  But  we  have  learned  since  Koch's 
great  discovery  more  than  we  knew  before  as  to  the  multiplicity  of  the  lesions 
following  the  local  and  general  action  of  his  bacillus,  and  also  more  as  to  their 
frequent  self-limitation,  and,  indeed,  curability. 

Pathological  Anatomy. — The  striking  morbid  feature  of  this  aifection 
is  the  presence  of  connective  tissue  in  the  lung  with  corresponding  destruction 
of  the  true  parenchyma.  The  changes  are  generally  unilateral,  and  may  be  so 
even  when  the  primary  process — broncho-pneumonia,  for  instance — is  essen- 
tially bilateral.  The  lower  are  more  frequently  affected  than  the  upper  lobes. 
Bands  of  fibrous  tissue  may  traverse  the  aff'ected  part,  and  these  bands  are, 
for  obvious  reasons,  less  likely  to  be  pigmented  in  the  young  than  in  adults.  Or 
the  distribution  of  the  connective  tissue  may  be  more  uniform,  producing  an 
appearance  which  has  been  compared  to  that  of  the  uterus  after  delivery.  Peri- 
bronchitic  thickening  is  practically  always  present  to  a  greater  or  less  degree, 
as  is  also  bronchial  dilatation,  resulting  in  the  formation  of  cavities  of  greater 
or  less  size. 

»  Another  mode  in  Avhich  cavities  are  formed  or  increased  in  size  is  through 
ulceration,  the  accompaniment  of  the  growth  of  tubercular  bacilli  or  the 
result  of  the  irritation  of  retained  and  decomposing  secretion,  or  both  at  once. 
Miliary  tubercles,  caseous  masses,  or  calcified  deposits  may  be  seen  by  the 
naked  eye.  The  microscope  may  reveal  tubercular  bacilli  in  active  growth  in 
the  secretion  or  the  tissues,  or  safely  imprisoned  within  the  connective  tissue. 
Here  and  there  within  the  diseased  portions  there  may  be  macroscopic  or  mi- 
croscopic islets  of  relatively  normal  or  of  emphysematous  lung-tissue.  The 
microscope  may  also  demonstrate  within  the  indurated  lung  or  the  thickened 
pleura  dilated  blood-  and  lymphatic-vessels. 

The  affected  lung  may  be  moderately  or  very  greatly  diminished  in  size, 
with  corresponding  contraction  of  the  chest,  approximation  of  the  ribs,  droop 
of  the  shoulder,  and  twist  of  the  vertebral  column. 

The  pleura  is  rarely  if  ever  spared ;  it  may  contain  an  encapsulated  collection 
of  fluid,  more  probably  sero-fibrinous.  Adhesions  vary  considerably  in  thick- 
ness and  density  ;  they  may  be  cartilaginous,  and  so  firm  that  the  lung  must  be 
cut  out  of  the  chest  at  the  autopsy.  It  seems  reasonable  to  suppose  that  when 
the  process  started  in  the  pleura  the  thickening  of  that  membrane  is  more  con- 


FIBROID    PHTHISIS.  965 

spicuous  than  when  it  started  in  the  lung  itself  and  secondarily  affected  the 
pleura,  as  does  every  inflammatory  process  of  the  lung  or  of  the  chest-wall 
which  approaches  one  or  the  other  layer  of  the  serous  cavity. 

The  sound  lung,  or  sound  portions  of  both,  is  the  seat  of  compensatory 
hypertrophy  ;  perhaps  of  emphysema,  either  confined  to  the  edge  or  more 
widely  distributed.  Adhesive  pericarditis  is  common  as  a  result  of  extension 
of  inflammation  from  the  pleura,  especially  when  the  left  lower  lobe  is  the  seat 
of  the  disease.  The  heart  itself  is  often  more  or  less  drawn  out  of  place,  and 
the  right  chambers  are  apt  to  be  dilated  and  hypertrophied  in  extensive  disease 
of  long  standing,  in  consequence  of  the  augmented  internal  pressure  to  which 
the  cavities  are  subjected  by  reason  of  the  increased  resistance  in  the  pulmo- 
nary circulation.  If  compensation  has  failed  in  the  right  ventricle,  the  common 
secondary  results  of  such  failure  are  shown  by  general  and  visceral  venous 
stasis. 

Symptoms  and  Course. — Cough  and  expectoration  are  practically  con- 
stant, though  they  vary  widely  in  degree  and  severity  in  different  cases  or  in 
the  same  case  at  different  times.  The  character  of  the  expectoration  is  not 
distinctive.  If  notable  cavities  of  bronchiectatic  or  other  origin  are  present, 
their  existence  may  be  suggested  by  a  more  or  less  periodically  profuse  ex- 
pectoration, by  profuse  expectoration  in  certain  positions  of  the  body,  or  by 
the  separation  of  the  sputum  on  standing  into  an  upper  frothy,  a  middle 
serous,  and  a  lower  layer  of  purulent  masses.  The  presence  of  tubercle  bacilli 
is  suggestive  of  a  recent  infection  from  without  or  of  a  fresh  outbreak  from 
within.  If  ulceration  is  going  on,  elastic  fibres  may  be  found.  Haemoptysis 
is  extremely  common,  is  often  repeated,  and  usually  moderate  in  amount.  It 
may,  however,  as  in  ordinary  phthisis,  arise  from  a  good-sized  vessel  travers- 
ing the  wall  of  a  cavity,  and  then  be  so  profuse  as  to  be  the  immediate  cause 
of  death.  Dyspnoea  may  be  absent  while  the  patient  is  at  rest,  but  very 
marked  after  but  slight  exertion. 

Constant  fever,  with  its  attendant  emaciation  and  constitutional  disturbance, 
is  absent.  The  process  in  itself  is  not  a  febrile  one,  and  a  rise  of  temperature 
which  may  be  found  at  any  time  is  attributable  to  some  secondary  or  compli- 
cating affection.  General  nutrition  may  be  excellent,  and  the  fat  layer  notable. 
Clubbing  of  the  tips  of  the  fingers  and  toes  and  incurvation  of  the  nails  may 
be  more  marked  in  this  than  in  any  other  condition,  save,  perhaps,  congenital 
heart  defects ;  this  is  an  infallible  indication  of  chronicity.  In  a  word,  the 
appearance  of  the  patient  may  be,  in  the  main,  that  of  one  in  perfect  health, 
from  which  a  wide  deviation  is  found  to  exist  when  the  clothing  is  removed 
from  the  chest  and  a  physical  examination  is  made. 

It  does  not  seem  advisable  under  the  circumstances  to  enter  here  into  a 
detailed  account  of  the  physical  signs,  which  are  so  similar  to  those  of  a  case 
of  chronic  tuberculosis.  I  shall  therefore  briefly  touch  only  on  those  which  are 
most  striking  and  distinctive. 

Inspection  is  apt  to  show  a  disparity  in  size  and  mobility  between  the  sides 
of  the  chest ;  unilateral  shrinkage,  the  droop  of  a  shoulder,  and  curvature 
of  the  spine  reaching  their  highest  expression  in  those  cases  originating  in  or 
complicated  by  extensive  pleural  changes.  Palpation,  auscultation,  and  per- 
cussion reveal  the  presence  of  consolidated  lung  containing  secretion,  perhaps 
of  cavity  formation.  As  contrasted  with  ordinary  phthisis,  these  changes  are 
more  apt  to  be  found  at  the  base  than  at  the  apex.  Cardiac  pulsation  may  be 
visible  over  unusually  large  or  in  unwonted  areas,  according  as  retraction  of 
the  lung  away  from  the  heart,  or  adhesions  to  the  pericardium  and  retraction  of 
the  heart  itself,  or  both  together,  may  happen  to  have  operated  in  the  case  in 


966  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

hand.  Sometimes,  however,  the  heart  is  unduly  overlapped  by  the  hypertro- 
phied  healthy  lung,  and  its  pulsations  may  then  be  obscured.  Although  the 
right  heart  is  apt  to  be,  often  markedly,  hypertrophied  and  dilated,  the  fact 
that  it  is  so  must  be  often  a  matter  rather  of  inference  than  of  direct  signs  fur- 
nished by  the  examination  of  the  organ  itself.  The  explanation  of  this  fact 
lies  in  the  altered  mutual  relations  of  the  lungs  and  heart  under  the  influence 
of  the  disturbing  factors  mentioned  above.  Cardiac  murmurs  bear  no  con- 
stant relation  to  the  condition. 

If,  for  any  cause,  the  compensatory  hypertrophy  of  the  right  ventricle  fails, 
the  characteristic  evidences  of  stasis  in  the  pulmonary  and  systemic  veins  are 
superadded  to  those  of  the  underlying  condition — cyanosis,  distention  or  pul- 
sation of  the  jugulars,  anasarca,  ascites,  enlarged  or  tender  liver,  the  urine  of 
passive  renal  congestion,  and  the  like. 

The  course  of  the  aifection  is  essentially  chronic,  and,  on  the  ■whole,  pro- 
gressive, though  apparently  stationary  periods,  perhaps  of  considerable  duration, 
seem  to  occur.  Intercurrent  attacks  of  bronchitis  are  not  rare,  and  certainly 
do  nothing  to  retard  progress.  Death  may  occur  from  failure  of  the  cardiac 
compensation,  haemoptysis,  exhaustion,  or  from  intercurrent  disease. 

Diagnosis. — This  can  seldom  present  any  great  difficulties,  provided  that  a 
good  history  can  be  obtained  and  a  careful  physical  examination  be  made.  The 
combination  of  a  history  of  chronic  cough  and  expectoration,  with  repeated 
haemoptysis;  the  physical  signs  of  pronounced  lung  destruction,  usually  unila- 
teral, often  with  cavity-formation ;  and  hypertrophied  and  dilated  right  ventricle, 
with  the  maintenance  of  a  surprisingly  good  condition  of  general  nutrition, 
presents  a  picture  which  is  perfectly  characteristic.  The  very  small  respiratory 
margin  is  also  noteworthy.  Chronic  pleurisy  with  great  thickening  of  the  mem- 
brane and  contraction  of  the  side  is  perhaps  more  liable  to  give  rise  to  error 
than  any  other  aff"ection.  The  history  of  the  case,  but,  above  all,  the  signs  of 
pronounced  pulmonary  changes,  and  the  occurrence  of  haemoptysis,  are  the 
chief  aids  in  the  diff'erentiation.  The  good  general  nutrition,  the  absence  of 
fever,  and  the  duration  and  mode  of  onset  of  the  trouble  are  sufficient  to 
exclude  ordinary  pulmonary  tuberculosis.  The  thoracic  physical  signs  of 
cancer  of  the  lung  or  pleura  might  be  similar ;  but  the  course  and  duration  are 
quite  different.  Congenital  syphilis  of  the  lung  is  of  pathological  rather  than 
clinical  interest.  Acquired  syphilis  of  the  lung  is  very  rare  in  children  :  it 
is  also  rare  in  adults,  but  resembles  clinically  ordinary  phthisis  more  than  the 
fibroid  variety,  which,  moreover,  is  not  amenable  to  mercury  and  the  iodides. 

ProgTiosis. — There  can  be  no  question  that  the  expectation  of  life  is  cur- 
tailed by  this  condition.  Probably  Dr.  Oliver  Wendell  Holmes  did  not  have 
it  in  mind  when  he  said  that  the  way  to  ensure  length  of  days  is  to  acquire  an 
incurable  disease.  And  yet  its  owners  may  live  many,  many  years.  The 
danger  is  rather  from  intercurrent  disease  than  from  the  fibroid  induration  of  the 
lung  itself.  If  the  patient's  circumstances  permit,  he  will  naturally  lead  a 
more  careful  life  than  if  he  were  sound  in  all  parts.  In  a  case  of  the  writer's, 
proving  fatal  at  twenty-eight  years  of  age,  the  onset  dated  back  presumably 
to  measles  at  the  age  of  seven,  and  yet  the  patient  worked  as  a  shoeblack  in  a 
damp,  narrow,  and  sunless  alley  in  all  sorts  of  weather  until  shortly  before  his 
death  from  haemoptysis.  Had  he  been  able  to  take  care  of  himself,  it  is  proba- 
ble that  he  might  have  lived  many  years  longer. 

Treatment. — It  is  obvious  enough  that  little  can  be  done  to  repair 
damage  already  done.  Therapeutic  effects  must,  therefore,  in  the  main,  be 
directed  to  staying  the  progress  of  the  affection  as  far  as  possible,  and  to  ward- 
ing off  intercurrent  diseases,  which  may  either  promote  the  extension  of  the 


FIBROID   PHTHISIS. 


967 


lessened  risks  rfcodsLd  Sonchifc  T^'  '"P?'^  f  ^''''  P""  ''■■■  'i* 
are  to  be  determined  by  "he  pecuIiarSe,  If!^"?"'"'"  and  character  of  exercise 
are  to  be  given  if  the  appetir^ndli^  t  oVSel^  'f'T 

rants  may  be  needed  from  time  to  time  Narcoti.i  l^i  I,  V  ^==P''<'">- 
occasionally  and  in  the  last  stamps  ^Z  t^    J^^arcoties  and  hypnotics,  except 

Iodide  of  potassium  ma^  Sder  |ood  serv  ce  i^  r"*".*?  "'  ^'"'  ^  l^  P"^^'"'' 

eonditr:f\ifrL^^,4"c -.^p--  ^2^:''''^-^  -^^"^ 


PART   IX. 
DISEASES  OF  THE  HEART. 


CONGENITAL  AFFECTIONS  OF  THE  HEART. 

By  barton  COOKE  HIRST,  M.D., 

Philadelphia. 


Cardiac  anomalies  of  pre-natal  origin,  like  other  developmental  abnormal- 
ities, cannot  be  easily  classified  in  a  thoroughly  satisfactory  manner.  Osier 
gives  an  etiological  division  into  (1)  those  affections  due  to  defective  develop- 
ment, (2)  those  resulting  from  intra-uterine  endocarditis ;  and  (3)  those  that  are 
caused  by  a  combination  of  both  causes.  The  same  author  employs,  however, 
the  following  general  classification :  I.  Conditions  in  which  structures  normal 
to  the  foetus  persist  during  extra-uterine  life,  such  as  open  foramen  ovale,  per- 
sistency of  the  Eustachian  valve,  and  patency  of  the  ductus  arteriosus.  II. 
True  anomalies  of  development,  as  absence  or  imperfection  of  the  ventricular 
septum,  absence  of  the  auricular  septum,  anomalous  division  of  the  truncus 
arteriosus,  transposition  of  the  great  vessels,  and  numerical  variations  in  the 
valve  segments.  III.  Conditions  caused  wholly  or  in  part  by  endocarditis,  as 
extreme  stenosis  of  the  cardiac  orifices,  puckering,  thickening,  and  adhesion  of 
the  valve  segments. 

The  writer  will  employ  Baginsky's  classification,  somewhat  modified,  as 
follows : 

1.  Patency  of  the  foramen  ovale. 

2.  Defect  of  the  ventricular  septum. 

3.  Anomalies  of  the  right  and  left  auriculo-ventricular  orifices. 

4.  Stenosis  and  atresia  of  the  pulmonary  artery. 

5.  Persistence  of  the  ductus  arteriosus. 

6.  Stenosis  of  the  aorta. 

7.  Transposition  of  the  arterial  trunks. 

8.  Numerical  anomalies  of  the  valve  segments. 

9.  Ectopia  cordis. 

1.  Patexcy  of  the  Foramen  Ovale. — Much  attention — more  than  it 
deserves — has  been  bestowed  upon  this  affection  of  the  heart.  Of  itself,  it  does 
not  entail,  as  a  rule,  any  disadvantage  upon  the  individual.  A  patent  foramen 
ovale  has  been  discovered  in  many  persons  dying  of  a  variety  of  diseases,  in 
Avhom,  during  life,  there  was  no  evidence  of  heart  embarrassment.  Unless 
there  be  associated  anomalies,  congenital  or  acquired,  increasing  the  pressure 
in  the  right  auricle,  the  blood  will  not  flow  in  any  quantity  from  right  to  left 
auricle,  even  though  the  foramen  be  open,  and  consequently  the  arterial  blood 

968 


CONGENITAL    AFFECTIONS   OF   THE   HEART.  969 

will  not  be  vitiated  to  any  appreciable  extent.  If  pressure  be  increased  in  the 
right  auricle  by  a  contracted  auriculo-ventricular  septum  or  by  an  obstacle  to 
the  escape  of  blood  from  the  right  ventricle,  then  the  stream  may  be  deflected 
into  an  abnormal  course,  the  heart  be  embarrassed  by  extra  work,  and  the 
blood  in  the  aorta  become  mixed.  The  child  will  be  cyanotic,  and  its  life  will 
very  likely  be  cut  short. 

If  the  size  of  the  patent  foramen  is  increased  by  a  defect  in  the  anterior 
muscular  septum  between  the  auricles,  as  well  as  in  the  membranous  septum,  the 
anomaly  is  a  very  serious  one,  I  have  had  an  opportunity  to  make  a  post- 
mortem examination  in  two  such  cases.  In  both  the  children  lived  but  a  few 
hours  after  birth,  and  they  were  intensely  blue.  In  one  the  cyanosis  reached 
a  grade  I  ha,ve  never  witnessed  before  or  since. 

The  cause  of  a  patent  foramen  ovale  is  either  an  absence  or  defective 
development  of  the  membrana  fossae  ovalis  or  a  defective  institution  of  respira- 
tion. Normally,  the  opening  is  closed  by  the  increased  blood-supply  to  the 
auricles  incident  to  the  beginning  of  respiration.  Should  the  latter  act  be 
imperfectly  performed,  as  in  atelectasis,  the  mechanical  force  to  close  the  fora- 
men by  pressure  upon  its  valve — with  the  subsequent  adhesion  of  its  free  edges 
to  the  rim  of  the  oval  fossa — is  lacking.  More  frequently,  however,  in  infants 
that  survive  birth  the  membrana  fossse  ovalis  is  lacking  or  ill  developed,  and 
the  foramen  consequently  cannot  be  closed.  It  is  claimed  by  Sansom  that 
patency  of  the  foramen  can  be  diagnosticated  during  life  by  cyanosis  without 
heart  murmur,  or  by  cyanosis  with  systolic  and  presystolic  murmurs  over  the 
cartilages  of  the  third  and  fourth  ribs.  But  if  one  remembers  that  there  are 
many  other  causes  of  cyanosis  in  the  new-born  infant  besides  heart  defects,  and 
that  an  open  foramen  uncomplicated  by  other  anomalies  may  very  likely  present 
no  symptoms  at  all,  the  difficulty  of  making  this  diagnosis  may  be  appreciated. 
As  interesting  anatomical  conditions  under  this  head,  but  Avithout  clinical  sig- 
nificance, are  to  be  noted  perforations  of  the  valve  of  the  foramen  ovale  and 
small  slit-like  openings  under  the  valve  where  it  has  not  adhered  to  the  rim 
of  the  opening.     The  last  are  very  common. 

2.  Defect  of  the  Ventricular  Septum. — This  anomaly  is  most  fre- 
quently associated  with  other  abnormalities  of  the  heart,  as  stenosed  orifices 
and  vessels,  or  defect  of  the  auricular  septum.  It  is  not  at  all  uncommon  in  its 
lesser  degrees,  but  total  defect  is  rare,  and,  when  present,  is  associated  almost 
always  with  defect  of  the  auricular  septum,  constituting  the  so-called  reptilian 
heart  or  cor  biloculare.  The  defect  is  most  frequently  found  in  the  anterior 
muscular  portion  of  the  septum,  as  shown  by  Rokitansky,  and  not  in  the  median 
membranous  portion,  where  it  formerly  was  believed  to  be  most  frequently 
situated,  but  is  in  reality  very  rarely  found.  The  efiect  of  an  unnatural  open- 
ing between  the  ventricles  is  a  propulsion  of  some  of  the  blood  from  the  left 
ventricle  into  the  right  during  the  former's  contraction.  Should  the  latter  suf- 
ficiently hypertrophy  to  dispose  of  the  extra  amount  of  blood  thrown  into  it, 
there  need  not  necessarily  be  striking  symptoms  of  heart  defect.  But  should 
the  hypertrophy  not  be  sufficient,  there  results  an  embarrassed  respiration  and 
an  obstructed  venous  circulation,  with  cyanosis  and  transudation  of  serum  into 
connective  tissue  and  body-cavities.  As  Baginsky  points  out,  the  cyanosis  is 
due  to  this  cause,  and  not  to  the  mixing  of  arterial  and  venous  blood. 

The  diagnosis  of  defect  in  the  ventricular  septum  can  be  made,  it  is  asserted 
by  Roger  and  Sansom,  by  a  loud  systolic  murmur  over  the  prgecordial  region 
and  between  the  shoulders,  not  transmitted  to  the  vessels.  The  existence  of  a 
ventricular  septum  defect  is  unfavorable  to  the  life  of  the  infant,  mainly  on 
account  of  the  associated  anomalies.     Sansom,  however,  records  a  case  in  a 


970    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

child  that  lived  eight  and  a  half  years,  and  Johnstone  another  that  lived  eeven 
years. 

3.  Anomalies  of  the  Right  and  Left  Auriculo-ventricular  Ori- 
fices.— These  consist  in  stenosis  and  valve  defects,  mainly,  the  result  of  an 
intra-uterine  endocarditis  of  the  right  and  left  heart-cavities.  Osier  claims 
that  the  endocarditis  is  secondary  to  developmental  anomalies  and  is  almost 
always  of  the  chronic,  sclerotic  type,  and  very  rarely  of  the  verrucose  or  warty 
variety.  He  describes  a  typical  specimen  as  presenting  thickened  valve  seg- 
ments, which  are  shrunken  and  smooth.  In  the  case  of  the  auriculo-ventricular 
valves  the  cusps  become  united  and  the  attached  chord?e  tendineae  are  thick- 
ened and  shortened.  In  the  semilunar  valves  all  trace  of  the  segments  usually 
disappears,  leaving  a  stiff,  membranous  diaphragm  perforated  by  an  oval  or 
rounded  orifice. 

Valve  defects  from  endocarditis  are  more  commonly  found  upon  the  right 
than  upon  the  left  side.  We  shall  first,  therefore,  glance  at  the  anomalies  of 
the  right  auriculo-ventricular  orifice. 

There  is  usually  a  thickening  of  the  tricuspid  valve  as  well  as  of  other 
portions  of  the  endocardium.  The  right  ventricle  is  small.  If  the  disease 
leads,  as  is  not  very  uncommon,  to  complete  atresia  of  the  orifice,  the  circula- 
tion is  only  possible  in  a  roundabout  way,  and  then  only  when  there  is  a  defect 
in  the  ventricular  septum.  The  blood  flows  from  the  right  to  left  auricle,  and 
from  the  left  ventricle,  in  part,  into  the  right,  and  so  into  the  pulmonary  artery. 
The  left  ventricle,  from  the  additional  work  thrown  upon  it,  is  dilated  and 
hypertrophied.  In  case  of  associated  stenosis  and  insufficiency  the  right  heart 
is  dilated  and  hypertrophied.  Cardiac  murmurs,  systolic  and  diastolic,  with  a 
thrill  imparted  to  the  thoracic  wall,  are  loud  and  distinct,  the  heart's  action  is 
labored,  the  cyanosis  is  marked,  and  passive  congestion  everywhere  is  pro- 
nounced, leading  on  slight  provocation  to  haemorrhages. 

In  addition  to  the  abnormalities  resulting  from  disease  in  the  tricuspid 
valves,  developmental  anomalies  may  be  found,  as  an  imperfect  separation  of 
the  cusps,  so  that  there  is  a  circular  opening  between  auricle  and  ventricle, 
with  an  annular  diaphragm  surrounding  it.  On  the  other  hand,  there  may  be 
four  cusps  instead  of  three. 

The  most  common  cause  of  abnormality  in  the  left  auriculo-ventricular 
orifice  is  a  left-sided  endocarditis.  If  stenosis  of  the  orifice  is  well  marked, 
the  blood  in  the  distended  left  auricle  flows  back  through  the  patent  foramen 
ovale  into  the  right  auricle,  thence  into  the  right  ventricle,  and  so,  by  the 
ductus  arteriosus,  into  the  aorta.  The  left  ventricle,  becoming  functionally 
more  or  less  useless,  undergoes  atrophy,  sometimes  to  a  very  marked  degree. 
When  the  child  is  born  the  determination  of  blood  to  the  lungs,  and  the 
increased  amount  flowing  to  the  left  auricle,  embarrass  the  heart  extremely. 
Congestion  of  the  lungs,  extreme  cyanosis,  and  an  early  death  is  the  result. 
As  in  the  right  orifice,  there  may  be  the  developmental  anomalies  of  imperfect 
differentiation  of  the  cusps  or  their  division  into  three  instead  of  two  segments. 

4.  Stenosis  and  Atresia  of  the  Pulmonary  Artery. — Osier  divides 
the  anomalies  of  the  pulmonary  orifice  into  stenosis,  atresia  of  the  orifice  and 
of  the  artery,  and  stenosis  of  the  conus  arteriosus. 

Stenosis  of  the  pulmonary  artery  is  one  of  the  commonest  and  most  im- 
portant congenital  defects  of  the  heart.  A  child  may  live  some  length  of 
time — may,  in  fact,  reach  adult  life — with  a  serious  narrowing  of  the  pulmonary 
orifice  and  with  enormously  dilated  and  hypertrophied  heart-cavities  and  mus- 
cles, without  special  symptoms  until  some  extra  strain  is  imposed  upon  the 
heart,  especially  by  congestion  of  the  lungs,  when  sudden  death  is  likely  to 


CONGENITAL    AFFECTIONS    OF    THE   HEART.  971 

occur.  On  the  other  hand,  intense  cyanosis  and  embarrassed  respiration  and 
circulation  may  be  manifested  from  the  first,  and  the  infant  may  live  but  a 
few  hours.  The  continued  existence  and  development  of  the  infant  depend 
upon  the  hypertrophy  of  the  heart.  If  this  be  truly  compensatory,  the  child 
may  thrive  surprisingly  well,  even  in  grave  cases.  The  prognosis  as  regards 
duration  of  life  is  better  than  in  any  other  form  of  congenital  heart  defect  of 
serious  character.  One  individual  reached  the  age  of  fifty-seven,  and  16  per 
cent.,  according  to  Assmus,  survive  the  twentieth  year.  But  the  tenure  of  life 
is  always  uncertain,  for  any  sudden  call  upon  the  heart  for  extra  work  may 
prove  fatal.  And  these  cases  are  particularly  liable  to  have  grafted  on  them, 
at  some  time  after  birth,  a  fungous  or  infectious  endocarditis  that  may  be  the 
immediate  cause  of  death.  Moreover,  individuals  affected  with  a  contracted 
pulmonary  orifice  are  peculiarly  liable  to  tuberculous  disease. 

The  cause  of  this  anomaly  is  almost  invariably  an  intra-uterine  endocarditis, 
but  it  may  possibly  be  a  developmental  defect.  The  symptoms  are  cyanosis, 
with  signs  of  embarrassed  circulation  and  respiration.  The  body  warmth  is 
likely  to  be  very  imperfectly  preserved.  The  slightest  exposure  of  the 
extremities  leads  to  a  remarkable  frigidity,  and  the  infant  manifests  signs 
of  discomfort  or  suffering  in  consequence,  unless  it  is  too  apathetic  to  take  note 
of  its  surroundings.  A  mental  and  physical  apathy  very  likely  characterizes  the 
individual  throughout  life. 

As  already  stated  there  may  be  no  special  symptoms,  even  in  bad  cases,  or 
at  most,  attacks  of  dyspnoea,  lividity  and  heart  palpitation  from  time  to  time. 

On  auscultation  a  loud  systolic  murmur  is  heard  over  the  second  and  third 
ribs  to  the  left  of  the  sternum,  and  at  the  apex,  which  is  not  transmitted  to  the 
carotids.  A  thrill  is  imparted  to  the  thoracic  wall,  the  area  of  cardiac  dulness 
is  much  increased,  and  the  anterior  wall  of  the  thorax  is  protruded  in  later  life. 

Complete  atresia  of  the  pulmonary  orifice  and  of  the  artery,  while  rarer 
than  stenosis,  is  not  very  uncommon.  The  condition  is  due  to  defective 
development,  and  not  to  disease.  If  the  atresia  is  of  early  appearance  in 
embryonal  life,  there  is  a  wide  opening  between  the  auricles  and  advanced 
atrophy  of  the  right  ventricle.  The  blood  flows  from  the  right  auricle  to  the 
left  auricle,  and  in  part  to  the  lungs  by  the  medium  of  the  ductus  arteriosus. 
If,  as  is  likely,  there  is  a  defect  in  the  ventricular  septum,  the  aorta  may  arise 
equally  from  both  ventricles,  or  even  belong  more  to  the  right ;  in  which  case 
the  latter  is  much  hypertrophied  and  dilated.  The  symptoms  are  more  pro- 
nounced and  the  prognosis  much  worse  than  in  stenosis.  There  is  intense 
cyanosis,  great  dyspnoea,  the  child  becomes  very  often  convulsed,  and  dies 
usually  in  a  few  hours. 

Stenosis  of  the  conus  arteriosus  forms,  according  to  Assmus  and  Osier,  a 
considerable  portion  of  the  cases  of  obstruction  at  the  pulmonary  orifice.  The 
former  collected  47  cases  of  the  kind.  The  condition  is  due  to  faulty  develop- 
ment. By  a  constriction  of  the  lower  portion  and  dilatation  above,  a  sort  of 
accessory  auricle  may  be  formed.  There  are  almost  always  other  defects  of 
development,  as  a  defective  ventricular  septum.  The  symptoms  are  those  of 
stenosis  of  the  pulmonary  orifice. 

5.  Persistence  of  the  Ductus  Arteriosus. — By  the  fourteenth  day, 
or  within  the  first  four  weeks  at  least,  the  ductus  arteriosus  is  closed  by  an 
overgrowth  of  the  cells  in  its  inner  Avail.  Occasionally,  in  consequence  of 
puerperal  infection  of  the  new-born  with  infected  thrombi,  or  on  account  of 
defects  in  cardiac  development,  or  as  a  result  of  the  imperfect  institution  of 
respiration  and  an  anomalous  pulmonary  circulation,  the  duct  remains  patent. 
It  has  been  my  experience,   in  making  post-mortem  investigations  upon  the 


972    AMERICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 

bodies  of  young  infants,  that  a  slight  degree  of  patency  is  by  no  means 
uncommon  during  the  first  year  of  life.  It  is  frequently  easy  to  pass  a  small 
probe  through  the  duct  or  to  squeeze  a  drop  or  two  of  blood  through,  but  in 
such  cases  the  duct,  of  course,  plays  no  part  of  practical  importance  in  con- 
veying the  main-stream  of  the  blood.  The  clinical  symptoms  of  an  efficient 
patency  of  the  ductus  arteriosus  are  rapid  hypertrophy  and  dilatation  of  the 
right  ventricle,  dilatation  of  the  pulmonary  artery,  increase  in  area  of  cardiac 
dulness,  long-continued  systolic  murmurs,  thrill  of  the  anterior  chest-wall, 
protrusion  of  the  upper  part  of  the  sternum,  attacks  of  dyspnoea,  cyanosis  or, 
perhaps,  an  almost  cadaveric  hue,  a  disposition  to  bronchitis  and  congestion  of 
the  lungs,  and  anasarca.  Atheromatous  processes  in  the  pulmonary  artery  are 
common  in  individuals  who  live  some  years. 

The  prognosis  is  not  favorable.  Of  sixteen  cases  7  died  in  childhood,  5 
lived  from  nineteen  to  thirty-four  years,  and  4  to  between  forty  and  fifty. 

6.  Stenosis  of  the  Aorta. — Obstruction  at  the  aortic  orifice  is  the  result 
of  developmental  defect  or  of  endocarditis,  as  in  the  case  of  obstruction  at  the 
pulmonary  orifice.  Stenosis  is  rarer,  while  atresia  is  relatively  more  common,  at 
the  aortic  than  at  the  pulmonary  orifice.  As  in  the  right  side  of  the  heart, 
the  conus  arteriosus  may  be  narrowed,  but  the  condition  is  rare.  Stenosis  of 
the  aortic  orifice  is  a  much  more  serious  condition  than  narrowing  of  the  pul- 
monary orifice.  Of  33  cases,  only  1  survived  the  first  month.  Stenosis  of 
the  conus  arteriosus,  on  the  other  hand,  does  not  seem  so  serious,  for  the 
majority  of  cases  have  been  observed  in  adults.  The  aorta  itself  may  be 
narrowed  at  the  insertion  of  the  ductus  arteriosus.  In  this  case  the  blood  cur- 
rent finds  its  way  to  the  lower  portion  of  the  trunk  and  the  lower  extremities 
by  a  roundabout  course  through  the  dilated  subclavian  arteries  and  by  their 
branches  anastomosing  with  the  intercostal  and  epigastric  arteries.  The 
arteries  of  the  upper  portion  of  the  body  may  be  demonstrated  to  be  much 
larger  and  fuller  than  in  the  lower,  as  in  a  comparison  between  the  radial  and 
crural  pulses.  The  prognosis  of  this  developmental  defect  is  good.  The  indi- 
vidual may  live  to  advanced  old  age. 

7.  Transposition  of  the  Arterial  Trunks. — This  anomaly  is  not  of 
great  interest  to  the  practitioner,  for  it  is  usually  associated  with  other  grave 
developmental  defects  that  make  extra-uterine  life  unlikely,  and.  of  itself,  it 
leads  to  an  early  death.  The  vitiated  blood  flowing  from  the  right  auricle  into 
the  right  ventricle  is  distributed  by  the  aorta  springing  from  this  ventricle  again 
to  the  body,  while  the  aerated  blood  from  the  left  auricle  is  conveyed  back 
again  to  the  lungs.  Continued  existence  at  all  is  usually  explained  by  an  open 
foramen  ovale  or  by  a  communication  between  the  pulmonary  veins  and  the 
right  side  of  the  heart.  Osier  describes  an  example  in  an  eight-months'  foetus, 
in  which  there  was  a  partial  transposition,  the  right  ventricle  giving  off  a  small 
branch  to  the  lungs,  and  the  major  part  of  its  stream  into  the  thoracic  aorta, 
while  from  the  left  side  sprang  an  arterial  trunk  that  divided  into  the  innomi- 
nate and  left  carotid  arteries.  Children  thus  aifected  are  deeply  cyanosed,  have 
dyspnoea,  are  prone  to  haemorrhages  and  rapid  cooling  of  the  skin  and  the  ex- 
tremities. They  are  apathetic  and  die  early.  Twenty  out  of  twenty-five  cases 
did  not  survive  the  first  year.  A  number  of  cases  has  been  collected  by 
Rauchfuss  and  Von  Etlinger. 

8.  Numerical  Anomalies  of  the  Valve  Segments. — The  valve  seg- 
ments may  be  diminished  in  number  by  failure  of  development  or  as  a  result 
of  endocarditis.  Of  itself  this  anomaly  has  little  importance  clinically,  but  it 
is  often  associated  with  other  defects,  as  in  the  ventricular  septum,  and  is  com- 
monly followed  by  sclerotic  changes  in  the  valves.     Supernumerary  valves  are 


K 


CONGENITAL   AFFECTIONS    OF   THE  HEART.  973 

not  uncommon.  As  many  as  five  semilunar  valves  have  been  observed.  This 
is  not  likely  to  be  accompanied  by  other  abnormalities  of  the  heart,  and  may 
have  no  clinical  significance. 

9.  Ectopia  cordis  is  the  result  usually  of  fissured  sternum  and  thorax,  and 
is  commonly  associated  with  a  congenital  fissure  of  the  whole  anterior  body- 
wall.  The  heart  may  also  be  displaced  upward  into  the  neck  or  downward 
into  the  abdominal  cavity.  Other  rare  congenital  malformations  of  the  heart 
are  found  in  acardia,  ill-developed  heart,  double  heart,  bifid  apex,  and  absence 
of  the  pericardium. 

Symptoms. — The  symptoms  of  all  congenital  heart  defects  have  a  certain 
general  resemblance,  as  has  been  noted  in  their  description  under  the  appro- 
priate divisions.  Cyanosis  is  common,  more  or  less,  to  them  all.  Indeed  this 
term  was  long  regarded  as  practically  synonymous  with  congenital  anomalies  of 
the  heart,  but  in  the  writer's  experience  the  following  conditions,  arranged  in 
the  order  of  their  frequency,  have  all  been  responsible  for  it :  Pneumonia 
(often  syphilitic);  premature  birth :  asphyxia;  atelectasis;  degeneration  of  the 
blood ;  malformation  of  heart  and  blood-vessels ;  interference  with  the  nerves 
of  respiration ;  malformations  of  respiratory  tract ;  congenital  pleurisy,  and 
partial  occlusion  of  the  trachea. 

Treatment. — The  treatment  of  congenital  heart  defects  comprises  hygienic 
management,  protection  from  cold  and  physical  exertion,  and  the  administration 
of  the  heart  tonics  to  tide  over  attacks  of  threatened  cardiac  failure  and  to  help 
the  development  of  a  compensatory  hypertrophy.  Medicinal  treatment  alone, 
however,  is  of  little  avail,  except  to  meet  temporary  indications.  If  compen- 
satory hypertrophy  is  not  soon  established  to  a  satisfactory  degree,  the  nrospect 
of  life  is  bad. 


ORGANIC  DISEASES  OF  THE  HEART. 

By  FLOYD  M.  CRANDALL,  M.  D., 
New  York. 


Diseases  of  the  Heart  during  childhood  present,  in  their  general  out- 
lines, conditions  very  similar  to  those  seen  in  the  adult.  In  their  details  many 
and  important  diiFerences  occur.  In  the  following  pages  these  differences 
receive  the  chief  attention,  it  being  taken  for  granted  that  the  reader  is  con- 
versant Avith  the  diseases  of  the  adult  heart  and  their  methods  of  detection. 
The  following  peculiarities  are  observed  in  the  normal  heart: 

I.  The  apex  lies  higher  in  the  chest  and  more  to  the  left  than  in  the  adult, 
being  outside  the  nipple  line. 

II.  The  apex-beat  in  the  infant  is  usually  difficult  of  detection ;  in  the  child 
it  is  more  clearly  visible,  and  can  be  detected  by  touch  more  readily  than  in 
the  adult. 

III.  The  area  of  dulness  is  comparatively  large,  so  that  the  normal  heart 
may,  without  caution,  be  considered  hypertrophied. 

IV.  Murmurs  are  heard  over  a  comparatively  wide  area,  being  frequently 
audible  over  the  entire  chest. 

V.  The  rate  may  be  increased  and  the  rhythm  disturbed  by  slight  causes, 
so  that  rapidity  and  irregularity  are  of  but  little  importance. 

VI.  In  rachitic  children,  owing  to  deformity  of  the  chest,  the  apex  may 
appear  m  an  abnormal  position. 

VII.  Prominence  of  the  prsecordia  is  sometimes  marked. 

Cardiac  disease  during  early  life  is  also  modified  by  the  fact  that  the  heart 
is  undergoing  numerous  changes  in  growth  and  development.  These  are  not 
constant,  but  occur  chiefly  at  certain  periods.  The  relative  weight  of  the  heart 
is  greatest  at  birth,  the  right  side  predominating  slightly  over  the  left.  During 
the  first  seven  years  there  is  an  increase  in  volume  of  about  80  per  cent. 
Between  seven  and  fourteen  the  increase  in  actual  volume  is  barely  10  per 
cent.  There  is  then  a  very  rapid  increase  of  almost  100  per  cent.  These 
changes  necessarily  modify  to  a  marked  degree  any  diseased  condition  which 
may  be  present,  and  are  of  especial  importance  as  regards  prognosis  and 
treatment. 

I.  Pericarditis. 

Inflammation  of  the  pericardium  during  childhood  presents  but  few  pecu- 
liarities pathologically.  At  this  period  of  life  inflammation  of  the  serous  mem- 
branes is  more  frequently  marked  by  effusion  than  in  the  adult,  and  the  peri- 
cardium presents  no  exception  to  the  rule.  Fluid  forms  with  great  rapidity, 
and  is  prone  to  be  purulent.  Endocarditis  is  a  common  accompaniment  of 
pericarditis,  and  the  walls  of  the  heart  are  always  more  or  less  weakened.  Not 
infrequently  pericardium,  endocardium,  and  muscle  are  all  involved.  Sturges, 
in  extensive  post-mortem  observations,  invariably  found  acute  rheumatic  endo- 

974 


DISEASES   OF   THE  HEART.  975 

carditis  accompanied  by  more  or  less  pericardial  inflammation  or  adhesion,  and 
believes  that  endopericarditis  is  the  most  common  cardiac  affection  of  early 
life.  It  is  quite  possible,  however,  that  conditions  present  in  cases  so  grave  as 
to  permit  of  post-mortem  observation  may  not  be  as  frequently  present  in  the 
less  serious  cases  which  survive. 

Etiology. — Pericarditis  is  seldom  a  primary  affection.  It  may  result  from 
injury  or  the  extension  of  inflammation  from  a  neighboring  organ,  but  more 
commonly  occurs  in  the  course  of  rheumatism  or  one  of  the  infectious  diseases. 
While  rheumatism  causes  by  far  the  greater  number  of  cases,  rheumatic  peri- 
carditis is  not  as  common  proportionately  as  in  adult  life.  Scarlet  fever, 
empyema,  and  pneumonia  are  frequent  etiological  factors.  In  young  infants 
purulent  pericarditis  sometimes  occurs  as  a  result  of  septicsemic  conditions  at 
the  umbilicus.  Rheumatic  pericarditis  develops  early,  and  sometimes  precedes 
the  articular  symptoms.  In  scarlet  fever  the  pericardial  inflammation  com- 
monly develops  during  the  second  or  third  week. 

Symptoms. — The  subjective  symptoms  of  pericarditis  are  usually  obscure, 
and  vary  with  the  different  stages  of  the  disease.  The  early  stage  is  frequently 
insidious  and  passes  unrecognized.  The  most  frequent  symptoms  are  pain  and 
palpitation.  Pain  may  be  confined  to  the  prsecordial  region,  or  may  be  reflected 
into  the  shoulder  or  referred  to  the  region  of  the  stomach.  It  varies  in  inten- 
sity from  a  simple  uneasiness  to  a  sharp,  lancinating  pain.  The  patient  some- 
times assumes  a  characteristic  position,  with  the  head  elevated  and  the  body 
thrown  somewhat  toward  the  left.  The  trunk  is  held  rigidly  quiet,  while  the 
legs  are  moved  freely.  The  pulse  is  full,  and  there  may  be  slight  fever  and  a 
hacking  cough. 

When  effusion  occurs  the  pain  gives  place  to  a  sense  of  oppression.  Res- 
piration becomes  labored,  and  the  countenance  assumes  an  anxious  expression 
or  a  look  of  actual  suffering.  The  face  is  livid  or  ashy  pale.  Dyspnoea  is 
marked  when  the  head  is  lowered.  The  pulse  is  weak,  irregular,  and  inter- 
mitting. In  fatal  cases,  as  the  effusion  increases,  attacks  of  syncope  occur, 
hiccough  develops,  and  delirium  appears,  followed  by  coma  and  death.  In  less 
severe  cases  praecordial  heaviness  and  dyspnoea  may  be  the  only  symptoms. 

Physical  Signs. — In  the  early  stages  the  heart's  action  is  usually  forcible, 
but  irritable,  and  often  irregular.  Percussion  shows  nothing  except,  perhaps, 
tenderness.  A  friction-sound  is  heard  upon  auscultation,  the  point  of  greatest 
intensity  being,  as  a  rule,  under  the  fourth  rib,  just  at  the  left  of  the  sternum. 
This  point  varies  with  the  position  of  the  patient  and  with  full  inspiration. 
The  sound  is  superficial,  and  has  but  a  slight  area  of  diffusion.  It  is  frequently 
double,  and  usually  creaking  or  rubbing  in  character,  but  may  be  crackling  or 
even  blowing.  It  sometimes  so  closely  simulates  the  mitral  regurgitant  mur- 
mur as  to  be  indistinguishable  from  it.  Friction-sounds  are  more  frequently 
absent  in  children  than  in  adults,  and  rarely,  when  present,  remain  more  than 
one  or  two  days.  The  early  detection  of  pericarditis  in  children  is  often  one 
of  the  most  difiicult  problems  in  the  domain  of  physical  diagnosis. 

In  the  stage  of  effusion  the  difficulties  in  diagnosis  are  but  slightly  dimin- 
ished. Owing  to  the  thinness  and  yielding  character  of  the  chest-wall  both 
the  apex-beat  and  the  normal  heart-sounds  may  be  readily  detected  when  con- 
siderable fluid  is  present.  In  some  instances  the  pulse  is  full  and  fairly  strong, 
while  the  apex-beat  is  feeble  or  imperceptible.  Occasionally  an  undulating 
impulse  may  be  felt  under  the  palm  when  the  actual  point  of  impact  cannot  be 
determined.  Prominence  of  the  prgecordia  is  sometimes  extreme.  The  area 
of  percussion  dulness  is  enlarged,  but  it  is  impossible  to  make  definite  state- 
ments as  to  its  exact  shape  and  extent.     It  is  modified  by  the  shape  of  the 


976    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

chest,  by  pleuritic  adhesions,  and  by  pulmonary  consolidation.  If  no  adhesion 
or  other  lesion  be  present,  the  area  of  dulness  assumes  a  somewhat  pyramidal 
shape,  being  broad  laterally  at  the  lower  portion  and  extending  well  up  to  the 
first  rib.  There  is  danger  of  mistaking  an  extremely  dilated  heart  with  feeble 
impulse  for  a  pericardial  effusion.  Rotch,  who  has  made  a  most  careful  series 
of  observations  upon  the  subject,  calls  attention  to  the  fifth  right  interspace  as 
a  region  of  great  importance  in  deciding  between  these  two  conditions.  While 
with  a  dilated  heart  partial  dulness  may  extend  to  the  right  of  the  sternum  in 
the  second  or  third  interspace,  it  rarely  appears  in  the  fifth,  and  absolute  dul- 
ness never.  Even  a  small  amount  of  effusion,  on  the  other  hand,  finds  its  way 
into  the  fifth  interspace,  causing  absolute  dulness.  Upon  the  left  of  the 
sternum  the  area  of  dulness  in  the  two  conditions  is  almost  identical. 

In  the  late  stages,  when  recovery  takes  place,  there  are  no  physical  signs 
by  which  pericardial  adhesions  may  be  positively  detected.  Intermittent  or 
disturbed  cardiac  action  following  a  pericarditis  without  evidence  of  an  endo- 
cardial lesion  offers  strong  presumption  that  such  adhesions  exist.  According 
to  Sturges,  a  rubbing  exocardial  sound  does  not  preclude  the  possibility  of 
pericardial  adhesion. 

Prognosis. — In  infancy  pericarditis  is  a  serious  and  usually  fatal  disease. 
During  childhood  the  tendency  is  to  recovery.  Not  infrequently  the  course  is 
rapid,  complete  resolution  taking  place  within  ten  days.  In  other  cases,  while 
ultimate  recovery  is  complete,  it  is  long  delayed.  In  still  others  adhesions 
remain  which  seriously  cripple  the  heart.  When  the  formation  of  fluid  is 
rapid,  embarrassment  of  the  heart's  action  becomes  alarming  and  sudden  death 
may  occur.  Myocarditis  is  a  frequent  and  serious  source  of  danger.  The 
longer  the  effusion  is  present  the  greater  this  danger  becomes.  The  dilatation 
resulting  from  myocarditis  is  sometimes  extreme,  but  if  the  child  is  in  fair 
general  condition  hypertrophy  follows,  and  is  usually  fully  compensatory. 

Treatment. — Any  constitutional  condition  to  which  pericarditis  may  be 
secondary  should  be  brought  under  control  as  quickly  as  possible.  Pain  and 
cardiac  irritability  should  be  at  once  relieved.  For  this  purpose  opium  stands 
without  a  rival,  and  is  the  most  important  agent  in  the  treatment  of  pericarditis. 
Sufficient  should  be  given  to  relieve  pain  and  maintain  a  mild  continuous  effect 
through  the  early  stages.  Though  it  may  be  administered  more  freely  than  in 
endocarditis,  the  condition  of  narcotism  should  never  be  induced.  Stimulants 
are  indicated  when  the  pulse  becomes  feeble  and  weak.  In  attacks  of  syncope 
quickly-acting  stimulants  like  Hoffman's  anodyne  are  demanded.  Digitalis 
aids  materially  in  maintaining  the  integrity  of  the  heart-muscle,  and  in  most 
cases  is  a  drug  of  much  value.  Occasionally,  when  there  are  extensive 
adhesions,  it  causes  palpitation  and  increased  irregularity,  and  must  be  discon- 
tinued. 

Locally,  poultices  or  large  hot  anodyne  applications  are  preferable  to  the 
ice-water  coil.  Blisters  should  never  be  employed.  Absorption  is  sometimes 
hastened  by  mercurial  ointment  applied  upon  flannel  over  the  praecordia. 

Nutrition  should  be  maintained  at  the  highest  possible  point,  but  over- 
loading of  the  stomach  must  be  carefully  guarded  against.  After  the  acute 
stages  tonics  are  usually  indicated,  for  pericarditis  is  eminently  a  disease  of  the 
weak,  anaemic,  and  feeble.  Absolute  rest  cannot  be  too  strongly  insisted  upon. 
Care  in  this  direction  should  not  be  relaxed  while  the  slightest  evidence  of 
impaired  cardiac  action  remains.  In  no  other  condition  is  weakening  of  the 
heart-muscle  so  common.  Weeks,  or  even  months,  must  sometimes  elapse 
before  active  exercise  can  be  safely  permitted. 

When  the  amount  of  fluid  becomes  so  great  as  to  seriously  threaten  life. 


DISEASES    OF   THE   HEART.  977 

paracentesis  is  demanded.  Death,  however,  very  rarely  results  from  pressure. 
Urgent  symptoms  are  often  transient,  and  disappear  without  mechanical  inter- 
ference. Much  has  been  said  regarding  the  harmlessness  of  the  operation,  but 
it  is  not  without  serious  dangers.  It  should  be  resorted  to,  however,  when  the 
fluid  is  found  to  be  purulent  or  so  excessive  in  quantity  as  to  endanger  life. 
Dieulafoy"s  or  Potain's  aspirator  should  be  employed  with  a  Fitch  needle, 
which  has  a  protector  to  be  pushed  over  the  point  after  it  is  introduced,  thus 
avoiding  the  danger  of  puncturing  the  heart-wall.  The  fluid  should  be  com- 
pletely removed.  The  fifth  intercostal  space,  just  to  the  left  of  the  sternum, 
is  the  point  usually  advised  as  the  seat  of  puncture.  Rotch,  however,  proposes 
the  fifth  intercostal  space  of  the  right  side  as  preferable,  since  it  would  here  be 
impossible  to  puncture  a  dilated  heart — an  accident  which  might  occur  on  the 
left  side. 

n.  Acute  Endocarditis. 

Inflammation  of  the  endocardium  is  a  frequent  disease  of  early  life. 
During  foetal  life  the  ricrht  side  of  the  heart  is  usuallv  involved,  after  birth  the 
left  side.  During  childhood  the  serous  membranes  are  especially  sensitive,  and 
there  is  a  marked  tendency  in  the  connective  tissue  to  cell-proliferation. 
Morbid  changes  are  chiefly  confined  to  the  valves  and  chordae  tendineae,  but  in 
some  instances  the  whole  endocardium  is  implicated.  As  a  rule,  the  fibrous 
structure  of  the  valves  bears  the  brunt  of  the  attack.  The  valves  are  simply 
folds  of  serous  membrane  bound  together  by  fibrous  tissue.  Inflammation  is 
attended  by  proliferation  of  cells  Avithin  the  endocardium,  pushing  it  up  into 
papillary  elevations,  and  also  by  proliferation  of  the  fibrous  tissue  itself.  This 
latter  change  is  the  most  characteristic  and  important  process  in  endocardial 
inflammation.  The  whole  valve  becomes  thickened  and  stifi",  and  the  chordae 
tendinete  are  afi"ected  in  a  similar  manner.  Xodules  are  most  numerous  alono; 
the  edges  of  the  valves,  where  they  form  rows  of  reddish  semi-translucent 
beads.  As  they  lie  directly  m  the  blood-current,  fibrin  is  gradually  deposited, 
forming  the  so-called  vegetations.  They  may  become  so  large  as  to  cause 
serious  mechanical  interference  with  valvular  action,  or  portions  may  be 
detached  and  swept  into  the  circulation.  Even  when  these  vegetations  are 
quite  numerous  they  may  undergo  resolution  and  disappear,  but  when  marked 
hyperplasia  of  connective  tissue  has  occurred,  the  almost  inevitable  result  is 
contraction,  with  consequent  puckering,  thickening,  and  distortion  of  the 
valves,  shortening  of  the  chordae,  or  narrowing  of  the  valvular  openings. 

Etiology. — Sex  cannot  properly  be  called  an  etiological  factor  of  endo- 
carditis, although  twice  as  many  girls  sufi"er  from  heart  disease  as  boys.  A 
boy  who  has  rheumatism  is  as  liable  to  a  cardiac  complication  as  a  girl,  but 
girls  are  more  subject  to  rheumatism  than  boys.  Of  my  own  cases,  38  per 
cent,  were  boys,  62  per  cent,  girls,  the  preponderance  of  girls  being  greatest 
under  eight  years. 

Age  is  a  more  important  factor.  Endocarditis  occurs  in  infancy,  and  even 
in  intra-uterine  life,  but  it  is  rare  under  five  years.  It  is  probably  more  com- 
mon during  the  three  years  between  eight  and  eleven  than  at  any  other  similar 
period  of  life. 

Rheumatism  is  by  far  the  most  important  exciting  cause  of  endocardial 
inflammation,  but  in  children  that  disease  is  so  uncertain  in  its  manifestations 
that  it  is  readily  overlooked.  In  the  majority  of  cases  it  appears  in  a  form 
which  in  the  adult  would  be  designated  as  subacute.  But  the  mildest  and 
most  transient  attacks  are  not  infrequently  accompanied  by  inflammation  of 

62 


978    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  endocardium,  which  would  be  overlooked  without  physical  examination. 
No  attack  of  joint-pain  in  a  child  is  too  mild  to  preclude  the  possibility  of  an 
accompanying  endocarditis.  I  have  seen  it  develop  during  the  course  of  torti- 
collis in  a  child  of  rheumatic  parentage.  Among  117  cases  of  cardiac  disease, 
I  found  rheumatism,  either  antecedent,  concurrent,  or  subsequent,  in  82  per 
cent.  A  definite  family  history  of  rheumatism  was  obtained  in  57  per  cent., 
excluding  grandparents.  Attention  has  been  directed  to  the  importance  of 
subcutaneous  fibrous  nodules  in  the  diagnosis  of  rheumatism,  and  it  is  believed 
that  similar  nodules  form  at  the  same  time  on  the  cardiac  valves.  While  they 
are  strongly  suggestive  of  endocarditis,  they  give  no  positive  evidence  of  that 
condition.  I  have  seen  a  profuse  crop  of  nodules  develop  without  the  slightest 
evidence  of  cardiac  disturbance. 

While  the  intimate  association  of  chorea  and  heart  disease  is  well  known, 
the  exact  etiological  relationship  is  still  uncertain.  Occasionally  endocarditis 
developing  during  a  choreic  attack  disappears  as  the  chorea  subsides ;  more 
commonly  it  leaves  a  permanent  lesion.  In  the  great  majority  of  cases  the 
murmur  is  not  functional,  but  organic,  and  is  due  to  well-defined  pathological 
changes  in  the  valves.  Thirty  per  cent,  of  my  cases  of  cardiac  disease  suf- 
fered at  some  period  of  their  lives  from  chorea,  but  24  per  cent,  gave  also  a 
clear  history  of  rheumatism.  Although  in  the  remaining  cases  no  positive 
history  of  rheumatism  could  be  obtained,  there  is  ground  for  belief  that  the 
endocarditis  of  chorea  is,  in  fact,  rheumatic. 

Scarlet  fever  is  occasionally  complicated  by  endocarditis.  In  rare 
instances  it  appears  early  in  the  disease,  but  more  commonly  develops  during 
the  stage  of  desquamation.  It  usually  appears  in  patients  showing  evidence 
of  nephritis,  and  is  probably  due  more  to  uraemia  than  to  the  poison  of  scarla- 
tina. Diphtheria,  measles,  erysipelas,  and  septicaemia  are  occasionally  com- 
plicated by  inflammation  of  the  endocardium. 

Symptoms. — Endocarditis  is  a  very  obscure  disease.  The  symptoms  are 
few  in  number  and  occur  in  no  fixed  order.  They  may  be  wholly  wanting,  and 
the  disease  may  run  its  course  without  presenting  any  appreciable  symptom. 
The  symptoms  of  the  acute  disorder  during  Avhich  it  develops  often  mask  or 
wholly  obscure  those  of  the  cardiac  complication.  When  accompanying  a 
rheumatic  attack  there  is  frequently  an  increase  in  temperature,  or  slight  fever 
appears  if  none  has  previously  been  present.  The  child  seems  more  ill  than 
the  arthritis  would  account  for.  There  may  be  a  peculiar  restless,  anxious 
expression,  with  a  tendency  to  cyanosis.  The  heart's  action  is  disturbed  and 
the  pulse  becomes  very  rapid  The  symptoms  depend  largely  upon  the  amount 
of  myocarditis  present.  If  the  muscular  tissue  is  much  involved,  palpitation, 
precordial  distress,  cyanosis,  and  dyspnoea  will  be  marked.  In  milder  and 
more  common  cases  none  of  these  symptoms  are  present  to  draw  attention  to 
the  heart  Anaemia  is  a  very  constant  accompaniment  of  endocardial  inflam- 
mation, and  develops  rapidly.  The  appearance  of  subcutaneous  fibrous 
nodules  should  always  lead  to  a  physical  examination  of  the  heart. 

The  tendency  to  recurrence  is  a  marked  feature  of  endocarditis.  An  endo- 
cardium that  has  once  been  inflamed  is  far  more  sensitive  thereafter  to  irritating 
blood-conditions.     Fresh  attacks  are  readily  lighted  up  by  slight  causes. 

The  occurrence  of  an  embolism  first  directs  attention  to  the  heart  in  some 
cases.  The  spleen  is  the  organ  most  frequently  aff'ected.  The  most  distinctive 
symptoms  result  from  embolism  of  the  brain,  the  middle  cerebral  artery  of  the 
left  side  being  commonly  the  seat  of  lesion,  with  resulting  hemiplegia  and 
aphasia.     Embolic  pneumonia  occurs  in  the  child  as  in  the  adult. 

Physical    Signs. — The  signs  obtained  by  physical  examination  are  the 


DISEASES   OF   THE  HEART.  979 

only  means  of  positive  diagnosis.  An  endocarditis  may,  in  rare  instances,  be 
present  for  several  days,  or  even  run  its  course,  without  developing  a  murmur. 
Occasionally  abnormal  sounds,  as  roughness,  muffling,  or  prolongation  of  the 
first  sound,  precede  an  actual  murmur.  In  most  cases  the  murmur  is  heard 
only  at  the  apex.  It  is  systolic,  soft,  and  blowing,  diifering  from  the  ordinary 
mitral  reguro-itant  in  its  limited  area  of  conduction.  It  is  more  intense  at  the 
apex,  but  it  is  not  transmitted  far  to  the  right,  and  is  rarely  audible  behind. 
It  usually  appears  early  in  an  attack  of  rheumatism,  and  is  organic.  It  some- 
times disappears,  leaving  no  valvular  lesion.  A  similar  murmur  occasionally 
appears  late  in  the  course  of  typhoid  fever,  and  is  probably  due  to  muscular 
insufficiency  the  result  of  anaemia  or  myocarditis.  The  murmur  of  scarlatina, 
chorea,  and  rheumatism  is  usually  entirely  different  in  character. 

Other  sounds  are  heard  at  the  apex  much  more  frequently  in  children  than 
in  adults.  Of  these  reduplication  of  the  second  sound  is  most  important. 
Reduplication  of  the  second  sound  at  the  base  is  frequently  heard  in  Bright's 
disease  of  the  adult,  but  as  heard  at  the  apex  in  children  it  is  probably  due  to 
asynchronous  action  of  the  mitral  and  tricuspid  valves,  the  result  of  stiffening 
of  the  mitral.  It  is  almost  a  certain  forerunner  of  a  mitral  obstructive  mur- 
mur. Sometimes  a  soft  blowing  murmur  is  heard  immediately  after  the  second 
portion  of  the  double  sound.  This  gradually  increases  in  length  and  intensity, 
and  develops  the  well-known  rumbling  murmur  of  mitral  stenosis.  In  very 
rare  instances  an  aortic  murmur  develops  early  in  endocardial  inflammation, 
either  alone  or  in  connection  with  a  mitral  murmur.  The  same  is  also  true 
of  tricuspid  regurgitation. 

When  acute  endocarditis  is  engrafted  upon  an  old  valvular  lesion,  its  diag- 
nosis is  especially  difficult.  If  the  patient  has  been  under  observation  and  the 
character  of  the  murmurs  is  known,  diagnosis  is  easy.  Marked  enlargement 
of  the  heart  is  strong  proof  of  an  old  lesion.  Extreme  subjective  symptoms 
of  cardiac  disease,  especially  oedema,  are  rarely  seen  in  primary  endocarditis, 
but  in  chronic  heart  disease  the  symptoms  are  all  aggravated  by  a  fresh  endo- 
cardial attack.  The  character  of  the  murmur  may  furnish  some  aid  in  diag- 
nosis, but  cannot  be  relied  upon.  A  soft  blowing  murmur  is  usually  recent ; 
if  harsh,  musical,  or  rough,  it  is  probably  old. 

Prog-nosis. — As  endocarditis  is  not  an  idiopathic  disease,  the  prognosis 
depends  largely  upon  the  condition  with  which  it  is  associated.  A  first  attack 
is  rarely  the  direct  cause  of  death.  It  is  extremely  variable  in  its  course.  It 
may  pass  away,  leaving  no  lesion  or  murmur,  but  more  frequently  a  valvular 
lesion  is  left  behind.  If  the  pulse  becomes  feeble,  and  the  child  loses  strength 
and  grows  rapidly  anaemic,  the  prognosis  is  bad.  It  is  bad  if  recurring  attacks 
of  rheumatism  appear  or  if  fibrous  nodules  recur  in  successive  crops.  Endo- 
carditis appearing  during  the  course  of  a  septic  disease  is  usually  ulcerative  in 
character,  and  the  prognosis  is  extremely  unfavorable.  Early  involvement  of 
the  aortic  valves  is  also  unfavorable.  It  is  not  wise  to  give  a  too  favorable 
prognosis  at  first,  especially  as  to  duration,  for  exposure  or  lack  of  rest  will 
materially  prolong  an  attack.  Duration  is  more  uncertain  in  children  than  in 
adults.  Loudness  of  the  murmur  is  of  but  little  importance,  but  the  greater 
the  number  of  murmurs  the  more  serious  is  the  condition.  The  murmur 
appearing  during  chorea  occasionally  disappears  as  the  choreic  movements  sub- 
side. This  is  sometimes  apparent  rather  than  real.  After  a  time  a  murmur 
which  has  almost  disappeared  may  return  and  continue  permanently — a  result 
that  is  probably  due  to  the  lighting  up  of  a  fresh  valvulitis,  consequent  upon 
the  occurrence  of  a  mild  rheumatic  or  choreic  attack.  On  the  whole,  the  ulti- 
mate prognosis  is  rather  better  in  children  than  in  adults.     Tissue-growth  is  so 


980    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

rapid  and  compensation  becomes  so  complete  that  an  endocarditis  of  not  excessive 
severity  may  produce  but  little  permanent  injury. 

Treatment. — The  constitutional  disease  with  which  endocarditis  is  asso- 
ciated should  receive  prompt  attention.  In  the  treatment  of  rheumatism  it  is 
not  sufficient  to  direct  our  efforts  simply  to  the  control  of  the  arthritis  and 
relief  of  pain.  The  possibility  of  endocarditis  must  also  be  considered.  The 
ideal  treatment  is  that  which  controls  the  arthritis,  reduces  fever,  relieves  the 
pain,  and,  above  all,  prevents  cardiac  complications.  In  my  experience  the 
ordinary  treatment  with  salicylate  of  sodium  has  not  fulfilled  these  requirements, 
for  it  has  not  perceptibly  removed  the  danger  of  endocardial  inflammation.  A 
patient  fully  under  the  influence  of  the  salicylate  will  not  infrequently  develop 
a  cardiac  murmur — an  accident  Avhich  occurs  much  less  frequently  under  the 
alkaline  treatment.  In  view  of  the  great  susceptibility  of  the  endocardium  in 
childhood  a  judicious  combination  of  the  salicylates  and  alkalies  offers  the  safest 
and  most  efficient  treatment.  If  endocarditis  develops,  the  salicylate  should  be 
dropped  or  administered  with  the  utmost  caution. 

Treatment  for  the  purpose  of  affecting  the  endocardium  directly  is  of  but 
little  avail,  yet  much  may  be  accomplished  by  drugs.  It  is  important  that  the 
rapidity  and  irritability  of  the  heart  be  lessened,  and  that  a  condition  of 
cardiac  rest  be  attained  as  far  as  possible.  Aconite  lessens  the  rapidity,  but 
it  also  Aveakens  the  force,  and  with  children  is  an  unsafe  drug.  Digitalis  must 
be  used  cautiously.  In  acute  endocarditis  developing  in  an  old  cardiac  case  it 
is  often  of  supreme  value.  When  the  heart's  action  is  tumultuous,  but  rapid 
and  weak,  it  may  be  given  with  the  most  satisfactory  results,  as  it  reduces  the 
frequency,  increases  the  force,  and  corrects  the  irregularity.  A  child  of  six 
years  may  take  four  drops  of  the  tincture  every  four  hours  for  one  or  two  days, 
when  the  dose  should  be  diminished.  Opium  is  also  of  great  value  in  rheu- 
matic endocarditis.  It  not  only  relieves  the  articular  pain,  thus  rendering 
general  bodily  quiet  possible,  but  it  has  a  most  happy  effect  in  steadying  and 
quieting  an  irritable,  irregular,  and  rapid  heart.  Two  minims  or  more  of  the 
deodorized  tincture  may  be  given  every  four  to  six  hours  at  six  years.  When 
pericarditis  is  also  present  opium  is  the  sheet-anchor.  Stimulants  should  be 
avoided  until  definitely  indicated.  When  dilatation  is  marked  they  are  de- 
manded, and  must  be  administered  freely.  When  the  fever  has  abated  a  tonic 
is  indicated,  for  anaemia  appears  early,  and  is  frequently  persistent  and  extreme. 
Citrate  of  iron  and  quinine  is  admirably  adapted  to  these  cases,  and  may 
be  given  in  doses  of  three  to  four  grains  three  times  a  day.  The  bitter 
wine  of  iron  is  also  an  excellent  preparation.  One  or  two  drops  of  Fowler's 
solution  may  be  added,  but  full  doses  of  arsenic  are  inadvisable.  When  the 
fever  ranges  high  during  the  acute  stages,  quinine  may  be  given  in  moderate 
doses,  but  antipyrine  and  acetanilide  are  too  depressing  to  be  employed  with 
safety.  Phenacetin  is,  perhaps,  admissible.  Administered  in  small  doses  it  is 
an  excellent  analgesic. 

Absolute  rest  and  protection  of  the  surface  from  cold  and  dampness  are  of 
far  more  importance  than  medicinal  treatment.  Without  these  precautions 
treatment  is  of  little  avail  in  preventing  permanent  valvular  lesions.  The 
child  should  Avear  a  flannel  jacket  or  night-dress,  and  be  placed  between  flan- 
nel blankets  instead  of  the  usual  sheets.  Even  in  mild  cases  of  acute  endo- 
carditis strict  rest  should  be  enjoined  and  insisted  upon  long  after  every  rheu- 
matic and  cardiac  symptom  has  disappeared.  If  a  permanent  murmur  results, 
it  is  often  difficult  to  determine  when  it  is  safe  for  the  child  to  leave  the  bed  and 
resume  play,  but  it  is  wise  to  err  on  the  side  of  caution.  This  enforced  rest  is, 
perhaps,  the  most  difficult  of  accomplishment  of  any  measure  in  the  treatment 


DISEASES    OF   THE  HEART.  981 

of  children,  particularly  in  families  where  discipline  is  lax.  It  can  be  obtained 
with  almost  any  child  with  determination  and  patience,  and  when  the  import- 
ance is  so  great  these  qualities  should  certainly  not  be  lacking. 

Local  applications,  while  less  efficacious  than  in  pericarditis,  are  of  con- 
siderable value.  Poultices  sometimes  give  marked  relief  from  prsecordial  dis- 
tress, but  caution  must  be  exercised  to  prevent  chilling  of  the  surface.  The 
application  of  a  weak  chloroform  liniment  upon  flannel  held  in  position  by  a 
flannel  band  is  safer  and  accomplishes  fully  as  much.  The  chest  should  always 
be  closely  protected  with  flannel. 

m.  Chronic  Heart  Disease. 

Chronic  valvular  disease  is  the  sequel  of  acute  endocarditis.  The  lesions 
in  childhood  do  not  diff"er  materially  from  those  of  the  adult.  Thickening  and 
distortion  of  the  valves  are  the  changes  most  frequently  observed,  but  vegeta- 
tions occasionally  appear.  They  are  most  common  on  the  auricular  surface  of 
the  mitral  valve.  Adherent  pericardium,  the  result  of  previous  pericarditis,  is 
very  common,  while  hypertrophy  of  the  cardiac  wall  is  more  frequent  and  exten- 
sive than  in  later  life. 

Etiology. — Acquired  valvular  lesions  result  from  acute  endocardial  inflam- 
mation. The  causes  of  such  inflammation  are  considered  in  detail  in  their 
appropriate  place. 

Clinical  History. — Cardiac  disease  presents  three  conditions  or  periods  : 

1.  Period  of  acute  inflammation. 

2.  Period  of  compensation. 

3.  Period  of  heart  failure. 

It  must  not  be  supposed  that  these  conditions  always  follow  each  other  in 
the  order  mentioned,  or  that  the  disease  runs  a  course  throusrh  three  definite 
stages  to  a  fatal  termination.  This  may  occur,  but  more  frequently  the  first 
condition  is  several  times  repeated,  and  the  third  is  often  transformed  into  the 
second  by  rest  and  treatment.  Compensation  occurs  with  great  rapidity  and 
completeness  in  children.  Failure  of  compensation  never  occurs  without  cause. 
The  most  frequent  causes  are  anaemia  and  impaired  general  nutrition  ;  acute 
intercurrent  diseases,  particularly  rheumatism  with  endocarditis ;  and  sudden 
heart-strain  from  excessive  muscular  exertion. 

Symptoms. — When  compensation  is  perfect  there  are  no  symptoms.  It 
not  infrequently  happens,  therefore,  that  a  murmur  is  discovered  when  there  is 
nothing  whatever  in  the  child's  history  or  appearance  to  direct  attention  to  the 
heart.  Dyspnoea  is  by  far  the  most  frequent  symptom,  with  palpitation  but 
little  less  common.  They  are  most  marked  when  the  aortic  valves  are  involved, 
but  dyspnoea  on  exertion  is  usually  present  with  mitral  stenosis.  Pain  as  an 
urgent  symptom  is  not  common,  and  is  more  frequently  associated  with  mitral 
stenosis  than  with  any  other  cardiac  lesion.  Cyanosis  and  oedema  are  rare, 
and  do  not  appear  until  other  symptoms  become  urgent.  (Edema  rarely 
pursues  a  typical  ascending  course.  Epistaxis  is  not  uncommon.  Persistent 
cough  and  subacute  bronchitis  are  frequent  accompaniments  of  mitral  ste- 
nosis. The  condition  often  observed  in  the  adult,  marked  by  dyspnoea  so 
extreme  as  to  prevent  sleep,  by  tumultuous  palpitation  and  extreme  cardiac  dis- 
tress, cyanosis,  and  dropsy,  is  rarely  seen  under  twelve  years. 

Mitral  Regurgitation. — Imperfect  closure  at  the  mitral  orifice  is  the  most 
common  cardiac  defect  during  childhood.  It  usually  results  from  pathological 
change  in  the  valves,  but  may  be  due  to  dilatation  of  the  ventricle  causing  a 
failure  of  coaptation  of  the  edge  of  the  valves.     The  murmur  is  systolic,  is 


982    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

heard  with  greatest  intensity  at  the  apex,  and  is  conveyed  to  the  left.  Such 
a  murmur  developing  during  the  course  of  a  rheumatic  endocarditis  is  organic 
and  probably  permanent.  If  developed  under  other  conditions  it  may  quickly 
disappear.  The  great  relative  frequency  of  this  murmur  is  shown  by  the- fol- 
lowing table,  compiled  from  my  own  history  books : 

Mitral  regurgitation  in  131  cases  (94.7  per  cent.),  alone  in  99  cases. 
Mitral  obstruction      "     17     "       11.8    "       "  "  4     " 

Aortic  regurgitation  "       9    "        6.3    "      "         "  0     " 

Aortic  obstruction     "     28    "      20.1    "       "         "  3     " 

Mitral  Stenosis. — The  frequency  of  the  presystolic  mitral  murmur  in 
childhood  is  comparatively  great.  In  my  cases  it  occurred  in  relation  to  mitral 
regurgitation  as  1  to  7.71.  Rheumatism  was  a  factor  in  its  production,  but 
was  less  strongly  marked  than  in  either  of  the  other  murmurs,  confirming  the 
statement  of  Sansom  that  mitral  stenosis  is  intimately  associated  with  rheu- 
matism, but  most  frequently  with  insidious  varieties.  Symptoms  are  somewhat 
more  marked  than  in  simple  mitral  regurgitation.  Pain  is  more  common  than 
with  any  other  lesion,  and  dyspnoea  on  exertion  is  the  rule.  Palpitation  is  also 
common,  while  bronchitis  and  cough  are  frequent  and  obstinate.  The  mitral 
obstructive  murmur  is  very  rare  in  infancy.  I  have  never  seen  it  under  five 
years.  It  is  slow  in  its  appearance,  never  developing  suddenly,  as  does  the  mitral 
regurgitant.  The  character  of  the  abnormal  sound  is  subject  to  change  from 
time  to  time — more  so  than  any  other  murmur.  It  may  become  very  faint  or 
even  imperceptible,  but  it  is  very  sure  to  return,  and  hopes  based  on  its 
disappearance  are  almost  certain  to  be  disappointed.  Frequently  there  is  no 
perceptible  cause  for  this  changeability. 

The  mitral  obstructive  is  probably  more  frequently  overlooked  than  any 
other  murmur,  yet  it  is  quite  distinct  and  characteristic.  It  is,  as  a  rule,  harsh 
and  of  a  rattling,  blubbering  character.  It  differs  decidedly  from  other  mur- 
murs in  one  particular  :  instead  of  rising  to  a  maximum,  and  then  gradually 
decreasing  or  shading  off  into  silence,  it  rises  rapidly  to  a  maximum,  and  sud- 
denly ceases  as  the  apex  strikes  the  chest-wall.  Its  area  of  diffusion  is  limited. 
As  the  stethoscope  is  carried  from  the  apex  a  point  is  quickly  reached  at  which 
the  mui'mur  suddenly  and  completely  ceases.  If  a  regurgitant  murmur  is  also 
present  and  the  heart  is  acting  rapidly,  the  two  murmurs  may  run  so  closely 
together  as  to  be  with  difficulty  separated.  In  this  case  the  first  portion,  or 
obstructive  murmur,  suddenly  ceases  at  a  given  point,  while  the  regurgitant 
remains  unchanged.  If  the  second  sound  is  reduplicated  at  the  apex,  the 
certainty  of  mitral  stenosis  is  increased.  A  thrill  is  by  no  means  so  com- 
mon as  in  the  adult.  It  is  sometimes  absent  in  well-marked  cases,  and  is  occa- 
sionally present  when  the  murmur  is  faint  and  uncertain.  The  left  auricle  is 
dilated  and  hypertrophied  in  cases  of  long  standing,  and  the  right  side  of  the 
heart  is  engorged  and  frequently  dilated.  Right-side  enlargement,  however, 
cannot  always  be  determined  by  physical  examination. 

Aortic  Stenosis. — Aortic  murmurs  are  much  more  definitely  associated 
with  rheumatic  histories  than  are  the  mitral,  and  indicate  a  more  extensive 
endocarditis.  An  aortic  obstructive  murmur  may  permanently  disappear. 
This  has  occurred  in  my  own  experience  tAvice,  two  years  being  required  in 
one  case  and  over  three  years  in  the  other.  A  change  in  character  is  not 
uncommon,  a  loud,  harsh  murmur  becoming  soft  and  bloAving  or  even  disap- 
pearing temporarily.  While  symptoms  are  in  many  cases  obscure,  they  are, 
as  a  rule,  somewhat  more  distinctive  than  when  mitral  regurgitation  alone  is 
present,  it  being  remembered  that  a  mitral  murmur  is  almost  invariably  an 
accompaniment  of  the  aortic.     Dyspnoea  is  frequent,  and  with  a  double  aortic 


DISEASES    OF   THE  HEART.  983 

murmur  dyspnoea  and  palpitation  upon  exertion  are  almost  constant.  Both 
symptoms  are  more  continuous,  and  depend  less  upon  exertion  than  in  the  case 
of  mitral  disease.  Ansemia  is  very  common ;  it  is  persistent  and  often  extreme. 
Physical  signs  differ  but  little  from  those  observed  in  the  adult. 

Aortic  Regurgitation. — This  is  the  most  infrequent  left-side  valvular 
lesion.  It  rarely,  if  ever,  occurs  alone  in  childhood,  and  in  but  one  instance 
have  I  heard  a  double  aortic  murmur  without  an  accompanying  mitral.  The 
symptoms  are  somewhat  more  marked  than  those  of  simple  aortic  stenosis,  for 
it  appears  only  after  extensive  endocardial  inflammation,  and  is  an  additional 
burden  to  an  already  disabled  heart. 

Tricuspid  Regurgitation. — This  condition  is  more  frequently  detected 
by  the  pathologist  than  by  the  clinician,  because  in  the  young  it  is  extremely 
difficult  of  differentiation  from  mitral  regurgitation.  In  early  infancy  a  mur- 
mur heard  with  greatest  intensity  at  or  just  to  the  right  of  the  apex  is  pre- 
sumably tricuspid.  If  the  lesion  is  serious,  right-side  enlargement  will  be 
present,  which  may  be  detected  by  an  area  of  dulness  at  the  right  of  the  sternum 
and  by  epigastric  pulsation.  When  added  to  mitral  and  aortic  disease  the 
symptoms  are  distinctive.  Visceral  enlargements  and  dyspepsia  are  invariably 
present,  but  jugular  pulsation  is  not  constant.  Palpitation,  dyspnoea,  cough, 
pain,  cyanosis,  and  oedema  develop  to  form  the  last  stage  of  a  fatal  malady. 

Prognosis. — The  elements  of  prognosis  are  numerous  and  complicated. 
Murmurs  alone  usually  furnish  insufficient  evidence  upon  which  to  base  an 
opinion.  The  action  of  the  heart,  the  condition  of  hypertrophy  or  dilata- 
tion, the  completeness  of  compensation,  and  the  general  physical  condition  of 
the  patient  must  all  be  taken  into  account.  The  social  condition,  surround- 
ings, and  mode  of  life  are  important  factors  and  must  be  duly  considered. 
Parental  discipline  is  also  an  element  of  great  importance.  In  a  wayward  and 
uncontrolled  child  the  prognosis  is  decidedly  worse  than  in  one  under  firm  and 
judicious  discipline.  On  the  whole,  the  prognosis  may  be  said  to  be  better  in 
the  child  than  in  the  adult. 

The  period  from  ten  to  fifteen  years  is  a  critical  one.  The  remarkable 
increase  in  the  volume  of  the  heart  at  the  time  of  puberty  has  already  been  re- 
ferred to.  A  patient  sometimes  progresses  satisfactorily  till  this  age  is  reached, 
when  the  whole  aspect  of  the  case  is  changed.  Compensation  becomes  imper- 
fect, the  child  grows  anaemic,  and  gives  evidence  of  impaired  nutrition.  Devel- 
opment is  retarded,  though  there  may  be  growth  in  height,  the  child  being  thin 
and  without  strength  or  vigor.  Sometimes  he  develops  into  a  fairly  healthy 
youth,  but  in  other  cases,  going  from  bad  to  worse,  finally  succumbs.  For- 
tunately, the  majority  of  patients  pass  safely  through  this  trying  period,  often 
without  perceptible  inconvenience.  Such  children,  if  a  mitral  regurgitation 
only  is  present,  usually  develop  into  healthy  men  and  women  and  never  show 
symptoms  of  cardiac  disease. 

The  etiology  aids  somewhat  in  prognosis.  The  more  distinctly  rheumatic 
the  patient,  the  worse  the  prognosis,  for  recurring  attacks  of  endocarditis  are 
to  be  feared.  Failure  of  compensation  resulting  from  an  attack  of  rheumatism 
or  scarlet  fever  is  of  far  greater  importance  than  that  developing  from  muscular 
strain,  ansemia,  over-study,  or  nervous  excitability.  Among  symptoms  cya- 
nosis and  oedema  are  of  the  most  serious  import. 

If  mitral  regurgitation  alone  is  present  and  the  child  is  strong  and  well- 
nourished,  the  probability  of  maintaining  compensation  is  good,  provided 
recurring  attacks  of  endocarditis  can  be  prevented.  The  prognosis  turns 
almost  entirely  upon  this  last  contingency,  and  this,  in  turn,  depends  in  large 
measure  upon  the  personal  and  family  history  as  regards  rheumatism.     Hence 


984    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  history  is  a  matter  of  decided  importance  in  prognosis.  Mitral  stenosis  is 
always  a  grave  condition,  but  is  somewhat  less  serious  in  young  children  than 
in  adults,  largely  because  the  pulmonary  arteries  adapt  themselves  more  readily 
to  the  abnormal  strain  placed  upon  them.  Compensation  sometimes  becomes 
perfect,  and  remains  so,  but  when  the  lesion  is  extreme,  it  does  not  admit  of 
complete  and  permanent  compensation.  When  pulmonary  symptoms  are  marked 
the  prognosis  is  especially  bad.  In  aortic  disease,  if  obstruction  alone  is  pres- 
ent, without  rheumatic  history,  the  prognosis  is  very  favorable.  The  murmur 
may  entirely  disappear.  If,  on  the  other  hand,  it  is  associated  with  a  mitral 
murmur  and  a  rheumatic  history  is  obtained,  the  case  is  a  grave  one :  the  dis- 
ease is  the  result  of  an  extensive  endocarditis,  which  will  probably  recur  to 
cause  more  and  more  distortion  of  the  valves.  Aortic  regurgitation  is  a  far 
more  serious  condition  than  aortic  stenosis,  and  when  both  murmurs  accompany 
a  mitral  the  prognosis  must  be  very  guarded.  Tricuspid  regurgitation  is  always 
a  serious  condition,  and  the  prognosis  is  unfavorable. 

Treatment. — The  successful  management  of  cardiac  disease  requires,  on 
the  part  of  the  physician,  a  clear  conception  of  its  various  stages  and  an  under- 
standing of  the  exact  condition  of  his  patient.  If  the  compensation  is  perfect, 
there  will  be  no  symptoms  of  heart  disease  and  nothing  to  treat.  All  that  can 
be  accomplished  in  any  case  not  suffering  from  acute  inflammation  is  to  estab- 
lish compensation.  If  that  is  already  accomplished,  it  is  the  height  of  impro- 
priety to  treat  the  patient  for  heart  disease.  The  error  must  not  be  made  upon 
the  other  extreme,  however,  that  the  physician  has  no  duty  in  the  case.  The 
child  should  be  kept  under  observation,  for  the  condition  of  compensation  may 
be  at  any  time  changed  to  that  of  heart  failure.  Nutrition  should  be  main- 
tained at  the  highest  possible  point  by  diet  and  properly  regulated  outdoor 
exercise.  The  child  should  be  especially  guarded  against  exposure  to  the 
exanthematous  diseases,  and,  above  all  else,  should  be  protected  from  conditions 
which  tend  to  precipitate  an  attack  of  rheumatism.  If  that  disease  does  de- 
velop, it  should  receive  prompt  and  vigorous  treatment.  Anaemia  is  a  condition 
full  of  peril  in  heart  disease,  for  when  it  is  extreme  compensation  is  not  long 
maintained.  It  should  be  combated  by  iron,  arsenic,  cod-liver  oil,  the  vege- 
table bitters,  and  a  generous  but  simple  and  digestible  diet.  The  question  of 
exercise  is  one  of  the  greatest  importance.  Violent  games  may  do  irreparable 
harm,  while,  on  the  other  hand,  if  the  child  be  debarred  from  reasonable  out- 
door exercise,  heart  failure  may  develop  from  anaemia  and  impaired  general 
nutrition.  Quiet  games  and  plays  are  to  be  definitely  prescribed,  with  the 
strictest  injunction  against  football,  baseball,  and  all  games  requiring  violent 
muscular  exertion  and  running.  The  clothing  should  also  receive  the  physician's 
attention,  flannels  being  prescribed  for  both  summer  and  winter. 

If  failure  of  compensation  appears,  absolute  rest  should  be  rigidly  enforced. 
The  cause  should  be  sought  and  removed  if  possible.  The  appetite  usually 
disappears  utterly,  and  the  stomach  becomes  irritable  and  enforced  alimentation 
is  necessary.  If  the  stomach  rejects  milk  and  lime-water,  animal  broths,  or 
koumyss,  it  may  retain  milk  peptonized  for  two  hours,  to  which  a  little  lemon- 
juice  may  be  added.  If  this  is  rejected,  nutritive  enemata  of  completely  pep- 
tonized milk  must  be  given  every  four  to  six  hours.  Medical  treatment  will 
prove  of  little  avail  if  the  child  is  permitted  to  lose  strength  from  lack  of 
nourishment. 

Among  drugs  digitalis  still  holds  its  position  as  first  and  most  important, 
but  it  must  be  employed  judiciously.  Much  harm  may  result  from  lack  of  judg- 
ment and  nice  discrimination  in  the  use  of  the  cardiac  stimulants  and  sedatives. 
By  increasing  the  force  of  the  systole,  prolonging  the  diastole,  and  contracting 


DISEASES   OF   THE  HEART.  985 

relaxed  arterioles  digitalis  restores  the  balance  of  the  circulation  when  deranged  by- 
valvular  lesions  or  weakness  of  the  heart-muscle ;  in  other  words,  it  re-establishes 
compensation.  Its  use  is  indicated  when  the  heart's  action  is  rapid,  feeble,  and 
irregular  and  the  pulse  shows  low  arterial  tension.  Rational  symptoms  offer 
more  reliable  indications  for  its  use  than  do  the  physical  signs,  but  both  should 
be  duly  considered.  Dyspnoea,  cough,  cyanosis,  oedema,  and  scanty  urine  are 
indicative  of  failing  heart-power,  and  call  for  a  cardiac  stimulant.  Mitral 
regurgitation  is  the  valvular  lesion  for  which  digitalis  proves  most  generally- 
useful.  With  mitral  stenosis  irregular  heart  action  is  sometimes  aggravated  by 
its  use.  In  that  case  convallaria  may  prove  efficient.  When  an  aortic  murmur 
is  present  digitalis  is  not  so  frequently  efficacious  as  in  mitral  disease  alone.  If 
compensation  is  good,  its  use  may  cause  alarming  symptoms,  and  in  any  case  it 
should  be  prescribed  cautiously  at  first.  Iron,  strychnine,  and  the  alkalies  are, 
as  a  rule,  more  efficacious.  In  tricuspid  regurgitation  digitalis  must  be  used 
with  extreme  caution.  The  tincture  is  the  preparation  most  commonly  employed, 
the  dose  varying  according  to  the  age  and  cardiac  condition  from  one  to  five  or 
six  minims.  It  is  often  very  badly  tolerated  by  the  stomach.  The  solid  prep- 
arations cause  far  less  gastric  disturbance,  and  may  be  usually  continued  for 
weeks  without  trouble.  The  dose  of  the  powdered  leaves  is  from  one-fourth 
grain  to  one-half  grain,  and  of  the  extract  one-fourth  of  these  amounts. 

In  case  of  great  restlessness  on  the  part  of  the  child,  with  palpitation 
and  cardiac  distress,  a  sedative  may  be  required.  Bromide  of  sodium  should 
be  first  tried  in  doses  of  three  to  ten  grains  every  six  hours.  If  this  be  unavail- 
ing, opium  may  be  cautiously  administered,  paregoric  being  selected  for  younger 
children,  and  the  deodorized  tincture  for  those  of  more  advanced  years.  Exces- 
sive palpitation,  with  dyspnoea  appearing  in  paroxysms,  is  often  quickly 
relieved  by  a  few  drops  of  compound  spirits  of  ether  combined  with  a  small 
dose  of  opium. 

If  the  urine  becomes  scanty  and  oedema  appears,  a  hot  digitalis  poultice 
should  be  applied  across  the  loins.  This  is  made  by  boiling  two  ounces  of 
digitalis  leaves  in  a  pint  of  water,  and  then  stirring  in  sufficient  linseed  meal. 
Digitalis  should  be  administered  freely,  and  in  this  condition  the  infusion  is 
most  effectual.  At  the  same  time  the  bowels  should  be  freely  acted  upon  by 
calomel.  The  compound  diuretic  pill  for  children  who  can  swallow  it  often 
relieves  the  symptoms  with  marvellous  rapidity.  It  consists  of  equal  parts  of 
calomel,  digitalis,  and  squill ;  one-third  to  one-half  grain  of  each  may  be  given 
at  twelve  years.  For  younger  children  the  tincture  of  digitalis  and  tincture 
of  squill  may  be  combined  with  spirit  of  nitrous  ether  or  citrate  of  potas- 
sium. 


THE  FUNCTIONAL  AFFECTIONS  OF  THE  HEART 
(THE  CARDIAC  NEUROSES). 


By  J.  C.  WILSON,  M.  D., 

Philadelphia. 


The  functional  affections  of  the  heart  include  those  motor  and  sensory- 
derangements  which  occur  in  the  absence  of  demonstrable  anatomical  changes 
in  the  organ. 

The  qualifying  adjective  "functional"  is  used  in  its  ordinary  sense,  to 
denote  the  absence  of  anatomical  lesions  demonstrable  during  life  or  after 
death.  It  is  appropriately  employed  in  this  connection  to  designate  disorders 
not  primarily  of  the  heart  itself,  but  rather  of  its  innervation.  Hence  these 
affections  are  also  properly  spoken  of  as  cardiac  neuroses. 

It  is  important  to  note  that  all  the  morbid  phenomena  observed  in  func- 
tional disorders  may  and  frequently  do  attend  the  structural  diseases  of  the 
heart. 

The  functional  affections  of  the  heart  which  occur  in  childhood  are — 

A.  Motor: 

1.  Derangements  of  rhythm. 

a.  Arrhythmia. 

h.  Rapid  heart — tachycardia. 

c.  Slow  heart — bradycardia  (brachycardia). 

2.  Momentary  arrest — syncope. 

B.  Sensory: 

Subjective  sensations  referred  to  the  praecordia. 
a.  Heart-consciousness. 
h.  Distress. 
c.  Pain. 

C.  Motor  and  Sensory  combined: 

Palpitation. 

Etiology. — The  influences  which  predispose  to  affections  of  the  heart  are 
the  same  in  childhood  as  in  adult  life.  They  consist  in  {a)  a  weak  and  delicate 
organization  associated  with  an  impressionable  nervous  system  ;  (6)  anaemic 
conditions  ;  (c)  lithaemia  and  allied  derangements  of  metabolism  and  excretion ; 
and  {d)  morbid  conditions  directly  affecting  the  nervous  system,  as  organic 
diseases  of  the  brain  and  cord,  chorea,  epilepsy,  and  the  acute  and  chronic 
infections.  To  this  list  must  be  added  adenoid  hypertrophies  of  the  pharyn- 
geal vault. 

Certain  of  these  conditions  are  inherited,  others  acquired.  Thus  the  chil- 
dren of  nervous  or  insane  parents,  those  begotten  of  elderly  persons,  those  born 
prematurely,  those  who  have  in  infancy  been  exposed  to  privation  and  neglect, 
or  who  have  suffered  from  serious  or  protracted  disease,  are  especially  prone  to 
functional  disturbances  of  the  heart.     To  a  less  extent  is  this  true  of  the 


FUNCTIONAL    AFFECTIONS    OF    THE   HEART.  987 

children  of  goutv  families  and  of  the  offspring  of  tuberculous  and  syphilitic 
parents.  The  tendency  to  functional  cardiac  trouble,  rarely  observed  in  early 
infancy,  usually  shows  itself  at  the  approach  of  the  seventh  or  eighth  year. 

The  exciting  causes  include  (A)  those  acting  upon  the  nervous  system  ;  (a) 
directly,  as  intense  mental  emotion,  fever,  anger,  passionate  grief;  or  (&) 
reflexly,  as  dentition,  gastro-intestinal  irritation  from  indigestion,  intestinal 
worms,  foreign  bodies  in  the  intestinal  canal ;  and  (B)  those  acting,  by  means 
of  mechanical  disturbance  of  the  circulation,  upon  the  heart,  as  violent  exer- 
cise or  exertion,  especially  after  meals. 

Functional  derangements  of  the  heart  are  much  less  frequent  in  childhood 
than  in  adult  life,  for  the  reason  that  the  Pandora's  box  of  vicious  habits,  the 
brunt  of  which  the  heart  must  sooner  or  later  bear,  is  only  opened  by  degrees, 
and,  happily,  not  often  early  in  life. 

Symptoms. — In  general  terms  the  symptoms  of  the  functional  disorders 
of  the  heart  in  childhood,  as  in  adults,  consist  in  derangement  of  the  motor 
functions  and  abnormal  sensations  referred  to  the  prgecordia.  These  motor  and 
sensory  derangements  are  not  always  associated.  More  commonly  the  move- 
ment of  the  heart  is  deranged,  its  action  being  accelerated,  retarded,  or  irregu- 
lar, without  abnormal  sensations  ;  occasionally  deranged  rhythm  of  frequency 
occurs  in  connection  with  prsecordial  distress  or  pain  or  a  sense  of  oppression, 
and  in  comparatively  rare  instances  prsecordial  pain  occurs  in  the  absence  of 
perturbation  of  the  movements.  Angina  pectoris  is  not  a  disease  of  childhood, 
nor  is  it  common  to  encounter  the  agonizing  pains  of  pseudo-angina  early  in 
life. 

When  the  functional  disorder  is  paroxysmal  or  of  a  high  grade  of  intensity, 
it  is  usually  accompanied  by  increased  frequency  and  shallowness  of  respira- 
tion, and  very  often  by  pallor  of  the  face  and  slight  cyanosis.  Especially  is 
pallor  associated  with  the  temporary  arrest  of  the  heart's  action  known  as 
fainting,  a  condition  also  usually  preceded  by  momentary  nausea. 

The  child,  ignorant  alike  of  the  existence  of  his  heart  and  of  its  functions, 
uncomfortable  as  he  may  be  in  other  respects,  escapes  the  anxiety  and  mental 
distress  which  in  the  adult  forms  so  important  an  element  in  the  paroxysmal 
functional  affections  of  this  organ. 

When  the  derangement  is  not  paroxysmal,  but  persistent,  the  rhythm  of  the 
respiration  is  not  usually  disturbed. 

It  is  to  be  borne  in  mind  that  in  childhood  both  the  respiration  and  the 
action  of  the  heart  are  normally  far  less  constant  in  rhythm  than  in  adults, 
that  they  are  more  readily  deranged  by  slight  causes,  and  that  the  action  of 
the  heart  is  often  irregular  during  sleep  and  much  influenced  by  inspiration 
and  expiration.  The  pulsus  paradoxus,  in  which  the  heart-beats  during 
inspiration  are  more  frequent,  but  less  full,  than  during  expiration,  may  often 
be  observed  in  perfectly  healthy  children  during  sleep. 

Physical  examination  yields  a  limited  number  of  definite  signs.  The  fre- 
quency of  the  heart's  action  and  the  degree  and  character  of  the  arrhythmia 
are  recognized  upon  palpation.  By  this  method  of  examination  we  also  detect, 
especially  on  palpation,  the  change  in  the  character  of  the  impulse,  which  is 
increased  in  force.  We  observe  also  by  this  means  and  by  inspection  that  the 
impulse  is  extended.  We  determine  by  the  position  of  the  apex-beat,  and 
may  confirm  by  percussion,  the  observation  that  the  heart  is  not  enlarged. 
Upon  auscultation  the  first  sound  is  found  to  be  sharp  and  valvular  and  short- 
ened in  duration,  while  the  second  sound  remains  distinct  or  is  accentuated. 
In  very  rapidly-acting  or  very  irregular  hearts  transient  murmurs,  usually  mitral 
systolic,  sometimes  develop. 


988    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Arrhythmia. — The  various  forms  of  arrhythmia  are  encountered  in  the 
functional  cardiac  affections  of  childhood.  The  paradoxical  pulse,  as  has  been 
mentioned,  is  frequently  observed  in  healthy  children  during  sleep.  When 
encountered  during  the  waking  hours  it  is  more  frequently  a  manifestation  of 
organic  than  functional  derangement  of  the  heart. 

The  rhythm  of  the  foetal  heart,  embryocardia,  a  condition  in  -which  the 
acoustic  properties  of  the  two  sounds  are  almost  identical  and  the  pauses 
nearly  equal  in  duration,  frequently  occurs  when  the  heart's  action  is  rapid. 
Other  forms  of  arrhythmia,  as  the  alternate  heart-beat  in  which  strong  and 
weak  contractions  occur  with  regular  alternation,  the  bigeminal  and  trigemi- 
nal pulsation  in  which  the  ventricular  contractions  occur  in  series  of  two  or 
three  separated  by  an  interval  or  by  feebler  contraction,  the  gallop  rhythm  and 
dicrotism,  are  rarely  observed.  The  disturbances  of  rhythm  in  which  with 
rapid  action  there  is  irregularity,  not  conforming  to  definite  type,  are  the  most 
common.  This  condition  in  its  more  marked  degrees  has  been  described  under 
the  term  delirium  cordis.  With  less  rapidity  of  action  there  may  be  recog- 
nized, upon  physical  examination,  short  series  of  three  or  four  forcible  heart 
contractions  followed  by  great  irregularity  and  feebleness  of  action,  this  succes- 
sion being  irregularly  repeated.  True  intermission  or  the  missing  of  a  car- 
diac beat — "heart  dropping,"  as  it  is  frequently  called,  a  condition  common  in 
adult  life — has  not  come  under  my  observation  in  childhood. 

Eapid  Heart  {Tachycardia). — The  action  of  the  heart,  normally  130 
to  140  per  minute  in  the  new-born,  gradually  decreases  in  frequency  until  the 
end  of  the  third  year,  when  it  ranges  about  90.  It  is  readily  accelerated  by 
slight  causes.  Great  increase  in  the  rapidity  of  the  heart's  action  is  encoun- 
tered in  fevers.  Rapidity  of  the  heart  is  also  induced  by  violent  emotion  and 
undue  exercise.  The  rapid  action  thus  induced  may  sometimes  persist  for  hours 
or  days.  The  paroxysmal  tachycardia  occasionally  encountered  in  adults  does 
not  occur  in  children. 

Slow  Heart  {Bradycardia.,  Brachycardia). — This  condition  is  not  com- 
mon in  childhood.  Slowness  of  the  pulse,  the  rate  falling  to  60  or  somewhat 
below  it,  is,  however,  occasionally  encountered  during  convalescence  from  the 
acute  infectious  diseases,  in  acute  rheumatism,  in  disorders  of  the  digestive 
system,  in  jaundice,  and  in  anaemia.  Slowness  of  the  heart's  action  has  been 
observed  in  post-epileptic  coma. 

Syncope  occasionally  occurs  in  nervous  and  impressionable  children. 
It  may  result  from  sudden  shock  or  intense  excitement.  On  several  occasions 
I  have  known  children  of  six  or  seven  years  of  age  to  faint  at  the  sight  of 
blood.  I  have  seen  a  boy  of  seven  faint  at  the  sight  of  the  denuded  spot  upon 
his  arm  caused  by  vaccination.  A  healthy  girl  eight  years  old,  of  shy  and 
timid  disposition,  fainted  at  the  dinner-table  upon  being  suddenly  addressed  by 
a  person  Avhom  she  did  not  know.  For  some  hours  she  remained  quiet  upon 
the  sofa,  the  pulse-rate  not  exceeding  60.  Actual  loss  of  blood,  even  when 
slight,  profuse  diarrhoea,  extreme  fatigue,  and  severe  pain  are  capable  of  pro- 
ducing syncope  in  impressionable  children. 

Heart  Coxsciousness  is  fortunately  extremely  rare  in  children.  The 
most  tumultuous  action  of  the  heart  may  take  place  apparently  without  sub- 
jective sensations.  It  occasionally  happens,  however,  that  older  children 
complain  of  the  beating  of  the  heart  without  pain  under  conditions  of  excite- 
ment or  fatigue  and  in  the  absence  of  over-action  amounting  to  palpitation. 

Precordial  Distress  is  occasionally  encountered.  It  is  usually  reflex 
in  character  and  caused  by  gastro-intestinal  irritation.    As  a  rule  it  is  transient. 

Precordial  Pain  is  rare.    A  remarkable  instance  of  distressing  prsecordial 


FUNCTIONAL   AFFECTIONS    OF   THE  HEART  989 

pain  in  a  lad  has  come  under  my  notice.  The  patient  was  the  feebler  one 
of  twins,  and  sufiered  in  various  ways  from  the  reflex  nervous  disturbances  due 
to  adenoid  vegetations  in  the  pharyngeal  vault.  Among  these  were  attacks 
of  pain  in  the  region  of  the  heart,  unaccompanied  by  disturbances  of  rhythm  or 
over-action,  and  occurring  in  paroxysms  repeated  on  several  successive  days. 

Palpitatiox  may  be  defined  as  over-action  of  the  heart  with  abnor- 
mal precordial  sensations.  These  sensations  are  always  distressing  and  very 
frequently  amount  to  actual  pain.  Palpitation  is  attended  by  increased  rapidity 
of  respiration  and  a  sense  of  oppression.  It  is  among  the  more  common  of  the 
functional  heart  affections  of  childhood,  usually  induced  by  over-exertion  or 
violent  emotions,  and  sometimes  occurring  without  recognizable  cause.  The 
condition  of  convalescence  from  acute  disease,  debility,  ansemia,  and  lithgemia 
are  predisposing  influences. 

Course. — The  course  of  the  functional  affections  of  the  heart  in  childhood  is 
in  the  main  transient.  If  recurrences  take  place,  they  gradually  cease  as  the 
general  health  improves.  This  is  especially  true  of  the  attacks  which  occur 
as  the  result  of  reflex  gastro-intestinal  derangements,  of  anaemia,  or  during 
the  convalescence  from  acute  disease.  The  attacks  which  are  met  with  in  con- 
stitutionally feeble  children,  in  those  who  are  lithsemic  or  who  have  habitually 
an  abundance  of  calcium-oxalate  crystals  in  the  urine,  yield  less  readily  and  more 
slowly  to  treatment.  The  mere  "impressionable  heart"  is  likely  to  be  func- 
tionally deranged  by  slight  causes  throughout  life.  It  is  not,  however,  incom- 
patible with  fairly  good  general  health  and  a  reasonable  expectancy  of  life. 

Diagnosis. — The  diagnosis  rests  upon  the  presence  of  the  symptoms  and 
signs  which  have  been  described,  in  association  with  the  constitutional  or  local 
conditions  in  which  functional  derangements  of  the  heart  are  known  to  occur, 
or  the  history  of  a  direct  exciting  cause.  The  absence  of  the  physical  signs 
of  organic  heart  disease,  and  of  the  rational  symptoms  of  transference  of  blood- 
pressure  from  the  arterial  to  the  venous  side  of  the  circulation,  must  further  be 
established. 

Prognosis. — The  prognosis  is  as  a  rule  favorable,  both  as  regards  the 
separate  attack  and  the  ultimate  recovery.  I  have  not  seen  organic  disease 
of  the  heart  develop  as  a  sequence  of  either  frequently-recurring  or  long- 
continued  functional  disorder. 

Treatment. — In  the  paroxysmal  forms  the  treatment  must  be  directed  to 
the  immediate  condition.  The  child  must  be  placed  at  rest  in  the  recumbent 
or  sitting  posture,  the  clothing  loosened,  every  effort  made  to  allay  fear  and  calm 
excitement.  The  face  and  hands  should  be  bathed,  and  by  degrees  the  atten- 
tion diverted.  If  necessary,  ammonia  may  be  inhaled  or  a  few  drops  of  the 
aromatic  spirit  of  ammonia  in  water  administered. 

In  the  case  of  syncope  the  recumbent  posture  should  be  maintained  for 
some  time  and  a  current  of  air  admitted.  The  face  may  be  sprinkled  with  cold 
water,  and  the  venous  circulation  in  the  limbs  favored  by  centripetal  frictions. 

Efforts  should  be  made  to  correct  those  conditions  which  act  as  predispos- 
ing influences.  Attention  to  hygiene  is  of  the  first  importance.  Systematic 
feeding  and  a  diet  at  once  nutritious,  easy-  of  digestion,  and  abundant,  are 
imperative.  Fresh  milk,  eggs,  broiled  and  roasted  meats,  bread-crusts,  fresh 
vegetables  and  fruits,  selected  and  regulated  according  to  the  age  of  the  child, 
constitute  the  dietary.  Quality  is  of  supreme  moment;  vai'iety  is  not  neces- 
sary. A  spoonful  of  preserves  or  jam  occasionally  should  be  regarded  as  a 
treat.  The  breakfast  should  be  taken  early,  the  dinner  at  midday,  supper  at 
five  or  six  o'clock,  and  bed-time  should  not  be  later  than  eight.  The  bath 
should  be  given  in  the  morning,  cold  or  at  most  only  tepid,  and  followed  by 


990    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

brisk  towelling  till  the  skin  glovrs.  By  day  and  night  the  clothing  must  be 
warm,  light,  and  loose.  Exercise  in  the  open  air  should  be  systematic  and 
regular.  Even  in  changeable  climates  delicate  children,  when  properly  clad, 
may  go  out  to  walk,  except  in  extremely  cold  weather  or  in  actual  storms, 
almost  every  day — not  only  without  injury,  but  even  with  positive  gain. 

Anaemic  conditions  require  prompt  and  careful  attention.  Among  the 
drugs  most  useful  in  their  management  are  alcohol,  cod-liver  oil — which,  in 
well-made  emulsion,  children  take  very  well — syrup  of  iron  iodide,  and  the 
various  preparations  of  mercury  and  of  arsenic  in  minute  doses. 

Lithiiemia,  whether  inherited  or  acquired,  demands  very  careful  study  and 
management.  Here  a  milk  diet  is  especially  useful,  and  an  occasional  laxa- 
tive. Where  the  fault  lies  with  the  nervous  system,  long  hours  of  rest, 
especially  rest  in  the  middle  of  the  day,  and  the  bromides,  are  of  advantage. 
Adenoid  vegetations  of  the  pharyngeal  vault  must,  when  discovered,  be  forth- 
with removed. 

Wholesome  moral  influences  and  discipline  at  once  gentle,  affectionate,  and 
firm  ai'e  of  untold  value  in  the  care  of  delicately  organized  and  impressionable 
children.  Those  who  have  the  care  of  the  young  ought  to  possess  in  a  high 
degree  that  rare  greatness  which  shows  itself  in  the  ruling  of  one's  own  spirit — 
said  to  be  beyond  that  which  enables  one  to  take  cities. 

If  disturbances  of  the  cardiac  function  occur  during  dentition,  the  stoma- 
titis which  often  arises  must  be  promptly  treated,  and  if  the  gum  over  a  pre- 
senting tooth   be  tense,  livid,  and  tender,  it  may  be  freely  incised. 

Derangements  of  digestion  are  best  managed  by  withholding  ordinary  food 
for  a  time,  giving  small  amounts  of  milk  and  lime-water,  a  calomel  purge,  and 
the  subsequent  administration  of  an  efficient  pepsin. 

If  intestinal  worms  be  present,  they  are  to  be  expelled  by  appropriate 
treatment. 

The  functional  derangements  of  the  heart  Avhich  occur  in  acute  disease  and 
during  convalescence  disappear  with  returning  health,  and  as  a  rule  demand  no 
especial  treatment. 

It  remains  to  speak  of  the  group  of  drugs  familiarly  knoAvn  as  heart  tonics. 
They  are  rarely  indicated,  often  used  with  no  good  effect.  What  the  heart 
most  needs  for  its  best  nutrition,  both  in  childhood  and  afterward,  is  well- 
oxygenated,  healthy  blood  and  moderate  and  fairly  regulated  work  ;  and  these 
constitute  the  greatest  need  also  of  the  nervous  system,  which  controls  and 
regulates  the  heart. 

Digitalis,  nux  vomica,  and  belladonna  are  often  required.  They  must, 
however,  be  given  only  in  response  to  clear  indications.  Their  employment  in 
short  courses  under  proper  circumstances  is  highly  beneficial  :  as  a  matter  of 
routine  they  are  not  only  generally  useless,  but  also  often  hurtful. 


PART  X. 
DISEASES  OF  THE  GENITO-URINARY  SYSTEM. 


HEMATURIA,    PYURIA,    CHYLURIA,    Al^URIA, 
AND  mCOT^TINEIs^CE  OF  URINE. 


By  E.  M.  BUCKINGHAM,  M.  D., 

BosTox. 


HEMATURIA. 


Blood  reaches  the  urine  from  any  part  of  the  urinary  passages.  Its 
quantity  varies  within  the  widest  limits,  and  the  color  of  the  urine  containing  it 
ranges  from  bright  red  to  smoky  red,  dark  greenish-brown,  or  almost  black. 
The  longer  it  remains  in  contact  with  urine,  and  the  more  thoroughly  mixed 
with  it,  the  darker  it  becomes,  especially  if  it  be  in  small  quantity.  A  very 
large  haemorrhage  is  more  likely  to  be  from  the  bladder,  and  a  small  one  from 
the  kidney.  It  has  therefore  been  assumed  that  the  presence  of  bright  blood 
shows  a  vesical,  and  of  dark  blood  a  renal,  haemorrhage.  This  is  not  neces- 
.sarily  true,  for  in  individual  cases  large  haemorrhages  have  been  seen  by  means 
of  the  electric  light  to  issue  from  the  ureters,  and  small  ones  may  certainly  come 
from  the  bladder.  If  blood  is  fresh  and  in  sufficient  quantity  to  render  the 
urine  alkaline,  it  may  settle  to  the  bottom  of  the  containing  vessel,  leaving  a 
clear  upper  layer  of  urine.  Clots  occur  only  when  the  blood  is  in  tolerably  large 
quantities,  and  especially  when  not  thoroughly  mixed  with  urine.  They  may 
be  large  enough  to  cause  pain  from  consequent  retention,  and  they  may  decom- 
pose and  give  rise  to  cystitis.  By  their  shape  they  sometimes  give  evidence 
of  their  place  of  origin,  but  moulds  of  the  ureters  may  resemble  those  formed  in 
the  prostate.  It  is  possible  for  urine  to  be  discolored  like  that  of  hsematuria 
without  containing  blood.  Icteric  urine  has  this  appearance  if  sufficiently 
charged  with  bile,  and  red  stains  of  uric  acid  upon  the  diapers  are  occasionally 
taken  for  blood.  In  hsemoglobinuria  no  red  corpuscles  are  present,  but  the 
urine  is  nevertheless  stained  with  blood-pigment.  When  urine  contains  any 
appreciable  amount  of  blood,  it  also  contains  albumin  in  appreciable  quantity. 
Blood-cells  are  probably  found  by  the  microscope,  but  they  become  swollen  and 
disintegrated  in  very  dilute  or  ammoniacal  urine. 

If  the  blood  has  its  source  in  the  urethra,  its  appearance  is  usually  confined 
to  the  beginning  of  micturition.  The  cause  may  be  traumatism,  including  the 
passage  of  small  ragged  calculi.  There  is  a  case  on  record  of  hgematuria  in  a 
child  from  urethritis  depending  upon  decomposition  of  urine  the  result  of  mal- 
position of  the  meatus,  and  entirely  and  quickly  relieved  by  operation.  Blood 
from  prostatitis — rare  in  children — precedes  the  urine  if  the  seat  of  inflamma- 
tion be  in  the  anterior  part  of  the  gland,  or  it  flows  backward  into  the  bladder 

991 


992    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  mixes  with  urine  if  it  comes  from  the  posterior  part.  Generally  the  last 
few  drops  contain  most  of  the  blood.  In  either  case  micturition  is  frequent 
and  painful,  and  is  generally  followed  by  tenesmus.  Rupture  of  a  vessel  at 
the  neck  of  the  bladder  might  cause  similar  symptoms.  If  pain  and  frequent 
micturition  are  both  absent,  this  region  can  with  tolerable  certainty  be  excluded 
as  the  source  of  htemorrhage.  If  cystitis  or  pyelitis  causes  hsematuria,  the 
urine  contains  pus.  The  pain  of  cystitis  is  more  likely  by  far  to  be  referred 
to  the  bladder,  and  that  of  pyelitis  to  the  back,  but  this  distinction  is  not  abso- 
lutely diagnostic.  Both  conditions  are  rare  in  childhood,  but  either  may  be 
excited  by  calculus,  tubercle,  or  acute  disease. 

Calculi  in  any  part  of  the  urinary  tract  may  occasion  hsematuria,  and  renal 
calculi  may  do  this  without  causing  other  symptoms.  Vesical  calculi  are  not 
uncommon  in  children,  but  do  not,  as  a  rule,  give  rise  to  much  bleeding.  This 
is  more  likely  to  come  from  a  calculus  impacted  in  the  ureter,  in  which  case 
there  is  probably  severe  pain. 

The  symptoms  of  tubercular  bladder  resemble  those  of  cystitis.  In  making 
this  diagnosis  one  should  eliminate  the  more  common  causes  of  bleeding,  and 
examine  elsewhere  for  tuberculosis,  which  is  seldom  if  ever  primary  in  the 
urinary  organs.  Bacilli  in  the  urine  would  help  the  diagnosis,  but  they  are 
stated  by  Osier  to  be  scanty  in  pyelitis ;  and  this  would  be  expected  where  the 
tubercular  surface  is  constantly  washed  with  urine.  Therefore,  their  absence 
would  not  exclude  this  disease. 

Prolonged  bleeding  with  intermissions  very  probably  comes  from  one  kid- 
ney or  its  pelvis,  intermissions  being  due  to  plugging  of  the  ureter.  Exacer- 
bations of  pain  during  intermissions  increase  this  probability.  Chill  or  vomit- 
ing may  accompany  them.  Generally,  however,  haemorrhage  starting  above 
the  bladder  is  not  painful. 

Blood  from  the  kidney  generally  contains  enough  renal  casts  and  epithelium 
to  suggest  its  source,  but  one  should  inquire  further.  Bloody  urine  is  a  symp- 
tom of  acute  nephritis.  There  is  generally  the  history  of  an  exciting  cause, 
and  often  much  oedema.  The  urine  not  only  contains  blood,  but  is  at  first 
scanty  and  of  high  specific  gravity,  with  albumin  and  numerous  renal  casts. 
Hyperaemia,  not  amounting  to  nephritis,  also  causes  bleeding.  The  difference  is 
one  of  degree.  Passive  hypersemia  from  a  weak  heart  may  produce  it.  It  may 
occur  in  the  course  of  chronic  parenchymatous  and  of  interstitial  nephritis, 
especially  toward  the  close,  but  is  by  no  means  universal  in  them  as  in  acute 
nephritis,  nor  are  these  diseases  so  common  in  childhood.  Some  drugs  cause 
hypersemia  or  nephritis,  and  therefore  haematuria.  Among  them  are  turpentine, 
cantharides,  potassium  chlorate,  carbolic  acid,  and  amyl  nitrite.  Rhubarb  is 
said  to  invariably  cause  it  in  certain  persons. 

Neoplasms  occasionally  cause  li?eniaturia,  but  less  frequently  in  children, 
because  carcinoma,  Avhich  often  bleeds,  is  rare  with  them,  while  sarcoma, 
which  is  more  common,  bleeds  less.  Villous  growths  in  the  bladder  give  rise 
to  serious  hsemoi-rhage.  If  in  the  prostatic  region,  there  may  be  pain  at  the 
end  of  micturition,  owing  to  the  tumor  being  squeezed  by  the  empty  bladder. 
Berkeley  Hill  writes  that  we  may  infer  that  blood  comes  from  a  villous  growth 
if  bleeding  is  profuse  at  first  and  painless,  and  lasts  from  a  few  days  to  a  w-eek 
or  more.  It  stops  as  suddenly  as  it  begins,  and  is  uninfluenced  by  rest  or 
exercise.  Fragments  are  occasionally  washed  out  in  the  urine.  Such  growths 
have  been  removed  by  the  dcraseur,  but  bleeding  often  stops  of  itself.  Harri- 
son reports  the  removal  of  a  small  fibroid  from  the  bladder  of  a  boy  of  seven- 
teen, giving  complete  relief  to  a  hemorrhage  which  recurred  at  intervals  of  two 
weeks.     There  was  severe  pain  in  the  penis. 


HEMATURIA.  993 

Certain  parasites  occasion  hjematuria.  The  rhabditis  genitalis,  as  de- 
scribed by  Scheiber,  -n-as  found  by  A.  Baginsky  in  the  urine  of  a  child  three 
and  a  half  years  old  with  hgemoglobinuria,  and  by  Peiper  and  Westphal  in  the 
urine  of  a  feeble  child  of  nine,  who  had  had  scarlatinal  nephritis  four  years 
before.  In  the  latter  patient,  pleuritis  occurred  in  October,  and  in  Novem- 
ber severe  hematuria,  followed  by  negative  urine  ;  then  for  a  short  time  there 
was  much  blood  and  pus  in  the  urine.  A  month  later  a  less  severe  haemor- 
rhage occurred,  at  the  beginning  of  which  the  amount  of  urine  was  tempo- 
rarily lessened.  In  two  days  the  microscope  detected  worms,  hardly  half  as 
large  as  trichinae,  which  on  comparison  appeared  to  be  the  Scheiber  worms. 
Many  were  found,  but  all  were  dead.  Xone  were  detected  in  the  blood,  stools, 
or  preputial  secretion.  Soon  hsematuria  ceased,  but  slight  albuminuria  lasted 
six  weeks,  when  more,  but  degenerated,  worms  were  passed.  Albuminuria  then 
ceased.  Meanwhile,  marked  improvement  in  enuresis  of  two  years"  standing 
occurred.  The  authors  are  cautious  about  assuming  relation  between  these 
worms  and  this  symptom. 

Berkeley  Hill  mentions  the  filaria  sanguinis  hominis  as  causing  haematuria : 
this  sometimes  occurs  in  chyluria,  believed  to  be  generally  due  to  this  parasite. 

The  Bilharzia  hi-ematobia.  first  described  by  Bilharz  of  Cairo,  is  found  in 
streams  in  Africa  from  the  Mediterranean  to  the  Cape  of  Good  Hope.  The 
mature  worm  is  too  small  to  be  seen  by  the  unaided  eye.  Eggs  have  been  found 
in  various  parts  of  the  body.  The  view  of  Bilharz,  that  it  is  swallowed 
in  unfiltered  drinking-water,  is  commonly  accepted.  Allen  of  Pietermariz- 
burg.  South  Africa,  reasons  from  its  greater  frequency  in  boys,  who  bathe  in 
rivers,  and  from  the  urethra  being  a  favorite  residence  for  it,  that  it  may  also 
enter  by  the  meatus.  He  states  that  he  can  sometimes  feel  a  colony  in  the 
upper  urethra  by  means  of  a  metallic  catheter,  and  reports  relief  from  urethral 
injections.  Haemorrhage  occasionally  causes  retention  from  clots,  and  may  be 
serious  from  prolonged  oozing,  but  patients  may  recover  after  years  of  suffer- 
ing. Davis  reports  that  the  use  of  kamala  appeared  to  limit  the  number  of 
embryos  passed. 

Malarial  htematuria  is  found  in  many  parts  of  the  world.  In  the  United 
States  it  is  confined  to  severe  cases,  and  generally  to  highly  malarial  regions. 
It  is  not  uncommon  in  the  South,  but  seems  less  frequent  in  cities  than  in  the 
country,  which  apparently  emphasizes  the  need  of  a  high  degree  of  malarial 
poisoning  to  produce  it.  Cases  are  reported  in  children  as  young  as  four  years ; 
these  were  of  a  distinct  adult  type,  marked  with  severe  chills  and  fever,  rather 
than  of  the  partly  masked  form.  Castle  states  that  malarial  haematuria 
is  not  invariably  accompanied  by  chill.  Some  cases  are  remittent  and 
some  pernicious.  The  presence  of  blood-pigment  may  be  continuous,  or  the 
urine  may  become  entirely  clear  between  paroxysms.  It  may  contain  many 
blood-corpuscles  or  only  a  few  with  much  haemoglobin,  or  blood-corpuscles 
may  be  entirely  absent,  although  the  urine  is  colored  with  blood-pigment. 
Day  states  that  the  urine  of  comparatively  mild  cases  is  more  likely  to  contain 
red  corpuscles  than  that  of  severe  ones.  It  has  been  urged  that  they  are 
present  at  first  and  decompose,  but  there  is  reason  to  believe  that  they  become 
altered  in  the  vessels,  allowing  the  escape  of  free  hemoglobin.  Various  theories 
have  been  advanced  to  account  for  malarial  haemoglobinuria :  (a)  the  action  of 
bile  on  the  blood  while  still  in  the  vessels,  supported  by  the  fact  that  injection 
of  bile  or  bile  acids  into  the  blood  has  produced  bloody  urine ;  {h)  the  general 
disturbance  of  the  spleen  and  liver,  organs  which  have  a  part  in  the  formation 
and  destruction  of  red  cells;  (c)  the  effect  of  external  cold  on  the  stagnant  blood 
of  the  extremities  during  paroxysms ;  {d)  the  direct  destructive  action  of  the 


994    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Plasmodium  malarige  upon  the  red  cells.  Malarial  haemoglobinuria  is  more  or 
less  combined  with  real  haemorrhage,  therefore  the  name  haematuria  is  probablj 
the  better  one.  It  is  a  grave  condition  at  best,  and  is  probably  often  fatal 
despite  every  method  of  treatment. 

Some  writers  of  the  Southern  States  assert  that  malarial  haematuria  is  not 
due  directly  to  malaria,  but  to  quinine.  This  causes  congestion  in  other 
organs,  and,  considering  the  enormous  doses  used  in  the  South, ^  it  possibly 
sometimes  excites  nephritis ;  but  there  is  a  malarial  haematuria  not  due  to 
quinine.  Hematuria  sometimes  precedes  any  treatment.  Owen  has  suddenly 
put  a  stop  to  it,  together  with  other  malarial  symptoms,  by  the  subcutaneous 
injection  of  quinine,  and  a  series  of  286  cases  collected  by  Howell  shows  that 
those  treated  with  quinine  and  calomel  made  the  best  recoveries. 

There  is  a  considerable  English  literature  relating  to  cases  of  paroxysmal 
haematuria,  in  which  evidence  of  malaria  is  absent  or  so  slight  as  to  cause  doubt 
if  it  be  a  factor  in  the  etiology.  Herringham  reports  the  cases  of  two  sisters  of 
four  and  a  half  and  three  and  a  half  years ;  and  four  other  cases  of  his  were 
under  five.  These  sisters  were  observed  from  November  to  May  during  several 
attacks.  They  were  at  first  coincident  with  exposure  to  cold,  but  one  occurred 
while  the  child  was  kept  in  bed.  There  was  generally  no  albuminuria,  except  a 
trace  before  some  paroxysms,  showing  that  it  was  mostly  haemoglobin  rather 
than  blood  that  entered  the  urine.  It  was  reported  that  both  children  had  been 
syphilitic,  and  he  states  that  Murri  of  Bologna  believes  paroxysmal  haematuria 
to  be  syphilitic.  Berkeley  Hill  also  states  that  hereditary  syphilis  gives  rise 
to  this  symptom.  Verco  reports  the  case  of  a  man  who  could  produce  haema- 
turia whenever  he  pleased  by  merely  going  into  the  cold.  It  was  accom- 
panied by  chill  and  a  temperature  of  from  101°  to  103°  F.  There  was  no 
albuminuria  in  the  intervals,  and  no  periodicity.  He  was  not  known  to  have 
had  malaria.  Rosenbach  is  quoted  in  the  American  Medical  Journal  (vol.  iii,  p. 
544)  as  reporting  a  case  excited  by  a  cold  bath  in  summer.  Other  patients  have 
paroxysms  only  in  winter.  In  considering  the  etiology,  it  must  be  remembered 
that  malaria  once  contracted  may  give  rise  to  symptoms  without  fresh  exposure, 
and  may  be  irregular  in  its  course.  On  the  other  hand,  the  reports  from  the 
South,  where  it  is  common,  show  malarial  haematuria  only  when  accompanied 
by  well-marked  malarial  symptoms.  Some  cases  of  paroxysmal  haematuria 
have  lasted  for  long  periods  and  have  recovered. 

Paroxysmal  haematuria  may  result  from  physical  exercise,  being  perhaps 
analogous  to  the  so-called  physiological  albuminuria  of  soldiers  after  forced 
marches.  Herringham  also  mentions  mental  exercise  as  a  cause,  and  reports  a 
case  where  it  was  brought  on  many  times  in  an  adult  by  worry  or  excitement. 
Lannois  reports  the  case  of  a  patient  whose  first  attack  was  at  the  age 
of  nine  years,  and  who  had  not  recovered  at  thirty-tAvo.  Paroxysms  were 
excited  by  gymnastics,  railroad  travelling,  light  work,  and  especially  by  long 
walks.  They  always  disappeared  with  rest  and  light  diet.  At  first  there  was 
but  little  blood,  and  that  disappeared  the  next  day.  At  one  time  albuminuria 
persisted  a  few  days.  During  the  height  of  paroxysms  the  microscope  showed 
red  blood-cells,  many  leucocytes,  and  renal  epithelium.  The  peculiarity  of 
this  case  is  its  long  duration.  There  were  no  malarial  phenomena  nor  any 
history  of  malaria  or  syphilis,  nor  had  the  patient  been  in  the  tropics.  Since 
childhood  he  had  occasional  pain  in  the  side,  which  led  Lannois  to  suspect  some 
obscure  disease  of  the  kidney. 

Among  badly-fed  children  scurvy  occasionally  causes  haemorrhage  into  the 

'  I  am  not  criticising  the  doses  in  question  :  no  one  has  a  right  to  do  that  without  the 
experience  in  malaria  that  Southern  physicians  have. 


PYURIA— CHYLUBIA—AXUBIA.  995 

urine  as  well  as  else"\vliere.  The  diagnosis  of  scorbutic  hgematuria  includes 
the  diagnosis  of  scorbutus.  (See  article  on  Scurvy.)  It  is  conceivable  that 
hsematuria  may  occur  in  natural  bleeders,  but  I  cannot  find  the  report  of  a  case 
within  ten  years. 

The  treatment  of  hasmaturia  will  be  indicated  by  the  exciting  causal  con- 
dition. 

Pyuria. 

Pus  may  enter  the  urine  at  any  point.  When  it  occurs  it  results  from 
some  underlying  cause,  but  it  is  seldom  found  in  the  urine  of  children,  because 
they  seldom  have  the  diseases  that  cause  it.  It  is  said,  indeed,  that  boys  may 
have  a  non-venereal  urethritis  from  debility.  Mild  vulvitis  and  vaginitis  from 
this  cause  are  rather  common.  Cystitis  ancl  pyelitis  are  very  occasional  sec{uel« 
of  several  acute  diseases.  They  may  be  occasioned  by  the  irritation  of  drugs 
and  of  saccharine  urine.  The  presence  of  calculi  is  possibly  the  most  frequent 
cause  of  this  rather  uncommon  symptom. 

Chyluria. 

Chyluria  is  especially  a  disease  of  certain  tropical  and  subtropical  regions, 
but  enough  cases  of  European  and  Xorth  American  origin  have  been  reported, 
particularly  in  the  southern  parts  of  the  United  States,  to  prevent  our  considering 
it  absolutely  tropical.  As  it  lasts  a  long  time  and  does  not  absolutely  disable 
the  patient,  it  may  be  imported  anywhere.  Prout  reports  a  case  at  eighteen 
months.  Cases  are  either  parasitic,  apparently  the  most  common,  or  non-para- 
sitic. Hunt  reports  a  traumatic  case,  probably  due  to  rupture  of  a  lymphatic 
in  the  kidney.  The  urine  remained  chylous  but  a  short  time.  At  first  it 
smelt  of  milk,  afterward  of  sour  milk.  The  same  and  also  a  putrid  odor  have 
been  observed  in  other  cases.  Parasitic  chyluria  is  due  to  the  presence  of  a 
minute  parasite,  the  filaria  sanguinis  hominis.  itself  the  product  of  a  parent 
parasite,  the  filaria  Bancrofti.  The  filaria  sanguinis  hominis  probably  estab- 
lishes a  fistula  between  the  lymphatics  and  the  urinary  organs.  It  is  found 
in  the  blood,  but.  as  a  rule,  only  in  the  late  afternoon  and  night,  though  by 
chancfino;  the  meal  hours  it  mav  be  found  at  other  times.  Although  usually 
a  parasite  of  warm  countries,  it  was  found  by  Weiss  in  the  urine  of  a  child  who 
had  never  been  out  of  Illinois. 

Patients  are  not  generally  very  ill.  but  chills  and  abnormally  high  or  low 
temperatures  are  reported,  and  the  disturbance  to  nutrition  from  prolonged  and 
occasionally  profuse  htemorrhage  leads  to  debility.  Attention  is  generally  first 
attracted  by  the  presence  of  chyle,  which  may  merely  make  the  urine  turbid 
or  as  white  as  milk.  Blood  may  precede  it.  The  presence  of  urinaiy  casts  is 
the  exception.  Elephantiasis  may  be  a  complication,  and  chyle  may  exude  from 
swellings  in  various  parts  of  the  body.  Cases  may  last  continuously  for  years 
or  may  intermit.  Suzuki,  by  limiting  diet,  and  especially  by  omitting  meat 
and  fat,  decidedly  lessened  the  chyle  in  the  urine.  Grimm  found  that  he  could 
regulate  the  amount  of  chvluria  bv  regulating  the  fat  ingested.  In  his  case 
there  was  enough  coagulation  to  cause  pain  in  the  bladder,  but  no  renal  colic. 
He  therefore  concludes  that  chyle  entered  the  urine  between  the  ureter  and  the 
urethra.  Sigmund  mentions  a  case  in  which  advantage  was  taken  of  a  pro- 
lapsed bladder  to  see  clear  urine  issuing  from  the  left  ureter. 

Anuria. 

Complaint  is  sometimes  made  that  the  urine  of  a  little  child,  generally  a 
baby,  is  suppressed.     This  may  depend  on  congenital  malformation  or  an  acute 


996    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

renal  disease,  but  usually  it  is  a  symptom  of  short  duration  and  no  danger. 
There  is  often  slight  fever  and  a  history  of  imperfect  digestion,  possibly  of 
difficult  dentition.  A  liberal  supply  of  drinking-water  is  tlie  only  treatment 
required. 

Incontinence  of  Urine. 

After  a  time,  differing  with  the  intelligence  of  the  child  and  the  pains  taken 
with  its  education,  probably  also  with  muscular  development,  children  learn  to 
use  the  chamber-vessel.  The  age  when  this  takes  place  averages  about  eighteen 
months,  but  is  sometimes  much  later.  An  undetermined  proportion  lose  con- 
trol of  the  bladder  after  acquiring  it;  this  occurs  before  the  age  of  six  or  seven. 
Incontinence  is  not  uncommon  in  any  class  of  society,  and  patients  often  come 
incidentally  under  observation  after  suffering  for  a  long  time,  the  delay  being 
due  to  the  prevalent  belief  that  spontaneous  recovery  occurs  about  puberty. 
Some  patients  have  incontinence  of  fieces  as  well  as  of  urine.  In  some 
this  condition  prevails  both  by  day  and  by  night,  in  some  few  by  day  only, 
but  by  far  the  most  numerous  class  is  that  which  has  nocturnal  inconti- 
nence of  urine  alone.  Occasionally  patients  pass  from  one  class  into  an- 
other. Among  nocturnal  cases  urine  is  passed  while  absolutely  unconscious, 
or  the  child  dreams  of  the  act  and  wakes  to  find  itself  wet.  This  hap- 
pens once  in  the  night  or  oftener.  Temporary  recoveries  sometimes  occur,  to 
be  followed  by  relapses,  and  incontinence  is  far  more  troublesome  in  winter 
than  in  summer.  These  considerations  should  make  us  careful  about  claiming 
results  for  treatment  unless  the  patients  are  Avatched  a  long  time,  especially  so 
if  recovery  occurs  in  the  spring.  Many  I'emedies  have  been  proposed,  and 
papers  written  to  show  the  brilliant  results  of  one  or  another  treatment,  yet  the 
number  of  cases  that  do  not  improve  continues  large.  The  failure  of  some 
practitioners  where  others  seem  to  succeed  is  due  partly  to  hasty  generalizations 
at  the  bottom  of  many  enthusiastic  papers,  partly  to  the  after-history  of  patients 
being  obtained  for  too  short  periods.  But,  with  all  allowances,  a  study  both 
of  the  literature  and  of  our  individual  patients  should  convince  us  that  we  are 
not  dealing  with  one  condition,  but  with  a  symptom  common  to  many  con- 
ditions. Unfortunately,  we  cannot  always  find  this  underlying  cause,  and  with 
our  present  knowledge  many  patients  must  be  treated  empirically.  When  we  do 
find  it,  we  sometimes  accomplish  much  more  than  can  be  done  by  blind  groping. 

A  few  cases  occurring  in  the  day-time  depend  on  postponement  of  micturi- 
tion owing  to  the  demands  of  play,  yet  there  are  cases  of  day-time  occurrence 
that  are  unavoidable.  I  have  notes  of  the  case  of  a  lady  who  is  never 
troubled  at  night,  but  who  wets  her  under-clothing  so  often  by  day  that  she 
always  wears  a  guard.  This  condition  has  lasted  since  early  girlhood,  and  is 
increased  by  excitement.  .  Large  doses  of  strychnine,  continued  for  some  weeks, 
gave  temporary  relief.  I  do  not  think  nocturnal  cases  are  due  to  carelessness 
in  any  appreciable  number.  Children  are  generally  mortified  at  this  failing, 
and  would  be  only  too  glad  to  avoid  it. 

Profound  sleep,  if  not  a  cause,  is  often  at  least  an  accompaniment.  This 
fact,  first  noticed  by  Trousseau,  receives  more  attention  from  French  than  from 
English-speaking  or  German  writers.  I  have  often  found  that  the  one  child  of 
a  family  that  wets  its  bed  is  also  the  soundest  sleeper.  Therefore  waking  the 
child  when  its  parents  retire  for  the  night  may  be  something  more  than  a  pal- 
liative, and  here  may  be  the  explanation  of  some  recoveries  as  patients  grow 
older,  when  sleep  becomes  less  sound  than  in  early  childhood.  Recovery  at 
puberty  is  more  often  attributed  to  some  obscure  influence  of  maturity  on  the 
genitals.     In  favor  of  this  view  it  may  be  said  that  some  women  recover  at 


INCONTINENCE    OF    UBINE.  997 

the  time  of  their  marriage.  Whatever  the  reason,  however,  many  recoveries 
do  occur  about  the  time  of  puberty. 

Many  patients  are  debilitated,  and  debility  often,  if  not  the  only  causal 
factor,  is  nevertheless  one  so  powerful  that  on  its  removal  the  child  recovers. 
A  large  proportion  of  such  patients  in  my  former  dispensary  service  were 
anaemic,  and  recovered  as  soon  as  given  enough  iron.  These  cases  were 
not  sufficiently  followed  up  for  me  to  speak  as  to  relapses  ;  but  patients, 
after  long  and  varied  treatment  without  result,  do  sometimes  get  well,  and 
stay  well,  on  proper  attention  being  paid  to  the  general  health.  Such  at- 
tention does  not,  of  necessity,  exclude  other  treatment.  I  have  notes  of  the 
case  of  a  boy  treated  with  belladonna,  strychnine,  and  electricity  many  times 
during  some  years,  but  with  no  permanent  result,  he  being  always  in  poor 
health.  When  eleven  years  old,  while  at  the  seashore,  as  badly  oif  as  ever  and 
without  treatment,  he  learned  to  swim,  and  returned  permanently  relieved,  and 
with  a  taste  for  athletics  for  which  he  had  been  formerly  too  weak.  Whether 
such  incontinence  as  this  is  caused  simply  by  a  weak  sphincter,  itself  a  part  of 
a  generally  weak  system,  or  whether  by  a  neurotic  condition  due  to  anaemia,  is 
a  matter  upon  which  one  may  speculate.  Certainly,  some  of  the  subjects  are 
neurotic.  Possibly  both  explanations  hold  good — sometimes  one,  sometimes 
the  other,  and  sometimes  both  together. 

Nux  vomica  and  its  equivalent,  strychnine,  are  often  used  successfully.  They 
have  a  good  effect  on  many  neurotic  people  and  are  general  tonics.  They  are  espe- 
cially indicated  when  we  know  the  sphincter  to  be  weak.  This  may  occur  if 
the  child  has  been  compelled  to  hold  its  water  too  long,  as  sometimes  happens 
at  school.  Cold  douches  to  the  perineum  are  probably  local  in  effect,  and  the 
same  is  true  of  electricity  and  massage.  Good  results  are  claimed  for  all  of 
them.  Electricity  is  generally  used  in  the  form  of  faradization,  with  one  pole 
on  the  lumbar  part  of  the  spine  and  one  in  the  urethra,  the  vagina,  or  on  the 
perineum,  the  sittings  lasting  a  few  minutes  each  day  or  every  other  day  and 
the  current  being  as  strong  as  the  child  will  bear.  I  object  to  introducing  the 
electric  or  any  other  sound  into  the  child's  urethra  or  vagina — especially  in 
girls  approaching  puberty — if  it  can  be  avoided,  and  therefore  prefer  the  peri- 
neum. This  care,  perhaps  excessive,  combined  with  a  possible  bad  selection 
of  cases,  may  partly  account  for  my  non-success  with  this  treatment.  Certainly, 
I  in  common  with  others  have  not  obtained  the  good  results  claimed. 

Local  massage  has  its  advocates.  Some  good  results  have  been  reported,  but 
this  method,  like  all  others,  has  its  failures.  Sanger  massages  the  sphincter  by 
introducing  a  probe  into  the  bladder  and  exercising  gentle  pressure  backward 
and  from  side  to  side.  The  danger  of  teaching  masturbation  is,  I  think,  to  be 
considered. 

There  is  a  class  of  cases  in  which  the  urine  is  sometimes  passed  with  great 
force,  evidently  from  some  other  factor  than  a  weak  sphincter.  There  are 
grounds  for  believing  many  of  them  to  be  hereditary ;  many  are  neurotic.  I 
have  met  in  one  family  of  three  children,  one  case  of  somnambulism,  two  of 
chorea,  and  one  of  nocturnal  incontinence,  the  last  ejecting  the  stream  violently 
by  day.  Chorea  is  itself  supposed  to  be  a  cause.  It  is  assumed  that  there  is 
want  of  co-ordination  between  sphincter  and  detrusor.  In  other  words,  such 
cases  are  choreic.  Such  considerations  lead  to  treatment  designed  to  allay 
irritability  of  the  bladder,  by  the  use  of  belladonna,  potassium  bromide,  and 
ergot.  Belladonna,  originally  given  by  Trousseau  in  a  single  night  dose,  has 
since  been  administered  in  three  daily  doses.  Baruch  gave  it  in  the  late  after- 
noon and  early  evening  in  a  series  of  cases,  thus  avoiding  the  probably  unneces- 
sary morning  dose,  and  better  graduating  that  in  the  evening.     This  is  of 


998    A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

some  importance,  as  it  is  often  necessary  to  approach  a  poisonous  dose ;  that  is, 
to  get  some  effect  on  the  pupil ;  and  also  because  the  continued  use  of  this 
drug  is  not  always  innocuous.  At  least,  I  believe  that  I  have  seen  gastric  dis- 
turbance and  general  malaise  result  from  its  prolonged  use.  It  is,  however, 
in  many  cases  the  most  eflBcient  treatment  known,  and  is  perhaps  to  be 
preferred  where  we  can  make  no  probable  diagnosis  of  the  underlying  cause. 
Relief  is  sometimes  temporary,  sometimes  permanent. 

Epilepsy  is  I'esponsible  for  a  certain  number  of  cases.  So  is  the  general 
disturbance  attending  the  onset  of  acute  disease.  Ergot,  by  lessening  conges- 
tion in  the  spinal  cord,  is  sometimes  of  use  where  there  is  a  very  irritable 
bladder. 

Children  whose  mode  of  life  affords  frequent  opportunity  for  micturition, 
make  use  of  it,  and  thus  accustom  the  bladder  to  contract  when  not  very  full. 
In  such  cases  a  dry  bed  can  sometimes  be  secured  by  gradually  training  the 
bladder  to  contain  greater  amounts,  thereby  educating  the  sphincter.  This 
plan  must  not  be  carried  out  too  heroically,  or  a  strained  instead  of  a  strength- 
ened sphincter  will  result.  It  is  said  that  sleeping  on  the  back,  by  causing 
urine  to  press  upon  the  most  sensitive  part  of  the  bladder,  is  an  exciting  cause, 
and  may  be  relieved  by  elevating  the  foot  of  the  bed. 

Urine  loaded  with  uric  acid,  urates,  oxalates,  or  phosphates  may  cause  incon- 
tinence, as  well  as  an  irritable  bladder ;  hence  the  urine  should  always  be 
examined.  Albuminuria  is  said  to  be  a  cause.  I  have  met  with  diabetes  in  a 
child,  where  the  real  diagnosis  would  have  been  overlooked  but  for  the  routine 
examination  for  sugar  in  this  affection.  Possibly  the  effect  of  ptomaines  on  the 
brain  may  be  to  produce  incontinence  in  some  children,  as  it  does  night-terrors 
in  others.  Whatever  the  explanation,  attention  to  the  digestive  organs  is  some- 
times of  great  use. 

The  influence  of  phimosis  is  exaggerated.  I  have  met  with  several 
cases  in  circumcised  Jews,  while  half  of  Townsend's  cases  were  in  girls.  Fur- 
thermore, patients  have  been  operated  on  without  relief.  Yet  phimosis  is 
sometimes  a  cause.  Patients  previously  carefully  treated  without  result  do 
sometimes  get  well  immediately  after  circumcision  or  even  after  breaking  up 
adhesions  between  prepuce  and  glans.  Phimosis  is  merely  one  of  several  con- 
ditions giving  rise  to  reflex  incontinence.  Among  others  are  a  small  meatus, 
rectal  polypi  and  fissures,  pin-worms,  hardened  faeces,  and  even,  in  one 
reported  case,  a  brass  button  in  the  nose.  Masturbation  is  said  to  sometimes 
result  in  incontinence. 

Davenport  reports  a  case,  and  refers  to  another,  in  which  malposition  of 
the  orifices  of  the  ureters  was  the  cause. 

Among  palliatives  is  avoidance  of  drinking  large  quantities  of  liquid  late 
in  the  day.  This  must  not  be  overdone,  for  a  too  concentrated  urine  may  be  as 
irritating  as  one  too  abundant.  Recrular  habits  of  life  seem  of  some  use.  I 
had  opportunity  to  observe  a  boy  admitted  to  the  hospital  on  the  day  that 
an  epidemic  of  measles  began  there.  As  he  had  been  exposed,  it  was  not 
thought  desirable  to  begin  treatment  until  he  had  had  the  disease.  He  had 
regular  diet  and  hours  with  no  excitement.  Before  the  incubation  period  was 
over  the  incontinence  had  ceased.  He  did  not  contract  measles,  and  after  a 
reasonable  time  of  observation  was  discharged. 

This  symptom,  then,  arises  from  the  most  varied  causes  and  repays  careful 
study  of  the  individual.  The  general  health  is  never  to  be  lost  sight  of. 
Hopes  of  relief  are  reasonable,  but  it  is  never  to  be  promised,  and  we  are 
not  justified  in  assuming  treatment  to  be  successful  until  after  a  long  lapse 
of  time. 


DIABETES   MELLITUS,    DIABETES    mSIPIDUS 
AND  LITHIASIS. 


By  JAMES  TYSON,   M.  D., 

Philadelphia. 


I.  Diabetes  Mellitus. 


Diabetes  Mellitus  is  a  constitutional  disease  especially  characterized  by 
the  secretion  of  an  abnormally  large  amount  of  urine  charged  with  sugar. 
While  in  adults  there  is  good  ground  for  admittino;  at  least  two  forms  of  dia- 
betes  mellitus,  a  mild  and  a  severe  form,  in  children  I  have  as  yet  met  only  the 
latter,  of  which  the  course  is  more  rapid  than  in  adults. 

Etiology. — The  etiology  of  diabetes  in  children  is  even  more  obscure  than 
in  adults.  In  both  heredity  is  an  acknowledged  influence,  but  with  this  ex- 
ception the  cause  of  diabetes  in  children  may  be  said  to  be  unknown.  In 
adults,  while  in  the  majority  of  cases  a  sufiicient  cause  is  sought  in  vain,  there 
are  certain  well-recognized  influences,  such  as  prolonged  overwork,  anxiety, 
and  grief,  which  favor  its  causation  :  these  agencies  cannot  operate  in  children. 
The  sex-relation  of  diabetes  is  reversed  in  children  as  compared  with  adults, 
it  being  more  common  in  girls  than  boys. 

Morbid  Anatomy. — In  the  matter  of  morbid  anatomy,  too,  we  are  unable 
to  find  lesions  which  can  be  held  responsible  for  the  disease.  Rather  are  they 
the  result  of  it.  It  is  true  that  recent  studies  have  shown  an  increasingly 
close  relation  between  diabetes  and  pancreatic  disease,  originally  pointed  out  by 
Lanceraux  a  number  of  years  ago.  Extirpation  of  the  pancreas,  according  to 
Von  Mehring,  Minkowski,  and  Lepine,  is  invariably  followed  by  diabetes  if  the 
extirpation  is  complete ;  and  although  De  Dominicis,  to  whom  we  are  indebted 
for  the  original  experiment,  and  De  Renzi  and  E.  Reale  deny  this,  it  is  still 
true  that  this  operation  is  followed  by  glycosuria  in  a  vast  majority  of  cases, 
while  every  year  furnishes  autopsies  in  which  pancreatic  lesions  are  far  more 
common  than  any  other.  At  the  same  time,  typical  cases  of  diabetes  are  con- 
stantly occurring  in  which  there  is  no  pancreatic  disease. 

Among  anatomical  lesions — in  addition  to  those  of  the  pancreas — which 
are  found  in  connection  with  diabetes,  may  be  mentioned  enlargement  and 
hardening  of  the  liver,  cirrhosis,  dilatation  of  its  capillaries,  amyloid  changes 
in  its  cells  ;  hyperjemia,  and  even  slight  grades  of  parenchymatous  inflamma- 
tion, of  the  kidney  ;  tuberculous  foci  and  cheesy  degeneration  of  the  lungs ; 
and  a  variety  of  lesions  of  the  nervous  system,  especially  in  the  neighborhood 
of  the  medulla  oblongata,  amono-  which  tumors  and  traumatic  lesions  are  the 
most  common. 

Symptoms. — In  children,  as  in  adults,  a  frequent  desire  to  pass  water, 
with  increase  in  quantity,  intense  thirst,  and  sometimes  great  appetite,  are 
the  symptoms  which  commonly  first  attract  attention.  Examination  of  the 
urine  discovers  the  presence  of  grape-sugar  or  glucose,  and  a  specific  gravity 


1000  A MBBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

usually  higher  than  normal,  1030  and  upward,  although  a  lower  specific 
gravity  does  not  preclude  the  presence  of  sugar  in  considerable  amount. 
Rapid  emaciation,  shrinking  and  dryness  of  the  tissues,  and  constipation  are 
early  associated.  If  we  add  the  peevishness  and  restlessness  which  grow  out  of 
these  conditions,  and  occasional  intense  itching  of  the  genitalia,  we  include  most 
of  the  symptoms  which  occur  in  children.  The  neuralgic  pains  and  rheumatic 
complications,  the  lung  involvement  so  often  seen  in  adults,  are  not  com- 
monly present  in  children.  Cataract  I  have  met  in  a  single  case,  a  boy  of 
sixteen.     It  was  double. 

The  state  of  the  urine,  which  contains  sugar  and  is  increased,  varies  as  it 
does  in  the  adult.  In  a  little  girl  four  and  one-third  years  old,  under  my  care 
for  some  time,  whose  case  may  be  considered  a  fair  example,  the  quantity 
ranged  from  65  to  200  ounces  (1950  to  6000  cc.)  in  the  twenty-four  hours, 
and  the  proportion  of  sugar  from  13  to  34  grains  to  the  ounce  (3  to  7.5  per 
cent.),  the  specific  gravity  1018  to  1040.  Toward  the  close  of  the  disease 
diacetic  acid  and  aceton  are  found  in  the  urine,  and  death  by  diabetic  coma  is 
not  unusual.  Concurrent  with  the  diaceturia  and  acetonuria  are  a  diacetaemia 
and  aceton^emia. 

Albuminuria  occurs  in  a  certain  number  of  cases  of  diabetes  in  children, 
as  in  adults,  from  two  causes :  first  as  the  result  of  irritation  of  the  tubular 
structure  of  the  kidney  by  the  sugar-charged  urine,  and  second  as  a  coin- 
cidence. 

Pneumonia  is  prone  to  occur,  as  in  adults,  tuberculosis  to  a  less  degree,  but 
gangrene  I  have  not  met  in  children.  The  suggestion  that  in  a  large  number 
of  these  cases  the  albuminuria  is  due  to  the  excessive  quantity  of  eggs  con- 
sumed in  the  diabetic  diet  I  do  not  consider  sustained  by  the  facts. 

Diagnosis. — With  such  a  train  of  symptoms  as  those  noted  there  should 
not  be  much  delay  in  recognizing  diabetes  mellitus,  even  without  an  examina- 
tion of  urine.  All  cases,  are  not,  however,  so  clear,  and  such  examination  is 
always  necessary  to  a  proper  study  of  any  case.  The  occasional  confusion  due 
to  the  reducing  effect  of  uric  acid  on  the  proto-salts  of  copper  should  be  borne 
in  mind.  The  darker  hue  and  scantiness  of  the  uric-acid  urines  should  excite 
suspicion,  while  the  absence  of  all  other  symptoms  of  diabetes  should  protect 
against  error. 

The  tests  for  sugar  at  once  most  delicate  and  to  be  relied  upon  are  the  cop- 
per tests,  and  of  these  the  most  satisfactory  is  the  solution  known  as  Fehling's.' 
In  using  Fehling's  solution  for  qualitative  testing  take  1  cc.  of  the  solution  and 
dilute  with  four  times  its  bulk  of  water ;  boil  the  mixture  thus  obtained,  and, 
if  it  remain  clear,  it  is  fit  to  be  used  in  completing  the  test.  If,  however,  there 
should  be  a  precipitate  of  the  red  suboxide  on  boiling  before  any  urine  is  added, 
the  solution  is  spoiled  and  a  fresh  one  should  be  obtained.  If  the  fluid  remain 
clear  after  the  first  boiling,  the  urine  should  be  added,  drop  by  drop,  until  a 
bulk  equal  to  the  original  mixture  of  Fehling's  solution  and  water  is  ob- 
tained ;  and  if  no  yellow  or  red  precipitate  takes  place,  the  urine  may  be 
said  to  be  free  of  glucose.     It  is  scarcely  necessary  to  say  that  the  gray  floccu- 

^  Fehling's  solution  is  thus  made:  Dissolve  34.639  grams  of  pure  crystallized  sulphate  of  cop- 
per in  200  cc.  of  distilled  water ;  173  grams  chemically  pure  crystallized  neutral  sodic-jiotassium 
tartrate  in  480  grams  of  solution  of  caustic  soda  of  sp.  gr.  1.14;  and  into  this  hasic  solution 
pour  the  copper  solution,  a  little  at  a  time ;  then  dilute  the  resulting  mixture  to  1  litre  with 
distilled  water.  The  tendency  of  Fehling's  solution  to  deteriorate  is  well  known.  This  may  he 
obviated  by  substituting  glycerin  or  mannite  for  the  tartaric  acid,  but  more  effectually  by  dis- 
solving the  sodic-potassium  tartrate  in  480  grams  of  solution  of  caustic  soda  and  diluting  to 
500  cc.  ;  the  copper  in  500  grams  of  distilled  water;  and  keeping  the  solutions  separate  until 
such  time  as  they  are  wanted,  when  1  cc.  of  each  will  furnish  2  cc.  of  Fehling's  solution. 


DIABETES  MELLITUS.  1001 

lent  precipitate  of  phosphates  which  sometimes  occur  should  not  be  mistaken 
for  a  precipitate  of  suboxide  of  copper. 

A  sufficiently  accurate  quantitative  test  may  be  made  with  Fehling's  solution 
thus  used  if  it  be  remembered  that  it  is  of  such  strength  that  if  the  cupric  oxide 
be  exactly  reduced — that  is,  if  the  color  is  exactly  removed  by  an  equal  bulk 
of  urine — that  particular  specimen  of  urine  contains  one-half  of  1  per  cent,  of 
sugar  ;  if  the  color  is  removed  by  half  of  the  bulk  of  urine,  the  sample  contains 
1  per  cent.;  and  if  twice  the  bulk  of  urine  is  required,  the  sample  contains  |- 
of  1  per  cent. ;  and  so  on.  Moreover,  if,  as  is  usually  the  case,  it  is  necessary, 
by  reason  of  the  large  percentage  of  sugar,  to  dilute  the  urine,  the  proportion 
should  be  1  to  9  of  water.  Then  we  proceed  as  before,  multiplying  the  result 
by  10.  When  it  is  remembered  that  it  is  impossible  to  judge  accurately  of  the 
progress  of  any  case  of  diabetes  mellitus  ivithout  a  quantitative  analysis  for 
glucose,  the  importance  of  having  an  easy  clinical  quantitative  method  will  be 
appreciated. 

In  the  absence  of  Fehling's  solution  the  original  form  of  the  copper  test  sug- 
gested by  Trommer  may  be  thus  used :  The  urine  is  first  alkalized  by  about  one- 
fourth  its  bulk  of  liquor  potassse,  and  then  a  drop  or  two  of  a  preferably  weak — 
say  1  to  30 — solution  of  cupric  sulphate  should  be  added.  A  precipitate  ensues, 
but  if  sugar  be  present  the  first  drop  or  two  of  the  copper  solution  is  redissolved 
on  shakincr.  The  addition  should  therefore  be  continued  until  a  sligrht  excess 
remains,  when  heat  is  applied,  and  in  a  few  seconds  a  precipitate  of  the  yellow 
cuprous  hydroxide  occurs.  This  subsequently  loses  its  water  and  becomes  the 
red  cuprous  oxide. 

Of  the  remaining  tests  for  sugar  it  will  be  sufficient  to  give  the  fermenta- 
tion test,  which  is  easy  and  serves  a  quantitative  as  well  as  a  qualitative 
purpose,  while  it  has  fewer  sources  of  error  than  any  of  the  other  tests.  The 
objections  to  it  are  that  it  requires  several  hours  for  its  operation,  and  that 
quantities  less  than  a  half  of  1  per  cent.,  or  2\  grains  to  the  ounce,  cannot  be 
detected.  The  simplest  method  of  its  application  is  as  follows  :  Having  taken 
the  specific  gravity  of  the  sample  to  be  tested,  fill  a  four-ounce  bottle  with  the 
urine,  to  which  add  a  small  piece — say  the  size  of  a  pea — of  German  yeast 
or  a  teaspoonful  of  brewer's  yeast,  after  which  shake  thoroughly;  put  aside  in 
a  warm  place,  temperature  60°  to  80°  F.,  for  at  least  twelve  hours.  At  the 
end  of  this  time,  sugar,  if  present,  will  have  been  converted  by  fermentation 
into  carbonic  acid  and  alcohol,  and  the  specific  gravity  proportionately  low- 
ered. For  practical  purposes  it  may  be  allowed,  as  originally  ascertained  by 
Dr.  Roberts,  that  for  every  degree  of  reduction  of  specific  gravity  on  the  urin- 
ometer  there  is  1  grain  of  sugar  to  the  fiuidounce.  Thus,  if  the  original  specific 
gravity  is  10-40,  and  the  specific  gravity  after  fermentation  1020,  there  are  20 
grains  to  the  fiuidounce.  From  this  the  percentage  may  be  ascertained  by 
multiplying  such  difi"erence  by  .23.  Thus  in  the  illustration  named  the  per- 
centage would  be  4.6. 

The  matter  of  the  selection  of  a  specimen  of  urine  for  analysis  is  of  the 
greatest  importance.  It  goes  without  saying  that  the  most  suitable  sample  is 
a  portion  of  the  whole  twenty-four  hours'  urine  collected  for  the  purpose.  But 
it  is  evident  that  it  is  often — indeed,  almost  always — impossible  to  do  this. 
Then  my  practice  is  to  take  two  samples  for  analysis — one  a  portion  of  that 
passed  on  rising  in  the  morning,  the  other  a  portion  of  that  first  passed  after 
the  evening  meal,  usually  that  passed  at  bed-time.  If  pains  be  taken  always 
to  examine  samples  thus  selected  under  the  same  conditions,  comparisons  may 
be  made  from  day  to  day  or  week  to  week  which  suffice  for  clinical  purposes. 

Prognosis. — The  prognosis  is  unfortunately  very  bad  in  children.     The 


1002  A3f£IiIC AN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

only  case  of  a  child  I  have  ever  known  to  recover  was  a  girl  of  twelve  under 
the  care  of  a  friend.  Life  may,  however,  be  prolonged  for  a  time  by  careful 
attention  to  dietetic,  hygienic,  and  medicinal  treatment.  The  course  is,  however, 
always  much  more  rapid  than  with  adults,  and  the  fatal  termination  comes 
sooner. 

Treatment. — In  children,  as  with  adults,  the  most  efficient  treatment  is 
the  dietetic,  and  the  greatest  difficulty  is  that  of  getting  a  substitute  for  bread. 
Of  the  various  so-called  gluten  flours  and  breads,  so  far  as  I  know,  the  only 
ones  made  in  this  country  which  contain  so  little  starch  as  to  justify  the  name 
pure  gluten  or  almost  pure  gluten  are  the  gluten  flour  of  Theodore  Metcalf  & 
Co.,  of  Boston,  Mass.,^  and  the  No.  1  gluten  biscuit  and  No.  1  gluten  meal 
of  the  Sanitarium  Food  Company  of  Battle  Creek,  Mich.  No  ncAv  prep- 
aration of  gluten  should  be  accepted  for  what  it  claims  to  be  unless  the  claim 
is  sustained  by  analysis.  In  England  and  France  diabetics  are  more  fortu- 
nate, as  they  can  secure  flour,  bread,  and  biscuits  containing  a  minimum  amount 
of  starch.  The  great  objection  to  all  pure  gluten  preparations  is  that  they  are 
more  unpalatable  than  the  bread  made  of  flour  from  which  the  starch  has  not 
been  removed.  But  it  should  be  made  clear  to  the  friends  of  the  patient  that 
he  must  make  his  choice  of  the  two  evils. 

It  is  not  always  necessary  that  the  purest  attainable  gluten  preparations 
should  be  used  in  mild  cases,  as  in  these  a  certain  amount  of  starch  is 
assimilable  ;  but  such  latitude  must  be  based  on  trial  of  fixed  quantities  of  the 
given  breads  associated  with  careful  quantitative  analyses  of  the  urine  selected 
as  directed.  To  such  the  so-called  '"  bran  bread  "  made  out  of  unbolted  flour,  in 
which  the  ratio  of  starch  is  of  course  less,  and  oatmeal  gruel  with  cream,  may 
be  allowed.  Unfortunately,  mild  cases  of  diabetes  are  not  commonly  found  in 
children. 

Among  the  substitutes  for  the  white  flour  so  much  used  is  almond  flour, 
and  it  is  totally  without  objections,  so  far  as  its  composition  is  concerned. 
The  patient  is  apt  to  tire  of  it  as  of  anything  else  from  exclusive  use,  and 
fair  digestive  capacity  is  required. 

Various  other  flours  have  been  suggested.  One  of  these  is  the  flour  of  the 
soya  bean  {Soya  hispida),  a  native  of  Japan,  but  now  extensively  grown 
in  Europe,  said  to  contain  only  4  per  cent,  of  starch.  It  is,  moreover, 
very  rich  in  nitrogenous  substances.  From  this  are  made  bread  and  biscuit. 
A  flour  known  as  pohiboskos  contains  a  small  quantity  of  starch,  and  is  a 
suitable  food  for  most  diabetics.  Fromentine  is  another  of  these  flours  made 
from  the  embryos  of  wheat,  which,  so  far  as  I  know,  is  not  yet  obtainable 
in  this  country.  Like  the  soya  flour,  it  contains  a  considerable  quantity  of 
oil,  which  not  only  renders  pannification  difficult,  but  disposes  to  early  ran- 
cidity. Efforts  are  also  being  made  to  isolate  for  the  same  purpose  legumine, 
the  caseine  of  the  leguminous  vegetables.  The  substance  so  isolated  is  known 
as  embryonine. 

^  The  following  are  the  directions  suggested  by  Dr.  John  A.  Jeffries  in  common  use   for 
making  gluten  biscuit  out  of  the  Metcalf  flour  : 

Gluten  flour 1  cup. 

Best  bran,  previously  scalded 1  cup. 

Baking  powder   .    . " 1  teaspoonful. 

(Or  the  equivalent  of  bicarbonate  of  soda  and  cream  tartar.) 

Salt to  taste. 

Eggs two. 

Milk  or  water 1  cup. 

Mix  with  a  £'.poon. 


DIABETES  IfELLITUS.  1003 

The  appended  table  is  one  which  has  been  my  guide  for  many  years,  and 
I  believe  it  includes  most  of  the  articles  admissible : 

Food  and  Drink  Admissible  in  Diabetes  Mellitus. — Shell-fish. — 
Oysters,  mussels,  and  clams,  raw  and  cooked  in  any  way,  without  the  addition 
of  flour. 

Fish  of  all  kinds,  fresh  or  salted,  including  lobst6rs,  crabs,  sardines,  and 
other  fish  in  oil ;  fish-roe,  caviar. 

Meats  of  every  variety  except  livers,  including  beef,  mutton,  chipped  dried 
beef,  tripe,  ham,  tongue,  bacon,  and  sausages ;  also  poultry  and  game  of  all 
kinds,  with  which,  however,  sweetened  jellies  and  sauces  should  not  be  used. 

Soups. — All  made  without  flour,  rice,  vermicelli,  or  other  starchy  sub- 
stances, or  without  the  vegetables  named  below  as  not  allowed ;  animal  soups 
not  thickened  with  flour,  such  as  bouillon,  beef-tea,  and  broths. 

Vegetables. — Cabbage,  cauliflower,  Brussels  sprouts,  broccoli,  green  string 
beans,  the  green  ends  of  asparagus,  spinach,  tomato,  dandelion,  mushrooms, 
lettuce,  endive,  coldslaw,  olives,  cucumbers,  fresh  or  pickled,  radishes,  sorrel, 
young  onions,  water-cresses,  mustard  and  cress,  turnip  tops,  celery  tops,  arti- 
chokes, gherkins,  okra,  parsley,  or  any  other  green  vegetables. 

Fruits. — Cranberries,  j)lums,  cherries,  gooseberries,  red  currants,  straw- 
berries, acid  apples,  lemons,  oranges  sparingly,  all  without  sugar.  Acid  fruits 
may  be  stewed  with  the  addition  of  bicarbonate  of  sodium  instead  of  sugar. 

Bread  and  cakes  made  of  gluten,  soya,  almond  flour,  inulin,  "•poluboskos," 
fromentine,  or  embryonine,  with  or  without  eggs  and  butter.  Grriddle-cakes, 
pancakes,  biscuit,  porridges,  etc.,  made  of  these  flours.  In  cases  requiring 
less  stringency  the  so-called  "bran  bread,"  made  of  unbolted  flour,  the  crust 
of  bread,  and  oatmeal  porridge  with  cream. 

Fggs  in  any  quantity,  and  prepared  in  all  possible  ways,  without  sugar  or 
ordinary  flours  ;  butter  and  cheese. 

Nuts. — All  except  chestnuts,  including  almonds,  walnuts^  Brazil  nuts, 
hazelnuts,  filberts,  pecan-nuts,  butternuts,  cocoanuts. 

Condiments. — Salt,  vinegar,  and  pepper  in  moderate  quantities. 

Jellies. — None  but  those  unsweetened,  except  by  saccharin.  They  may 
be  made  of  calf's-foot  or  gelatin  and  flavored  with  wine. 

Drinks. — Coffee,  tea,  and  cocoa-nibs,  with  milk  or  cream,  but  without 
sugar ;  also  Yichy,  Vals,  and  Carlsbad  waters,  carbonated  waters,  and  all 
mineral  waters  freely ;  lemonade  without  sugar,  acid  wines,  including  claret, 
Bordeaux,  Rhine,  and  still  Moselle  wines,  diluted  with  Vichy  or  similar  waters, 
very  dry  sherry  ;  unsweetened  brandy,  whiskey,  and  gin.  No  malt  liquors, 
except  those  ales  and  beers  which  have  been  long  bottled  and  in  which  the 
sugar  has  largely  been  converted  into  carbonic  acid  and  alcohol.  Saccharin 
may  be  used  for  sweetening. 

To  he  Especially  Avoided. — Potatoes,  white  and  sweet,  rice,  beets,  carrots, 
turnips,  parsnips,  peas,  and  beans ;  all  vegetables  containing  starch  or  sugar 
in  any  quantity ;  sweet  wines,  including  sherry,  Madeira,  port,  and  cham- 
pagne. 

The  hygienic  treatment  of  diabetes  mellitus  is  important.  The  patient 
should  be  bathed  frequently,  and  brisk  friction  should  succeed  the  bathing  in 
order  to  stimulate  the  circulation.  Out-door  life  and  muscular  exercise,  short 
of  that  suflicient  to  excite  fatigue,  should  be  insisted  upon,  the  idea  being  to 
stimulate  every  process  which  may  result  in  the  oxidation  of  sugar.  For  a  like 
reason  the  sleeping-room  should  be  well  ventilated  and  the  purest  air  supplied 
to  it. 

The  medicinal  treatment  of  diabetes  is  limited,  as  there  are  few  drugs 


lOOAAMUBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

having  power  to  control  the  defective  assimilation  resulting  in  sugar  excretion. 
The  most  efficient  of  these  is  undoubtedly  opium  and  its  preparations  and  alka- 
loids, any  one  of  which  possesses  this  power.  Codeine  is,  however,  the  prepa- 
ration usually  selected,  because  it  is  less  apt  to  produce  the  harmful  effects  of 
the  other  chief  alkaloid,  morphine.  It  is,  however,  much  more  expensive. 
While  generally  better  borne  than  morphine,  it  does  sometimes  nauseate  as 
well  as  constipate.  That  it  controls  the  sugar  output  is  abundantly  proven. 
Moreover,  I  have  reason  to  believe  from  my  own  experience  that  it  occasionally 
happens  that  where  sugar  has  disappeared  during  treatment  by  codeine,  it  does 
not  return  after  discontinuance.  It  is  desirable,  however,  to  put  off  the  use  of 
opium,  as  a  rule,  until  other  measures  and  drugs  fail.  If  the  efficiency  of 
opium  in  diabetes  be  based  upon  its  sedative  action,  then  the  bromides  should 
also  be  useful,  and  it  does  occasionally  happen  that  they  serve  a  good  purpose ; 
but  in  my  experience  they  are  of  limited  utility. 

After  opium,  arsenic  is  perhaps  the  drug  which  has  longest  maintained  its 
reputation  as  a  remedy  in  diabetes  mellitus,  but  its  usefulness,  like  that  of 
most  drugs,  is  limited  to  the  milder  cases.  There  is  no  better  preparation  than 
Fowler's  solution,  of  which  the  dose  is  so  easily  regulated.  The  action  is  unex- 
plained, although  a  reasonable  theory  has  recently  been  advanced  by  Cuth- 
bertson  of  Chicago,  who  says  it  is  partly  local  upon  the  stomach,  bowels,  or 
respiratory  organs,  and  partly  on  blood-cells,  increasing  their  activity,  and 
therefore  the  oxidation  of  sugar.  The  dose  must  be  regulated  by  the  age, 
from  a  drop  to  five  drops  three  times  a  day,  increased  until  slight  oedema  of 
the  face  results.  It  is  often  combined  with  lithium  carbonate,  1  to  5  grains, 
by  which  its  effect  is  sometimes  increased.  The  bromide  of  arsenic,  originally 
recommended  by  Clemens,  is  sometimes  given,  but  I  have  not  found  it  more 
efficient  than  Fowler's  solution.  The  preparation  commonly  used  is  Clemens's 
solution  of  bromide  of  arsenic,  of  which  the  dose  is  2  to  5  minims,  the  smaller 
dose  for  children. 

Ergot  is  a  drug  which  is  sometimes  efficacious,  but  I  value  it  less  highly 
than  I  used  to.  That  it  sometimes  exerts  a  controlling  effect  I  have  not  the 
least  doubt.  The  best  form  is  the  fluid  extract  in  doses  of  five  minims  to 
a  drachm. 

That  the  coal-tar  series  of  antipyretics,  including  antipyrine,  antifebrin, 
phenacetin,  and  sulfonal,  prominently  brought  forward  by  the  French  school 
of  physicians,  have  in  the  milder  forms  of  diabetes  a  controlling  influence,  I  can 
also  assert  from  my  own  experience.  As  claimed  by  the  French  school, 
their  efficiency  is  increased  by  combinations  with  alkalies,  sodium  carbonate 
being  commonly  used  in  the  proportion  of  twice  the  dose  of  the  antipyretic. 
Thus,  if  15  grains  of  antipyrine  are  given,  30  grains  of  sodium  bicarbonate  are 
added,  and  these  doses  are  recommended  by  Dujardin-Beaumetz  and  Germain- 
See  for  adults.  They  are  bulky  and  apt  to  derange  the  stomach,  and  they 
should  not  be  given  after  meals.  My  method  has  been  to  give  the  com- 
bined drugs  in  equal  doses  before  meals.  For  children  they  should  be  much 
smaller — 3  to  10  grains  of  the  drug,  with  an  equal  quantity  of  sodium  bicar- 
bonate. If  the  antipyretic  is  given  alone,  it  may  be  given  after  meals, 
although  a  somewhat  larger  dose  is  then  required. 

Salicylate  of  sodium  has  some  reputation,  and  may  be  used,  especially 
when  the  diabetes  is  associated  with  rheumatism. 

Alkalies  alone,  doubtless,  have  an  effect  in  the  diabetic  process,  and  it  is 
this  constituent  to  which  the  alkaline  mineral  Avaters  of  Vichy,  of  Vals,  and  of 
Carlsbad  owe  their  chief  efficiency.  None  of  the  negative  mineral  waters  in 
this  country,  so  much  vaunted  by  their  owners  as  specifics,  have  in  my  expe- 


DIABETES  INSIPIDUS.  1005 

rience  anv  effect  whatever.  Persons  visiting  the  sources  of  these  waters  may 
be  benefited,  but  the  associated  diet,  and  not  the  waters,  is  the  efficient  agent. 

A  great  many  remedies  have  from  time  to  time  been  suggested  as  useful  in 
diabetes,  and  I  have  tried  most  of  them  as  opportunity  presented,  generally 
with  negative  results.  One  of  the  most  recent  of  these  is  jambul  {Syzygium 
jamholanum).  A  careful  and  systematic  trial  by  myself  in  three  cases  has 
resulted  in  signal  failure.     The  dose  given  is  from  ten  drops  to  a  drachm. 

The  latest  of  these  remedies  is  creasote,  which  I  have  not  yet  tried.  It  is 
recommended  by  Audibert  as  producing  excellent  results  where  diet  did  not 
seem  in  any  way  to  influence  the  intensity  of  the  glycosuria.  The  quantities 
used  were :  first  2,  then  4,  and  finally  6,  grains  daily  for  adults.  The  gly- 
cosuria steadily  diminished  in  one  case  in  spite  of  the  fact  that  the  patient, 
despairing  of  any  results,  deliberately  neglected  all  dietetic  rules. 

n.  Diabetes  Insipidus. 

Diabetes  insipidus  is  a  nervous  afi"ection,  mainly  functional,  characterized 
by  the  secretion  of  a  large  amount  of  urine  of  low  specific  gravity. 

While  diabetes  insipidus  is  a  much  rarer  disease  than  diabetes  mellitus,  it  is 
believed  to  be  relatively  more  frequent  in  children  than  the  latter.  Out  of  70 
cases  collected  by  Roberts,  22  were  under  ten  years  of  age,  and  13  between  ten 
and  twenty  ;  out  of  85  by  Strauss,  21  were  under  ten  ;  and  of  87  by  Yon  der 
Heijden,  7  were  under  ten  and  19  between  ten  and  twenty. 

Etiology. — Nervous  influences,  such  as  those  which  produce  hysteria — 
viz.  shock,  fright — are  the  principal  causes  of  diabetes  insipidus.  Thus  a  boy 
of  ten  years,  recently  treated  by  myself,  was  choreic  at  various  times  prior  to 
the  attack  of  polyuria,  and  was  very  nervous  throughout  the  illness,  from 
which  he  recovered. 

Morbid  Anatomy. — No  definite  morbid  anatomy  has  been  found  asso- 
ciated with  simple  polyuria.  The  kidneys  have  been  found  sacculated  in 
various  degrees,  more  likely  as  a  consequence  of  the  enormous  accumulation 
of  liquid  filling  the  bladder  and  pressing  backAvard  through  the  ureters  upon 
the  kidney  structure,  causing  its  atrophy.  Tubercular  and  gliosarcomatous 
tumors  in  the  neighborhood  of  the  floor  of  the  fourth  ventricle  have  been 
found. 

Symptoms. — The  chief  symptom  is  a  profuse  polyuria  associated  with 
a  proportionate  thirst.  The  quantity  of  urine  exceeds  tliat  of  all  ordinary 
cases  of  diabetes  mellitus.  The  boy  of  ten  referred  to  would  pass  a  quart  at 
a  single  sitting,  while  the  frequency  of  the  desire  to  pass  water  made  it  impos- 
sible to  attend  school.  The  specific  gravity  is  proportionately  low,  generally 
1002  to  1006,  and  I  have  known  it  to  be  scarcely  above  1000.  For  the 
twenty-four  hours'  urine  the  other  constituents  remain  usually  normal,  while 
albuminuria  is  much  more  rare  than  in  diabetes  mellitus. 

As  a  natural  result  of  such  a  condition  there  is  great  dryness  of  the  skin 
and  mucous  membranes.  On  the  other  hand,  there  is  never  that  extreme 
emaciation  seen  in  children  with  diabetes  mellitus,  and  the  patients  are  often 
fairly  well  nourished.  This  is  favored  by  the  fact  that  the  appetite  is  apt  to 
be  increased,  from  which,  indeed,  derangements  of  digestion  may  result. 

Other  nervous  symptoms  frequently  attend  or  precede  diabetes  insipidus, 
such  as  chorea,  restlessness,  and  sleeplessness. 

DiagTiosis. — The  diagnosis  of  diabetes  insipidus  is  easy.  The  enormous 
quantity  of  urine  passed,  its  low  specific  gravity,  and  the  absence  of  sugar, 
if  maintained  for  anv  length  of  time,  can  mean  nothing  else.     It  is  barely 


lOOQ  A  JfUBICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

possible  that  the  milder  forms  might  be  confounded  with  chronic  interstitial 
nephritis  in  adults,  but  in  children  this  seems  impossible.  The  presence  of  ti 
trace  of  albumin  should,  however,  lead  to  an  exhaustive  examination  of  the 
urine  for  casts  and  other  signs  of  interstitial  nephritis — a  very  rare  disease  in 
children. 

Prog-nosis. — The  prognosis  in  my  experience  is  generally  favorable,  the 
patient  sooner  or  later  getting  well. 

Treatment. — Cases  under  my  care  have  usually  yielded  sooner  or  later  to 
ergot  or  gallic  acid,  the  former  in  beginning  doses  of  10  minims  of  the  fluid 
extract,  or  less  according  to  age,  and  increasing  until  results  are  obtained  or 
full  doses  reached  without  effect.  Gallic  acid  may  be  given  in  5-grain  doses  at 
the  beginning  and  increased.  For  antipyrine  and  antifebrin  great  efficiency  in 
the  treatment  of  this  affection  has  recently  been  claimed.  While  I  have  as  yet 
had  no  opportunity  to  try  them,  my  experience  with  these  drugs  in  diabetes 
mellitus  leads  me  to  expect  that  they  will  be  even  more  efficient  in  diabetes 
insipidus.  The  same  reasoning  leads  me  to  expect  that  bromide  of  potassium 
would  be  useful,  as  it  sometimes  is. 

Valerian  is  one  of  the  older  remedies  for  simple  polyuria,  and  it  can  be 
easily  understood  Avhy  it  should  be  useful  in  nervous  cases.  The  older  physi- 
cians used  powdered  valerian  and  valerianate  of  zinc,  but  at  the  present  day 
the  more  elegant  preparation  of  elixir  of  the  valerianate  of  ammonium,  in  doses 
of  half  a  drachm,  a  drachm,  or  more  according  to  age,  should  be  substituted. 
The  exceedingly  disagreeable  smell  of  the  substance  is  in  the  way  of  its  gen- 
eral use.  Opium  is  also  recommended  in  diabetes  insipidus,  but  has  made  for 
itself  no  reputation  like  that  it  has  attained  in  saccharine  diabetes. 

A  blister  at  the  nape  of  the  neck  or  on  the  epigastrium  was  suggested  by 
Roberts,  and  might  be  expected  to  be  of  service  by  its  impression  on  the  ner- 
vous system.  The  constant  galvanic  current  would  be  reasonably  useful  from 
the  same  standpoint,  and  is  recommended  by  Seidel  and  Kuelz,  the  former  of 
whom  applied  daily  one  pole  of  a  strong  battery  over  the  loins  near  the  spine 
and  the  other  as  deeply  as  possible  over  the  hvpochondrium. 

In  the  matter  of  drinking  water  a  moderate  restriction  should  be  exercised 
in  diabetes  insipidus,  but  to  cut  down  the  amount  of  water  largel}'  is  a  cruelty 
unjustified  by  the  results.  The  cry  for  water  is  a  demand  to  make  up  a  loss 
from  the  economy  by  the  kidneys.  It  is  an  effect,  and  not  a  cause.  Yet  it  is 
possible  to  carry  drinking  to  excess  after  a  habit  is  once  acquired,  and  for  the 
effect  thus  to  become  the  cause.  To  prevent  this  a  reasonable  oversight  should 
be  exercised. 

in.    LiTHIASIS. 

LiTHiASis  is  the  deposition  of  certain  solids  of  the  urine  in  the  urinary 
tract,  any  portion  of  which,  from  its  beginning  in  a  Malpighian  capsule  to  its 
terminal  expansion,  the  bladder,  may  be  the  seat  of  such  deposit.  The 
sediments  thus  precipitated  include,  in  the  order  of  frequency,  first,  uric  acid 
and  its  compounds  of  sodium,  potassium,  and  ammonium ;  second,  oxalate  of 
lime ;  and.  third,  the  phosphates  of  calcium,  magnesium,  and  ammonium.  A 
clot  of  blood  or  fragment  of  foreign  matter  may  be  the  nucleus  of  calculi  thus 
formed.  They  may  be  so  minute  as  to  be  barely  visible  to  the  naked  eye, 
constituting  sand  or  gravel,  or  they  may  be  a  couple  of  inches  or  more  in  diam- 
eter, when  they  are  spoken  of  in  common  language  as  stones  in  the  kidney  or 
bladder. 

As  stated,  the  most  frequent  sediments  are  uric  acid,  which  are  often  found 
in  the  shape  of  red  sand  in  the  very  first  urinary  discharges  of  the  new-born 


LITHIA8IS. 


1007 


infant.  Calculi  may  form,  consisting  of  pure  uric  acid  or  its  compounds,  but 
they  are  seldom  large.  Less  common  are  small  stones  of  pure  oxalate  of  lime. 
More  commonly  large  stones  consist  of  nuclei  of  uric  acid  or  oxalate  of  lime, 
around  which  phosphates  are  deposited  in  concentric  layers.  Phosphates  rarely 
form  the  nuclei  of  stones.  The  alkaline  reaction  of  urine,  which  is  necessary 
to  the  deposit  of  phosphates,  is  not  common  in  children  fed  on  milk.  It  is 
not  until  vegetable  substances  are  added  to  the  diet  that  the  alkaline  reaction 
becomes  conspicuous.  More  frequently  the  alkalinity  necessary  to  the  pre- 
cipitation of  phosphates  is  the  consequence  of  organic  matter  generated  in 
inflammatory  processes,  especially  those  excited  by  calculi  themselves.  •  This 
occurs  as  soon  as  they  reach  a  sufficient  size  to  act  as  irritants  producing  local 

Fig.  1. 


Calculi  impacted  in  the  Ureters.    From  a  boy  of  5  years  (Tyson). 


inflammation.  They  thus  become  surrounded  by  alkaline  urine,  whence  phos- 
phates are  deposited  in  concentric  layers  around  the  uric-acid  or  oxalate-of- 
lime  nucleus. 

It  has  been  said  that  calculi  may  form  in  any  part  of  the  urinary  tract. 
Hence  they  may  be  found  imbedded  in  the  kidney,  circumscribed  and  encap- 
sulated in  the  centre  of  the  organ.  Thus  situated,  they  may  grow  by  accretion 
until  they  have  almost  destroyed  the  entire  organ,  filling  up  its  pelvis  and  cal- 
yces, converting  the  entire  kidney  into  a  pus-sac  ;  or  they  may  even  make  their 
way  through  the  capsule  of  the  kidney  into  the  perinephric  tissues,  and  thence 


lOOS  AMERICA Jf  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

down  into  the  pelvic  cavity.  Appended  is  a  drawing  of  a  remarkable  specimen 
occurring  in  the  practice  of  the  writer  in  a  boy  of  five  years,  twice  success- 
fully operated  upon  for  stone  in  the  bladder,  the  first  time  when  but  three  years 
old.  He  perished  finally  of  exhaustion.  The  necropsy  only  revealed  the  extent 
of  the  mischief.  The  stone  in  the  left  ureter  was  spirally  spindle-shaped,  and 
measured  5.5  cm.  long  and  1.5  cm.  wide  in  the  thickest  part.  The  stone  in 
the  right  ureter  was  10.5  cm.  long  and  1  cm.  through  at  its  thickest  part.  The 
bladder  also  contained  a  small  stone  2.5  cm.  long  and  ranging  in  diameter  from 
.5  to  .75  cm. 

Etiolog-y. — It  would  scarcely  be  profitable  to  attempt  to  discuss  the  causes 
why  in  one  child  there  is  a  tendency  to  deposit  uric-acid  sediment,  or  why  in 
another  under  apparently  the  same  conditions  an  oxalic-acid  lithiasis  should 
exist.  The  conditions  which  favor  phosphatic  deposits  have  been  mentioned. 
Whatever  may  be  the  cause  of  each,  there  can  be  no  doubt  that  in  every  case 
the  deposit  of  sediments  is  favored  by  a  reduction  in  the  amount  of  water  sep- 
arated by  the  kidneys — a  condition  which  depends  largely  on  the  amount  of 
liquid  ingested.  The  reaction  of  the  urine,  whether  acid  or  alkaline,  also  plays 
an  important  role.  Phosphatic  sediments  are  never  spontaneously  deposited 
from  an  acid  urine,  nor  uric  acid  from  an  alkaline  urine.  The  law  cannot  be 
so  sharply  laid  down  with  regard  to  oxalate  sediments,  crystals  of  oxalate  of 
lime  being  deposited  in  alkaline  as  well  as  acid  urines,  although  I  believe  the 
reaction  of  urine  containing  them  is  most  frequently  acid. 

Calculi  may  present  themselves  at  any  age,  and  probably  begin  their 
formation  sometimes  even  before  birth.  At  any  rate,  large  stones  have  been 
removed  from  the  bladders  of  children  in  the  first  year  after  birth — too  large,  it 
would  seem,  to  have  been  produced  in  the  short  time  which  had  elapsed  since 
birth. 

Symptoms. — The  symptoms  of  lithiasis  in  the  child  vary  very  greatly 
according  to  seat  and  degree.  For  convenience,  such  symptoms  may  be  divided 
into  those  caused  by  sand  or  gravelly  deposits,  those  caused  by  calculi  in  the 
bladder  of  such  size  as  to  justify  the  term  "stone,"  and  those  caused  by  calculi 
impacted  higher  up  in  the  urinary  tract,  in  the  pelvis  of  the  kidney  and  in 
the  ureters. 

Sand  or  Crravel  in  the  Bladder. — A  simple  peevishness  or  fretfulness  or 
other  evidence  of  pain  in  an  infant,  with  retractions  of  the  limbs,  may  be  caused 
by  gravel,  evidence  which  is  confirmed  by  red-pepper-like  sediment  on  the 
napkin  or  an  unusually  dark  staining  of  the  latter  by  urine.  The  same  condi- 
tion in  an  older  child  may  give  rise  to  more  intelligible  manifestations  of  dis- 
comfort, which  may  be  located  in  the  lumbar  region,  in  the  groin,  or  in  the 
urethra.  A  very  common  mode  of  manifestation  of  discomfort  in  the  latter 
situation  and  in  the  neck  of  the  bladder  is  traction  upon  the  prepuce,  which 
often  becomes  elongated  in  consequence.  At  this  early  age  a  frequent  desire 
to  pass  water,  and  especially  wetting  the  bed  at  night,  should  lead  to  examina- 
tion of  the  urine,  the  presence  wherein  of  uric-acid  or  oxalate-of-lime  sediments 
would,  together  with  dark  color  and  high  specific  gravity,  add  further  probability 
of  the  presence  of  such  a  cause. 

Stone  in  the  ^/afZc/cr  manifests  itself  by  very  much  the  same  symptoms,  though 
intensified,  especially  the  disposition  to  draw  upon  the  prepuce  and  frequency  of 
micturition.  Tenderness  in  the  region  of  the  kidney  will  be  found  where  the 
pelvis  is  the  seat  of  detention  of  the  calculus,  and  not  infrequently  bulging, 
and  even  fluctuation  from  the  presence  of  pus,  may  be  detected.  Abdominal 
palpation  should  not  be  neglected,  as  enlargements  of  the  kidney  are  very  apt 
to  be  anterior  in   direction.     Examination   of  the  urine  may  give    negative 


LITHIASIS,  1009 

results,  or  it  may  show  the  presence  of  the  crystals  already  mentioned ;  more 
frequently  the  secretion  contains  evidence  of  irritation  of  the  bladder  in  the 
presence  of  mucus  or  pus,  while  a  trace  of  albumin  will  attend  the  presence  of 
pus.  When  mucus  or  pus  is  absent,  the  microscope  may  still  discover  mucus 
threads  or  so-called  mucus-casts,  which  always  mean  irritation  of  the  genito- 
urinary passages  short  of  what  is  sufficient  to  produce  mucus  or  pus  in  the  urine. 
Such  urines,  if  not  already  alkaline  when  passed,  readily  become  so,  and  the 
alkalinity  thus  produced  tends  to  make  the  urine  viscid  and  glutinous.  Where 
the  alkalinity  takes  place  in  the  bladder  in  the  presence  of  pus,  this 
glairy  material  is  formed  in  the  viscus,  and  micturition  becomes  difficult  or 
impossible. 

Such  a  set  of  symptoms  will  of  course  suggest  the  use  of  the  bladder-sound, 
by  which  a  stone  is  commonly  readily  recognized. 

The  continuance  of  symptoms  of  such  severity  as  are  caused  by  the  larger 
stones  soon  affects  the  general  health  of  the  patient,  as  attested  by  feverishness 
and  gradually  growing  emaciation,  which  may  terminate  in  death. 

Diagnosis. — This  is  successful  according  as  the  lines  of  investigation  may 
be  thorough  or  otherwise  in  the  examination  of  urine,  palpation,  and  the  use 
of  the  sound. 

ProgTiosis. — This  is  generally  favorable,  the  use  of  appropriate  solvent 
medicines  and  diet  being  sufficient  to  correct  the  states  wherein  only  gravelly 
sediments  are  present ;  while  the  surgeon's  knife  even  more  promptly  removes 
the  stone  from  the  bladder  or  kidney,  nephrotomy  to-day  saving  many  lives 
which  would  have  formerly  been  lost.  It  is  only,  for  the  most  part,  those  cases 
which  have  advanced  too  far,  or  which  present  the  peculiar  conditions  presented 
in  Fig.  1,  which  are  beyond  the  reach  of  any  remedy,  and  gradually  wear 
out  the  patient. 

Treatment. — As  soon  as  a  stone  of  size  sufficient  to  be  recognized  by  a 
sound,  or  by  localized  pain  or  tenderness  in  the  kidney  itself,  is  discovered, 
there  is  but  one  course  to  be  pursued.  The  case  must  be  handed  over  to  the 
surgeon.  At  the  present  day  no  intelligent  physician  expects  to  dissolve  away 
a  stone  by  medicinal  treatment. 

From  the  physician's  standpoint,  treatment  is  therefore  limited  to  such 
cases  in  which  the  lithiasis  is  confined  to  gravelly  sediments.  Of  these  there 
can  be  no  rational  treatment  except  after  a  thorough  chemical  and  microscopi- 
cal study  of  the  urine,  and,  although  symptoms  may  be  relieved  without  such 
study,  the  success  attained  is  accidental,  and  reflects  no  credit  on  him  who 
employs  it.  The  management  demanded  by  different  conditions  is  often  dia- 
metrically opposite. 

If,  on  examination,  the  urine  is  found  highly  acid  in  reaction,  depositing 
uric-acid  sediments,  the  treatment  is  pre-eminently  by  alkalies.  It  does  not 
much  matter  what  alkalies  are  used.  They  should,  however,  be  associated  with 
an  abundance  of  liquid,  in  order  the  better  to  furnish  a  solvent  for  the  uric 
acid.  The  liquor  potassae  of  the  U.  S.  Pharmacopoeia  is  an  excellent  remedy  in 
doses  of  5  to  20  minims,  the  dose  being  adapted  to  the  age  of  the  patient  and 
administered  three  or  four  times  a  day.  The  object  should  be  to  alkalize  the 
urine,  and  in  testing  it  a  time  of  day  should  be  selected  when  the  urine  is  most 
likely  under  ordinary  circumstances  to  be  acid.  Such  a  time  is  the  early  morn- 
ing before  food  is  taken.  Milk  is  an  admirable  medium  for  liquor  potassse.  The 
salts  of  potash  are  also  useful,  and  there  is  less  danger  of  an  overdose.  The  citrate 
and  carbonate  are  equally  efficient  in  doses  of  5  to  15  grains  three  or  four  times 
a  day,  or  oftener  if  necessary  to  secure  an  alkaline  reaction.  With  alkalinity 
established,  uric  acid  cannot  be  precipitated.     On  the  other  hand,  care  must 

6* 


1010  AMEBICAW  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

be  taken  to  avoid  the  opposite  extreme — having  escaped  Scylla,  to  steer  clear 
also  of  Charybdis.  If  the  urine  be  made  too  highly  alkaline,  the  phosphates 
■will  fall  and  the  sediments  of  these  urinary  constituents  arise.  The  alkaline 
mineral  waters,  of  which  the  imported  Vichy  waters  are  the  type,  and  even 
negative  mineral  waters,  are  useful  in  the  uric-acid  lithiasis. 

The  new  substance,  piperazine,  is  an  admirable  solvent  for  uric  acid  in 
doses  of  3  to  5  grains  for  children. 

On  the  other  hand,  if  we  have  an  alkaline  urine  to  contend  with  and  per- 
sistent phosphatic  deposits,  we  must  seek  to  make  the  urine  acid.  This,  unfor- 
tunately, is  not  so  easy.  There  are  very  few  medicines  which  have  this  tend- 
ency. Benzoic  acid  and  boric  acid  are  the  only  ones,  and  neither  of  them 
is  well  borne  in  large  doses  by  children.  But  they  should  be  given  in  doses 
of  1  to  5  grains  every  three  hours,  or  often  enough  to  secure  the  acid  reaction 
sought  for. 

Oxalate  of  lime,  unfortunately,  is  insoluble  in  both  acids  and  alkalies.  At 
the  same  time,  it  is  sometimes  formed  under  the  same  conditions  as  uric  acid. 
The  same  general  plan  of  treatment  may  be  carried  out. 

Oxalate-of-lime  sediments  frequently  attend  dyspeptic  states,  which  are 
successfully  treated  by  acids,  especially  nitromuriatic,  which  should  be  cau- 
tiously administered  in  combination  with  suitable  doses  of  tincture  of  nux 
vomica,  or  even  strychnine,  with  pepsin  or  pancreatin. 

Where  the  composition  of  gravel  cannot  be  determined,  it  is  a  great  deal 
better  to  give  an  abundance  of  distilled  water  than  the  alkalies  and  alkaline 
mineral  waters,  by  which  we  only  add  fuel  to  the  flame  if  it  happens  that  we  are 
dealing  with  phosphatic  gravel. 

As  to  diet,  if  the  gravel  be  uric  acid,  meats  and  albumens  should  be  limited, 
as  they  tend  to  produce  an  acid  urine  and  uric-acid  sediments.  On  the  other 
hand,  milk  and  vegetables  tend  to  alkalize  the  urine.  Abundant  experience 
has  taught  me  that  not  only  during  childhood,  but  also  during  infancy,  parents 
are  too  indifferent  about  giving  their  children  pure  water  to  drink.  Children 
should  be  encouraged  to  drink  water  between  meals,  and  infants  should  be 
given  pure  water  to  drink  two  or  three  times  a  day.  They  soon  grow  fond  of 
it,  and  in  this  way  liquid  is  furnished  to  flush  out  the  excretory  channels  of  the 
economy,  and  to  dissolve  the  solids  which  can  only  be  removed  in  solution. 

In  children,  no  less  than  in  adults,  pain  must  be  relieved  by  appropriate 
anodynes.  The  milder  preparations  of  opium,  as  paregoric,  should  be  made 
to  suffice,  because  of  the  danger  of  the  stronger  preparations.  The  sup- 
pository is  a  convenient  and  effectual  medium.  Phenacetin  will  often  relieve 
the  milder,  and  sometimes  even  quite  severe,  degrees  of  pain,  especially  if  it 
be  renal.     Five  to  ten  grains  may  be  given  at  a  dose. 


ACUTE  AIN'D  CHROIN^IC  NEPHRITIS,  AND  AMY- 
LOID DISEASE  OF  THE  KIDNEY. 


By  I.  N.  DANFORTH,  M.  D., 

Chicago. 


I.  Acute  Tubal  Nephritis. 

Synonyms. — Acute  catarrhal  nephritis  ;  Acute  desquamative  nephritis ; 
Acute  croupous  nephritis ;  Acute  parenchymatous  nephritis ;  and  Acute 
Bright's    disease. 

Etiology. — In  adult  life  exposure  to  cold  and  "^\-et  is  the  most  common 
cause  of  acute  tubal  nephritis,  but  it  is  a  curious  and  interesting  fact  that  the 
disease  is  very  rarely  produced  in  children  in  this  way.  My  experience  quite 
accords  with  that  of  Ralfe,  who  says,  "  I  have  never  yet  succeeded  in  obtaining 
a  history  of  exposure  to  cold  and  wet  in  a  case  of  acute  nephritis  occurring  in 
childhood."  The  usual  causes  are  acute  febrile  diseases,  especially  the  exanthe- 
mata ;  septic  diseases,  like  diphtheria  and  erysipelas  ;  and  traumata,  such  as 
burns,  scalds,  and  injuries  involving  the  nervous  centres.  Certain  drugs  in 
use  among  children,  notably  cantharides  and  turpentine,  are  capable  of  inflam- 
ing the  kidneys,  and  I  have  known  the  extravagant  use  of  highly-flavored 
confections  produce  the  same  result. 

Symptoms. — The  symptoms  of  a  well-marked  case  of  acute  nephritis  are 
ahvays  pronounced  and  aggressive.  The  patient  is  sometimes  seized  with  an 
initiatory  chill,  but  if  this  is  absent  pyrexia  is  always  present,  the  temperature 
ranging  from  100°  to  103°,  or  even  104°F.,  and  maintaining  this  altitude  for 
from  six  to  twelve  days.  The  pulse  is  frequently  tense,  and  has  a  peculiarly 
quick,  short,  nervous  beat,  thus  giving  expression  to  the  cardiac  irritation 
characteristic  of  the  uragmic  state.  The  tongue  is  coated,  the  appetite  lost,  and 
the  bowels  constipated.  There  is  generally  deep  dull  pain  in  the  lumbar 
region,  due  to  the  swollen  condition  of  the  kidneys.  Headache  is  a  prominent 
symptom,  vertigo  is  not  uncommon,  transitory  strabismus  sometimes  occurs, 
and  if  relief  is  not  promptly  obtained  ursemic  convulsions  supervene,  to  be  fol- 
lowed by  partial  or  perhaps  profound  coma,  with  probably  dilated,  but 
certainly  uncontracted,  pupils.  If  the  coma  is  not  complete,  obstinate 
nausea  with  violent  retching  will  probably  occur ;  that  is,  the  vomiting  of 
urgemia. 

The  urine  is  diminished  in  quantity  from  the  first,  and  this  significant 
symptom  progresses  until  complete  suppression  may  occur.  The  reaction  is 
usually  acid ;  the  specific  gravity  increases  from  1.025  to  1.040,  in  the  early 
stage,  but  diminishes  later ;  the  color  varies  from  pink  to  a  vivid  red,  the 
intensity  of  the  color  denoting  roughly  the  quantity  of  blood  present,  for  it 
rarely  happens  that  acute  nephritis  is  not  attended  by  well-marked  hsematuria. 
Albumin  is  always  present  in  large  quantities,  at  least  one-quarter,  and 
frequently  three-quarters,  by  volume ;    that  is,  when  a  specimen  of  urine  is 

1011 


1012  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tested  by  heat  and  nitric  acid  in  a  test-tube  and  allowed  to  stand  for  twelve 
hours,  the  albumin  will  occupy  from  one-quarter  to  three-quarters  of  the  space. 
A  copious  sediment  will  fall  when  the  urine  is  set  aside ;  this  is  made  up  of 
hyaline,  epithelial  and  blood-casts,  free  blood-globules,  many  of  them  crenated, 
renal  epithelium,  granular  urates,  and  amorphous  matter.  In  the  early  stage 
blood-casts  will  predominate ;  later  on,  epithelial  and  hyaline  casts  are  more 
abundant,  and  before  convalescence  is  established  some  fatty  or  granular  casts 
may  appear,  although  they  are  usually  few  and  far  between,  unless  the  case 
falls  into  a  chronic  condition. 

Dropsy  appears  very  early  in  the  case,  generally  manifesting  itself  first  in 
the  lower  eyelids,  cheeks,  or  the  loose  tissues  of  the  neck  ;  it  then  invades  the 
feet  and  travels  upward,  reaching  the  scrotum  or  labiiie,  then  the  abdominal 
cavity,  and  it  may  be  the  pleural  or  pericardial  cavities.  Oedema  of  the  lungs 
may  occur ;  the  glottis  may  be  distended  with  fluid,  threatening  or  even 
causing  death  by  asphyxia,  although  this  can  generally  be  avoided.  As 
already  intimated,  the  heart's  action  is  rapid  and  the  systole  is  quick,  powerful, 
and  "  angry,"  because  of  ur?emic  irritation  and  increased  arterial  tension. 

The  foregoing  account  of  symptoms  relates  to  a  well-marked  typical  case. 
Of  course  mild  cases  occur,  when  the  symptoms  are  much  less  pronounced ;  bui 
it  is  also  true  that  cases  of  greater  severity  and  more  rapid  progress  are  occa- 
sionally seen,  which  generally  prove  rapidly  fatal  from  acute  ursemia. 

Morbid  Anatomy. — The  kidney  is  swollen,  not  hypertrophied,  but  dis- 
tended with  blood  and  also  by  the  contents  of  the  convoluted  tubes.  Dickin- 
son relates  a  case  in  which  the  capsule  of  both  kidneys  was  ruptured  by  the 
intense  distention  caused  by  congestion,  but  this  is  a  very  exceptional  occur- 
rence. The  color  of  the  kidney  is  much  darker  than  normal,  and  the  stellate 
veins  stand  out  with  great  distinctness.  If  the  organ  be  laid  open  lengthwise, 
blood  will  drip  freely  from  the  cut  surface,  and  it  will  be  seen  that  the  cortical 
substance  is  apparently  much  increased.  The  Malpighian  bodies  sometimes 
project  above  the  level  of  the  incised  cortex,  and  may  be  felt  as  little  rounded 
bodies  under  the  finger.  Microscopic  section  shows  the  small  vessels  much 
dilated,  especially  those  of  the  glomeruli ;  in  fact,  these  are  in  many  instances 
ruptured.  The  convoluted  tubes  are  much  distended  by  casts,  blood-globules, 
cast-ofi"  epithelia,  and  granules  or  crystals  of  urinary  salts,  and  the  straight 
tubes  are  in  less  degree  distended  by  similar  contents.  If  the  disease  passes 
into  the  chronic  stage,  of  course  the  kidney  will  show  granular  or  fatty  degen- 
eration. 

Diagnosis. — The  diagnosis  of  acute  nephritis  can  scarcely  be  said  to  pre- 
sent any  difficulties.  The  rapid  invasion,  early  occurrence  of  dropsical  effusion, 
arterial  tension,  and  especially  the  scantiness  of  the  urinary  secretion,  together 
with  its  pink  or  red  color,  at  once  indicate  the  nature  of  the  illness.  Of  course 
an  examination  of  the  urine  will  at  once  remove  all  doubts.  Acute  nephritis 
may  be  complicated  with,  or  rather  preceded  by,  chronic  nephritis,  but  a 
microscopic  examination  of  the  urinary  sediment  will  at  once  reveal  the 
characteristic  fatty  or  granular  casts,  which  will  establish  the  real  facts  in  the 
case.  Moreover,  a  careful  inquiry  into  the  history  of  the  patient  will  result  in 
the  discovery  of  symptoms  indicating  pre-existing  renal  disease.  Cyanotic 
induration  of  the  kidneys  may  possibly  be  mistaken  for  acute  nephritis,  but  a 
careful  examination  of  the  heart  will  clear  up  the  doubt,  since  this  disease 
is  almost  invariably  associated  with  some  obstructive  lesion  of  the  cardiac 
valves,  especially  the  mitral.  Careful  inquiry  will  also  develop  the  fact  that 
the  disease  has  existed  for  a  length  of  time  which  rules  acute  nephritis  out  of 
the  question.      As  cyanotic  induration  is  not  very   uncommon  in  children, 


PLATE  XXI. 


c^ 


/>• 


^■■ 


^    y 


I 


/-•. 


•^i^^^c*. 


TUBE-CASTS  AND  URIXAHY  SEDIilEXTS. 

Pi&.  1.  Hyaline  Cast,  Lithie-Acid  Crystals,  Granular  Epithelia  (Acute  Tubal  Nephritis).    X  150  diameters 

Fig.  2.  Epithelial  Cast,  Lithic-Acid  Crystals  (Acute  Tubal  Nephritis).    X  150  diameters. 

Fig.  3.  One  Epithelial  and  Two  Hyaline  Casts  (Chronic  Interstitial  Nephritis),    x  150  diameters. 

Fig.  4.  Hyaline  Cast  and  Renal  Epithelia,  stained  (Chronic  Interstitial  Nephritis),    x  150  diameters. 

Fig.  5.  Waxy  Cast  (Amyloid  Degenerationj.    x  150  diameters. 


ACUTE    TUBAL   NEPHRITIS.  1013 

it  should  always  be  borne  in  mind  when  renal  symptoms  are  under  investi- 
gation. 

Prognosis. — Acute  nephritis  is  always  a  grave  disease,  and  is  by  no  means 
free  from  danger.  Yet,  if  recognized  early  and  treated  appropriately,  there 
are  few  serious  diseases  that  yield  better  results.  Of  course,  I  am  now 
speaking  of  uncomplicated  diseases.  But  the  danger  is  greatly  increased 
if  the  child  has  cardiac  insufficiency,  bronchitis,  tuberculosis,  or  any  other 
organic  affection.  If  proper  treatment  be  not  instituted  until  inflammatory 
exudation  has  been  poured  into  the  tubes  and  capsules  of  Bowman,  the 
chances  of  recovery  are  diminished,  although  the  case  is  not  hopeless.  Sup- 
pressio  urinse  and  uraemic  convulsions  indicate  a  condition  of  extreme  danger, 
but  I  have  seen  several  perfect  recoveries  even  after  these  untoward  symptoms 
have  appeared.  Children  are  more  apt  to  recover  than  adults  ;  in  fact,  granted 
an  otherwise  healthy  child,  an  early  diagnosis,  and  prompt  and  vigorous  treat- 
ment, the  great  majority  of  cases  will  recover  without  damage  to  the  kidneys. 

Treatment. — Promptitude  without  precipitation  and  vigor  without  rash- 
ness should  guide  the  physician  in  the  treatment  of  acute  nephritis.  It  is  fre- 
quently the  case  that  a  judicious  blow  at  the  right  time  saves  a  life,  and,  on 
the  other  hand,  it  is  equally  true  that  hesitation  and  delay  cost  the  life  or 
blight  the  future  of  many  a  child.  If  the  child  be  strong  and  vigorous  and 
the  attack  be  violent,  it  will  be  wise  to  apply  three  or  four  leeches  over  each 
kidney,  or,  if  the  leeches  cannot  be  obtained,  blood  should  be  taken  by  means 
of  cups.  The  amount  must  of  course  depend  on  the  age  and  strength  of  the 
child,  but  two  ounces  would  be  none  too  much  to  take  from  each  renal  region 
if  the  child  be  from  six  to  eight  years  of  age  and  in  vigorous  health  at  the 
time  of  the  attack.  Immediately  following  the  bleeding  a  large  hot  linseed 
cataplasm  should  be  applied,  so  as  to  entirely  encircle  the  body  at  the  level  of 
the  kidneys.  If  the  poultices  be  covered  with  rubber  cloth  or  oiled  silk,  they 
need  not  be  changed  oftener  than  every  six  hours.  It  is  very  important  that 
they  be  made  to  "fit"  the  body  closely,  and  if  a  little  powdered  mustard  be 
incorporated  in  each  poultice,  it  will  be  an  improvement.  But  no  stimulating 
applications,  like  turpentine  stupes,  should  be  employed  in  the  early  stage  of 
the  disease. 

The  practitioner  should  next  turn  his  attention  to  the  all-important  neces- 
sity for  securing  elimination  of  the  urinary  factors  by  other  agents  than  the 
kidneys.  Fortunately,  the  alimentary  tract  and  the  skin  afford  ample  means 
for  accomplishing  this.  A  vigorous  cathartic  should  be  given,  and  I  am  much 
in  favor  of  administering  from  one  to  three  grains  of  calomel,  and  following  it 
in  three  or  four  hours  with  an  appropriate  dose  of  solution  of  citrate  of  mag- 
nesium. The  bowels  should  be  kept  loose  for  several  days  or  until  the  danger 
from  the  acute  invasion  has  passed  ;  and  this  for  two  reasons  :  first,  for  the 
purpose  of  compelling  the  bowels  to  take  up  a  portion  of  the  work  of  the  kid- 
neys, so  that  the  latter  may  have  the  benefit  of  a  season  of  physiological  rest ; 
secondly,  for  the  purpose  of  using  the  vast  alimentary  area  as  a  "  derivative  " 
surface.  Cathartics  produce  more  or  less  hypersemia  of  the  intestinal  mucous 
membrane,  and  if  the  circulatory  current  is  "determined  "  toward  the  intestine, 
it  is  proportionally  drawn  away  from  the  engorged  kidneys — a  result  that  is 
very  desirable.  I  have  many  times  seen  the  good  results  of  this  practice,  and 
am  therefore  confident  that  it  is  something  more  than  a  mere  theory.  Of  course 
the  most  useful  cathartics  are  those  which  produce  free  watery  evacuations. 
The  skin  is  also  a  vast  eliminating  organ,  and  the  reciprocal  relations  existing 
between  the  skin  and  kidneys  are  well  known  to  physiologists.  The  physician 
should  take  full  advantage  of  this  fact  in  the  treatment  of  acute  nephritis,  and 


1014  AMEBICAJV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


encourage  copious  as  well  as  constant  diaphoresis.  For  this  purpose  jaborandi, 
or  its  alkaloid  pilocarpine,  and  the  hot-air  or  vapor  bath  are  both  prompt, 
efficient,  and  certain.  I  have  seen  such  excellent  results  from  the  use  of 
hot  dry  air  that  I  do  not  hesitate  to  urge  its  employment  in  every  severe 
case  of  acute  nephritis.  My  method  is  as  follows  :  The  patient,  all  but  his 
head,  is  placed  in  a  "  tent  "  (made  by  supporting  the  bed-clothes  upon  arches 
or  semicircles  of  half-hoops  or  bent  Avire)  and  the  bed-clothes  are  drawn  closely 
about  the  neck,  so  as  to  exclude  cold  air  and  include  hot  air ;  the  perforated 
tin  box  (1)  is  then  placed  under  the  bed-clothes  by  the  side  of  the  patient 

Fig.  1. 


Apparatus  for  the  Administration  of  the  Hot-air  Bath.    The  top  and  inner  side  of  the  box  are  made  of 

perforated  tin. 

and  about  six  inches  away  from  him ;  a  current  of  hot  air  from  a  spirit  lamp  (3) 
is  now  conducted  into  the  perforated  tin  box  (which  acts  as  a  "register" 
or  "  radiator  ")  through  the  tin  pipe  (2),  as  shown  in  the  figure.  The  result  is 
usually  very  copious  diaphoresis,  which  may  be  maintained  for  many  successive 
hours,  or  even  days  in  cases  of  emergency.  In  one  case  which  seemed  well- 
nigh  hopeless,  the  hot-air  apparatus  was  kept  in  action  almost  constantly  for  ten 
days,  and  the  patient  made  a  perfect  recovery.  In  some  cases  the  hot  dry  air 
evokes  sensations  of  "faintness"  or  "smothering;"  when  this  happens  the 
heat  should  be  increased  very  slowly,  so  as  not  to  alarm  or  excite  the  patient. 
Now  and  then  a  case  will  be  encountered  which  will  not  bear  dry  heat  at  all, 
while  moist  heat  will  be  tolerated  with  both  comfort  and  benefit.  A  few 
heated  bricks,  wrapped  in  wet  cloths  and  placed  around  the  patient  under 
the  tent,  will  produce  active  diaphoresis.  This  method,  however,  is  less  effi- 
cient than  dry  heat,  and  the  latter  will  almost  invariably  be  tolerated  after  a 
few  trials. 

In  jaborandi  we  have  a  most  powerful  and  certain  diaphoretic,  and  one 
which  is  entirely  safe  if  used  at  the  proper  time  and  place.     In  practice  the 


ACUTE    TUBAL   NEPHRITIS.  1015 

alkaloid  pilocarpine,  the  active  principle  of  jaborandi,  will  be  found  the  most 
convenient  and  efficient  and  by  far  the  easiest  of  administration.  In  cases 
of  unusual  danger,  where  copious  or  excessive  diaphoresis  is  imperatively 
necessary,  pilocarpine  in  connection  with  the  hot-air  bath  is  invaluable.  But 
a  proportionally  larger  dose  must  be  given  to  a  child  than  to  an  adult.  To  a 
child  of  seven  or  eight  years  one-eighth  of  a  grain  of  the  nitrate  of  pilo- 
carpine will  be  a  medium  dose,  and  if  copious  sweating  does  not  commence 
in  half  an  hour  the  dose  should  be  repeated.  It  may  be  given  either  by  the 
mouth  or  hypodermatically,  although  in  an  urgent  case  the  latter  method  should 
be  adopted,  and  it  is  always  preferable.  In  a  given  case  experience  will  soon 
determine  what  dose  should  be  employed.  When  bronchial  catarrh  is  present, 
pilocarpine  is  said  to  have  produced  profuse  and  even  fatal  transudation  of  fluid 
into  the  bronchial  tubes,  so  that  patients  have  been  "drowned"  in  their  own 
secretions.  I  have  seen  no  such  results,  and  I  believe  the  danger  of  this  acci- 
dent has  been  overestimated ;  but  where  any  considerable  pulmonary  or  bron- 
chial lesion  exists  I  place  the  patient  in  the  hot-air  bath  ten  or  fifteen  minutes 
before  giving  the  pilocarpines  so  that  the  flow  of  blood  shall  be  predetermined 
toward  the  surface  of  the  body.  Three  very  desirable  results  follow  the  use 
of  pilocarpine  in  acute  nephritis :  namely,  the  reduction  of  arterial  tension, 
the  reduction  of  the  temperature,  and  the  free  elimination  of  urea  by  the  skin, 
as  shown  by  its  enormous  increase  over  the  normal  amount  in  the  perspiration 
(Bartholow).  In  cases  of  danger,  where  dropsical  effusions  threaten  the  heart 
or  lungs,  or  where  ursemic  symptoms  are  imminent,  or  where  progressive  coma 
indicates  transudation  into  the  intracranial  cavities,  the  hot-air  pilocarpine 
sweat  should  be  repeated  daily,  or  even  twice  in  the  twenty-four  hours,  until 
the  immediate  peril  is  averted.  Here  and  there  a  case  will  be  encountered  in 
which  the  hot-water  bath — placing  the  patient  in  the  bath-tub  with  the  water 
at  the  temperature  of  95°  to  105°  F. — will  answer  best,  because  both  the  dry 
air  and  steam  are  equally  repugnant.  "When  this  is  the  case,  by  all  means 
let  the  hot  bath  be  employed,  but  let  it  also  be  remembered  that  the  hot 
dry  air  is  therapeutically  the  most  efficient,  because  it  produces  the  most 
copious  diaphoresis ;  the  steam-bath  is  next  best,  while  the  hot-water  bath 
possesses  the  least  eliminative  power. 

It  would  be  a  waste  of  time  to  discuss  the  older  and  now  wellnigh  obsolete 
diaphoretics  in  view  of  the  certainty  which  follows  the  use  of  those  already 
mentioned. 

While  the  above  methods  of  treatment  are  being  pushed,  certain  internal 
remedies  may  be  used  as  adjuncts  for  the  purpose  of  lowering  temperature, 
lessening  arterial  tension,  calming  nervous  excitement,  and  unloading  the 
kidneys  of  the  products  of  exudation  and  waste.  These  various  indications 
may  be  met  by  such  remedies  as  aconite,  codeine,  or  the  bromides,  and  the 
potassic  salts,  especially  the  acetate  or  citrate,  or  the  acetate  of  sodium.  I  fre- 
quently prescribe  some  such  mixture  as  the  following : 

'Sf.   Tr.  aconit fsss. 

Codeine gi'-  ij- 

Potass,  citrat 3iij. 

Glycerin! f|ij. 

Aquae  cinnamom q.  s.  ad  fsviij. — M. 

Sig.  A  dessertspoonful  every  two  hours  in  half  a  glass  of  pure  water. 

This  formula  is  intended  for  a  child  of  seven  or  eight  years  of  age ;  of  course 
the  quantities  must  be  increased  or  diminished  according  to  age.     In  some 


1016  AMEEICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cases  it  will  be  found  that  the  codeine  provokes  nausea  ;  when  this  happens, 
sodium  bromide  or  potassium  bromide  may  be  substituted.  In  other  cases  the 
potassic  citrate  will  cause  gastric  eructations  or  troublesome  flatulency;  this  will 
call  for  the  use  of  potassic  acetate  or  sodium  acetate  in  its  place.  The  above 
formula  is  given  simply  as  a  suggestion ;  it  must  be  varied  so  as  to  suit  the 
indications  as  they  arise.  The  practitioner  should  first  have  a  clear  and  definite 
comprehension  of  what  he  wishes  to  accomplish  ;  then,  and  then  only,  can  he 
set  about  an  intelligent  adaptation  of  means  to  ends. 

If  the  foregoing  measures  are  promptly  and  vigorously  carried  out,  it  is  not 
probable  that  urasmic  convulsions  will  supervene  ;  but  if  they  do,  the  physician 
must  be  prepared  to  act,  as  it  were,  by  instinct.  He  must  act,  and  deliberate 
afterward.  Place  the  child  immediately  in  a  bath  at  the  temperature  of 
100°  F. :  administer  chloroform  by  pouring  10  to  20  drops  upon  a  napkin  and 
holding  it  very  nea)\  but  not  in  contact  ivitJi,  the  nose  until  the  spasms  are 
controlled ;  if  the  child  be  vigorous,  healthy,  and  plethoric,  apply  a  couple  of 
leeches  to  each  temple,  and  allow  the  bites  to  bleed  until  the  temporal  arteries 
soften  and  cease  throbbing  ;  administer  5  to  10  grains  of  sodium  bromide  every 
hour  till  its  effect  is  manifested ;  give  a  brisk  cathartic — and  I  know  none 
better  than  a  full  dose  (say  5  grains)  of  calomel ;  after  the  convulsions  cease 
remove  the  child  from  the  hot  bath  to  the  hot-air  tent  (as  before  described),  and 
administer  hypodermatically  |  grain  of  pilocarpine. 

It  will  be  of  very  little  use  to  administer  diuretics  at  this  time,  as  the 
kidneys  are  not  at  all  likely  to  respond  under  such  circumstances,  but  it  will 
be  entirely  in  order  to  administer  10  grains  of  the  acetate  or  citrate  of  potas- 
sium every  two  hours,  dissolved  in  a  liberal  quantity  of  water. 

It  will  generally  be  found,  however,  that  the  renal  congestion  will  be  so 
much  relieved  by  the  action  of  the  cathartic  and  diaphoretic  that  the  kidneys 
will  resume  their  functions  spontaneously.  For  several  days  after  a  urgemic 
convulsion,  or  until  the  kidneys  resume  their  action,  the  child  should  be  care- 
fully watched,  should  be  kept  in  bed.  and  given  a  milk  diet,  and  the  action  of 
the  diaphoi'etics  and  cathartics  should  be  kept  up  in  a  moderate  degree.  While 
umemic  convulsions  in  children  seem  frightfully  dangerous,  it  is  nevertheless 
true  that  in  most  cases  the  danger  is  more  apparent  than  real,  and  recoveries 
are  by  no  means  unusual. 

The  treatment  above  given  is  that  which  is  adapted  to  the  first  stage  of 
acute  nephritis  only.  It  is  now  incumbent  upon  us  to  consider  what  should  be 
done  after  the  violence  of  the  first  attack  is  past  and  convalescence  has  fairly 
commenced. 

The  problem  before  us  is  to  restore  to  their  structural  integrity  kidneys 
which  have  been  intensely  congested,  which  have  suffered  laceration  of  many 
of  their  minute  blood-vessels,  whose  glomeruli  and  tubules  have  been  invaded 
by  copious  fibrinous  exudation,  which  is  still  taking  place,  although  in  a  com- 
paratively slight  degree. 

In  all  cases  of  albuminuria  with  scantiness  of  urine  the  temptation  to 
administer  diuretics  is  very  great,  and  yet  in  the  great  majority  of  cases  no 
more  unwise  measure  could  be  adopted.  It  is  always  true  that  stimulating  or 
irritating  diuretics  should  be  carefully  avoided  unless  some  very  imperative 
demand  for  their  employment  exists.  In  fact,  diuretics  bear  the  same  relation 
to  inflammation  of  the  kidneys  that  cathartics  do  to  inflammation  of  the 
alimentary  canal.  A  mild  aperient  for  a  specific  purpose  may  be  proper  in  a 
case  of  enteritis  ;  so,  under  similar  conditions,  a  mild  diuretic  may  be  proper  in 
a  case  of  nephritis  :  but  in  neither  case  can  the  remedy  be  regarded  as  curative 
of  the  lesion.     In  nephritis,  as  we  have  seen,  the  renal  tubes  become  occluded 


ACUTE    TUBAL    NEPHBITIS.  '  1017 

by  fibrinous  casts,  and  experience  has  demonstrated  that  these  casts  are  solu- 
ble in  the  alkaline  salts  of  potassium.  It  is  therefore  advisable  to  administer 
10  grains  of  the  citrate  of  potassium,  dissolved  in  half  a  glass  of  water  or 
lemonade,  every  three  hours,  it  being  well  known  that  citric  acid  and  the 
citrates  are  converted  into  alkalies  after  ingestion.  If  there  be  any  serious 
indication  of  cardiac  exhaustion,  digitalis  may  be  combined  with  the  potassium, 
but  not  unless  it  is  clearly  indicated.  I  am  persuaded  that  the  indiscriminate 
and  ill-judged  use  of  digitalis  and  other  cardiac  tonics  is  productive  of  more 
harm  than  good.  It  should  be  remembered  that  digitalis  and  other  cardiac 
tonics  are  not  direct  but  indirect  diuretics,  acting  by  virtue  of  their  power  of 
increasing  arterial  tension.  But  the  potassic  salts  are  "direct"  diuretics;  that 
is,  they  actually  increase  elimination  of  the  factors  of  the  urine,  especially  urea, 
the  most  important  of  them  all.  Thus  they  subserve  two  useful  purposes  :  they 
remove  from  the  occluded  tubes  the  plugs  of  fibrin  and  other  material,  and  they 
rouse  the  dormant  epithelia  of  the  convoluted  tubes  into  action  without  unduly 
exciting  them.  The  vegetable  potassic  compounds,  more  particularly  the 
citrate  or  acetate,  may  very  properly  be  continued  in  medium  doses  until  the 
albumin  has  disappeared  from  the  urine. 

One  of  the  constant  results  of  nephritis  is  anaemia,  frequently  of  a  very 
pronounced  type.  This  is  due  to  loss  of  blood,  loss  of  albumin,  but  perhaps 
quite  as  much  to  the  body  waste  which  attends  pyrexia  and  the  cessation  of 
assimilating  power.  No  acute  disease  produces  such  rapid  and  extreme  anaemia 
as  acute  nephritis.  It  is  important  that  it  be  recognized  early,  before  the 
anfemic  or  "run-away"  heart  is  developed,  which  is  so  prone  to  result  in 
valvular  disease  and  a  life  of  suffering.  The  remedies  are  rest  in  the  recum- 
bent position,  appropriate  food  (of  which  I  shall  speak  presently),  and  the 
chalybeate  tonics.  Of  the  latter,  the  "mistura  ferri  et  ammonii  acetatis  " 
(otherwise  known  as  "Basham's  mixture")  or  the  ferri  et  potassii  tartras,  or 
the  ferrum  dialysatum  have  given  me  the  best  results,  and  I  have  mentioned 
them  in  the  order  of  their  comparative  value.  Basham's  mixture  is  an  elegant 
diuretic  tonic,  usually  very  well  borne  and  easily  assimilated.  It  can  be  given 
as  soon  as  the  temperature  falls  to  the  normal  point,  and  thus  the  practitioner 
can  anticipate  and  prevent  the  extreme  anaemia  so  sure  to  follow  if  the  case  be 
allowed  to  drift  on.  When  the  urine  is  scanty  and  the  sediment  abundant,  it 
is  an  excellent  plan  to  combine  equal  parts  of  a  saturated  solution  of  potassium 
citrate  with  Basham's  mixture,  of  which  a  teaspoonful  every  three  hours  may 
be  given  to  a  child  eight  years  old.     A  very  good  formula  is  the  following : 

I^.   Sol.  potassii  citratis  (sat.), 

Mist,  ferri  et  ammonii  acetatis  .    .    .    .     aa  f|j. 

Glycerini fgj. 

Aquae q.  s.  ad  f^iv. — M. 

Sig.  A  dessertspoonful  every  three  hours  in  water. 

I  am  much  in  the  habit  of  adding  glycerin  to  diuretic  formulae,  because 
it  seems  in  some  unexplained  manner  to  promote  their  action.  At  a  later 
period,  when  the  kidneys  no  longer  require  any  specific  medication  and  a 
stronger  tonic  is  desirable,  the  potassic  tartrate  of  iron  may  be  substituted  in 
doses  of  from  3  to  5  grains  three  times  a  day.  No  other  therapeutic  measures 
will  be  required  unless  special  complications  arise :  if  this  be  the  case,  they 
must  be  met  according  to  the  indications  in  each  particular  instance. 

The  diet  of  a  child  suffering  from  acute  nephritis,  or,  in  fact,  any  lesion 
inducing  renal  inadequacy,  is  of  the  utmost  importance.     Both  theory  and 


1018  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

experience  concur  in  the  necessity  for  excluding  a  nitrogenous  dietary.  In 
the  early  stage  of  acute  nephritis  all  solid  food  should  be  cut  off.  This  exclu- 
sion should  extend  also  to  broth,  beef-tea.  soups,  and  all  forms  of  liquid  diet  of 
which  beef  or  mutton  forms  the  basis.  The  ideal  food  is  milk,  and  during  the 
period  of  invasion  this  should  be  taken  sparingly.  Milk  and  water  (half  and 
half)  is  an  excellent  combination,  as  it  combines  nutrition  with  a  natural 
diuretic.  As  the  kidneys  regain  their  activity  and  fever  subsides  pure  milk 
mav  be  given,  toixether  with  bread,  oatmeal,  or  crackers.  A  little  fruit,  as  a 
baked  apple  or  the  juice  of  an  orange,  may  also  be  allowed,  but  the  diet  should 
be  increased  slowly  and  cautiously,  and  flesh  food  must  be  prohibited  until  the 
casts  and  albumin  have  been  absent  for  several  consecutive  weeks,  and  even 
then  it  should  be  given  only  in  small  quantities  once  a  day. 

A  few  general  suggestions  may  not  be  improper.  The  patient — be  he  child 
or  adult — should  not  be  discharged  as  "  cured,"  but  should  be  kept  under 
observation  long  after  all  signs  and  symptoms  of  trouble  have  disappeared.  If 
frequent  examinations  of  the  urine  are  kept  up.  as  they  should  be.  the  practi- 
tioner will  be  surprised  every  now  and  then  to  find  a  little  albumin  and  a  few 
small  structureless  hyaline  casts  appearing,  even  after  they  have  been  absent 
for  manv  weeks.  So  lono;  as  this  is  the  case  there  is  great  danger  of  a  sudden 
return  of  the  acute  symptoms  with  a  fatal  result,  or  of  the  supervention  of 
chronic  nephritis.  Avith  equally  sad.  although  less  sudden,  consequences.  It  is 
therefore  the  duty  of  the  physician  to  warn  parents  of  the  lurking  perils,  and 
to  exercise  a  personal  supervision  over  the  patient  until  health  is  fully  restored. 

Again,  muscular  exercise  is  dangerous  to  a  patient  recovering  from  acute 
nephritis,  because  it  strains  the  heart  and  loads  the  urine  Avith  nitrogenous 
products  of  disassimilation.  thus  throwing  work  upon  the  kidneys  which  they 
cannot  safely  do.  The  patient  should  therefore  be  kept  quiet  for  a  much 
longer  time  than  seems  necessary  to  parents  and  friends.  Lastly,  the  patient 
should  be  warmly  clad  and  carefully  guarded  from  exposure  to  wet  and  cold. 
Woollen  garments  and  confinement  within  doors  should  be  insisted  upon  until 
the  child's  symptoms  and  the  weather  give  concurrent  testimony  that  gentle 
exercise  in  the  open  air  may  be  cautiously  entered  upon.  To  some  these 
suggestions  may  seem  superfluous,  but  to  observe  them  will  do  no  harm,  while 
if  they  are  neglected  the  lives  of  helpless  children  may  pay  the  fearful  penalty. 

n.  Chronic  Tubal  Nephritis. 

Synonyms. — Chronic  diff"use  nephritis ;  Chronic  catarrhal  nephritis ; 
Chronic  croupous  nephritis;  Chronic  parenchymatous  nephritis ;  and  Chronic 
Bright's  disease. 

Etiolog-y. — Acute  nephritis  is  the  most  common  cause  of  chronic  nephritis 
in  children.  Scarlatina  stands  next  in  order  ;  then  comes  exposure  to  cold 
and  Avet,  especialW  when  combined  with  malarious  or  other  unhealthful  sur- 
roundings, as  is  so  frequent  among  the  children  of  the  neglected  poor.  Long- 
continued  suppuration,  although  more  likely  to  produce  amyloid  degenera- 
tion of  the  kidneys,  may  cause  chronic  tubal  nephritis,  probably,  as  Bartels 
suggests,  because  "  something  is  developed  in  these  collections  of  pus  which 
is  taken  up  into  the  blood  by  absorption  and  excreted  by  the  kidneys, 
and  which,  during  its  excretion,  excites  an  inflammation  of  these  excretory 
organs."  Xearly  twenty  years  have  elapsed  since  these  words  were  written, 
and  we  do  not  yet  know  what  that  "  something  "  is,  but  in  the  light  of  modern 
pathological  research  we  can  easily  understand  that  the  toxic  derivatives  of 
chronic  suppuration  might  easily  worry  the  kidneys  into  chronic  inflammation. 


CHRONIC   TUBAL   NEPHRITIS.  1019 

Diphtheria  must  certainly  be  regarded  as  a  cause  of  chronic  as  well  as  of 
acute  nephritis,  and  so  must  measles,  but  less  frequently.  Few  cases  of 
diabetes  mellitus  terminate  without  the  supervention  of  chronic  tubal  nephritis. 
Finally,  anything  Avhich  demands  constant  overwork  of  the  kidneys,  or  which 
results  in  a  slight  but  lon^-continued  irritation  of  them,  may  prove  the  ground- 
work of  chronic  tubal  nephritis. 

Symptoms. — The  symptoms  vary  very  much  in  diiferent  cases,  being 
modified  by  the  rapidity  Avith  which  the  disease  progresses.  When  the  progress 
is  rapid  the  symptoms  are  more  pronounced,  and  vice  versa.  In  a  typical  case 
of  chronic  tubal  nephritis  the  first  symptom  attracting  attention  is  likely  to  be 
great  debility  and  well-marked  anaemia.  The  pulse  is  small,  rapid,  and  feeble, 
and  ansemic  cardiac  murmurs  are  common.  There  will  probably  be  no  rise  of 
temperature,  or,  if  any,  very  slight  and  inconstant.  The  digestion  is  impaired, 
the  tongue  coated,  and  the  bowels  torpid  or  loose  and  irregular.  Following 
these  symptoms,  and  frequently  coincident  with  them,  is  dropsy,  generally  first 
manifested  on  the  dorsum  of  the  foot  and  around  the  ankle-joints,  or  perhaps 
it  is  first  seen  in  the  swollen  and  transparent  eyelid.  There  is  also  a  marked 
pallor  or  waxy  appearance  of  the  face,  which  is  quite  characteristic.  The 
dropsy  extends  up  the  loAver  extremities,  invades  the  abdomen,  may  reach  the 
chest  and  oppress  the  lungs  and  heart,  so  as  to  become  a  source  of  serious 
danger,  although  this  can  generally  be  avoided. 

The  disease  is  usually  divided  into  three  stages ;  this  division,  though  some- 
what arbitrary,  is  convenient.  During  the  first  stage  the  urine  is  generally 
scanty,  dark,  and  turbid ;  of  variable,  but  with  a  tendency  to  high,  specific 
gravity  (1020  to  1025),  and  heavily  loaded  with  albumin  (2  grams  or  more  to 
the  litre),  as  determined  by  Esbach's  "  albuminometer  " — the  best,  because  the 
simplest,  apparatus  yet  devised  for  the  practical  quantitative  estimation  of  albu- 
min. After  standing,  the  urine  deposits  an  abundant  precipitate  composed  of 
hyaline  and  epithelial  casts,  with  occasionally  a  blood-cast,  renal  epithelia,  and 
granular  matter  of  indeterminate  origin.  Chemical  examination  will  show  the 
percentage  of  urea  to  be  much  less  than  normal,  while  the  chlorides,  sulphates, 
and  phosphates,  though  diminished  somewhat,  are  nearer  the  normal  point. 

With  the  development  of  the  second  stage  the  urine  increases  in  quantity, 
but  becomes  pale  in  color,  sometimes  all  but  colorless,  of  low  specific  gravity 
(1005  to  1010),  less  turbid,  but  not  quite  clear,  and  the  sediment  diminishes 
very  much  in  quantity,  and  also  becomes  nearly  colorless.  But  the  quantity 
of  albumin  remains  large,  rarely  falling  below  1^  grams  to  the  litre,  and  the 
solid  excreta  are  still  markedly  deficient.  The  casts  also  change.  The  blood- 
casts  disappear  entirely  ;  the  hyaline  casts  increase  in  number,  and  many  of 
them  are  large  and  somewhat  distorted,  showing  that  they  are  formed  in  tubes 
which  have  shed  their  epithelium.  The  epithelial  casts  present  a  granular 
cloudy  appearance,  and  their  borders  are  eroded  or  "nibbled,"  showing  that 
fatty  change  has  commenced  in  the  epithelia  and  that  the  walls  of  the  tubes 
have  become  roughened  and  irregular.  As  the  disease  progresses  an  occasional 
wave  of  renal  hypersemia  may  occur,  when  the  urine  again  becomes  scanty, 
dark,  and  cloudy,  and  the  casts  characteristic  of  the  first  stage  reappear,  but 
intermingled  with  these  will  be  found  the  granular  casts  which  belong  to  the 
second  stage,  so  that  no  serious  confusion  as  to  the  diagnosis  need  occur. 

With  the  commencement  of  the  third  stage  the  urine  again  becomes  scanty 
and  cloudy,  but  is  still  pale  and  watery.  The  albumin  does  not  diminish,  but 
is  more  likely  to  increase.  The  casts  now  become  "fatty  ;  "  that  is,  they  are 
large,  short,  irregular,  with  rough  borders,  and  contain  fine  fatty  granules, 
minute  drops  of  fat,  and  epithelial  cells  in  an  advanced  state  of  fatty  degenera- 


imO  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tion.  During  this  stage  periods  of  partial  or  incomplete  suppression  of  urine 
are  apt  to  occur,  followed  by  uremic  convulsions,  succeeded  by  coma,  or  per- 
haps sudden  death  without  coma ;  or  drowsiness  may  gradually  steal  over  the 
patient,  until  it  becomes  coma  ending  in  death.  Meantime  the  dropsy  becomes 
general,  the  limbs  swell  almost  to  bursting,  the  abdomen  becomes  distended 
with  fluid,  the  thoracic  cavity  gradually  fills,  pulmonary  oedema  Avith  impeded 
respiration  occurs  ;  the  heart  labors  violently  until  it  suddenly  fails  from  ex- 
haustion, and  death  ensues.  It  must  not,  however,  be  inferred  that  all  cases 
present  these  distressing  symptoms.  In  the  majority  they  are  either  not  wit- 
nessed at  all  or  are  easily  anticipated  and  prevented. 

Diagnosis. — Chronic  tubal  nephritis  may  be  confounded  with  (a)  chronic 
interstitial  nephritis ;  {b)  amyloid  disease  of  the  kidney ;  {c)  cyanotic  indura- 
tion of  the  kidney. 

(a)  Chronic  interstitial  nephritis  is  very  rare  in  children,  but  it  is  not  diffi- 
cult to  differentiate  it  from  tubal  nephritis.  Chronic  interstitial  nephritis 
(renal  cirrhosis)  is  characterized  by  its  slow  and  insidious  development ;  by  the 
increased  volume  of  urine ;  by  its  low  specific  gravity  and  small  amount  of 
albumin ;  by  the  absence  of  dropsy,  except  in  the  last  stage ;  by  the  early  de- 
velopment of  cardio-vascular  tension  ;  and,  generally,  by  well-marked  lithfemia. 
None  of  these  symptoms  are  present  in  chronic  tubal  nephritis. 

(6)  Amyloid  disease  of  the  kidney  is  most  likely  to  occur  in  children,  and, 
as  it  sometimes  occurs  in  connection  with  tubal  nephritis,  a  certain  diagnosis 
may  be  impossible.  The  distinctive  features  of  amyloid  disease  are  an  increased 
quantity  of  urine  with  a  comparatively  large  amount  of  albumin  ;  absence  of 
leucocytes  and  epithelial  cells,  but  the  presence  of  numerous  small  hyaline 
casts  which  are  perfectly  structureless,  but  some  of  which  are  likely  to  give 
the  characteristic  reaction  with  iodine.  There  is  usually  considerable  disturb- 
ance of  the  digestive  tract,  with  hypertrophy  of  the  liver  and  spleen,  and  this 
disease  is  almost  always  caused  by  and  associated  with  syphilis,  tuberculosis,  or 
some  chronic  disease  involving  suppuration.  These  diagnostic  points  are  quite 
sufficient  to  distinguish  an  uncomplicated  case  of  chronic  tubal  nephritis  from 
an  uncomplicated  case  of  amyloid  disease. 

(r)  Cyanotic  induration  of  the  kidneys  only  occurs  where  there  is  some 
obstructive  lesion  of  the  organs  of  circulation  which  retards  the  movement  of 
blood  through  the  kidneys  and  produces  venous  stasis.  There  is  little  albumin 
in  the  urine;  the  casts  are  few,  generally  small,  and  of  the  hyaline  variety; 
dropsy  is  generally  limited  to  the  lower  extremities ;  respiration  is  difficult ; 
much  exercise  is  impossible ;  and  the  circulation  is  much  embarrassed.  None 
of  these  peculiar  features  belong  to  chronic  tubal  nephritis.  But  careful  atten- 
tion to  the  history  and  constructive  symptoms  of  tlie  latter  almost  invariably 
enables  the  practitioner  to  arrive  at  a  correct  diagnosis. 

Morbid  Anatomy. — In  a  given  case  the  morbid  appearances  will  depend 
entirely  upon  the  stage  at  which  the  examination  is  made.  I  shall  briefly  de- 
scribe the  macroscopic  and  microscopic  changes  Avhich  are  peculiar  to  each  of 
the  three  stages,  which  are  themselves  founded  upon  the  anatomical  changes  so 
uniformly  present. 

During  the  first  or  hyperaemic  stage  the  kidney  is  either  of  normal  size  or 
only  slightly  enlarged  ;  the  capsule  is  somewhat  cloudy,  but  strips  off"  easily, 
leaving  the  surface  of  the  kidney  smooth  and  red  or  purple.  On  section  blood 
oozes  from  the  cut  vessels,  and  the  cortex  is  seen  to  be  relatively  increased. 
The  vessels  in  the  "boundary  layer"  are  turgid  and  frequently  tortuous,  and 
the  vasa  recta  stand  out  as  well-defined  red  lines  running  toward  or  into  the 
apices  of  the  cones.     Between  the  straight  vessels  numerous  white  or  grayish 


CHRONIC   TUBAL    NEPHRITIS.  1021 

lines  will  be  seen ;  these  are  the  straight  tubes  occluded  and  distended  by 
casts  and  epithelia.  Microscopic  study  of  a  section  of  the  cortex  will  show 
that  the  blood-vessels  are  dilated  and  tortuous — that  the  convoluted  tubes  are 
stuifed  with  fibrinous  casts,  perhaps  blood-globules,  and  enlarged  epithelial 
cells,  some  of  which  are  in  a  state  of  "cloudy  swelling." 

The  second  or  hypertrophic  stage  results  in  considerable,  and  sometimes 
extreme,  enlargement  of  the  kidney ;  the  capsule  is  but  little  changed  and 
strips  off  easily,  leaving  the  surface  generally  smooth,  but  with  here  and  there 
a  slight  cicatrix-like  depression.  Its  color  is  variable  and  mottled,  showing 
pale  grayish  or  whitish  spots  or  islands  surrounded  by  interlacing  groups  of 
"stellate"  vessels,  which  are  beautifully  displayed.  The  pale  spaces  are  the  dis- 
tended fatty  convoluted  tubes  lying  near  the  surface.  On  laying  the  kidney 
open  longitudinally  it  will  be  seen  that  the  cortex  is  increased,  but  pale  or 
yellowish,  and  that  it  is  anaemic  rather  than  hypergemic.  The  Malpighian 
bodies  are  not  enlarged  and  prominent  as  in  the  stage  of  hypersemia.  The 
vessels  in  the  boundary-layer  are  thickened  and  enlarged,  but  not  distended 
with  blood.  The  cones  or  pyramids  have  undergone  no  essential  change. 
This  is  the  so-called  "large  white  kidney"  or  "large  fatty  kidney."  The 
microscope  shows  the  convoluted  tubes  distended  with  epithelia  in  an  advanced 
state  of  fatty  degeneration  ;  they  also  contain  granular  casts  and  fine  fatty 
granules  which  have  not  fused  into  drops.  The  Malpighian  bodies  are  some- 
what enlarged,  and  the  space  between  the  glomerulus  and  the  capsule  of 
Bowman  is  apt  to  be  occupied  by  exuviated  epithelial  cells  in  a  state  of  fatty 
transformation.  The  walls  of  the  blood-vessels  may  be  somewhat  thickened, 
but  not  markedly  so.  It  will  be  seen  that  the  "  hypertrophy  "  is  more  apparent 
than  real,  and  that  it  is  mainly  due  to  the  distention  of  the  tubuli  contorti,  each 
one  of  which  occupies  far  more  space  than  it  does  normally.  The  connective 
tissue  is  not  materially  increased. 

The  third  or  last  stage  is  very  appropriately  known  as  the  stage  of 
"atrophy."  The  kidney  is  small,  shrivelled,  mottled,  but  the  predominant 
color  is  gray  or  grayish  yellow.  It  is  never  red.  The  capsule  is  generally 
slightly  thickened,  but  strips  off  easily,  except  that  here  and  there  it  may 
bring  a  small  bit  of  the  kidney  with  it.  The  surface  of  the  organ  is  no  longer 
smooth,  but  broken  by  alternating  elevations  and  depressions.  On  section  it 
is  seen  that  the  cortex  is  wasted  or  atrophied,  while  the  medullary  portion  is 
not  materially  changed.  The  cut  surface  is  frequently  oily  to  the  touch,  and  if 
it  be  scraped  with  a  scalpel,  drops  of  oil  will  appear  upon  the  blade.  Microscopic 
sections  show  many  of  the  tubules  shrivelled  and  wasted — many  others  dis- 
tended with  fatty  casts,  free  fat-drops,  and  epithelial  cells  in  complete  fatty 
degeneration.  The  walls  of  the  blood-vessels  are  much  thickened,  and  the 
connective  tissue  is  somewhat  increased,  but  has  not  entered  upon  the  con- 
tractile process  which  produces  cirrhosis.  It  should  also  be  observed  that  the 
kidney  is  pale  throughout  its  entire  extent,  which  fact  differentiates  it  from  the 
"cirrhotic  kidney,"  to  be  considered  presently. 

Prognosis. — During  the  first  or  inflammatory  stage  recoveries  are  common. 
They  ought  to  be  more  so.  An  early  and  correct  diagnosis  and  an  appropriate 
line  of  treatment,  administered  with  some  faith  in  its  efficacy,  are  indispensable 
to  the  successful  treatment  of  chronic  nephritis.  Unfortunately,  the  impression 
is  quite  too  general  among  the  profession  that  chronic  Bright's  disease  is  always 
incurable,  and  impressions  ingrained  for  years  are  apt  to  become  dogmas. 
Nevertheless,  chronic  tubal  nephritis,  at  any  time  up  to  the  actual  develop- 
ment of  the  second  or  degenerative  stage,  is  a  curable  disease,  and  especiall^y 
so  in  children,  in  whom  the  constructive  forces  are  at  their  best. 


1022  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

After  the  development  of  the  second  stage,  or  that  of  pseudo-hypertrophy, 
the  prognosis  is  far  less  favorable,  yet  not  absolutely  hopeless.  I  have  seen 
recoveries  take  place  when  all  the  symptoms  indicated  the  inception  of  fatty 
changes  in  the  kidney.  Each  day's  delay  renders  the  prognosis  less  hopeful, 
and  as  the  hyaline  casts  diminish  and  the  fatty  casts  increase  in  numbers  the 
prognosis  increases  in  gravity. 

With  the  development  of  the  third  stage,  or  that  of  atrophic  wasting,  all 
hope  of  recovery  ends.  As  functional  organs  the  kidneys  are  now  practically 
destroyed.  Disti*essing  symptoms  may  be  relieved  and  life  may  be  prolonged, 
but  that  is  all.  Yet  the  physician  must  be  sure  of  his  diagnosis  before  he 
abandons  hope,  and  in  the  practice  of  medicine  it  is  far  better  to  err  on  the 
optimistic  than  on  the  pessimistic  side.  The  disappearance  of  hyaline  casts  or 
their  very  infrequent  appearance,  the  prevalence  of  large  irregular  fiitty  casts, 
which  are  short,  broken,  and  loaded  with  fatty  epithelium  and  fat-drops, 
together  with  progressive  diminution  in  quantity  of  the  urine,  are  the  most 
reliable  diagnostic  factors. 

Treatment. — The  treatment  of  every  case  of  chronic  nephritis  should  stand 
by  itself,  and  should  be  carried  out  in  accordance  with  a  Avell-digested  plan 
founded  upon  an  accurate  determination  of  the  stage  of  the  disease. 

During  the  first  stage,  where  the  condition  of  the  kidneys  is  something 
similar  to  that  in  acute  nephritis,  the  chief  object  is  to  place  the  inflamed 
organs  at  rest."  The  patient  should  therefore  be  kept  as  quiet  as  possible  and 
carefully  guarded  from  exposure  to  cold.  The  bowels  should  be  kept  freely 
open  by  means  of  saline  cathartics.  The  skin  must  be  actively  stimulated  and 
made  to  do  vicarious  duty  by  means  of  hot  air  and  pilocarpine.  The  kidneys 
should  be  relieved  of  tube-casts  and  other  obstructive  material  by  the  use  of 
the  potash  salts,  much  as  indicated  in  the  article  on  Acute  Tubal  Nephritis. 
In  fact,  the  general  indications  are  practically  the  same,  and  the  same  measures 
should  be  employed,  only  less  vigorously.  The  diet  should  be  the  same — 
namely,  milk  in  some  form  with  a  little  fruit — and  the  patient  should  be  urged 
or  tempted  to  drink  water  freely.  A  little  fish,  a  bit  of  broiled  quail,  or  a 
chicken's  wing  may  occasionally  be  allowed  for  the  purpose  of  varying  the 
monotony,  but  grills  and  roasts  must  be  forbidden.  The  child  should  be  kept 
warm  and  the  inner  garments  should  be  of  wool.  I  particularly  insist  on 
woollen  stockings — a  point  that  will  surely  be  neglected  by  mothers  and  nurses 
unless  insisted  upon  by  the  medical  adviser.  As  the  case  progresses  toward 
recovery  chalybeate  tonics  are  indicated,  and  I  advise  the  employment  of  those 
already  mentioned  in  the  article  on  Acute  Nephritis,  to  which  reference  may 
be  had  for  details. 

During  convalescence  the  patient  should  be  carefully  watched,  and  it  must 
not  be  forgotten  that  convalescence  is  not  perfect  recovery.  Albuminuria  will 
disappear  slowly,  and  will  reappear  after  long  intervals  of  absence,  thus  show- 
ing that  the  renal  vessels  have  not  yet  recovered  their  tonus ;  the  heart  will 
remain  irritable  and  weak  for  a  long  period  ;  and  the  haemogenetic  power  of 
the  little  patient  Avill  be  recovered  slowly.  Hence  careful  but  not  ostentatious 
or  over-officious  watching  will  be  required  for  several  months  after  all  symp- 
toms have  disappeared. 

When  the  disease  becomes  chronic,  as  indicated  by  the  symptoms  denoting 
"fatty  kidney,"  the  treatment  will  be  somewhat  different.  The  kidneys  must 
now  be  relieved  as  much  as  possible  by  bringing  the  skin  and  intestinal  tract 
into  play.  Minute  doses  of  pilocarpine — ^-^  of  a  grain  for  a  child  of  six  or 
eight  years — may  be  given  four  times  a  day.  A  warm  salt-and-water  bath 
three  times  a  week,  followed  by  smart  friction,  is  a  very  useful  adjunct  to  the 


CHRONIC   TUBAL   NEPHRITIS.  1023 

pilocarpine,  the  bath  of  course  being  given  in  a  warm  room.  If  the  skin  is 
rough  and  dry,  it  is  a  very  good  plan  to  rub  the  child  with  fresh  and  well- 
warmed  olive  or  sweet  almond  oil  after  each  salt  bath.  These  measures  may 
be  continued  indefinitely. 

Cathartics  must  be  employed  frequently,  but  wisely.  Violent  catharsis  is 
rarely  required ;  gentle  stimulation  of  the  bowels  is  frequently  needed,  and  is 
very  useful,  both  for  its  derivative  and  its  eliminant  effect.  The  saline  cathar- 
tics are  most  useful,  but  an  occasional  cholagogue,  like  the  following,  will  not 
be  amiss : 

I^.   Resin,  podophylli g'"-  j* 

Hydrarg,  chlorid.  mit gr.  x. 

Sodii  bicarbonatis gr.  xxx. — M. 

Ft.  chart.  No.  X. 
Sig.  One  powder  to  be  given  every  third  night. 

Diuretics  should  be  used  sparingl}?,  and  not  with  any  expectation  of  "  cura- 
tive results."  The  acetate  or  citrate  of  potassium,  and  the  bitartrate  in  the 
form  of  "  imperial  drink  "  [U.  S.  P.],  are  the  safest  and  most  efficient.  They 
should  be  given  freely  diluted.  Cardiac  tonics  will  doubtless  be  required  as 
the  case  progresses,  but  they  should  be  reserved  until  they  are  actually  needed, 
as  their  premature  employment  exhausts  the  heart-muscle  unnecessarily.  Of 
the  various  heart  tonics,  digitalis  and  strophanthus  are  the  most  reliable.  The 
chalybeate  tonics  will  be  indicated,  and  the  mixture  of  the  acetate  of  iron  and 
ammonia,  the  potassio-tartrate  of  iron,  and  the  newer  preparation  called  "  fer- 
rum  dialysatum,"  have  my  preference  in  the  order  Avritten.  Special  symptoms 
will  require  attention.  Dropsy,  if  excessive,  demands  active  diuretics,  as 
squill,  apocynum  cannabinum,  or  that  excellent  preparation,  "  Trousseau's 
diuretic  wine,"  which  consists  of — 

Junip.  contus.,  gx  ;  Pulv.  digitalis,  3ij  ;  Pulv.  scillse,  5J  ;  Vini  Xerici,  Oj  ; 
macerate  for  four  days,  and  add  potass,  acetatis,  ^iij  ;  express  and  filter.  Dose, 
one  teaspoonful  in  water  every  three  hours  for  a  child  of  six  or  eight  years, 
(Tyson's  BrigMs  Disease  and  Diabetes). 

Hydragogue  cathartics  and  active  diaphoresis  must  be  employed  in  con- 
junction with  the  diuretics  ;  among  the  former,  calomel  and  jalap,  concen- 
trated solutions  of  salines,  and  elaterium  are  the  best,  in  about  one-third 
the  dose  of  an  adult  for  a  child  from  six  to  eight  years  old.  As  to  diapho- 
retics, the  hot-air  apparatus  (see  page  1014),  with  pilocarpine,  stands  first 
always  ;  but  the  hot  bath  or  warm  pack,  aided  by  pilocarpine,  may  be  employed 
for  the  want  of  something  better.  It  may  be  found  necessary  to  make  minute 
punctures  through  the  skin  of  the  ankle  or  dorsum  of  the  foot,  so  that  the 
dropsical  fluid  may  drain  away.  I  prefer  the  point  of  a  sharp  tenotomy  blade 
for  this  purpose.  If  urgemic  symptoms  appear,  they  must  be  treated  as  already 
indicated.  Uraemic  asthma  is  likely  to  arise ;  it  may  be  temporarily  relieved 
by  nitrite  of  amyl,  spirits  of  chloroform,  elixir  of  valerianate  of  ammonium,  or 
any  other  antispasmodic  at  hand,  but  it  is  a  consequence  of  uraemia  and  calls 
for  increased  elimination.  Insomnia  may  be  relieved  by  sulphonal,  chloral, 
somnal,  or  any  of  the  newer  hypnotics.  1  am  accustomed  to  giving  paregoric 
to  children  with  chronic  Bright's  disease  who  are  kept  awake  by  distressing 
symptoms,  and  with  the  happiest  effects,  although  the  practice  is  not  in  strict 
accordance  with  therapeutic  orthodoxy. 


1024  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

m.  Amyloid  Disease  op  the  Kidney. 

Synonyms. — Waxy  kidney  ;  Lardaceous  disease  ;  Depurative  disease. 

Etiolog-y. — The  most  common  causes  of  amyloid  kidney  are  syphilis ; 
exhaustive  and  long-continued  suppuration,  especially  if  associated  with  necro- 
sis of  the  vertebnie,  as  in  Pott's  disease,  or  of  disease  of  the  large  joints,  as  in 
coxalgia ;  phthisis  pulmonalis ;  chronic  ulcerative  disease  of  the  bowels ;  and 
chronic  albuminuria.  As  some  of  these  aifections  are  not  uncommon  in 
children,  it  follows  that  they  are  liable  to  amyloid  disease  of  the  kidney. 
The  most  perfect  or  complete  specimen  that  I  have  ever  seen  occurred  in  a 
girl  of  ten  years,  who  was  fairly  worn  out  with  repeated  abscesses  due  to 
Pott's  disease.  Amyloid  disease  rarely  occurs  in  a  child  under  five  years,  for 
the  reason  that  the  above-named  causes  rarely  exist  prior  to  that  age ;  yet 
Dickinson  cites  a  case  of  amyloid  spleen  in  a  boy  two  and  a  half  years  old  who 
had  an  exhausting  abscess  of  the  thigh. 

Pathological  Anatomy. — In  the  early  stage  the  kidneys  are  about 
normal  in  size  and  present  little  change  except  to  the  experienced  observer, 
who  will  note  a  peculiar  paleness,  together  with  a  translucent  appearance,  when 
thin  sections  are  held  between  the  eye  and  a  strong  light.  The  capsule  is  non- 
adherent. When  the  kidney  is  laid  open  no  essential  change  in  the  relative 
proportion  of  cortex  and  medulla  is  seen,  but  all  parts  appear  pale  and  com- 
paratively bloodless.  If  a  few  drops  of  an  iodine  test-solution  be  applied,  mul- 
titudes of  mahogany  red  or  reddish-brown  points  will  appear,  thus  locating  the 
infiltrated  Malpighian  bodies. 

At  a  more  advanced  stage  the  kidneys  are  enlarged,  sometimes  consider- 
ably, though  not  to  an  extreme  degree,  unless  amyloid  disease  and  chronic 
tubal  nephritis  coexist.  Tiie  pale  waxy  or  bacony  appearance  will  now  be 
very  apparent,  and  the  iodine  reaction  will  extend  to  the  convoluted  tubes,  the 
vessels  of  the  labyrinth,  and  the  vasa  recta. 

In  the  last  stage  the  kidney  is  atrophied,  contracted,  and  deformed.  The 
capsule  is  thickened  and  adherent,  the  cortex  is  wasted,  and  one  is  reminded 
of  the  cirrhotic  kidney,  except  that  the  latter  is  red  or  brownish  red,  while  the 
one  under  discussion  still  preserves  its  pale  waxy  appearance.  Microscopic 
sections  show  the  glomeruli,  the  capillaries  of  the  labyrinth,  the  vasa  recta,  and 
most  of  the  tubules  infiltrated  with  the  characteristic  waxy  material.  The 
application  of  the  iodine  test-solution  ^  enables  the  observer  to  accurately  differ- 
entiate the  infiltrated  from  the  normal  structure. 

Prognosis. — As  a  clinical  fact,  amyloid  disease  is  incurable.  In  a  given 
case,  if  the  cause  can  be  effectually  and  permanently  removed  before  the  kid- 
neys are  damaged  beyond  the  power  of  carrying  on  their  functions,  life  may  be 
prolonged  indefinitely.  Moreover,  if  the  patient  be  a  child  of  six  or  eight 
years,  subsequent  growth  and  development  may  practically  restore  the  structure 
and  function  of  the  diseased  organs.  So  much  for  theory.  In  practice  we 
generally  find  that  the  cause  cannot  be  removed ;  that  the  liver  is  almost  sure 
to  be  infiltrated  with  amyloid  deposit  to  quite  as  great  an  extent  as  the  kidneys ; 
and  that  in  most  cases  the  spleen  suffers  as  well.  In  other  words,  we  are  taught 
that,  under  certain  conditions,  amyloid  disease  is  curable,  but  in  practice  these 
fortunate  conditions  are  hardly  ever  met  with :  hence  the  disease  is  scarcely 
ever  cured. 

'  I  recommend  the  following  formula: 

R .  lodi  .       .  gi".  iij. 

Potassii  iodidi gr-  '*'.)• 

Glycerini f2j. 

Aquae  dest ad  f^j. — M. 


CHRONIC  INTERSTITIAL    NEPHRITIS.  1025 

Treatment. — Obviously  the  most  important  thing  is  the  discovery  and 
removal  of  the  cause.  As  I  have  already  said,  if  this  can  be  accomplished,  the 
progress  of  the  disease  may  be  arrested  and  the  patient  may  live  out  his  days.  In 
clinical  experience  this  can  rarely  be  done.  The  next  best  thing  is  to  reduce 
suppuration  to  the  minimum,  and  secure  free  drainage  and  asepsis  for  sup- 
purating cavities  ;  to  remove  dead  bone  if  it  exists,  and  encourage  the  process 
of  repair  if  possible ;  to  adopt  the  most  approved  treatment  for  tuberculosis  if 
present,  including  change  of  climate  Avhen  it  is  necessary  and  practicable ;  to 
institute  antisyphilitic  treatment  when  indicated  ;  and,  in  fine,  to  search  out  and 
remove  the  cause  if  possible.  We  possess  no  specific  agents  for  the  cure  of  amy- 
loid disease.  The  iodides — especially  of  iron  and  potassium — have  been  highly 
recommended  and  much  employed,  but  I  have  never  seen  any  positive  results 
follow  their  use.  Theoretically,  I  should  expect  more  from  arsenic  or  the  chlo- 
ride of  gold  and  sodium.  Diuretics  must  be  given  if  symptoms  of  suppression 
show  themselves.  Diarrhoea,  which  is  likely  to  be  troublesome,  must  be  treated 
on  general  principles.  Anaemia — always  pronounced  in  amyloid  disease — should 
be  combated  by  iron,  malt,  cod-liver  oil,  arsenic,  and  especially  by  a  liberal 
diet,  which  may  be  safely  given  unless  nephritis  should  complicate  matters.  If 
dropsy  becomes  troublesome,  the  diaphoretics,  diuretics,  and  cathartics  already 
recommended  will  answer  every  purpose.  Uraemia  is  not  likely  to  occur,  as 
the  functional  power  of  the  kidney  is  destroyed  so  slowly  that  the  system 
acquires  "toleration;"  but  if  it  occurs  it  must  be  treated  promptly  and 
vigorously  as  already  indicated.  If  nephritis  arises,  it  will  require  the  prompt 
employment  of  the  measures  recommended  in  a  previous  article ;  it  is  of  course 
a  dangerous  complication  and  one  of  not  very  infrequent  occurrence.  Other 
complications  may  arise,  just  as  they  may  in  the  course  of  any  other  chronic 
disease,  and  must  be  met  and  treated  according  to  the  indications  presented 
in  each  individual  case  ;  but  the  physician  should  remember  that  the  elim- 
inating power  of  the  kidneys  is  more  or  less  damaged,  and  he  must  exercise 
due  care  in  the  use  of  certain  drugs,  like  digitalis,  which  have  a  cumulative 
tendency. 

IV.  Chronic  Interstitial  Nephritis. 

Synonyms. — Renal  cirrhosis  ;  Gouty  kidney  ;  Granular  degeneration ; 
Contracted  kidney ;  Renal  sclerosis,  etc. 

Btiolog-y. — Among  the  most  frequent  causes  of  interstitial  nephritis  are 
rheumatism  and  gout  (more  correctly  called  lithaemia),  alcoholism,  lead-poison- 
ing, valvular  disease  of  the  heart,  malaria,  mental  strain,  heredity,  and  chronic 
lesions  of  the  genito-urinary  tract.  As  these  causes  are  hardly  ever  active  in 
childhood,  it  follow^s  that  cirrhotic  kidney  is  exceedingly  rare  under  puberty. 
All  authors'  to  whose  writings  I  have  access  agree  that  it  is  not  a  disease  of 
childhood.  I  have  never  seen  a  case  in  a  patient  under  thirty.  Bartels 
records  one  case  at  eighteen  years,  and  Dickinson  one  "between  eleven  and 
twenty  years."  Suppurative  interstitial  nephritis,  pyelo-nephritis,  or  "  surgical 
kidney,"  may  occur  in  children,  but  it  does  not  fall  within  the  scope  of  this 
work.  It  is  of  course  possible  that  heredity  or  cardiac  disease  may  cause  con- 
tracted kidney  in  childhood,  but  in  clinical  experience  we  rarely  meet  with  such 
cases. 

Symptoms. — The  following  are  the  four  classic  symptoms  of  interstitial 
nephritis,  and  I  may  mention  them  in  the  order  of  their  occurrence  :  (1)  increased 
arterial  tension,  with  a  sharply  accentuated  second  sound  of  the  heart :  the 
increased  arterial  tension  is  easily  recognized  by  examining  the  pulse ;  (2)  the 

65 


1026  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

small  amount  of  albumin  present  (rarely  more  than  1  to  2  per  cent,  by  volume) 
or  its  entire  absence  for  considerable  periods  of  time  ;  (3)  the  small  number  of 
casts,  their  small  size  and  structureless  or  hyaline  appearance,  and  their  form, 
•which  is  in  many  instances  twisted  or  distorted;  (4)  the  appearance  of  albumin- 
uric retinitis,  which  is  a  late  and  very  characteristic  symptom. 

These  four  symptoms  are  so  nearly  always  present  in  interstitial  nephritis, 
and  so  uniformly  absent  in  other  forms  of  renal  disease,  that  they  may  be 
regarded  as  pathognomonic.  Early  in  this  disease  the  urine  is  pale  and  watery, 
increased  in  quantity,  and  of  low  specific  gravity  (1005  to  1010). 

Pathological  Anatomy. — Chronic  interstitial  nephritis  results  in  the  pro- 
duction of  the  •'  small  red.  "  ''  contracted,"  or  "  cirrhotic"  kidney.  The  kid- 
neys are  contracted,  atrophied,  rough  or  nodulated,  and  dark  red  or  brownish 
red.  The  capsule  is  thickened,  and  when  pulled  off  tears  away  portions  of  the 
kidney  with  it.  On  section  it  is  observed  that  the  cortex  is  very  much  wasted, 
and  the  medulla  somewhat  so.  The  arteries  are  enlarged,  tortuous,  prominent, 
and  unyielding  or  inelastic.  The  organ  is  indurated  and  condensed.  Micro- 
scopic sections  show  a  great  increase  of  the  connective  tissue,  with  wasting  and 
distortion  of  the  tubules  and  the  smaller  blood-vessels.  Broad  bands  of  con- 
nective tissue  will  be  seen  between  the  remaining  tubules  and  surrounding  the 
Malpighian  bodies.  Many  minute  cysts  will  be  seen  which  are  due  to  dilata- 
tions of  the  tubuli  mainly,  but  partly  to  dilated  Malpighian  bodies. 

Prognosis. — Chronic  interstitial  nephritis  is  incurable.  The  damage  done 
by  overgrowth  of  connective  tissue  cannot  be  repaired.  Yet  it  is  quite  pos- 
sible to  arrest  the  further  increase  thereof,  and  thus  practically  arrest  the 
disease  and  prolong  life  indefinitely.  Much  depends  upon  the  patients  habits, 
environment,  temperament,  age,  and  social  condition.  Under  favorable  cir- 
cumstances so  much  can  be  accomplished  that,  so  far  as  the  patient  is  concerned, 
a  practical  cure  may  be  expected.  But  the  physician  must  not  forget  the 
inveterate  tendency  of  connective  tissue  toward  mischief  when  once  aroused, 
and  he  must  regard  the  disease,  although  latent,  as  still  present  and  ready  tp 
break  forth  at  any  unusual  provocation. 

Treatment. — I  reaffirm  and  refer  to  all  that  I  have  said  in  the  forecroinor 
pages  regarding  habits,  dress,  exercise,  and  food  and  drink,  except  that  the 
dietary  may  include  a  little  fish  or  fowl  or  a  small  allowance  of  almost  any 
kind  of  game  once  a  day.  Medical  treatment  should  be  directed  to  the  arrest 
of  the  further  development  of  pathological  connective  tissue  in  the  kidney. 
For  this  purpose  the  remedies  most  efficient  in  my  experience  are  bichloride 
of  mercury,  iodide  of  potassium,  and  chloride  of  gold  and  sodium,  in  small 
doses  long  continued.  I  use  but  one  of  these  remedies  at  a  time,  but  alter- 
nate them  at  intervals  of  two  or  three  weeks.  If  the  kidneys  falter,  diure- 
tics are  indicated,  and  I  have  found  the  lactate  of  strontium  a  prompt  and 
efficient  diuretic  in  this  form  of  Brights  disease.  It  may  be  given*  in  doses  of 
5  grains  three  times  a  day  to  patients  from  six  to  eight  years  old.  Diure- 
tine  sometimes  answers  very  well,  but  is  quite  likely  to  fail  altogether.  Of 
course  the  potash  salts  may  be  given  with  every  expectation  of  good  results. 
Chalybeate  tonics  are  indicated  in  most  cases,  and  the  tincture  of  the  chloride 
of  iron  is  particularly  adapted  to  our  wanrs.  If  combined  with  syrup  of 
lemon  (I^i.  Tr.  ferri  chloridi,  f^j  ;  syr.  limonis,  adfgij. — M.)  it  makes  a  very 
palatable  mixture,  and  Avill  be  readily  taken  by  children.  Heart  failure, 
uraemia,  and  other  complicating  symptoms  must  be  met  and  treated  as  already 
indicated  in  the  foregoing  articles. 


TUMORS  AND  OTHER  ENLARGEMENTS  OF  THE 

KIDNEY. 


By  THOMAS  R.  NEILSON,  M.  D., 
Philadelphia. 


Tumors  of  the  kidney  are  met  with  in  infancy  and  childhood  with  suiB- 
cient  frequency  to  make  the  subject  one  of  great  importance  from  a  clinical 
point  of  view.  In  the  allotted  space  the  different  varieties  of  these  tumors,  or 
those  diseases  of  the  kidney  which  may  constitute  tumor,  will  of  necessity  be 
considered  somewhat  briefly.  But,  while  no  extended  discussion  of  the  subject 
can  be  attempted,  the  effort  will  be  made  to  present  as  compactly  as  possible 
the  essential  facts. 

In  addition  to  solid  growths — neoplasms — certain  other  affections,  cysts, 
hydronephrosis,  pyonephrosis,  and  perinephritic  abscess,  may  give  rise  to 
enlargement  in  the  renal  region.     These  will  be  first  taken  up. 

Renal  Cysts. 

Congenital  Cystic  Degeneration  of  the  Kidney. 

This  condition  may  cause  tumors  of  considerable  dimensions.  It  sometimes 
results  in  destroying  the  life  of  the  foetus  or  in  premature  birth,  and  so  great 
may  be  the  size  of  the  tumor  that  delivery  is  impossible  and  embryotomy  is 
required.  In  less-marked  cases  the  child  may  live  a  few  months  or  even  a 
year  or  two,  and  may  not  give  evidence  of  the  affection  by  the  presence  of 
tumor,  but  sooner  or  later  is  likely  to  perish  either  from  uraemia  or  from 
exhaustion.  In  this  disease  the  kidney  is  studded  with  or  changed  into  a  con- 
glomeration of  cysts  of  varying  sizes,  filled  with  a  fluid  usually  clear,  but 
sometimes  turbid,  and  containing  urea  and  urinary  salts.  Both  kidneys  are, 
as  a  rule,  affected. 

The  condition  is  generally  accompanied  by  defects  of  development  of  the 
urinary  apparatus,  such  as  absence  of  the  pelvis  of  the  kidney  or  the  ureter, 
exstrophy  of  the  bladder,  and  malformations  of  the  genitalia,  as  well  as  vices 
of  comformation  of  the  extremities,  hare-lip,  cleft  palate,  etc.  The  origin 
of  tlie  affection  has  been  explained  by  Virchow  as  due  to  an  imperforate  con- 
dition of  the  straight  tubes  of  the  papillae,  resulting  from  a  prenatal  inflam- 
mation caused  by  impaction  of  the  ducts  with  uric  acid  and  the  urates,  and 
leading  to  retention  of  secreted  urine  and  dilatation  of  the  uriniferous  tubules. 
Another  view  of  the  etiology  has  been  taken  by  Koster,  who  considers  the 
condition  to  be  due  to  defective  development.  The  accompanying  abnormalities 
of  the  urinary  organs,  as  well  as  of  other  parts  of  the  body,  would  seem  to  favor 
this  theory,  at  least  in  some  cases. 

Cystic   degeneration  is   not  likely  to   call  for  surgical  treatment.     Even 

1027 


1028  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

though  there  should  be  marked  symptoms  caused  by  the  dimensions  of  the 
tumor,  the  strong  probability  of  both  kidneys  being  affected  and  the  fatal  tend- 
ency of  the  disease  would  interdict  any  radical  interference,  and  even  aspira- 
tion could  offer  but  slight  temporary  relief,  if  any  at  all. 

Paranephric  Cyst. 

Another  variety  of  renal  cysts  which  may  be  met  with  in  children  is  one 
which  grows  in  the  cellulo-adipose  tissue  surrounding  the  kidney,  the  cyst  not 
being  primai'ily  connected  with  the  kidney.  Morris,  in  his  work  on  Surgical 
Diseases  of  the  Kidney,  mentions  an  interesting  case  of  this  kind  reported  by 
Mr.  Caesar  Hawkins,  observed  in  a  boy  six  years  old.  In  this  instance  the 
cyst  developed  from  an  imperfect  third  kidney,  and  reached  great  proportions, 
extending  from  the  low^er  border  of  the  thorax  to  Poupart's  ligament.  The 
cyst  seemed  to  be  like  the  simple  renal  cysts  met  with  in  adults,  and  was  filled 
wdth  a  clear  fluid  which  contained  neither  albumin  nor  urinary  salts. 

Paranephric  cysts  may  be  of  congenital  origin,  as  in  the  case  just  referred 
to,  and  sometimes  they  may  be  due  to  traumatism.  They  may  communicate 
secondarily,  by  a  fistulous  tract,  with  the  pelvis  of  the  kidney  or  the  ureter. 
The  diagnosis  of  the  tumor  from  other  forms  of  renal  cyst  and  from  hydrone- 
phrosis must  be  difficult,  if  not  sometimes  impossible. 

Treatment. — These  cysts  should  be  evacuated  with  the  aspirator,  and  the 
procedure  repeated  if  the  fluid  should  reaccumulate.  If,  after  this  has  been 
tried,  the  cyst  should  rapidly  fill  up  again,  it  Avould  be  better  to  cut  down  upon 
it  and  incise  it,  securing  it  to  the  margins  of  the  wound  in  the  integument, 
thus  maintaining  drainage. 

Hydatid  Cysts  of  the  Kidney. 

The  ova  of  the  taenia  echinococcus,  a  diminutive  species  of  tapeworm 
infesting  some  of  the  lower  animals,  notably  dogs,  sheep,  and  swine,  are  some- 
times transmitted  to  man  in  food  and  drinking  water,  and  give  rise  to  what  are 
known  as  hydatid  cysts.  In  the  kidney  hydatids  are  not  so  frequent  as  in  the 
liver,  the  statistics  of  Davaine,  quoted  by  Roberts,  showing  the  proportion  to 
be  1  to  about  5|. 

Pathology  and  Ssnnptoms. — Hydatid  of  the  kidney  may  be  met  with  at 
any  age,  although  less  often  in  children  than  in  adults,  and  is  unilateral, 
involving  the  left  oftener  than  the  right  kidney.  Palpable  tumor  is  produced 
in  somewhat  less  than  one-half  of  the  cases.  The  cyst,  surrounded  by  a  capsule 
of  fibrous  tissue  and  having  in  its  interior  the  characteristic  daughter  cysts, 
usually  develops  in  the  parenchyma  of  the  kidney,  but  sometimes  between  the 
organ  and  its  capsule,  and,  as  it  grows,  encroaches  on  the  kidney  tissue,  causing 
more  or  less  atrophy.  Sometimes  several  hydatids  are  found  in  the  same  kid- 
ney. These  cysts  tend  to  rupture  and  discharge  their  contents,  and  this  may 
take  place  into  the  pelvis  of  the  kidney,  which  is  the  usual  place,  into  the 
intestine,  or  into  the  lung.  The  peritoneum  is  generally  pushed  forward  by  the 
tumor,  and  rupture  into  its  cavity  never  occurs. 

Unless  the  cyst  has  attained  proportions  sufficient  to  constitute  a  tumor,  or 
unless  it  should  rupture  and  discharge  its  contents  in  the  urine,  there  may  be 
no  evidence  of  its  presence.  The  tumor  generally  occupies  the  loin,  is  globular 
in  outline,  and  more  or  less  fluctuating.  The  thrill  or  fremitus  supposed  to  be 
peculiar  to  hydatids  is  a  very  uncertain  symptom  of  the  disease  in  the  kidney, 
having  seldom  been  observed  in  recorded  cases.     Rupture  of  the  cyst  into  the 


TUMORS    OF   THE   KIDNEY.  1029 

pelvis  or  ureter  is  manifested  by  pain  in  the  lumbar  region,  together  with  a 
sensation  of  something  having  given  way.  Then,  as  the  vesicles  descend 
through  the  ureter,  symptoms  similar  to  those  caused  by  the  passage  of  a  renal 
calculus  will  be  provoked.  The  vesicles  may  become  impacted  and  obstruct 
the  ureter,  giving  rise  to  distention  of  the  kidney  with  urine;  or,  reaching  the 
bladder  and  escaping  into  the  urethra,  they  may  obstruct  that  channel  and  cause 
retention  of  urine.  The  escape  of  the  hydatid  vesicles,  or  of  portions  of  the 
laminated  cyst-wall,  or  of  the  peculiar  booklets  of  the  echinococcus  in  the 
urine  positively  establishes  the  presence  of  the  aifection.  In  some  cases  pus 
has  been  noticed  in  the  urine  during  the  discharge  of  the  cyst.  After  once 
evacuating  itself  the  tumor  may  subside,  or,  on  the  other  hand,  it  may  fill 
again  and  empty  itself  as  before,  and  this  may  happen  at  greater  or  less  inter- 
vals for  a  long  time,  even  many  years.  Should  the  cyst  undergo  suppuration, 
fever  and  other  evidences  of  constitutional  disturbance  will  result. 

Diag-nosis. — A  renal  tumor  is  easily  recognized  as  an  hydatid  cyst  when 
vesicles,  particles  of  cyst-wall,  or  booklets  appear  in  the  urine.  In  the  absence 
of  this  evidence  the  tumor  may  readily  be  mistaken  for  hydronephrosis,  other 
varieties  of  renal  cyst,  or  pyonephrosis.  Hydatids  differ  from  malignant 
tumors  of  the  kidney  in  their  slow  development  and  the  absence  of  constant 
pain  and  cachexia. 

Prog-nosis. — The  disposition  of  these  cysts  to  rupture  and  discharge  their 
contents  by  the  urinary  channels  or  to  disappear  without  evacuation  makes  the 
prognosis  usually  good.  If,  however,  the  tumor  continues  to  increase  in  size, 
it  may  lead  to  serious,  sometimes  fatal,  results  from  destruction  of  the  paren- 
chyma of  the  kidney  or  from  pressure  upon  other  organs.  Suppuration,  either 
in  or  about  the  cyst,  is  a  grave  complication,  and  death  may  follow  rupture  into 
the  pleural  cavity  or  the  bronchi. 

Treatment. — With  the  object  of  destroying  the  life  of  the  parasite  certain 
anthelmintics,  such  as  oil  of  turpentine,  male  fern,  and  the  like,  have  been 
exhibited,  but  there  is  no  evidence  of  their  efiiciency.  When  hydatids  are  dis- 
charged in  the  ui'ine,  alkaline  diluents  should  be  freely  given  for  the  purpose 
of  increasing  the  secretion  of  urine,  and  thereby  favoring  the  washing  out 
of  the  pelvis  and  ureters.  Beraud  is  mentioned  by  Roberts  as  having  had 
a  case  in  which  the  administration  of  nitre  caused  an  increase  in  the  discharge 
of  vesicles.  Renal  colic  induced  by  the  escape  of  hydatids  into  the  pelvis  and 
ureter  should  be  treated  as  when  due  to  other  causes. 

If  the  cyst  does  not  discharge,  but  continues  to  increase,  or  if  it  should  sup- 
purate, or  if,  from  obstruction  of  the  ureter,  sudden  distention  of  the  kidney 
should  occur,  surgical  interference  will  be  called  for.  Under  these  circumstances, 
while  aspiration  may  afford  relief,  the  best  prospect  of  success  is  offered  by 
cutting  down  to  the  tumor,  opening  the  cyst,  and  suturing  its  edges  to  the 
external  wound. 

Hydronephrosis. 

The  term  "  hydronephrosis  "  signifies  dilatation  of  the  kidney  and  the  ureter 
from  some  hindrance  to  the  outflow  of  urine.  The  affection  may  be  either 
unilateral  or  bilateral.  Its  causes  may  be  divided  into  congenital  and  acquired. 
When  the  cause  is  congenital,  it  does  not  necessarily  follow  that  the  hydrone- 
phrosis is  present  at  birth ;  it  may  not  develop  for  some  years  later.  In 
extreme  cases  the  condition  has  caused  dystochia,  necessitating  embryotomy. 

Etiology  and  Pathology. — The  obstacle  which  leads  to  the  formation  of 
hydronephrosis  may  be  any' one  of  several.      Thus  an  excessive  angulation  of 


W^O  AMERICA JV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  junction  of  the  ureter  with  the  pelvis  of  the  kidney,  a  twisting  contrac- 
tion, imperforate  condition,  or  valvulation  of  the  ureter,  compression  of  that 
duct  by  an  abnormal  supernumerary  renal  artery,  and  obstruction  of  the 
urethra  by  a  septum  of  mucous  membrane,  are  all  recognized  causes,  falling 
under  the  congenital  class.  As  acquired  causes  may  be  named  obstruction  of 
ureter  from  injury  due  to  the  passage  of  a  calculus  or  from  traumatism  from 
without,  stone  in  the  bladder,  vesical  tumors,  stricture  of  the  urethra,  phimosis, 
and  habitual  frequent  micturition.  Floating  or  movable  kidneys  are  sometimes 
hydronephrotic. 

The  proportion  of  cases  in  which  there  is  tumor  is  small,  but  the  distention 
sometimes  reaches  enormous  dimensions.  The  appearance  of  the  sac  varies, 
sometimes  being  quite  thin  and  pellucid,  while  at  others  it  is  thick  and  opaque. 
The  accumulation  of  urine  first  distends  the  pelvis  of  the  kidney  ;  then  the 
calyces  becomes  dilated,  and  by  degrees  the  resulting  compression  causes  absorp- 
tion of  the  renal  substance,  until  none,  or  but  a  mere  trace,  of  it  remains. 
The  tumor  thus  formed  is  a  cyst,  sometimes,  but  not  always,  subdivided  by 
fibrous  septa.  Its  contents  differ  in  the  majority  of  instances  from  normal 
urine.  Often  a  fluid  resembling  water  is  found  ;  in  other  instances  it  may  be 
brownish  ;  and,  again,  colloid  material  may  fill  the  sac.  The  fluid  may  contain 
no  salt  but  chloride  of  sodium ;  or  uric  acid  and  its  salts,  oxalate  of  lime,  and 
the  phosphates  may  be  present,  as  may  albumin,  pus,  muco-pus,  and  epi- 
thelial cells  in  some  cases. 

Symptoms.  — When  the  affection  is  limited  to  one  kidney,  and  the  sac  so 
small  as  not  to  produce  tumor,  it  may  give  rise  to  no  definite  symptom  ;  on  the 
other  hand,  occasionally  there  may  be  lumbar  pain,  thirst,  frequent  micturition, 
or  intermittent  anuria.  When  both  kidneys  are  hydronephrotic,  uraemia  may 
result.  When  tumor  is  present,  it  is  situated  in  the  first  place  in  the  loin  or 
flank  ;  later  it  becomes  more  prominent  in  the  abdomen,  and  may  even  reach 
such  a  size  as  to  extend  from  the  median  line  in  front  to  the  vertebral  column 
behind,  and  from  the  hypochondriac  region  above  to  the  iliac  region  below. 
A  very  large  tumor  will  by  its  presence  create  considerable  pain,  and  in  those 
cases  in  which  the  trouble  results  from  an  obstruction  in  itself  painful  there 
will  naturally  be  much  suffering.  The  tumor  on  percussion  is  dull,  and  on 
palpation  is  soft  and  fluctuating,  and  sometimes  a  lobulated  condition  of  its  out- 
line may  be  noticed.  The  abdominal  viscera  may  be  variably  displaced 
according  to  the  size  as  well  as  the  direction  in  which  the  cyst  extends,  and 
symptoms  referable  to  its  pressure  on  the  different  organs  or  the  diaphragm 
may  result.  Sudden  subsidence  of  the  tumor,  either  complete  or  partial,  may 
occur  synchronously  with  the  passage  of  a  large  amount  of  urine.  The  urine 
under  these  circumstances  is  of  a  lower  specific  gravity  than  normal,  and  may 
occasionally  contain  pus,  muco-pus,  or  even  blood.  Hydronephrosis  is  some- 
times intermittent. 

Diagnosis. — In  the  few  cases  in  which  the  abdominal  tumor  subsides 
during  the  discharge  of  a  large  quantity  of  urine  the  diagnosis  presents  little 
difficulty.  Under  other  circumstances  hydronephrosis  may  resemble  renal,  ova- 
rian, hepatic,  or  splenic  cysts,  pyonephrosis,  perinephritic  abscess,  and  ascites. 
There  may  be  considerable  difficulty  in  making  the  diagnosis  from  renal  cysts, 
except  in  the  case  of  hydatids,  when  vesicles  appear  in  the  urine.  Ovarian 
cysts  may  be  distinguished  by  their  relation  to  the  colon,  which  is  generally 
behind  them,  and  by  the  absence  of  dulness  on  percussion  of  the  loin.  In 
ascites  the  area  of  flatness  on  percussion  changes  on  alteration  of  the  patient's 
position,  while  in  hydronephrosis  it  remains  fixed.  Pyonephrosis  and  peri- 
nephric abscess  present  a  history  of  pyuria  or  the  constitutional  signs  of  sup- 


TUMORS   OF   THE  KIDNEY.  1031 

puration,  and  oedema  and  redness  of  the  integument  of  the  lumbar  region  not 
characteristic  of  this  aiFection.  Hepatic  and  splenic  cysts  are  affected  by  the 
movements  of  respiration  rather  more  than  the  hydronephrotic  enlargement, 
and  tend  to  become  prominent  anteriorly  rather  than  toward  the  loin. 

Prognosis. — When  the  condition  is  unilateral,  and  the  other  kidney  is 
equal  to  carrying  the  burden  of  sufficient  urinary  excretion,  there  is  no  imme- 
diate risk  of  life.  Even  if  the  cyst  be  large  the  prognosis  is  not  unfavorable 
if  it  be  evacuated  early.  But  if  the  tumor  increase  to  a  great  extent,  fatal 
consequences  may  result  from  its  pressure  upon  other  organs,  from  rupture  into 
the  peritoneal  cavity,  or  from  uraemia.  In  bilateral  cases  death  will  sooner  or 
later  be  caused  by  the  diminution  of  kidney  tissue  induced  by  pressure  of  the 
accumulated  fluid. 

Treatment. — When  there  is  no  trouble  from  the  size  of  the  tumor  hydro- 
nephrosis requires  no  treatment.  Massage  is  sometimes  recommended  with  the 
idea  of  removing  the  cause  of  obstruction,  but  if  practised  the  danger  of  rup- 
turing the  cyst  should  be  borne  in  mind.  Large  tumors,  accompanied  by  much 
pain  or  by  urgent  pressure  symptoms,  call  for  evacuation  of  the  fluid,  which  is 
most  easily  accomplished  by  aspiration.  This  may  be  repeated  if  the  sac  fills 
again.  In  inserting  the  trocar  a  spot  should  be  chosen  where  there  is  no  risk 
of  wounding  the  peritoneum,  for  if  this  should  happen  the  escape  of  some  of 
the  cyst  fluid  into  the  peritoneal  cavity  would  be  attended  with  great  danger. 
If  after  repeated  aspirations  the  sac  refills,  lumbar  nephrotomy  should  be  per- 
formed. The  cyst,  having  been  exposed  and  emptied,  should  be  secured  to 
the  margins  of  the  wound,  and  after  exploring  with  a  probe  for  calculus  in  the 
pelvis  or  ureter  a  large  drainage-tube  should  be  inserted.  The  after-treatment 
consists  in  antiseptic  irrigation  of  the  cyst,  for  which  purpose  either  boric-acid 
solution  or  Thiersch's  fluid  may  be  used.  If  a  persistent  fistula  should  follow 
this  operation,  and  if  it  be  known  that  the  amount  of  renal  tissue  remaining  is 
insignificant,  nephrectomy  is  to  be  recommended. 

Pyonephrosis. 

Distention  of  the  kidney  with  pus  or  with  urine  and  pus  is  called  pyone- 
phrosis. 

Etiology  and  Pathology. — The  condition  may  originate  from  any  of  the 
causes  which  give  rise  to  hydronephrosis,  provided  that  pyelitis  be  developed. 
Also  it  may  result  from  injury,  from  tuberculosis,  or  from  diphtheria  and  other 
zymotic  diseases. 

Distention  of  the  pelvis  and  calyces  and  wasting  of  the  renal  parenchyma 
from  pressure  occur  just  as  in  hydronephrosis,  and  the  kidney  is  eventually 
replaced  by  a  mere  lobulated  pouch.  The  tumor  is  whitish  in  color,  with  walls 
of  variable  thickness,  and  the  sac-contents  are  purulent  urine  or  pus  mixed 
with  blood  and,  in  some  cases,  phosphatic  material.  The  mucous  membrane 
of  the  pelvis  is  pale  in  color  and  much  thickened.  A  large  pyonephrotic  kid- 
ney causes  displacement  of  other  organs,  and,  especially  if  due  to  impacted 
stone,  may  ulcerate,  discharging  its  contents  into  one  of  the  hollow  abdominal 
organs  or  into  the  peritoneal  cavity,  or,  becoming  adherent  to  the  abdominal 
wall,  it  may  discharge  externally,  establishing  a  fistula. 

Symptoms. — While  in  some  cases  there  may  be  no  perceptible  swelling, 
pyonephrosis  usually  gives  rise  to  a  fluctuating  or  elastic  tumor  in  the  renal 
region.  It  is  generally  accompanied  by  pain,  the  character  of  which  depends 
on  the  cause  of  the  obstruction.  Sometimes  it  is  very  severe.  It  originates 
in  the  lumbar  region,  and  is  increased  by  pressure  from  in  front,  but  relieved 


1032  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

by  pressure  in  the  loin.  Chills,  fever,  sweating,  diarrhoea,  and  vomiting  are 
present,  together  Avith  marked  loss  of  flesh.  In  eases  in  which  the  obstruction 
is  not  complete  the  urine  voided,  although  containing  pus,  maj^  be  normal  in 
reaction,  being  mixed  with  that  secreted  by  the  sound  kidney;  later  it  is  liable 
to  become  alkaline.  When  the  obstruction  is  complete,  pyuria  will  not  be 
observed.  In  pyonephrosis  resulting  from  stone  there  will  be  a  history  of 
pyuria  and  hjematuria  extending  over  a  considerable  period. 

Diagnosis. — Pyonephrosis  may  be  confused  with  the  same  conditions  as 
hydronephrosis.  The  constitutional  symptoms  which,  on  the  one  hand,  estab- 
lish the  diagnosis  from  hydronephrosis,  on  the  other  hand  render  the  affection 
liable  to  be  mistaken  for  perinephritic  abscess. 

Prognosis. — The  prognosis  is  more  grave  than  in  hydronephrosis,  and  is 
manifestly  more  serious  if  the  condition  be  bilateral  than  when  only  one  kid- 
ney is  aifected.  The  nature  of  the  cause  of  the  pyonephrosis,  and  whether  the 
accumulation  has  been  gradual  or  sudden,  materially  influence  the  chances  of 
life.  If  it  has  been  gradual,  the  opposite  kidney  may  become  hypertrophied 
and  do  duty  for  the  diseased  one.  Spontaneous  removal  of  an  obstructing 
calculus  is  a  favorable  occurrence,  as  is  the  discharge  of  the  cyst  into  some 
part  of  the  ui'inary  organs  below  the  seat  of  obstruction.  A  fatal  termination 
may  be  reached  by  the  sac  rupturing  into  the  peritoneum,  from  the  results  of 
pressure  upon  other  organs,  from  pyaemia,  septicaemia,  or  amyloid  disease 
induced  by  prolonged  suppuration,  even  though  the  pyonephrosis  has  dis- 
charged its  contents  externallv  or  into  the  intestines. 

Treatment. — In  cases  where  the  obstruction  is  not  complete  the  treatment 
may  be  expectant.  The  patient  should  be  kept  at  rest  with  warm  applications 
to  the  abdomen  and  lumbar  region.  The  condition  of  the  digestive  organs 
should  be  carefully  seen  to,  and  light,  easily-assimilable  nourishment  given. 
When  obstruction  is  complete  and  the  tumor  rapidly  increases  in  size,  causing 
marked  pain,  and  the  constitutional  eff"ects  of  the  suppuration  are  severe,  or 
symptoms  consequent  upon  pressure  become  urgent,  interference  is  indicated 
and  lumbar  nephrotomy  should  be  performed.  When  the  cyst  has  been  open- 
ed a  finger  should  be  inserted,  not  only  to  explore  for  a  stone,  but  to  feel  for 
and  to  break  down  any  septa  which  may  subdivide  the  sac,  so  that  all  parts  of 
it  may  be  well  drained.  The  cyst  should  be  drawn  up  into  the  wound  and 
sutured  to  its  edges,  a  drainage-tube  left  in,  and  the  cavity  washed  out  daily 
with  antiseptic  fluids,  as  in  hydronephrosis. 

In  cases  where  the  kidney  tissue  is  ascertained  to  be  destroyed,  or  where 
the  health  is  seriously  impaired,  or  Avhere  prolonged  suppuration  continues  in 
spite  of  thorough  drainage,  nephrectomy  should  be  the  operation  selected. 

Perinephritic  Abscess. 

Perinephritic  abscess,  resulting  from  inflammation  of  the  fatty  and  areolar 
tissue  surrounding  the  kidney,  may  be  met  with  at  any  age  from  the  earliest 
weeks  of  infancy. 

Etiology  and  Pathology. — Perinephritis  may  be  either  a  primary  or  a 
secondary  condition.  Primarily,  it  may  arise  from  traumatism,  exposure  to 
cold,  or  as  a  sequela  to  the  zymotic  diseases ;  secondarily,  it  may  result  from 
renal  calculus,  pyelitis,  pyelo-nephritis  (or  "surgical  kidney,"  so  called),  pyo- 
nephrosis, cysts,  tumors,  and  tubercular  disease  of  the  kidney,  vesical  calcu- 
lus, stricture  of  the  urethra,  and  phimosis.  Again,  the  suppuration  may  be 
traced  to  disease  of  the  vertebrae,  to  abscess  resulting  from  perforative  ulcer- 
ation of  the  colon  or  ileum,  or  to  retrocaecal  abscess.     In  some  instances,  accord- 


TUMORS    OF    THE   KIDXEY.  1033 

ing  to  Steven,  infection  from  inflammation  originating  in  the  bladder  may 
extend  by  means  of  the  lymphatics  of  the  ureter  to  the  capsule  of  the  kidney 
and  the  tissue  surrounding  it,  the  kidney  itself  escaping.  In  the  same  way  it 
is  possible  that  the  source  of  the  inflammation  might  be  traced  to  other  remote 
points. 

When  suppuration  occurs  the  abscess  is  generally  at  first  limited  by  a  well- 
defined  wall  of  lymph,  but  the  nature  of  the  tissue,  like  that  in  the  ischio- 
rectal fossa,  is  such  as  to  favor  extension  of  the  suppurative  process,  and  the 
pus  soon  works  its  way  in  various  directions  through  the  loose  cellular  and 
fatty  tissue.  From  its  original  situation  it  may  burrow  through  the  lumbar 
muscles  and  point  in  the  loin,  or  it  may  travel  downward  and  appear  in  the 
thigh,  like  a  psoas  abscess,  or,  getting  beneath  the  pelvic  fascia  and  passing 
through  the  sacro-sciatic  notch,  it  may  point  in  the  buttock.  Extending 
upward,  the  pus  may  pass  through  the  diaphragm  and  cause  pleurisy,  empy- 
ema, pneumonia,  or  may  discharge  into  the  bronchi.  Again,  the  abscess  may 
rupture  into  the  peritoneum,  the  colon,  small  intestine,  stomach,  bladder,  or 
prostatic  urethra. 

In  the  primary  cases  the  kidney  may  be  found  macerated  or  broken  down 
by  the  action  of  the  surrounding  pus,  while  in  secondary  cases  of  renal  origin 
there  will  be  found  the  special  morbid  conditions  to  which  the  abscess  is  due. 

Symptoms. — The  patient  will  usually  first  complain  of  pain  in  the  lumbar 
region,  extending  forward,  generally  severe,  and  aggravated  by  motion  as  well 
as  by  pressure.  At  the  same  time  it  will  be  observed  that  the  trunk  is  bent 
toward  the  affected  side,  and  the  thigh  is  kept  slightly  flexed  upon  the  abdo- 
men and  rotated  outward.  On  assuming  the  erect  posture  the  patient  assists  in 
supporting  his  weight  by  bearing  with  his  hand  upon  the  thigh  of  the  afi"ected 
side.  Examination  will  reveal  more  or  less  fulness  or  prominence  of  the  loin 
instead  of  the  normal  concavity,  and  in  marked  cases  palpation  and  percussion 
will  map  out  a  well-defined  tumor.  This  latter  symptom  may  not  be  present 
for  any  great  length  of  time  in  consequence  of  the  tendency  of  the  pus  to 
burrow.  The  integument  of  the  part  is  oedematous,  waxy,  red  or  congested, 
and  hot  to  the  touch. 

The  constitutional  symptoms  are  prominent,  consisting  of  decided  elevation 
of  temperature,  reaching  as  high,  perhaps,  as  104°  F.,  chills,  sweating,  ano- 
rexia, and  diarrhoea.  Pressure  of  the  abscess  upon  the  lumbar  plexus  of 
nerves  excites  pain  in  its  various  branches,  which,  together  with  the  attitude 
assumed,  may  lead  to  error  in  diagnosis.  The  urine,  except  in  those  cases  in 
which  the  abscess  is  the  result  of  violence,  and  in  which  there  may  be  haema- 
turia  or  pyuria,  presents  no  especial  characteristics.  In  some  primary  cases 
there  may  be  a  little  albumin,  resulting  from  high  temperature,  or,  when  the 
abscess  is  large  and  produces  congestion  of  the  kidney  from  pressure,  some 
blood  may  be  found. 

Diagnosis. — The  local  and  constitutional  signs  of  a  fully-developed  peri- 
nephritic  abscess  are  generally  sufficiently  clear  to  leave  little  room  for  doubt  as 
to  the  diagnosis.  It  may,  however,  be  confused  with  hydronephrosis,  pyoneph- 
rosis, cysts  and  tumors  of  the  kidney,  lumbago,  disease  of  the  vertebrae, 
coxalgia,  psoas  abscess,  and  perityphlitic  abscess.  It  is  not  possible  here  to 
point  out  the  distinguishing  features  of  these  affections.  Careful  and  exact 
examination,  together  with  the  accurate  history  of  the  case  in  question,  will 
usually  easily  remove  any  difficulty  that  may  be  in  the  way  of  establishing  the 
diagnosis. 

Prognosis. — The  prognosis  depends  upon  the  cause  of  the  abscess,  although 
the  condition  should  always  be  regarded  as  a  serious  one.     When  the  abscess 


1034  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

results  from  pyonephrosis  or  from  disease  of  some  other  organ,  the  outlook  is 
more  grave  than  when  it  is  primary.  The  prognosis  is  most  favorable  when 
the  pus  is  evacuated  early,  while  in  unrelieved  cases  a  fatal  termination  is  to 
be  apprehended  from  tlie  discharge  of  the  pus  into  other  organs — into  the 
peritoneum,  the  pleural  cavity,  lungs,  or  bronchi.  Amyloid  disease  is  immi- 
nent when  the  suppuration  is  long  continued. 

Treatment. — At  the  onset  attempts  may  be  made  to  induce  resolution  of 
the  perinephritis,  for  which  purpose  cupping  or  leeching  of  the  loin  and  the 
application  of  an  ice  poultice  may  be  tried.  The  patient  should  be  kept  upon 
a  liquid  diet,  a  simple  fever  mixture  should  be  prescribed,  the  bowels  kept 
freely  opened,  and  opium  given  for  the  relief  of  pain.  If  these  measures  fail 
to  ameliorate  the  local  and  constitutional  symptoms,  warm  flaxseed  poultices 
should  be  applied,  quinine  added  to  the  medicinal  treatment,  and  the  patient 
closely  watched.  Increased  elevation  of  temperature  or  the  occurrence  of  chills 
and  sweating,  being  tokens  of  suppuration,  call  for  prompt  resort  to  the  knife. 
Delay  is  dangerous,  since  it  renders  possible  burrowing  of  the  pus.  Therefore, 
in  spite  of  the  absence  of  fluctuation,  a  free  incision  in  the  lumbar  region 
should  at  once  be  made  down  to  the  perirenal  tissue.  Then  with  the  finger 
this  should  be  carefully  explored  or  teased  apart  until  the  abscess,  which  is 
sometimes  deeply  seated,  is  found.  The  opening  made  with  the  finger  should 
be  enlarged  by  inserting  a  pair  of  long-bladed  haemostatic  forceps  and  sepa- 
rating the  blades.  This  being  done,  the  abscess-cavity  should  be  washed  out 
and  a  good-sized  drainage-tube  inserted.  Later,  strips  of  iodoform  gauze  may 
be  gently  pushed  into  the  cavity  beside  the  tube,  and  the  packing  gradually 
lessened  and  the  tube  shortened  as  granulation  progresses. 

In  cases  in  which  the  abscess  is  secondary  to  disease  of  the  kidney,  nephrot- 
omy or  nephrectomy  may  be  called  for,  according  to  the  condition  found  at  the 
time  of  operation. 

Tumors  op  the  Kidney. 

New  growths  of  the  kidney,  as  met  w^ith  in  children,  are  for  the  most  part, 
if  not  entirely,  of  the  malignant  class.  While  it  is  possible  that  benign  growths 
may  occur,  investigation  of  statistics  has  failed  to  find  any  case  which  has  been 
the  subject  of  surgical  operation.  Malignant  tumors  may  involve  the  kidney 
either  primarily  or  secondarily,  but  it  is  only  with  the  primary  tumors  that  we 
are  here  concerned. 

Etiology  and  Pathology. — Some  of  these  growths  are  congenital.  In 
other  cases  their  origin  is  attributed  either  to  the  irritation  of  a  renal  calculus 
or  to  injury,  such  as  contusions  or  falls  upon  the  loin,  although  it  is  not  very 
easy  to  understand  how  this  latter  cause  can  be  operative. 

Unlike  similar  formations  elsewhere  in  the  body,  malignant  tumors  of  the 
kidney  are  met  with  more  frequently  in  the  first  ten  years  of  life  than  during 
the  period  of  life  generally  recognized  as  that  of  malignancy.  They  may  occur 
at  any  age  in  childhood,  although  the  greater  number  of  cases  have  been 
observed  in  children  under  five.  Thus,  in  54  cases  references  to  which  the 
writer  has  obtained,  9  were  under  one  year  old,  17  between  the  ages  of  one 
and  three,  18  between  three  and  five,  6  between  five  and  eight,  and  4  between 
eight  and  twelve  years  of  age.  As  to  sex,  in  40  cases  in  which  it  was  stated 
22  were  females  and  18  were  males.  The  tumor  is  unilateral  as  a  rule.  When 
both  organs  are  the  seat  of  growths,  except  in  cases  of  congenital  myosarcoma, 
the  involvement  of  one  organ  is  secondary  to  the  disease  in  the  other.  Of  80 
cases,  the  right  kidney  was  the  seat  of  the  neoplasm  in  14,  the  left  in  12,  and 
both  were  involved  in  4. 


TUMORS    OF    THE  KIDNEY.  1035 

The  great  majority  of  these  renal  tumors  in  children  are  sarcomata.  Out  of 
52  cases,  43  were  instances  of  sarcoma,  while  9  were  designated  as  encephaloid 
carcinoma.  The  variety  of  sarcouia  most  often  found  is  the  round-celled,  both 
large  and  small,  the  spindle-celled  variety  being  less  frequent.  These  growths, 
which  are  first  usually  encapsuled,  but  which,  owing  to  their  rapid  develop- 
ment, soon  extend  through  their  capsule,  may  begin  at  the  hilum  and  either 
spread  around  and  envelop  the  kidney,  or  they  may  extend  into  the  kidney, 
which  ultimately  becomes  stretched  out  as  a  thin  layer  over  the  tumor.  More 
often  they  originate  in  the  cortex,  being  separated  from  the  surrounding  renal 
tissue  by  a  capsule  until  the  latter  gives  way,  when  the  sarcoma  extends  through- 
out the  kidney.  In  addition  to  the  round-celled  and  spindle-celled,  other 
varieties  of  sarcoma  which  have  been  found  are  adenomo-sarcoma,  in  which  the 
sarcomatous  tissue  and  that  of  the  glandular  substance  of  the  kidney  are  com- 
bined; myxo-sarcoma,  in  which  the  elements  of  mucous  tissue  are  combined 
with  sarcoma;  alveolar  sarcoma;  and  myo-sarcoma  and  rhabdo-myoma.  Tumors 
of  the  last-named  kind  are  of  congenital  origin,  and  consist  of  a  mixture  of 
striped  muscle  tissue  and  sarcoma  tissue.  They  may  be  either  unilateral  or 
bilateral,  sometimes  reach  a  very  large  size,  and  are  rapidly  fatal.  Owing  to 
special  characteristics,  certain  sarcomata  have  been  described  as  fibrous  and 
fibro-fatty  tumors. 

Sarcomata  of  the  kidney  grow  rapidly  and  are  highly  vascular,  extravasa- 
tions often  taking  place  into  them.  They  frequently  break  down  in  places 
and  form  cysts  containing  blood  and  clots. 

The  variety  of  carcinoma  which  has  been  most  frequently  met  with  is  the 
encephaloid,  although  any  of  the  varieties  may  be  found.  Encephaloid  cancer 
of  the  kidney  has  sometimes  attained  immense  proportions.  The  growth  may 
invade  the  entire  kidney,  being  disseminated  throughout  it  and  producing  a 
tumor  possessing  the  general  outline  of  the  organ,  or  it  may  develop  from  one 
part  of  the  organ  and  have  an  irregular  outline.  The  origin  of  the  growth  is 
traced  to  the  intertubular  connective  tissue,  its  epithelium  being  derived  from 
proliferation  of  the  normal  renal  epithelium.  Like  sarcomata,  carcinomata 
grow  rapidly.  It  is  doubtful  whether  some  of  the  tumors  specified  in  the  older 
classification  as  encephaloid  cancer  would  not  now  be  placed  under  the  heading 
of  sarcoma. 

Lymphadenomata  have  been  occasionally  observed  in  the  kidney,  but  are 
secondary  to  disease  in  the  lymphatic  system.  It  is  possible  that  a  growth  of 
this  kind  might  be  mistaken  for  a  round-celled  sarcoma. 

Malignant  growths  of  the  kidney  spread  by  means  of  the  lymphatics  and 
veins.  Carcinomata  are  particularly  apt  to  involve  and  extend  by  the  veins. 
Secondary  formations  soon  take  place.  The  lumbar  glands  are  early  infected. 
The  tumor  may  by  pressure  cause  erosion  of  the  vertebrae,  and,  opening  the 
spinal  canal,  involve  the  meninges,  and  even  the  cord  itself,  by  direct  extension. 

Symptoms. — In  addition  to  tumor,  which  is  the  symptom  most  invariably 
present,  malignant  disease  of  the  kidney  causes  pain,  emaciation,  cachexia, 
frequent  perhaps  involuntary  micturition,  hgematuria,  and  various  symptoms 
resulting  from  pressure  of  the  growth. 

The  tumor,  if  detected  early,  will  be  found  confined  to  the  loin,  where  it 
causes  more  or  less  fulness  or  prominence.  In  some  recorded  cases  the  growth 
has  attained  an  immense  size,  occupying  the  whole  abdominal  cavity,^ pressing 
upward  the  diaphragm  and  embarrassing  the  thoracic  organs.  Again,  in 
other  cases  it  may  be  very  difiicult,  if  not  impossible,  to  detect  a  palpable 
tumor,  even  though  metastasis  has  taken  place.  Pain  in  the  lumbar  region  is 
an  early  indication,  but  while  in  older  children,  as  in  adults,  it  is  an  important 


1036  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

sign,  it  is  very  doubtful  if  in  very  young  subjects  it  could  be  relied  upon,  as  it 
is  not  likely  that  it  would  be  intelligently  located.  It  is  dull  in  character  and 
usually  constant,  although  occasionally  paroxysmal,  differing,  however,  from 
the  pain  due  to  renal  calculus  in  not  being  either  aggravated  by  motion  or 
relieved  by  rest.  Hsematuria  is  not  always  noted  as  a  symptom.  When  it 
does  occur  it  is  constant,  and  although  in  some  cases  it  may  not  be  alarming,  the 
bleeding  may,  on  the  other  hand,  be  very  severe.  Sometimes  clots  may  obstruct 
the  urethra  or  may  distend  the  bladder,  or,  again,  may  become  wedged  in  the 
urethra.  The  haemorrhage  may  be  due  to  the  calculus  from  which  the  tumor 
may  have  arisen,  or  it  may  result  from  the  neoplasm  involving  and  extending 
into  the  pelvis  of  the  kidney  and  then  ulcerating. 

The  tumor,  as  it  grows,  may  encroach  upon  and  compress  the  nerves  of  the 
lumbar  plexus,  giving  rise  to  pain,  and  even  to  paralysis  in  the  parts  supplied 
by  its  branches.  From  pressure  upon  the  veins  within  the  abdomen  cedema 
of  the  lower  extremities  and  engorgement  of  the  superficial  abdominal  veins  are 
produced.  Other  symptoms  due  to  the  pressure  of  the  tumor  are  constipation, 
jaundice,  anorexia,  and  vomiting. 

The  urine  will  be  found  normal  unless  the  growth  has  involved  the  pelvis 
of  the  kidney,  when  it  may  contain  blood,  blood-casts,  albumin,  epithelium, 
pus,  or  portions  of  the  ulcerating  tumor.  Although  convulsions  have  taken 
place  in  a  few  cases,  uraemia  rarely,  if  ever,  occurs. 

Diagnosis. — The  salient  symptoms  of  renal  neoplasms  are  rapidly-increasing 
tumor  and  pain.  If  to  these  haematuria  be  added,  the  diagnosis  should  not  be 
difficult.  If  the  tumor  be  large,  however,  there  may  be  some  difficulty  in 
deciding  whether  on  the  right  side  it  is  not  a  cyst  or  enlargement  of  the  liver, 
or  on  the  left  whether  it  is  not  an  enlarged  spleen,  particularly  as  renal  tumors, 
as  well  as  those  of  the  liver  and  spleen,  are  affected  by  the  movements  of  respi- 
ration. The  examination  will  usually  be  more  satisfactory  if  the  child  be 
under  ether  or  chloroform  anaesthesia.  The  relation  of  the  ascending  colon  on 
the  right  side  and  the  descending  colon  on  the  left  to  these  tumors  is  an 
important  point.  Unless  the  growth  be  very  large  or  has  extended  in  one 
particular  direction  from  the  kidney,  the  colon  should  be  found  in  front  of  it. 
In  cases  where  the  tumor  is  very  large  the  bowel  may  be  pushed  aside,  either 
inward  or  downward.  Another  point  of  distinction  is  that  renal  tumors  can 
usually  be  traced  deeply  into  the  loin.  Other  affections  with  which  these 
growths  may  be  confounded  are  cysts  of  the  ovary,  faecal  accumulations,  and 
perityphlitic  abscess.  Ovarian  cysts  should  have  the  bowel  behind  them  and 
not  in  front,  and  are  generally  easily  made  out  by  rectal  or  vaginal  exami- 
nation ;  and  perityphlitic  abscess  will  usually  present  constitutional  symptoms, 
which,  together  with  the  history,  will  clear  up  any  doubts  that  may  exist. 

Prognosis. — Malignant  disease  of  the  kidney  can  of  course  terminate  in 
only  one  way.  The  child  may  live  but  a  few  weeks  after  the  appearance  of 
the  growth,  or  he  may  live  a  year  perhaps,  the  average  being  six  or  seven 
months.  In  children  these  neoplasms  are  usually  softer,  grow  faster,  and 
exhibit  their  malignant  nature  more  speedily  than  in  adults. 

Treatment. — The  question  as  to  whether  operative  treatment  should  be 
resorted  to  in  malignant  renal  growths  is  one  that  can  be  answered  only  after 
considering  the  merits  of  each  particular  case.  Nephrectomy  is  of  course  to 
be  thought  of  only  in  those  cases  in  which,  so  far  as  examination  can  deter- 
mine, the  disease  is  in  all  probability  confined  to  the  kidney,  under  which  cir- 
cumstances there  may  be  some  possibility  of  the  removal  completely  eradicating 
it,  or,  if  it  fails  in  that,  of  somewhat  prolonging  life. 

A  review  of  the  literature  of  the  subject  shows  the  results  of  nephrectomy 


TUMOBS    OF   THE   KIDNEY.  1037 

for  renal  tumor  in  cliilclren  to  be  not  very  flattering.  The  late  Prof.  S.  "W. 
Gross  collected  16  operations  upon  children  between  sixteen  months  and  seven 
years  of  age.  Of  these,  9  died  and  7  recovered  from  the  operation.  Of 
the  latter,  5  were  known  to  have  died  from  recurrence  of  the  disease  at  times 
varying  from  five  to  sixteen  months  after  the  operation,  while  in  the  remaining 
2  the  result  was  not  ascertained.  Dr.  Gross  considered  nephrectomy  to  be 
positively  contraindicated  in  sarcoma  in  children. 

Dr.  Marie  B.  Werner  has  tabulated  31  operations,  including  some  of  those 
collected  by  Gross.  A.n  additional  case  is  mentioned  by  Newman  in  the  table 
in  his  "  Lectures  to  Practitioiiers  on  the  Surgical  Diseases  of  the  Kidney.''  Of 
these  32  cases,  16  survived  and  16  perished  from  the  operation.  Recurrence 
is  known  to  have  taken  place  in  8  of  the  16  cases  which  recovered  from  the 
operation,  the  shortest  time  before  death  occurred  being  two  months,  and  the 
longest  eight  months.     In  the  other  eight  cases  the  ultimate  result  was  not 

I'll 

ascertained.  One  of  them  died  a  year  and  a  half  after  the  operation,  but  the 
cause  of  death  is  not  stated. 

Butlin,  in  his  work  entitled  "  The  Operative  Surgery  of  Malignant  Disease," 
says  of  nephrectomy  for  sarcoma  in  children  that  "  not  one  thoroughly  success- 
ful case  can  be  claimed,  and  it  is  probable  that  the  operation  will  fall  into  dis- 
repute." 

Judging  by  the  ultimate  result  in  those  cases  of  operation  in  which  it  was 
ascertained,  there  can  be  no  doubt  that  the  weight  of  evidence  is  unfavorable 
to  nephrectomy  for  malignant  disease  in  children.  If  there  be  any  hope  of 
success  from  the  operation  as  a  radical  measure,  it  must  be  when  it  is  performed 
at  a  very  early  period  of  the  disease.  Each  case,  however,  must  be  judged  on 
its  own  merits.  If  the  operation  is  to  be  undertaken,  there  should  be  absence 
of  evidence  of  dissemination  of  the  disease,  and  the  general  condition  of  the 
child  should  warrant  so  severe  a  procedure.  If  resorted  to,  nephrectomy 
should  be  performed  by  the  abdominal  incision,  since  the  space  in  the  loin  in 
children  is  insufficient  to  permit  the  safe  removal  of  a  tumor  even  if  it  be  of 
moderate  size.  The  risks  of  the  operation  are  very  considerable,  heemorrhage, 
shock,  collapse,  and  peritonitis  being  the  imminent  dangers  encountered. 
Owing  to  the  high  degree  of  vascularity  of  these  growths  the  danger  of  pro- 
fuse bleeding  during  their  removal,  especially  if  adhesions  have  to  be  broken 
up,  is  very  great. 

In  cases  which  do  not  permit  of  operation  all  that  can  be  done  is  to  attempt 
to  afford  some  palliation  for  the  symptoms  to  which  the  tumor  gives  rise.  Pain 
should  be  subdued  by  the  administration  of  opium  and  the  local  use  of  bella- 
donna plaster,  or  opium,  chloral,  chloroform,  aconite,  and  belladonna  in  lini- 
ment. Haemorrhage  will  call  for  the  employment  of  haemostatic  remedies, 
such  as  gallic  acid  and  ergot.  Morris  speaks  highly  of  ferric  alum  for  this 
purpose. 


VESICAL   CALCULUS 

By  J.  WILLIAM  WHITE,  M.  D., 

Philadelphia. 


Varieties  of  Calculus  found  in  Children. — The  uric-acid  calculus  is 
by  far  the  most  common  kind  found  in  children.  Statistics  by  different  authors 
variously  place  it  from  two-thirds  to  five-sixths  of  all  stones.  It  was  first 
described  by  Scheele  in  1776.  It  may  be  composed  exclusively  of  uric  acid, 
or  it  may  be  mixed  more  or  less  with  oxalate  of  lime  and  the  urates  of  ammo- 
nium and  sodium  either  in  its  intimate  structure  or  in  alternating  layers.  It 
is  generally  oval,  rarely  very  large,  and  sometimes  quite  smooth,  though  more 
often  granular  or  slightly  tuberculated.  The  color  varies  from  a  light  fawn — 
almost  white — to  a  brownish  or  blackish  red.  There  are  two  forms — the  lami- 
nated and  the  amorphous — although  a  stone  may  contain  layers  of  both.  The 
laminated  variety,  when  cut  through  the  centre  and  polished,  resembles  an 
agate  ;  but,  besides  the  concentric  curved  lines,  radiating  lines  may  often  be 
seen  extending  from  the  centre  to  the  periphery-  This  variety  is  very  hard, 
and  when  broken  splits  into  angular  and  often  sharp-pointed  fragments.  The 
amorphous  uric-acid  calculus  is  structureless  or  sandy  on  section,  and  generally 
of  a  dirty  reddish-yellow  color.  It  is  sometimes  quite  soft  and  breaks  into 
irregular  fragments. 

Next  in  frequency  to  the  uric-acid  stone  comes  the  oxalate-of-lime  or  mul- 
berry calculus,  first  described  by  Wollaston  in  1797.  It  is  generally  round, 
covered  with  blunt  points  or  spicules,  very  hard,  and  varies  in  color  from  a  dark 
gray  to  a  broAvnish  black. 

Urate  of  ammonium  occasionally  occurs  as  a  calculus,  but  is  usually  in 
combination  with  uric  acid.  When  it  does  occur  it  is  flattened,  oval,  smooth, 
or  granular,  brittle,  and  of  a  clay  color. 

The  mixed  or  fusible  phosphate,  the  ammoniaco-magnesian  phosphate, 
phosphate  of  calcium,  carbonate  of  calcium,  cystic  oxide,  xanthic  oxide,  fib- 
rinous, fatty  (urostealith),  and  indigo  calculi  are  extremely  rare,  or  never  occur 
in  children  as  pure  calculi,  although  some  of  them  may  enter  into  the  composi- 
tion of  a  stone  with  uric  acid. 

Stone  in  children  may  be  small  or  large,  from  a  few  grains^  to  an  ounce  or 
more;  soft  or  hard,  depending  upon  its  composition  and  the  length  of  time  it 
has  taken  to  form ;  single  or  multiple  ;  free  or  attached  to  the  bladder-walls, 
either  by  a  band  of  lymph  or  by  being  caught  in  one  of  the  folds  of  mucous 
membrane.  It  almost  always  has  its  origin  in  the  kidney,  unless  it  be  formed 
around  some  foreign  body  which  has  been  introduced  into  the  bladder.     The 

*  Sir  Henry  Thompson  objects  to  giving  a  concretion  of  less  than  20  grains  in  weight  the 
name  of  "  calculus  "  or  "  stone."  While  there  may  be  some  practical  advantage  in  this  limitation 
in  the  case  of  adults  as  regards  especially  the  significance  of  statistics,  there  can  be  none  in 
children. 

1038 


VESICAL    CALCULUS.  1039 

experiments  of  Rainey,  Ord,  Vandyke  Carter,  and  others  have  shown  that 
"  urinary  calculus  is  not  an  accidental  agglomeration  of  solids,  crystalline,  and 
amorphous,  in  a  cement  of  mucus,"  but  that  it  is  a  "  massive  crystallization  of 
urinary  ingredients  in  a  colloid  substance,"  the  formation  of  which  occurs  in 
obedience  to  a  fixed  law.  Although  the  frequency  of  the  uric-acid  calculus  is 
doubtless  due  to  the  excess  of  uric  acid  in  the  urine  of  children  and  to  the 
presence  in  the  kidneys  of  infarctions  which  are  almost  entirely  composed  of 
uric  acid,  and  which  Virchow  has  shown  to  be  very  common,  almost  constant, 
during  infancy,  yet  it  must  be  remembered  that  some  colloid  substance,  as 
mucus,  albumin,  pus,  etc.,  has  to  be  present  or  no  stone  will  be  formed,  and  the 
crystals  will  pass  out  with  the  urine  in  the  well-known  cayenne-pepper  or  brick- 
dust  deposit. 

Btiolog'y. — As  just  stated,  the  two  chief  causes  of  stone  are  crystals  in 
the  urine  and  the  presence  of  a  colloid  substance.  How  far  the  production 
of  these  two  causes  is  influenced  by  heredity  it  is  very  diflficult  to  state. 

That  stone  is  occasionally  found  with  exceptional  frequency  in  certain 
families  there  can  be  no  doubt,  but  before  its  occurrence  is  assigned  to  heredity 
it  should  be  remembered  that  there  may  be  some  local  cause  equally  affecting 
all  the  members  of  a  family  and  peculiar  to  their  place  of  residence,  not  to  their 
physical  condition. 

Cadge,  some  years  ago,  made  the  following  interesting  remarks  as  to  this 
point :  "  In  five  instances  I  have  operated  on  brothers,  and  in  four  other  in- 
stances I  have  operated  on  one  brother, -and  other  surgeons  on  another.  Mr. 
Clubbe  of  Lowestoft  has  given  us  a  curious  history  of  a  stone-family  :  Three 
brothers  were  cut  for  stone  by  Mr.  Clubbe ;  a  fourth  passed  a  stone ;  a  fifth 
child  died,  aged  three  months,  with  every  symptom  of  stone ;  a  female  child 
now  has  vesical  irritation  and  bloody  urine.  The  father  and  mother  are  con- 
stantly passing  large  quantities  of  lithic  acid  ;  the  grandfather  passed  one  stone, 
and  the  grandmother  seven  ;  a  great-uncle  was  cut  for  stone,  and  six  uncles 
and  four  aunts  all  suffer  either  with  fits  of  gravel  or  from  lithic  deposits  ;  and, 
to  finish,  a  cousin  passes  calculi.  There  is  considerable  historical  testimony  in 
favor  of  this  hypothesis.  We  know  that  Montaigne  and  his  father  both  died 
of  stone  in  the  bladder,  and  we  remember  how  he  moralizes  on  the  incompre- 
hensible wonders  of  the  hereditary  transmission  of  mental  and  bodily  resem- 
blances and  infirmities.  The  celebrated  minister  Sir  Robert  Walpole  and  his 
brother  Horace  (who  once  represented  this  city  in  Parliament)  were  both 
afflicted  with  stone  ;  and  their  mother  also  had  stone." 

It  is  probable  that  gout  and  rheumatism  increase  any  tendency  to  the  for- 
mation of  stone,  as  they  are  usually  accompanied  by  acid  urine,  with  an  increase 
in  uric  acid  and  the  urates.  As  gout  is  hereditary,  the  tendencies  to  stone, 
which  it  produces,  may  also  be  hereditary.  But  gout,  as  a  rule,  is  an  inherit- 
ance of  the  rich,  brought  on  by  generations  of  over-eating  and  drinking,  and 
yet  it  is  a  remarkable  fact  that  the  children  of  the  rich  are  singularly  free 
from  calculus,  while  the  children  of  the  poor  make  up  more  than  one-half  of 
the  cases  of  stone  in  the  tables  of  statistics.  Deschamps,  at  the  close  of  the  last 
century,  said  that  during  the  thirty  years  in  which  he  treated  people  afflicted 
with  calculus,  he  had  yet  to  see  the  child  of  a  rich  man  affected  with  stone. 
Sir  William  Fergusson  is  quoted  as  saying  that  he  had  but  once  received  a  fee 
for  operating  on  a  child.  Of  the  863  cases  of  stone  which  Sir  Henry  Thomp- 
son treated  in  private  practice,  but  3  were  under  sixteen  years  of  age,  and  only 
8  from  sixteen  to  twenty-four.  In  explanation  of  this  Sir  Henry  Thompson 
says:  "Insufficient  food,  clothing,  and  fresh  air,  the  necessary  accompaniments 
of  poverty,  appear  to  encourage  calculous  formations  among  children,  but  not 


1040  AMERICAN  TEXT-MOOK  OF  DISEASES  OF  CHILDREN. 

among  adults.  Habits  of  self-indulgence,  in  relation  chiefly  to  diet,  and  indo- 
lence, encourage  calculous  formation  in  elderly  adult  males,  but  the  children 
of  such  parents  are  not  so  aifected.  Hard  physical  labor  and  a  regimen  which 
necessarily  contains  simple  diet,  largely  cereal,  with  animal  food  in  small  pro- 
portion, even  although  often  associated  with  intemperate  habits  and  with  un- 
healthy dwellings,  discourage  calculous  formations  among  all  classes  of  the  com- 
munity alike." 

It  is  a  well-known  fact  that  stone  occurs  much  more  frequently  in  certain 
districts  than  in  others,  but  a  satisfactory  explanation  of  this  has  not  been 
given.  It  is  possible  that  climate  may  have  some  slight  influence  over  the 
production  of  these  aff'ections,  as  in  very  changeable  regions  calculous  diseases 
are  more  common  than  in  those  localities  where  the  temperature  is  more  uni- 
form. This  may  be  due  to  a  lack  of  proper  clothing  and  insufiicient  protection 
of  the  skin,  whereby  its  functions  become  disturbed  and  the  kidneys  are  re- 
quired to  perform  an  excess  of  labor.  In  the  United  States  stone  is  much 
more  common  in  Kentucky,  Tennessee,  Ohio,  Virginia,  and  North  Carolina 
than  in  any  other  portions  of  the  country,  and  yet  we  have  a  vast  area  of  ter- 
ritory which  is  similarly  located,  geographically,  geologically,  and  climatically, 
in  which  stone  is  rarely  if  ever  encountered.  In  England  calculus  is  common 
around  Norfolk  and  Manchester,  while  in  other  regions,  which  are  in  the  same 
latitude  and  subject  to  the  same  temperature,  it  is  almost  unknown.  Neither 
can  it  be  attributed  to  hard  water  alone,  as  Mastin  shows  that  in  parts  of  Ken- 
tucky and  Tennessee,  where  the  water  is  soft,  calculous  diseases  are  common, 
and  just  as  frequently  met  with  as  in  the  limestone  districts.  Again,  Mr.  Dud- 
geon of  Pekin  informs  us  that  at  Canton  in  China  stone  is  frequently  met  with, 
while  around  Pekin  it  is  hardly  ever  seen ;  yet  the  water  of  Pekin  is  full  of 
lime,  while  the  Canton  water  is  soft. 

It  would  seem  that  race  has  some  influence  over  stone  formation.  The 
negro  in  America  is  said  to  be  remarkably  free  from  calculus,  and  Rayer  says 
that  in  Egypt  he  escapes,  while  the  Arab  suffers. 

Diet  and  regimen,  at  least  in  the  cities,  have  much  more  to  do  with  the  pro- 
duction of  stone  than  heredity,  climate,  water,  soil,  etc. ;  and  I  believe  that 
Mr.  Cadge  has  come  nearer  the  cause  when  he  says  that  the  frequency  of 
calculus  in  children  will  be  found  in  strict  accordance  with  the  difficulty  in 
procuring  milk.  He  adds:  "A  few  years  ago,  after  removing  a  stone  from 
a  child  of  well-to-do  parents,  I  was  remarking  to  one  of  my  assistants  that  this 
was  the  first  instance  in  my  practice,  and  that  I  attributed  the  general  absence 
of  stone  in  such  persons  to  the  free  use  of  milk :  the  mother  volunteered  the 
statement  that  in  a  large  family  this  was  her  only  child  who  never  could  take 
milk,  and  who.  therefore,  never  had  any." 

Sex  undoubtedly  has  an  influence  upon  the  frequency  of  vesical  but  not  of 
renal  calculus.  There  is  no  reason  why  the  female  is  not  as  liable  to  the  for- 
mation of  calculous  concretions  within  the  kidney  as  the  male  ;  but,  the  nucleus 
having  once  descended  to  the  bladder,  the  large  size  and  shortness  of  the  urethra, 
the  absence  of  the  prostate,  and  the  comparative  freedom  from  urethral  diseases 
and  vesical  catarrh  are  almost  sufficient  to  secure  immunity.  Giraldes  asserts 
that  vesical  calculus  happens  twenty-four  times  more  frequently  in  boys  than  in 
girls,  while  Neubauer  found  but  5  girls  in  100  cases. 

Relative  Frequency  of  Calculus. — Most  of  the  statistics  of  cases  of 
calculus  agree  in  that  children  make  up  one-half  or  a  little  more  than  one-half 
of  the  number.  In  a  collection  of  1103  cases  by  Prout,  594  were  under  four- 
teen years  of  age.  In  Cheselden's  series  of  213  cases,  115  were  under  ten 
and  62  were  from  ten  to  twenty  years  old.     Robert  Smith's  543  cases  from 


VESICAL    CALCULUS.  1041 

Leeds  and  Bristol  show  253  to  be  under  sixteen.  Sir  Henry  Thompson's  elab- 
orate table  of  1827  cases  shows  that  1001  were  under  sixteen  years  of  age.  In 
Dolbeau's  collection  of  5376  cases,  2416  were  under  the  age  of  puberty.  No 
period  of  life  is  exempt  from  the  liability  to  stone.  Langenbeck  found  a  cal- 
culus in  the  bladder  of  a  male  foetus  of  six  months,  and  Jacobi  has  reported  a 
case  in  which  the  child  was  only  ten  days  old  when  symptoms  of  difficult  mic- 
turition were  noticed,  and  another  case  of  an  infant  who  passed  blood  soon  after 
birth,  the  first  urine  being  voided  forty-eight  hours  later,  and  a  reddish, 
gritty  mass  being  found  in  the  diapers.  He  has  detected  six  cases  of  congenital 
renal  calculi  in  forty  autopsies,  and  believes  that  many  cases  of  so-called  intes- 
tinal colic  occurring  in  children  are  in  truth  cases  of  renal  colic.  The  passage 
of  a  calculus  is  frequently  accompanied  by  haemorrhage  and  followed  by  sec- 
ondary nephritis. 

In  Thompson's  table  the  frequency  of  stone  rapidly  increases  from  birth 
to  the  fourth  and  fifth  years  of  life,  after  which  it  gradually  decreases  to  the 
age  of  puberty.  The  fallacy  of  depending  upon  these  figures  has,  however, 
been  shown  by  various  writers,  and  Sir  Henry  Thompson  says  that  after  inves- 
tigating the  old  statistics  of  stone  and  those  collected  prior  to  1850,  he  found 
them  misleading.  He  adds:  "So  far  from  the  stone  being  more  common  in 
children  than  in  adults,  according  to  the  universal  belief  at  the  period  referred 
to,  justified  as  it  was  by  the  records  of  hospital  practice,  I  was  soon  in  a  posi- 
tion to  affirm  that  stone  was  more  common  among  men  of  sixty  years  of  age 
and  upward  than  at  any  other  period  of  life.  For  let  it  be  remembered  that 
all  existing  records  of  practice,  whether  found  in  museums  or  reported  by  the 
operators  themselves,  from  all  sources  previous  to  the  middle  of  the  present 
century,  showed  that  half  the  total  number  of  operations  for  calculus  occurred 
in  childhood  and  youth.  The  truth,  nevertheless,  is  that  a  very  large  majority 
of  calculous  cases  Avas  then,  as  now,  to  be  found  in  persons  above  fifty  years  of 
age,  but  the  fact  was  then  unknown ;  the  calculi  were  simply  overlooked,  not 
being  suspected  to  exist;  and  one  obvious  reason  of  the  oversight  is  to  be  found 
in  the  fact  that  the  early  symptoms  in  elderly  subjects  are  extremely  slight — 
a  rule  with  only  few  exceptions — contrasting  strongly  with  the  marked  and 
painful  symptoms  rarely  absent  in  the  young." 

Agnew,  after  quoting  the  figures  of  Gross,  Civiale,  and  Thompson,  show- 
ing 62.33  per  cent,  under  twenty  years  of  age,  adds:  "These  estimates,  how- 
ever, are  calculated  to  mislead,  from  the  disparity  which  must  necessarily  exist 
between  the  different  classes  of  patients  when  the  number  of  each  is  contrasted 
Avith  the  entire  population  living  at  the  same  ages.  Were  the  statistics  based 
on  this  principle,  a  result  the  reverse  of  that  exhibited  would  be  shown.  In 
other  words,  the  tendency  to  calculous  disorders  would  be  found  to  increase 
with  advanced  age.  The  inaccuracy  of  all  statistics  with  regard  to  the  age  of 
calculous  patients  will  be  further  shown  by  the  fact  that  the  date  has  been 
fixed  at  the  time  the  patient  was  operated  on,  though  the  disease  may  have 
existed  several  years  previously." 

Mr.  Coulson  has  made  a  similar  remark,  viz.  "  that  an  error  has  crept  in 
from  not  using  the  proper  precaution  to  distinguish  between  absolute  and  rela- 
tive numbers.  To  determine  liability  the  absolute  numbers  should  be  corrected 
by  the  number  of  persons  living  at  the  several  periods  of  life  enumerated. 
Thus,  if  all  persons  under  twenty  were  affected  with  stone  and  all  over  seventy 
were  affected  with  the  like  complaint,  it  is  evident  that  the  liability  would  be 
the  same,  though  the  absolute  number  of  persons  attacked  would  be  very  dif- 
ferent." Mastin  says  :  "  To  enable  us  to  determine  the  liability  of  chil- 
dren of  a  certain  age  to  stone,  we  must  correct  the  absolute  numbers  by  the 


1042  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

numbers  of  persons  of  all  ages  living  at  the  several  perifxls  of  life  enumerated. 
Corrected  in  this  manner  statistics  would  most  probably  show  that  young  per- 
sons are  much  less  liable  to  calculous  affections  than  is  generally  believed," 

Symptoms. — The  symptoms  of  vesical  calculus  in  children  are  for  the 
most  part  the  same  as  in  adults,  but  they  present  certain  peculiarities  due  to  the 
age  of  the  patient.  If  the  child  be  not  old  enough  to  appreciate  when  he  is 
sick,  and  to  describe  the  character  and  locality  of  the  pain,  the  surgeon  has  to 
rely  almost  entirely  upon  objective  symptoms  for  his  diagnosis.  But  if  the  child 
be  old  enough,  in  many  cases,  before  the  development  of  vesical  symptoms,  the 
descent  of  the  nucleus  from  the  kidney  will  be  announced  by  a  group  of  symp- 
toms known  as  nephritic  colic.  While  feeling  perfectly  well  he  is  suddenly 
seized  with  a  violent  pain,  felt  first  in  the  lumbar  or  hypochondriac  region,  and 
rapidly  extending  down  the  line  of  the  ureter  toward  the  scrotum  and  end  of 
the  penis.  The  testicle  is  drawn  upward  by  spasm  of  the  cremaster  muscle. 
The  pain  follows  the  branches  of  the  lumbar  plexus  into  the  groin,  thigh,  and 
hypogastrium.  Vesical  irritation  and  tenesmus  are  frequent.  Faintness,  cold 
sweating,  convulsions,  and  even  collapse,  may  be  present.  These  symptoms 
may  cease  as  suddenly  as  they  began,  but  the  relief  will  not  be  permanent  until 
the  stone  has  passed  into  the  bladder.  As  long  as  the  stone  is  in  the  ureter,  the 
attacks  of  colic  succeed  each  other  at  intervals  of  a  few  minutes  to  an  hour  or 
more.  The  urine  is  high-colored,  scanty,  and  may  even  be  almost  suppressed. 
A  history  of  this  kind  is  an  important  indication  in  cases  of  suspected  stone, 
and  should  lead  the  surgeon  to  make  repeated  examinations  if  the  following 
group  of  symptoms  or  the  majority  of  them  be  present: 

(1)  Frequent  micturition  or  incontinence  of  urine,  more  marked  by  day  than 
by  night;  also  more  marked  if  the  stone  has  an  irregular  surface  than  if  it  is 
smooth,  and  increased  by  active  motion  while  at  play  or  driving  over  rough  roads. 
This  symptom  is  more  marked  and  more  common  in  children  than  in  adults. 

(2)  Pain. — The  characteristic  pain  of  stone  is  darting  and  burning,  and 
is  felt  during  urination,  but  is  most  severe  at  the  termination  of  the  act,  when 
the  irritated  mucous  membrane  of  the  empty  bladder  comes  in  contact  with  the 
calculus.  The  pain  is  rarely  referred  to  the  bladder,  but  is  felt  on  the  under 
surface  of  the  penis  a  short  distance  behind  the  external  meatus.  It  is  so 
severe  as  sometimes  in  children  to  cause  convulsions,  and  often  continues  for  a 
long  time  or  until  sufficient  urine  has  collected  to  remove  the  walls  of  the  blad- 
der from  close  contact  with  the  stone.  In  cases  of  encysted  stone  pain  may  be 
almost  entirely  absent.  Handling  of  the  penis  and  traction  on  the  prepuce  to 
relieve  the  pain  gradually  stretch  the  foreskin  until  it  becomes  abnormally 
long,  and  induce  priapism,  which,  owing  to  the  congestion  of  the  vessels  of  the 
prostato-vesical  region,  often  leads  in  children  to  the  habit  of  masturbation. 

(3)  Sudden  Interruption  of  the  Stream  during  Urination. — In  the  early 
period  of  the  stone,  while  the  calcidus  is  still  small  and  movable,  it  is  often 
swept  into  the  neck  of  the  bladder  and  acts  as  a  ball-valve,  completely  obstruct- 
incr  the  vesical  orifice  of  the  urethra.  The  child  soon  leams  the  best  method 
of  obviating  this  difficulty,  and  will  assume  some  peculiar  or  unusual  position 
which  experience  has  taught  him  Avill  dislodge  the  stone  and  permit  the  com- 
pletion of  the  act. 

(4)  Hcematuria  is  rare  as  a  symptom  in  children.  It  is  due  to  the  wounding 
of  the  congested  mucous  membrane  by  contact  with  the  calculus,  hence  it  is 
aggravated  by  exercise  and  is  most  noticeable  at  the  end  of  urination. 

(5)  Evacuation  of  the  hoicels  during  urination,  with  prolapse  of  the  rectum, 
is  a  frequent  symptom  when  the  vesical  tenesmus  is  great  on  account  of  the 
violent  straining  to  void  the  last  few  drops  of  urine. 


VE8ICAL    CALCULUS.  1043 

(6)  The  presence  of  muco-pus  in  the  urine  is  a  corroborative  symptom  due 
to  tlie  concomitant  cystitis,  and  is  of  no  special  diagnostic  value. 

(7)  Reflex  pains  in  different  parts  of  the  body  are  sometimes  associated 
with  stone.  In  many  cases  the  pains  will  be  referred  to  the  rectum  or  perineum, 
but  sometimes  to  portions  of  the  body  far  removed  from  the  seat  of  the  trouble, 
as  in  the  upper  extremities,  the  back,  lungs,  stomach,  thighs,  and  feet. 

The  principal  symptoms,  then,  are  frequent  desire  to  urinate,  with  incon- 
tinence or  very  rarely  retention ;  pain  referred  to  the  end  of  the  penis ;  sudden 
stoppage  of  the  stream ;  tenesmus ;  prolapse  of  the  rectum ;  and  priapism,  with 
occasionally  more  or  less  cystitis  and  hsematuria. 

But  the  existence  of  this  group  of  symptoms  cannot  justify  a  positive  diag- 
nosis of  stone  unless  further  it  is  felt  and  heard  by  the  surgeon  with  the  aid  of 
the  sound.  The  stone  may  be  in  the  kidney  or  under  the  prepuce.  Rectal  trou- 
bles, prolapse  from  various  irritations,  as  worms,  ulceration,  etc.,  may,  by  reflex 
irritation,  affect  the  functions  of  the  bladder  apparently  as  seriously  as  though 
it  were  the  principal  organ  involved.  Diseases  of  the  kidneys,  phimosis, 
adherent  prepuce,  irritating  smegma,  etc.  may  also  produce  analogous  symp- 
toms, and,  on  the  other  hand,  there  is  no  ordinary  symptom  which  may  not  be 
absent  in  a  case  of  stone. 

Diagnosis. — The  diagnosis  of  stone  is  therefore  to  be  made  with  the  sound. 
Many  different  forms  of  vesical  sound  have  been  recommended,  but  the  best 
and  simplest  has  a  straight  steel  shaft  with  a  short  curve  near  the  tip  and  a 
smooth  flattened  handle.  The  tip  should  be  blunt  and  of  slightly  larger  calibre 
than  the  shaft,  so  that  the  walls  of  the  urethra  may  not  grasp  the  shaft  so  tightly 
as  to  interfere  with  the  delicacy  of  the  movements.  The  curve  at  the  tip  should 
be  shorter  than  in  the  adult  sound,  owing;  to  the  anatomical  difference  of  the 
parts  in  children.  Sounding  should  always  be  done  with  the  patient  under 
ether  unless  there  is  a  good  reason  for  not  doing  so  in  the  special  case.  The 
patient  should  be  in  a  recumbent  or  semi-recumbent  position,  the  abdominal 
walls  well  relaxed  by  slight  elevation  of  the  shoulders,  the  knees  drawn  up, 
and  the  thighs  somewhat  separated.  During  the  exploration  the  bladder  should 
be  moderately  distended  with  water.  The  sound  being  warm  and  well  oiled,  it 
is  held  lightly  but  securely  by  the  handle,  and  the  surgeon  should  allow.it  to 
glide  along  the  upper  surface  of  the  urethra,  more  by  its  own  weight  than  by 
using  any  pushing  force.  Once  in  the  bladder,  the  cavity  should  be  explored 
in  a  systematic  manner.  The  sound  should  be  partially  withdrawn  and  reinserted 
in  a  straight  line,  the  handle  being  slightly  raised  and  depressed  from  time  to 
time.  The  beak  of  the  sound  should  then  be  turned  toward  one  side  of  the  blad- 
der, and  should  be  made  to  traverse  the  arc  of  a  circle,  sweeping  transversely 
through  the  bladder  from  above  downward.  It  should  then  be  turned  to  the 
opposite  side,  and  the  same  manoeuvre  repeated.  If  the  stone  is  not  found 
in  this  manner,  the  searcher  should  again  be  introduced  to  its  full  length,  and 
the  tip  turned  gently  toward  the  floor  of  the  bladder,  and  then  rotated  from 
side  to  side,  while  the  instrument  is  gi'adually  withdrawn  until  it  comes  in  con- 
tact with  the  vesical  neck.  If  the  stone  be  of  moderate  size,  in  nine  cases  out 
often  it  is  struck  and  heard  at  once,  and  its  mobility  in  the  bladder  is  recognized. 
So  positive  are  these  sensations  that  the  nature  of  the  case  is  determined  even 
by  an  inexperienced  examiner.  A  few  surgeons  consider  it  sufiicient  to  feel 
the  stone  with  the  tip  of  the  instrument,  but  the  majority  prefer  to  demonstrate 
its  presence  by  eliciting  the  characteristic  click.  The  latter  is  certainly  by 
far  the  most  definite  and  satisfactory  symptom  it  is  possible  to  obtain,  and, 
although  even  that  does  not  entirely  exclude  the  possibility  of  error,  it  reduces 


1044  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

it  to  a  minimum,  especially  in  children,  where  tumors  with  calcareous  incrusta- 
tions are  exceedingly  rare. 

Among  the  sources  of  failure  in  the  detection  of  stone  are  (1),  the  sound 
may  be  pushed  through  the  delicate  urethra  immediately  anterior  to  its  unde- 
veloped prostate,  when  it  would  at  once  enter  the  ischio-rectal  space,  where, 
in  the  Very  loose  tissues  of  the  child,  it  may  be  moved  about  almost  as  freely 
as  if  it  were  in  the  bladder  ;  or  (2),  without  breaking  through  the  urethra,  the 
loosely-attached  bladder  may  be  pushed  before  the  sound.  This  is  especially 
likely  to  occur  in  children  as  compared  with  adults.  (3)  A  more  or  less  com- 
pletely encysted  condition  of  the  calculus,  leaving  little  or  nothing  of  its  sur- 
face exposed  to  immediate  touch.  This  is  exceedingly  rare  in  young  persons. 
(4)  The  presence  of  a  diverticulum  containing  a  stone  and  communicating 
with  the  bladder  by  a  small  aperture,  the  calculus  in  such  a  case  being  prac- 
tically extra-vesical.  This  is  a  condition  usually  associated  with  long-continued 
obstructive  disease,  and  is  almost  never  found  in  children.  (5)  The  stone  may 
be  suspended  by  a  thread  of  lymph  from  the  summit  or  the  anterior  wall  of  the 
bladder.  (6)  The  surface  of  the  stone  may  be  covered  with  a  blood-clot  or  with 
lymph,  so  as  to  prevent  the  characteristic  sound  from  being  elicited. 

It  is  a  curious  fact  in  the  history  of  stone  in  the  child,  as  well  as  in  the 
adult,  that  one  surgeon  may  detect  the  calculus  and  another  of  equal  expe- 
rience may  miss  it. 

The  examination  for  stone  in  female  children  does  not  differ  materially  from 
the  same  procedure  in  the  male.  Owen  quotes  Holmes's  remark  :  "  I  hope  it 
may  not  be  impertinent  to  point  out  that  at  very  early  ages  the  vagina  may  be 
mistaken  for  the  urethra,"  and  adds,  "  This  caution  is  extremely  pertinent:  if 
there  be  any  doubt,  a  second  sound  may  be  deliberately  passed  into  the  vagina 
to  prove  that  the  first  has  entered  the  bladder  ;  or  the  finger  may  be  passed 
into  the  rectum  to  show  that  the  vagina  is  free  ;  or  the  beak  of  the  sound  may 
be  felt  for  above  the  pubes." 

Preventive  Treatment  of  Stone. — As  we  have  seen,  most  of  the  cases 
in  children  belong  to  the  ignorant  and  poorer  classes,  subjects  of  improper  diet 
and  unfavorable  surroundings.  If  such  cases  could  be  treated  in  the  early 
formative  stage,  there  is  no  doubt  but  that  much  might  be  done  to  prevent  the 
formation  of  stone.  In  the  preventive  treatment  of  calculus  the  avoidance  of 
catarrhal  conditions  of  the  urinary  tract  is  of  the  greatest  importance.  The 
main  colloid  for  acid  stone  is  probably  mucus,  and  a  little  scratching  of  the 
mucous  membrane  by  the  points  of  the  crystals  or  irritation  by  concentrated 
urine  is  sufficient  to  call  out  enough  mucus  to  act  as  a  colloid.  Our  object 
should  then  be  to  make  the  urine  as  bland  and  abundant  as  possible,  and 
for  this  purpose  there  is  nothing  better  than  milk  and  the  free  use  of  water  as 
a  beverage  between  meals.  The  particular  kind  of  water  to  be  used  is  of  minor 
importance,  as  the  most  noted  waters  in  the  treatment  of  stone  seem  to  have 
purity  as  their  chief  recommendation.  A  proper  diet  for  such  a  case  should  be 
chosen  from  the  following  articles  :  fish,  poultry,  bread,  all  cereals,  green  vege- 
tables, salads,  fruits,  and  eggs.  Sugar  and  the  different  kinds  of  fats  are  harmful, 
as  is  an  excess  of  the  dark  meats.  Over-eating  is  especially  and  particularly 
to  be  avoided.  Highly-seasoned  articles  of  food  are  even  more  objectionable 
with  children  than  with  adults,  as  they  tend  to  excess  in  eating,  and  in  addition 
often  cause  acute  indigestion  or,  worse  still,  a  chronic  acid  dyspepsia. 

The  solvent  treatment  of  stone  has  but  little  to  recommend  it.  Brodie  tried 
injections  of  dilute  nitric  acid  ;  Roberts  has  experimented  with  potassium 
citrate  and  acetate ;  Garrod,  with  the  lithia  salts  ;    Vogt,  with   piperazine ; 


VE8ICAL    CALCULUS.  1045 

Beale,  with  ammonium  carbonate,  etc.  Electrolysis  has  also  been  tried  even 
more  unsuccessfully. 

All  these  procedures  are  more  objectionable  in  children  than  in  adults. 
Vesical  injections  of  all  kinds  are  relatively  more  irritating  on  account  of  the 
greater  delicacy  of  the  mucous  membrane.  The  administration  of  large  doses 
of  alkalies  and  diuretics  by  the  mouth  are  almost  certain  to  interfere  with  diges- 
tion, and  thus  do  more  harm  than  good.  In  the  presence  of  excess  of  uric  acid 
or  urates  or  oxalates  in  the  shape  of  crystals,  the  free  use  of  water,  and  of 
small  doses  of  lithia  with  potassium  carbonate,  is  of  great  value  in  prophylaxis  ; 
carbonated  "  lithiated  Vichy"  water,  a  commercial  product,  is  often  agree- 
able and  useful,  but  is  sometimes  disliked  by  children  on  account  of  its  eifer- 
vescence. 

Anatomy  of  the  Urinary  Organs  in  Children. — This  may  be  briefly 
alluded  to  before  describing  the  operative  treatment  of  stone.  In  the  infant 
the  bladder  is  egg-shaped,  having  the  larger  end  resting  in  the  pelvis.  There 
is  no  marked  fundus  or  base  to  the  bladder  in  the  young  child,  and  it  is  situated 
mainly  in  the  abdomen.  As  the  pelvic  cavity  increases  in  size  the  bladder 
gradually  descends  into  it,  and  the  infant  about  this  time  assuming  the  perpen- 
dicular attitude,  it  has  been  thought  that  the  weight  of  the  urine  tends  to  make  the 
lower  part  more  capacious.  Observations  upon  the  dimensions  and  position  of 
the  bladder  will  naturally  vary  with  the  empty  or  distended  state  of  the  organ. 
Through  childhood  until  toward  puberty,  when  the  organs  of  generation  are 
developed  and  the  neighboring  parts  assume  their  normal  adult  relations,  the 
urinary  bladder  is  always  so  loosely  attached  to  the  pelvic  walls  that,  although 
it  may  have  settled  into  the  pelvis,  it  will  require  very  little  force  to  push  it 
upward  into  the  abdomen.  This  lax  condition  of  the  bladder-attachments  is 
of  great  importance  in  the  consideration  of  surgical  interference  in  this  region. 
In  the  young  child  the  anterior  wall  of  the  abdomen,  from  the  symphysis  pubis 
almost  to  the  umbilicus,  is  in  close  relation  to  the  bladder,  and  the  neck  of  the 
bladder  and  urethral  orifice  are  about  on  a  level  with  the  upper  border  of  the 
pubic  symphysis. 

The  peritoneum  is  reflected  entirely  over  the  posterior  surface  of  the  blad- 
der in  the  child.  The  recto-vesical  pouch  usually  embraces  the  prostatic  region 
very  closely,  and  is  liable  to  injury  in  children  during  the  operation  of  litho- 
tomy, causing  peritonitis,  the  most  frequent  fatal  termination  in  that  operation. 

The  anterior  surface  of  the  bladder  is  always  uncovered  by  the  peritoneum 
in  children.  The  capacity  of  the  bladder  in  infancy  is  smaller  than  in  after 
years,  and  this  may  account  for  the  frequency  with  which  young  children 
micturate. 

The  prostate  glaiid  is  very  small  in  children.  According  to  Sir  Henry 
Thompson,  this  gland  "at  the  age  of  seven  years  weighs  only  about  thirty 
grains,  and  between  eighteen  and  twenty  years  it  weighs  two  hundred  and  fifty 
grains,  or  nearly  nine  times  as  much." 

The  urethra,  in  males,  appears  to  increase  slowly  in  length  from  birth  until 
puberty  is  reached.  Its  canal  is  more  dilatable  than  was  formerly  supposed  in 
both  adults  and  children.  The  meatus  is  often  constricted,  so  that  only  a  small- 
sized  catheter  or  sound  can  be  introduced,  but  if  the  orifice  is  incised  quite  a 
large  insti'ument  will  readily  pass.  The  membranous  part  of  the  urethra  in 
children  is  relatively  very  long,  owing  to  the  smallness  of  the  prostate  gland  at 
that  period  of  life.  In  sounding  the  bladder  in  a  child  it  should  be  remem- 
bered that  the  urethra  lies  close  to  the  rectum,  and  that  its  walls  are  exceed- 
ingly thin  and  delicate. 

The  degree  of  curvature  of  the  urethra  is  greater  in  the  child  than  in  the 


1046  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

adult,  but  there  are  variations  in  this  respect  naturally  following,  as  do  those 
pertaining  to  the  contiguous  parts,  upon  growth  or  immature  development. 

In  the  female  the  urethra  is  imbedded  in  the  anterior  wall  of  the  vagina, 
which  is  sometimes  of  large  size  in  childhood,  and  corresponds  to  the  upper 
part  of  the  prostatic  portion  of  the  male  passage.     It  is  very  distensible.^ 

The  Operative  Treatment  of  Stone. — Three  methods  for  removal  of 
stone  from  the  bladder  of  male  children  are  open  to  the  operator:  1.  Supra- 
pubic lithotomy  ;  2.  Perineal  lithotomy  ;   3.  Litholapaxy. 

The  statistics  of  these  operations  (see  next  page)  indicate  unmistakably  the 
rejection  of  the  first  as  a  routine  method  in  children.  It  should  be  reserved  for 
those  calculi  which  are  both  too  large  for  the  perineal  operation  and  too  hard  for 
crushing — a  very  rare  combination. 

A  comparison  of  the  two  other  methods  is,  however,  pf  much  practical 
importance  at  this  time,  the  statistical  evidence  having  only  recently  justified 
positive  conclusions.^ 

Until  comparatively  recent  times  the  very  low  mortality  of  perineal  lith- 
otomy in  children  in  the  hands  of  skilful  operators  made  it  seem  a  work  of 
supererogation  to  seek  for  a  better  method  of  operation.  A  safer  could  scarcely 
be  found.  A  high  rate  of  mortality  after  lithotomy  was  almost  always  due  to 
deaths  among  elderly  adults.  Fergusson  and  Velpeau,  and,  later,  Freyer, 
Thompson,  and  others,  objected  to  the  crushing  of  stone  in  boys  on  account  of 
the  undeveloped  condition  of  the  genito-urinary  organs,  the  smallness  of  the 
bladder,  the  narrowness  of  the  urethra,  and  the  liability  to  laceration  of  the 
vesical  and  urethral  mucous  membrane.  No  instrument  had  been  invented 
by  which  litholapaxy  could  be  performed  with  safety  in  male  children. 

Other  objections  were  advanced  from  time  to  time,  mainly,  however, 
relating  to  the  same  anatomical  points,  and  (before  the  introduction  of  lith- 
olapaxy) to  the  difficulty  of  getting  rid  of  the  fragments,  but  the  majority  of 
them  are  now,  in  the  light  of  the  modern  improvements  in  lithotrity,  without 
applicability. 

Angesthesia  has  made  the  "extreme  sensibility"  of  the  part  and  the  "indo- 
cility"  of  the  patients  of  little  moment.  Otis  has  shown  that  in  children,  as 
in  adults,  the  "small  diameter  of  the  urethra"  may  be  greatly  increased  with 
entire  safety.  He  says  that  the  proportionate  relation  between  the  circumfer- 
ence of  the  urethra  and  that  of  the  penis,  which  he  has  already  demonstrated 
in  adults,  holds  good  in  children.  Thus,  with  a  circumference  of  penis  of  one 
and  a  half  inches,  as  in  a  child  from  two  to  three  years  of  age,  the  size  of  the 
urethra  would  not  be  less  than  sixteen  millimetres  in  circumference;  and  this 
urethral  calibre  increases  or  diminishes  about  two  millimetres  for  every  quarter 
inch  added  to  or  subtracted  from  the  penile  circumference.  It  is  but  fair  to 
mention  that  Morelli  has  called  attention  to  a  fact  upon  which  some  of  the 
success  of  the  Indian  surgeons  may  depend — viz.  the  very  early  age  at  which 
the  children  of  tropical  and  Eastern  countries  reach  full  sexual  development. 
This  may  permit  the  use  of  larger  instruments  on  an  average  at  a  given  age 
than  would  be  possibly  in  Europe  or  America,  and  would  facilitate  and  extend 
the  possibilities  of  litholapaxy. 

Antisepsis  during  and  after  the  operation  has  minimized  the  danger  of 
laceration  of  the  mucous  membrane ;  instruments  have  been  made  which  are  at 
the  same  time  small  enough  to  permit  of  their  introduction  into  the  urethra 

^  For  further  information  I  may  refer  to  McClellan's  Anatomy,  from  which  the  above 
account  has  been  condensed. 

'■'As  my  opinion,  arrived  at  a  few  years  ago  [Medical  News,  May  17,  1890),  remains 
unchanged,  and  has  indeed  been  strengthened  by  later  experience,  I  may  be  excused  for  sum- 
marizing here  the  views  then  expressed  and  making  such  additions  as  seem  important. 


VESICAL    CALCULUS.  1047 

and  bladder  of  Youncr  infants,  and  stroncr  enoucrh  to  deal  with  very  larcre  'and 
very  hard  calculi;  Bigelow  has  oyercome  the  difficulty  of  getting  rid  of  the  frag- 
ments ;  and  the  argument  from  statistics  is  at  least  neutralized  by  the  records 
of  Keegan  and  Freyer. 

Cabot  has  given  the  most  recent  statistics  of  the  three  operations,  made  up 
from  a  series  of  published  cases  and  from  others  obtained  by  him.  As  all 
the  cases  were  operated  upon  after  1878,  and  as  they  are  classified  according 
to  age,  they  are  especially  valuable  for  the  purpose  of  this  paper.  They  may 
be  compared  as  follows  for  children  under  fourteen:  Suprapubic  lithotomy, 
591  cases;  74  deaths;  12.52  per  cent,  of  mortality.  Perineal  lithotomy,  539 
cases;  16  deaths;  2.96  per  cent,  of  mortality.  Litholapaxy,  241  cases;  4 
deaths;  1.66  per  cent,  of  mortality. 

Recurrence. — In  the  face  of  these  fi enures  and  of  the  foregoing  facts  there 
is  but  one  argument  remaining  which,  to  my  mind,  has  any  weight  as  urged 
against  the  operation  of  litholapaxy  in  children,  and  that  is  the  alleged  greater 
probability  of  recurrence. 

As  regards  the  two  great  classes  of  operative  procedures  for  the  removal  of 
calculus — the  cutting  and  the  crushing  operations — all  forms  of  lithotomy  as 
compared  with  all  forms  of  lithotrity  and  at  all  ages,  there  can  be  little  doubt 
that  the  statistical  evidence  in  relation  to  recurrence  is  at  present  in  favor  of 
lithotomy.  But  it  should  not  be  accepted  without  reservation.  Many  of  the 
tables,  notably  those  of  Sir  Henry  Thompson  and  of  Mr.  Cadge,  are  based  on 
an  experience  extending  over  many  years  and  antedating  the  introduction  of 
litholapaxy.  Those  tables  make  the  proportion  of  recurrence  after  lithotrity 
about  1  in  7  or  1  in  8.  and  after  lithotomy  about  1  in  20 ;  but,  like  so  much 
of  the  statistical  matter  which  our  text-books  and  journals  contain,  they  are 
useless  or  misleading  at  the  present  day.  The  two  principal  causes  which  lead 
to  recurrence  are — a.  The  failure  to  remove  every  portion  of  stone  at  the  first 
operation ;  h.  The  new  formation  of  stone  in  the  kidney  and  its  descent  into 
the  bladder.  In  the  tables  of  Mr.  Donald  Day,  based  on  the  records  of  the 
Norwich  Hospital,  the  first  class  includes  two-thirds  of  all  the  cases  of  recur- 
rence. But  circumstances  have  altered.  The  employment  of  a  large-sized 
evacuating-tube.  the  immediate  and  thorough  emptying  of  the  bladder,  the 
minute  pulverization  usually  possible  with  completely  fenestrated  lithotrites, 
the  increased  knowledge  of  the  great  tolerance  of  the  bladder  to  prolonged 
manipulations  if  they  are  gentle  and  skilful,  have  all  combined  to  place  the 
question  of  recurrence  upon  a  very  different  level,  and  to  make  the  collection 
of  a  new  set  of  statistics  as  to  recurrence  absolutely  necessary  before  venturing 
to  draw  any  positive  conclusions. 

But  if,  for  the  sake  of  argument,  we  investigate  existing  statistics  on  this 
subject,  we  find  that  the  great  majority  of  cases  of  relapse  or  recurrence  have 
taken  place  in  patients  past  middle  life,  and  especially  in  very  old  persons 
with  enlarged  prostates  and  feeble  or  atonic  bladders.  It  will  be  recognized 
at  once  that  these  conditions  do  not  prevail  in  children.  The  prostate  is 
undeveloped;  the  bladder  is  almost  an  abdominal  organ;  no  pouch  exists  at 
the  fundus ;  sacculation  is  nearly  or  quite  unknown  •}  cystitis  is  a  compara- 
tively manageable  complication ;  the  expulsive  power  is  proportionately  greater 
than  in  the  male  adult,  in  whom  a  "physiological  atony"  is  not  at  all  infre- 
quent. In  addition  to  the  reasons  above  given  for  not  anticipating  the  forma- 
tion of  new  calculi  in  children  around  nuclei  of  vesical  origin,  it  may  be  rea- 
sonably expected  that  the  conditions  favoring  the  development  of  renal  calculi 

^  Fergusson  said  that  even  in  adults  "  sacculated  stones  "  were  generally  met  with  by  young 
lithotomists. 


1048  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN, 

will  be  more  easily  treated  and  controlled  in  children  than  in  adults.  Cer- 
tainly among  well-to-do  people  who  can  carry  out  a  proper  system  of  diet  and 
medication  it  is  fair  to  suppose  that  the  lithic  diathesis,  of  whatever  variety, 
will  be  more  readily  combated  in  children  whose  diet  and  drugs  and  mode  of 
life  can  be  rigidly  administered  than  in  adults  with  fixed  and  often  very  pre- 
judicial habits.  Mr.  Cadge  expressly  states  that  this  was  true  in  his  own 
cases,  and  adds  that  he  has  no  personal  experience  of  lithotrity  in  children. 

Jacobson  at  one  time  asserted  that  this  important  matter — the  percentage  of 
recurrences  after  litholapaxy — had  been  left  undealt  with  by  Keegan,  then  the 
chief  advocate  of  this  operation  in  male  children. 

Keegan,  in  reply,  says  that  in  his  monograph  on  the  subject  (1886)  he 
did  not  deal  with  this  point,  because  then  he  had  only  had  58  cases  in  male 
children  and  boys.  Later  (1890),  the  operation  having  been  on  trial  for  more 
than  seven  years,  and  he  having  collected  145  cases,  110  of  Avhich  he  had  per- 
formed himself,  he  felt  competent  to  consider  the  question,  and  said :  "  As  to 
the  outcome  of  this  practice  and  experience,  I  have  arrived  at  the  conclusion 
that  recurrence  of  stone  does  not  follow  litholapaxy  in  male  children  any  oftener 
than  it  does  lateral  lithotomy,  provided  that  the  former  operation  be  skilfully 
performed.  It  will  be  conceded  that  recurrence  of  stone  after  litholapaxy, 
when  performed  on  adult  and  aged  male  patients,  is  less  than  that  which 
in  former  days  followed  the  now  obsolete  lithotrity  of  many  sittings.  But  it 
must  be  admitted  that  recurrence  of  stone  does  occasionally  follow  litholapaxy 
in  old  patients.  When,  however,  we  come  to  investigate  the  causes  of  this 
recurrence,  we  find  that  the  main  factors  which  bring  it  about  in  aged  patients 
do  not  exist  in  the  case  of  male  children  and  boys."  He  states  that  he  began 
in  1881  to  use  litholapaxy,  and  that  of  the  145  cases  operated  on  since  but  one 
boy  has  returned  with  a  second  calculus. 

Freyer  records  3  cases  of  recurrence  in  65  children,  the  average  age  of 
whom  was  seven  and  a  half  years. 

For  these  reasons,  while  admitting  that  the  question  of  recurrence  is  still 
sub  judice,  I  am  distinctly  of  the  opinion  that  there  is  little  probability  that 
there  will  be  enough  difference  between  the  proportions  of  relapses  in  children 
after  lithotomies  and  after  litholapaxies  to  justify  any  decided  preference  on 
that  ground  alone. 

The  position  of  litholapaxy  in  children  is  moreover  strengthened  by  a  review 
of  the  history  of  lithotomy,  which,  unlike  the  operation  with  which  we  contrast 
and  compare  it,  has  undergone  but  little  change  for  many  years. 

The  improvements  in  suprajmbie  lithotomy/  have,  it  is  true,  rendered  it 
applicable  to  a  much  wider  range  of  cases,  and  it  is  equally  true  that  its  most 
favorable  results  have  been  attained  in  children ;  but  thus  far,  as  we  have  seen, 
the  statistics  of  suprapubic  lithotomy  in  children  do  not  compare  favorably  with 
those  of  either  litholapaxy  or  lateral  lithotomy.  This  is  probably  due  to  the 
fact  that  in  a  large  proportion  of  cases  the  operation  was  selected  only  after 
litholapaxy  had  been  attempted  and  failed,  or  else  was  originally  chosen  on 
account  of  the  unusual  character  of  the  calculus. 

It  is  true  that  MacCormac  has  reported  33  cases  of  suprapubic  lithotomy 
without  a  death,  but  they  were  from  scattered  sources  and  did  not  constitute  a 
consecutive  series.  There  is  no  means  of  knowing  how  many  unsuccessful,  and 
therefore  unreported,  cases  occurred  during  the  same  period. 

It  will  probably  always  be  employed  in  preference  to  lateral  or  median  lithot- 
omy in  cases  of  extremely  large  or  exceptionally  hard  stones;  but  when  we 
remember  that  Freyer  has  removed  by  litholapaxy  a  calculus  weighing  808 
grains  from  a  boy  of  nine,  and   Keegan  one  of  700  grains  (and  of  uric  acid) 


VESICA L    CAL  CUL  US.  1 049 

from  a  boy  nine  and  a  half,  it  is  evident  that  neither  size  nor  hardness  offers  an 
insuperable  bar  to  the  latter  operation. 

Median  litJiotomy  in  children,  although  advocated  by  some  surgeons,  is 
objectionable  on  account  of  the  greater  danger  of  wounding  the  bulb  or  the 
rectum,  and  the  difficulties  in  obtaining  space  through  which  to  pass  the  finger 
into  the  urethra  and  the  bladder.  It  is  indeed  true  that  the  passage  of  the  finger 
is  not  absolutely  necessary,  although  it  has  always  been  one  of  the  time- 
honored  rules  of  lithotomy  not  to  withdraw  the  staff  until  the  finger  is  in  con- 
tact with  the  stone.  I  have,  however,  frequently  seen  Dr.  Agnew,  when 
operating  on  young  children,  introduce  a  pair  of  very  small  lithotomy  forceps 
along  the  groove  of  the  staff,  separate  them,  and  seize  the  stone,  and  then,  after 
the  removal  of  the  staff,  extract  the  calculus,  the  finger  never  having  been  in 
the  bladder.  I  have  used  the  same  manoeuvre  myself  with  success.  I  sup- 
posed it  was  original  with  Dr.  Agnew  (and  believe  he  was  of  the  same  opinion), 
but  I  found  that  Mr.  Cadge  recommended  almost  precisely  the  same  method  as 
both  safe  and  efficient,  adding,  "  I  dare  say  it  has  been  adopted  by  others,  but 
I  do  not  find  it  alluded  to  in  modern  text-books."  It  must  be  remembered, 
however,  that  its  adoption  places  the  surgeon  in  almost  the  same  situation  in 
regard  to  the  possibility  of  leaving  ddbris  or  unnoticed  stones  in  the  bladder  as 
he  occupies  after  a  litholapaxy.  If  the  stone  is  soft  and  breaks  down  under  the 
foi'ceps,  or  if  there  are  multiple  calculi,  he  will  be  dependent  on  the  touch  and 
sound  elicited  by  the  vesical  explorer,  just  as  after  the  other  operation. 

If,  then,  the  introduction  of  the  finger  be  dispensed  with  in  either  median 
or  lateral  lithotomy  in  children,  these  operations  lose  one  of  their  alleged  advan- 
tages— viz.  the  assurance  of  the  absolute  removal  of  all  calculous  fragments. 
If  it  be  insisted  upon,  it  constitutes  in  a  small  proportion  of  cases  an  unavoid- 
able source  of  both  difficulty  and  danger.  Sir  William  Fergusson,  Keith, 
Thompson,  Cadge,  and  many  others  have  recorded  occasional  trouble  with  this 
step  of  the  operation.  The  latter  surgeon  remarks,  apropos  of  Fergusson's 
case  :  "  He  was  a  master  of  the  art  of  operative  surgery  ;  if  the  difficulty 
occurred  to  him,  we  may  conclude  that  it  is  not  unlikely  to  occur  to  any 
of  us," 

Lateral  lithotomy  in  children,  in  addition  to  the  special  difficulty  due  to  the 
smallness  of  the  parts,  the  high  position  of  the  bladder  above  the  pelvis,  the 
delicacy  and  mobility  of  the  deep  urethra  and  the  vesical  neck,  has  one  pos- 
sible contra-indication  which  should  not  be  lost  sight  of.  If  the  incision  be 
prolonged  a  little  too  far  backward,  the  left  ejaculatory  duct  can  hardly  escape 
division  and  subsequent  obliteration ;  and  although  this  may  not  be  a  serious 
accident  in  cases  in  which  the  integrity  of  the  opposite  half  of  the  genitals,  the 
testicle,  duct,  etc.,  is  unimpaired,  yet  it  leaves  the  patient  entirely  dependent 
on  that  one  side  for  fertility  if  not  for  potency.  Mr.  Teevan  has  reported  four 
cases  of  sterile  husbands  among  lithotomized  patients.  Langenbeck  and  Sir 
William  MacCormac  have  called  attention  to  the  same  danger,  and  Keegan 
believes  the  lateral  operation  to  be  frequently  followed  by  emasculation. 
Dennis  quotes  Dr.  Charles  Leale  in  relation  to  several  cases  coming  under  his 
own  observation,  in  which  such  patients  grew  up  with  shrill  voices,  atrophied 
testicles,  absence  of  hair  upon  the  face,  etc. ;  in  fact,  with  all  the  character- 
istics of  eunuchs.  The  evidence  as  to  this  point  is  as  yet  fragmentary  and 
inconclusive,  but  is  of  sufficient  importance  to  deserve  careful  consideration, 
although  Ehrmann  characterizes  the  fear  of  sterility  as  a  "  bugbear." 

The  objections  to  perineal  lithotomy  in  children  are,  however,  at  least  as 
weighty  as  any  that  have  been  urged  against  litholapaxy. 

The  ease  and  satisfaction  to  both  patient  and  surgeon  with  which  the  latter 


1050  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

operation  may  be  performed  I  can  best  illustrate  by  a  brief  abstract  of  one  of 
the  earliest  of  my  own  cases  : 

C.  W ,  a  small  boy,  aged  five  and  a  half,  was  brought  to  me  by  his 

father  in  October,  1889,  on  account  of  nocturnal  incontinence  of  urine.  He 
had  a  long,  tightly-adherent  prepuce  with  pin-point  aperture.  It  "  ballooned  " 
at  each  act  of  urination.  I  circumcised  him,  gave  small  doses  of  belladonna 
and  bromide  of  sodium,  and  dismissed  him,  apparently  cured,  in  November. 

In  January  he  was  brought  to  me  again  by  his  nurse,  who  told  me  that  his 
symptoms  had  returned.  I  then  sounded  him  for  stone,  but  failed  to  find  it. 
Insisting  (according  to  my  invariable  rule  in  such  cases)  upon  a  second  exami- 
nation before  giving  a  positive  opinion,  I  easily  found  a  calculus.  I  recom- 
mended crushing,  and  after  a  little  delay  the  parents  consented.  On  February 
20th,  the  child  being  etherized,  I  drew  off  the  urine  and  injected  three  ounces 
of  warm  boric-acid  solution  (fifteen  grains  to  the  ounce)  into  the  bladder.  I 
then  enlarged  the  meatus  ^  and  introduced  a  Weiss  fenestrated  lithotrite.  No.  16 
French.  This  went  in  with  ease.  The  stone  was  readily  seized  and  broken. 
I  spent  twenty-five  minutes  in  pulverizing  it,  paying  especial  attention  to  gen- 
tleness of  movement  and  to  the  avoidance  of  rude  or  unnecessarily  wide  sepa- 
ration of  the  jaws  of  the  instrument.  A  No.  16  tube  was  then  introduced  and 
a  Bigelow  evacuator  employed.  In  about  eighteen  minutes,^  as  no  more  frag- 
ments or  dust  could  be  perceived,  the  tube  was  withdrawn  and  the  bladder 
carefully  explored  with  a  vesical  sound.     Nothing  was  discoverable. 

The  time  of  operation  was  forty-three  minutes ;  weight  of  dried  calculus, 
170  grains.  The  child  was  sitting  up  in  bed  on  February  22d,  and  was  out  of 
bed,  playing  about  the  room,  on  February  25th.  The  nocturnal  incontinence 
persisted  for  a  week  or  ten  days,  and  then  disappeared  entirely.  There  was  no 
fever,  bleeding,  chill,  or  other  alarming  symptoms. 

The  parents  were  nervous,  consented  reluctantly  to  this  operation,  and 
would  certainly  have  postponed  a  lithotomy  for  a  long  time,  much  to  the  child's 
detriment. 

This  is  a  typical  case  of  litholapaxy  in  a  young  boy.  I  have  now  had 
many  such  cases,  and  have  never  had  a  moment's  anxiety  about  the  little 
patients.  It  can  scarcely  be  wondered  at  that  after  his  experience  Keegan 
writes  that  he  would  as  soon  think  of  cutting  an  old  man  for  the  removal  of  a 
small  stone  as  of  performing  lateral  lithotomy  on  a  boy  whose  urethra  would 
readily  admit  the  passage  of  a  No.  8  (No.  15  French)  lithotrite,  and  whose 
sj;one  was  neither  abnormally  large  nor  hard.  Nor  is  it  surprising  that  Freyer 
says  that,  lithotomy  in  the  adult  having  been  practically  blotted  out  of  his 
practice,  he  looks  forward  confidently  to  lithotomy  in  children  meeting  with  a 
similar  fate.  Freyer  says:  "When,  in  1885,  Keegan  first  shoAved  that  Bige- 
low's  operation  was  capable  of  successful  extension  to  the  case  of  male  children, 
I  lost  no  time  in  procuring  the  necessary  instruments  and  applying  the  opera- 
tion to  such  cases.     In  two  papers  I  placed  before  the  profession  full  details  of 

'  Otis  recommends  performing  the  meatotomy  long  enough  before  the  litholapaxy  to  allow 
the  parts  to  heal.  This  is  certainly  desirable  for  some  reasons,  but  in  nervous  children  its  advan- 
tages are  counterbalanced  by  the  need  for  two  fixed  appointments,  two  operations,  etc.  I  have 
never  found  any  harm  resulting  from  the  y)lan  I  here  followed. 

^  The  pressure  on  the  rubber  bulb  during  the  process  of  evacuation  should  be  slight  and 
frequent  rather  than  slow  and  vigorous.  Prof  Bigelow  himself  called  my  attention  to  the  much 
greater  value  of  the  former  method,  and  I  have  repeatedly  verified  the  correctness  of  the  state- 
ment. Not  only  is  the  danger  of  driving  back  into  the  bladder  sharp  fragments  of  stone  mate- 
rially lessened,  but  the  swiftness  and  eflPectiveness  of  the  outward  current  are  much  increased. 
I  so  often  see  an  entirely  unnecessary  degree  of  force  expended  in  the  working  of  the  bulb  during 
this  stage  of  a  litholapaxy,  even  by  expert  operators,  that  it  seems  worth  while  to  make  this 
note. 


VESICAL    GALGULU8,  1051 

49  cases  of  litholapaxy  undertaken  by  me  in  male  children  or  boys  below  the 
age  of  puberty.  Since  then  67  males  of  fifteen  years  and  under,  suffering  from 
stone,  have  come  under  ti*eatment,  and  in  QQ  of  these  I  have  performed  litho- 
lapaxy— in  all  with  complete  success.  In  only  one  instance  was  it  necessary 
to  have  recourse  to  lithotomy  (suprapubic).  The  greater  my  experience  of 
litholapaxy  amongst  male  children  becomes,  the  more  I  am  fascinated  by  this 
operation.  Though  the  average  number  of  days  such  cases  were  kept  in  hos- 
pital was  five  and  a  half  as  a  rule,  these  little  patients  may  be  seen  playing 
about  the  day  after  the  operation,  perfectly  happy  and  untroubled  by  urinary 
symptoms  of  any  kind." 

Cadge,  MacCormac,  Jacobson,  Kingston,  Keyes,  Hunt — indeed,  most  recent 
writers — press  the  conviction,  though  in  less  sweeping  terms,  that  the  field  of 
litholapaxy  in  children  is  likely  to  be  considerably  enlarged  in  the  near 
future. 

I  have  once,  in  a  patient  of  Dr.  E.  L.  Duer's,  been  compelled  to  abandon 
the  operation  on  account  of  the  impossibility  of  inserting  the  evacuator, 
although  a  lithotrite  of  equal  calibre  had  gone  in  easily.  Walsham  and  Mar- 
shall have  called  attention  to  the  necessity  of  having  a  number  of  sizes 
of  lithotrites  and  evacuating  tubes,  as  they  had  both  found  great  difiiculty 
toward  the  end  of  the  operation  in  children  in  introducing  an  instrument  which 
had  passed  easily  at  its  commencement.  This  is  the  only  experience  of  the  sort 
I  have  had  in  a  child.  The  patient,  aet.  ten  years,  passed  40  grains  of  detritus, 
and  a  few  weeks  later  I  removed  a  calculus  weighing  240  grains  by  the  lateral 
operation.      Convalescence  was  then  uninterrupted. 

Basing  my  opinion  on  the  facts  mentioned  in  this  paper  and  on  my  personal 
experience,  I  believe  the  following  conclusions  to  be  justifiable : 

1.  In  every  case  of  calculus  in  male  children^  litholapaxy,  on  account  of 
ease  of  performance,  low  mortality,  speedy  recovery,  and  absence  of  danger 
of  emasculation,  should  be  the  operation  of  predilection,  division  of  the  meatus 
being  freely  resorted  to  if  that  portion  of  the  urethra  offers  an  obstacle  to  the 
introduction  of  instruments. 

2.  The  lithotrite  and  evacuating-tube  should  be  of  a  size  which  can  be 
inserted  into  the  bladder  without  much  effort  or  over-distention,  and  great 
gentleness  should  be  observed  in  passing  these  instruments.  Keegan  says : 
"■  When  I  advocate  litholapaxy  as  being  the  best  operation,  in  my  opinion,  for 
the  great  majority  of  stones  occurring  in  male  children  and  boys,  I  do  so 
with  a  very  important  reservation — viz.  that  no  one  should  attempt  to  per- 
form it  in  boys  until  he  has  first  gained  some  practical  experience  of 
it  in  adult  males.  The  surgeon  who  meets  with  cases  of  stone  only  at  rare 
intervals  during  his  career  will  be  acting  more  wisely  if  he  adheres  to  lateral 
lithotomy  or  suprapubic  cystotomy.  It  is  his  misfortune,  and  not  his  fault,  that 
he  has  not  been  afforded  many  opportunities  of  gaining  a  practical  familiarity 
with  the  use  of  the  lithotrite." 

3.  The  instruments  should  be  Avithdrawn  and  reintroduced  as  seldom  as  pos- 
sible, the  stone  being  finely  pulverized  before  the  lithotrite  is  taken  out  at  all. 
In  seeking  for  or  attempting  to  seize  the  stone  care  should  be  taken  to  avoid 
such  wide  separation  of  the  blades  as  will  bring  the  male  blade  in  frequent 
contact  with  the  vesical  neck.  The  crushing  should  invariably  be  done  only 
after  rotating  the  blades  into  the  centre  of  the  bladder.  Every  particle  of 
the  calculous  dust  should  be  evacuated. 

4.  Rest  in  bed,  milk  diet,  and  sterilization  of  the  urine  by  boric  acid  or 

1  These  remarks  apply  almost  as  well  to  adults. 


1052  ami:ricax  text-book  of  diseases  of  children. 

salol  given  internally,  both  before  and  after  the  operation,  are  valuable  adju- 
vants.    During  the  operation  every  antiseptic  precaution  should  be  observed. 

Southam  very  properly  emphasizes  the  importance — «,  of  this  preliminary 
sterilization  of  the  urine  by  the  administration  of  salol  and  boric  acid,  and  if 
need  be  by  irrigation  of  the  bladder ;  and  6,  the  avoidance  of  shock  by 
thorough  protection  of  the  patient  against  surface  chilling. 

5.  The  exceptional  cases  of  calculi  which  are  both  large  and  hard  may  be 
best  treated  by  suprapubic  lithotomy,  but  neither  unusual  size  nor  a  moderate 
degree  of  densitv  should  of  itself  alone  be  thought  positivelv  to  contraindicate 
litholapaxy. 

6,  Perineal  lithotomy  has  now  a  very  limited  field,  and  should  be  employed 
chiefly  in  those  cases  of  stone  thought  to  be  of  small  or  medium  size,  in  which 
no  lithotrite.  however  small,  can  be  introduced  with  safety.^ 

Operative  Treatment  for  Stone  in  Female  Children. — Surgical  opinion 
in  regard  to  the  choice  of  operation  in  female  children  has  not  as  yet  become 
so  definitely  established.     The  possible  methods  are — 

a.  Vaginal  Lithotomy.,  which  is  attended  with  much  disturbance  of  the  parts, 
requires  over-stretching  of  the  vagina,  section  of  the  fourchette.  destruction  of 
the  hvmen,  etc.,  and  which,  even  in  good  hands,  has  not  infrequently  been  fol- 
lowed by  a  permanent  vesico-vaginal  fistula. 

h.  Dilatation  of  the  Urethra. — This  is  easy  and  safe  in  the  case  of  small 
stones,  but  in  larger  ones,  and  especially  if  incision  of  the  urethra  is  required, 
is  extremely  liable  to  be  followed  by  incontinence. 

c.  Suprapubic  Lithotomy. — This  is  at  present  the  operation  of  choice  with 
manv  surgeons.  Jacobson  thinks  it  would  be  wiser  to  make  use  of  it  in  all 
but  the  very  smallest  stones.  He  adds :  '"I  would  refer  my  readers  to  a  case 
of  suprapubic  operation  by  Mr.  Barwell  m  a  child  aged  nine,  from  whom  a  stone 
weighing  two  and  a  half  ounces  Avas  successfully  removed.  It  is  interesting  to 
note  that  Mr.  Barwell  was  led  to  adopt  the  suprapubic  operation  from  his 
having  had  within  seven  months  no  less  than  three  cases  of  vesico-vaginal 
fistul^e  originating  in  the  extraction  of  calculi  during  infancy  and  youth  by 
different  surgeons," 

cl.  Litholapaxy. — The  statistics  which  are  slowly  accumulating  (chiefly  from 
Indian  sources)  tend  to  show  that  this  will  be  the  operation  of  the  future,  but 
cases  of  stone  in  female  children  are  so  rare  comparatively  that  the  figures  thus 
far  available  cannot  be  regarded  as  conclusive.  The  difficulty  of  crushing  in 
such  small  bladders  has  been  alluded  to.  but  it  is  usually  not  greater  than  in  the 
case  of  males.  If  a  lithotrite  and  a  fair-size  evacuating-tube  can  be  inserted 
without  over-distention  of  the  urethra,  there  would  seem  to  be  no  a-priori  rea- 
son why  the  operation  should  not  be  as  successful  in  females  as  in  males. 

The  details  of  the  performance  of  the  various  operations  in  both  male 
and  female  children  belong  to  the  systematic  works  on  general  and  operative 
surgery,  and  need  not  here  be  considered. 

It  may  be  remarked,  finally,  however,  that  an  improvement  in  results 
scarcely  less  than  that  found  in  other  branches  of  surgery  has  followed  the  in- 
troduction of  antisepsis  into  genito-urinary  work,  and  that,  whichever  operation 
is  selected  in  a  given  case  of  vesical  calculus  in  a  child,  the  little  patient  is  on 
the  averaure  safer  to-dav  than  he  was  in  the  hands  of  even  the  most  skilful 
operator  twenty-nve  years  ago.^ 

^An  American  Tejt-Book  of  Surc/ery,  1892. 

^  I  desire  to  acknowledge  my  obligation  to  Dr.  Eobert  G.  Le  Conte  for  the  collection  of 
much  statistical  matter  upon  which  some  of  the  above  statements  are  based  and  for  further  aid 
in  the  preparation  of  this  article. 


GONORRHCEA  AND  VULVOVAGINITIS. 

By  J.  WILLIAM  WHITE,  M.  D., 

Philadelphia. 


I.    GONORRHCEA   IN  MaLE  OhILDREN. 

In  male  children  specific  urethritis  does  not  differ  materially  in  its  course, 
symptoms,  and  complications  from  the  same  disease  in  the  adult.  The  cause 
is  often  some  sexual  relation  established  between  the  child  and  an  adult  female 
for  purposes  of  sexual  gratification  of  the  latter,  even  though  the  boy  may  be 
so  young  that  intromission  is  impossible.  In  other  cases  mediate  contagion  has 
occurred  by  means  of  dirty  clothing,  towels,  or  cloths  used  by  older  persons  of 
the  same  household,  etc.  In  others,  chiefly  in  boys  near  the  age  of  puberty, 
the  disease  is  acquired  in  the  customary  manner — i.  e.  during  actual  or  at- 
tempted intercourse. 

Symptoms. — The  usual  symptoms,  purulent  discharge,  ardor  urinse, 
chordee,  frequent  urination,  etc.,  are  present.  Of  the  complications,  phimosis 
and  balano-posthitis  are  more  common  than  in  the  adult,  owing  to  the  rela- 
tively excessive  length  of  the  prepuce  and  to  the  delicate  character  of  the 
mucous  membrane  lining  it  and  covering  the  glans.  Cystitis  is  not  uncom- 
mon; epididymitis  is  more  so.  Prostatitis,  as  might  be  expected,  is  almost 
unknown,  or  at  least  cannot  be  differentiated  from  vesical  inflammation.  The 
intensity  of  the  urethritis  and  the  severity  of  the  symptoms  are  both  rather 
greater  than  in  the  average  case  in  the  adult,  and  the  accompanying  constitu- 
tional disturbance  is  much  more  marked. 

Diagnosis. — As  such  cases  are  not  infrequently  the  basis  of  legal  pro- 
ceedings, the  physician  should  be  especially  guarded  in  pronouncing  upon  the 
character  of  the  disease  in  any  given  instance.  While  specific  urethritis  can 
usually  be  traced  to  one  or  the  other  of  the  causes  above  named,  there  are 
many  cases  of  simple  urethritis  which  are  clinically  indistinguishable,  and  the 
non-specific  nature  of  which  can  only  be  recognized  by  the  absence  of  a  his- 
tory of  infection  on  the  one  hand,  and  by  the  existence  of  a  sufficient  trau- 
matism, such  as  the  passage  of  instruments,  the  ejection  of  a  calculus,  etc.,  on 
the  other.  I  have  seen  severe  urethral  inflammation  follow  retention  and  decom- 
position of  smegma  beneath  a  long,  tight  prepuce,  the  orifice  of  which  was  so 
small  that  "ballooning"  occurred  with  each  act  of  urination.  In  such  cases  a 
small  quantity  of  urine  is  always  retained  beneath  the  foreskin,  and  cleanliness 
is  impossible.  In  comparison,  however,  with  the  number  of  cases  in  which 
this  condition  exists  in  children  the  frequency  of  occurrence  of  urethritis  as  a 
result  is  extremely  small,  and  caution  should  be  observed  in  attributing  a  par- 
ticular urethritis  to  this  cause. 

While  bacteriological  investigation  will  throw  much  light  upon  the  etiology 
of  a  case  of  this  kind,  our  information  is  not  yet  definite  enough  to  enable  us 
to  predicate  absolutely  upon  the  presence  of  the  gonococcus  the  specific  char- 

1053 


1054  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

acter  of  the  inflammation.  It  renders  it  highly  probable  that  the  disease  is 
the  result  of  infection,  direct  or  indirect,  from  another  person  having  the  same 
disease,  but  it  is  not  yet  safe  to  say  more  than  that.  Competent  observers,  such 
as  Bumm,  assert  that  in  the  normal  urethra  a  diplococcus  is  found  having  all 
the  peculiarities  of  the  gonococcus.  If  this  be  true,  even  if  it  occurs  with 
great  rarity,  it  is  apparent  that  it  destroys  the  diagnostic  value  of  the  gonococ- 
cus in  medico-legal  cases.  A  knowledge  of  its  presence  is,  however,  of  use 
clinically,  as  indicating  an  inflammation  of  more  severe  type  than  the  simple 
urethritis  in  which  the  infection  has  been  exclusively  with  staphylococci  or 
streptococci. 

Treatment. — The  child  should  be  kept  in  bed.  If  there  is  marked  phi- 
mosis, the  prepuce  should  be  slit  up  the  dorsum,  or,  if  the  oedema  and  inflam- 
matory exudate  are  not  too  extensive,  a  formal  circumcision  should  be  per- 
formed. The  organ  should  be  wrapped  in  cloths  wet  with  lead-water  and 
laudanum,  and  the  constitutional  disturbance  controlled  by  mild  laxatives, 
small  doses  of  aconite,  and  full  doses  of  potassium  bromide.  An  excellent 
formula  is  the  following,  the  doses  of  which  are  proper  for  a  child  five  years 
of  age: 

I|«.  Potassii  bromidi Sj. 

Acid,  borici gr.  xlviij. 

Tinct.  aconiti lUiij- 

Tinct.  belladonnne ITLxij. 

Spts.  setheris  nitrosi f^iij- 

Mist,  potassii  citrat q.  s.  adf^vj. — M. 

Sig.  Dessertspoonful  in  water  every  two  hours. 

The  diet  should  consist  almost  exclusively  of  milk. 

When  the  inflammatory  symptoms  have  subsided  the  use  of  injections  may 
be  begun.  They  should  be  from  one-half  to  two-thirds  of  the  strength  required 
for  the  adult,  and  the  excellent  rule  applicable  to  the  latter  should  not  be 
deviated  from — viz.  to  avoid  the  production  of  pain  by  the  free  dilution  of  the 
injection  to  any  necessary  extent. 

It  is  often  well  to  begin  with  a  lead-and-laudanum  injection,  substituting 
the  extract  of  opium  for  the  tincture : 

I^.  Ext.  opii  aq gr.  vj. 

Liq.  plumbi  subacetat.  dil fsvj. — M. 

Sig.  Use  locally. 

Later,  an  antiseptic  and  astringent  injection  like  the  following  may  be 
employed  with  advantage  : 


Hydrarg.  chlorid.  corros. 


rr-  ^V- 


Acid,  boric 3j. 

Zinci  sulpho-carbolat gr.  xij. 

Liq.  hydrogen  peroxid f.^ss. 

Aquse  rosae f 5vss. — M. 

Sig.   Use  locally. 

These  injections  should  be  given  by  a  nurse  immediately  after  the  child  has 
urinated.  From  half  a  drachm  to  a  drachm  is  a  sufficient  quantity  to  throw  in 
at  one  time. 


GONOBBHCEA    AXD    VULVO- VAGINITIS.  1055 

During  the  subsiding  stage  the  internal  administration  of  salol  will  be  of 
use,  and  if  an  irregular  febrile  movement  persists,  as  is  sometimes  the  case,  full 
doses  of  quinine  night  and  morning  will  be  of  great  value. 

n.    VULVO-VAGINITIS. 

The  vulvo- vaginitis  of  children  may  be — a,  Catarrhal  or  irritative  ;  h, 
Gonorrhoeal. 

a.  The  catarrhal  form  is  caused  by  any  simple  irritant,  the  commonest 
causes  being  the  prolonged  contact  of  the  parts  with  filthy  diapers,  the  retention 
of  urinous  and  sometimes  of  faecal  matter  between  the  labia,  all  forms  of 
dirt,  seat-worms,  etc.  It  may  be  excited  by  any  traumatism  or  by  an  attempt 
at  rape.  It  is  an  almost  pure  vulvitis,  the  vagina  being  but  slightly  involved 
and  the  urethra  very  rarely. 

It  is  characterized  by  the  ordinary  symptoms  of  inflammation,  heat,  swell- 
ing, redness,  pain  or  itching,  and  sometimes  by  extensive  excoriation  or  actual 
ulceration. 

b.  The  gonorrhoeal  form  is  much  more  severe.  There  is  free  purulent  dis- 
charge, much  swelling  of  the  external  genitalia,  intense  hypertemia  of  the 
mucous  surfaces,  which  bleed  readily  when  touched,  ardor  urinEe,  pelvic  and 
abdominal  pain,  and  often  some  endometritis,  with  tenderness  and  swelling 
of  the  uterus. 

The  constitutional  symptoms  are  quite  marked.  The  fever  often  has  a  high 
range  and  is  very  persistent.  The  local  conditions  are  apt  to  be  rebellious  to 
treatment. 

Diagnosis. — The  diagnosis  between  these  two  conditions  is  often  a  matter 
of  the  gravest  importance,  not  so  much  perhaps  to  the  little  patient  as  to  others 
who  may  be  suspected  of  being  the  source  of  infection. 

The  clinical  diagnosis  will  be  based  upon  the  presence  or  absence  of  the 
causes  of  catarrhal  vulvitis  enumerated  above,  and  upon  the  extent  and  charac- 
ter of  the  symptoms.  The  catarrhal  variety  is  not  markedly  contagious,  does 
not  give  rise  to  purulent  ophthalmia,  and  yields  readily  to  treatment.  The 
reverse  is  true  of  the  gonorrhoeal  variety.  The  former  occurs  most  frequently 
during  the  first  two  years  of  life  ;  the  latter,  from  the  third  to  the  seventh  year. 

The  bacteriological  diagnosis  is  open  to  the  same  uncertainties  as  have  been 
mentioned  in  relation  to  urethritis  in  male  children. 

One  of  the  most  carefully  observed  cases  which  has  been  recorded  is 
reported  by  Dr.  Edward  Martin,^  and  appears  to  show  that  the  discharge  from 
a  case  of  vulvo-vaginitis  acquired  in  an  entirely  non-venereal  manner,  appa- 
rently originating  de  novo,  is  capable  of  exciting  a  severe  attack  of  typical 
gonorrhoea  when  inoculated  in  a  healthy  urethra.  In  5  of  9  cases  he  made 
careful  microscopic  examinations,  and  found  gonococci  present  in  all.  In  all 
but  one  the  possibility  of  contagion  was  positively  denied. 

The  general  evidence  shows  a  remarkable  difference  between  the  histories 
of  some  of  the  cases  and  their  bacteriology,  as  in  the  above  instances,  and  also 
between  the  results  arrived  at  by  different  observers.  Yibert  and  Bordas 
in  six  cases  of  purely  traumatic  vulvo-vaginitis  found  diplococci  absolutely 
identical  with  the  gonococci.  On  the  other  hand,  Martin  failed  to  find  gono- 
cocci in  a  sincrle  case  of  irritative  vulvo-vaginitis,  although  he  examined  a  con- 
siderable  number.     It  is  apparent,  therefore,  that  the  mere   presence  of  the 

^  Jour,  of  Cut.  and  Gen.  Urin.  Dis.,  November,  1892.  Dr.  Martin's  excellent  article  con- 
tains a  r&um^  of  the  latest  observations  on  this  subject,  and  may  be  referred  to  with  advantage 
I  have  used  it  in  the  preparation  of  this  paper. 


1056  AMEBICAJV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

gonococcus  does  not  justify  the  unreserved  diagnosis  of  specific  infection, 
although  it  may  be  said  strongly  to  favor  that  view  and  practically  to  establish 
it  when  the  clinical  symptoms  coincide. 

When  the  disease  appears  at  a  very  early  age,  it  is  almost  always  the  result 
of  infection  from  a  gonorrhoeal  inflammation  of  some  portion  of  the  generative 
tract  of  the  mother.  Later,  especially  if  there  is  an  accusation  of  rape  directed 
against  any  one,  it  is  well  to  remember  that  the  same  liability  exists,  and  that 
the  disease  may  have  been  carried  by  the  fingers  or  garments  of  the  mother. 

Treatment. — In  the  catarrhal  variety  absolute  cleanliness,  obtained  by 
frequent  bathing  in  warm  water  and  soap  and  favored  by  first  pouring  carbol- 
ized  oil  (1  :  60)  over  the  region,  dryness  of  the  parts  produced  by  the  gentle 
use  of  absorbent  cotton,  separation  of  the  labia  by  portions  of  cotton  or  gauze, 
and  the  use  of  some  dusting  powder,  such  as  that  given  below,  are  the  essentials 
of  treatment  : 

i|i.   Pulv.  zinci  oxidi, 

Pulv.  acid,  boric da.  §ss. 

Pulv.  amyli      §j. 

In  the  gonorrhoeal  form  a  little  more  active  treatment  is  required.  Vaginal 
douches  of  hot  soda  solution  or  of  soapsuds,  followed  by  antiseptic  irrigation, 
are  to  be  employed  two  or  three  times  daily  ;  the  soda  may  be  of  the  strength 
of  1  per  cent ;  the  antiseptic  solution  should  contain  bichloride  of  mercury 
(1 :  4000),  or  carbolic  acid  (1  :  100),  or  boric  and  salicylic  acids  (10  gr.  of  the 
former  and  5  gr.  of  the  latter  to  f§j),  or  silver  nitrate  (1  ;  5000).  It  is 
important  after  each  irrigation  to  dry  the  parts  carefully  but  gently,  and  then 
to  use  a  dusting  powder,  keeping  the  labia  separated. 

If  the  urethra  is  involved,  and  especially  if  there  are  evidences  of  cystitis, 
the  internal  administration  of  boric  acid  and  salol,  or  of  some  such  mixture  as 
that  previously  given  for  the  same  disease  in  boys,  will  be  found  useful. 

In  all  varieties  of  this  disease  the  general  health  of  the  little  patient  should 
be  scrupulously  looked  after,  as  struma,  anaemia,  and  digestive  derangements  are 
frequently  found  associated  with  local  causes  in  producing  the  symptoms  or 
favoring:  their  continuance. 


PHIMOSIS,  ADHERENT  PREPUCE,  PARA- 
PHIMOSIS. 

By  henry  R.  WHARTON,  M.  D., 

Philadelphia. 


I.  Phimosis  and  Adherent  Prepuce. 

Phimosis  consists  in  a  contraction  of  the  orifice  of  the  prepuce,  which  is 
frequently  associated  with  elongation  of  the  prepuce,  preventing  the  exposure 
of  the  glans  penis.  The  condition  may  be  either  congenital  or  acquired.  In 
congenital  cases  the  contraction  is  much  more  marked  in  the  inner  or  mucous 
layer  of  the  prepuce,  which  adheres  closely  to  the  glans  penis.  Acquired 
phimosis  is  usually  seen  in  children  who  have  suffered  from  balanitis,  and  is 
not  common  in  very  young  children.  Adherent  prepuce  is  a  very  common 
condition  during  early  infancy,  and  is  often  associated  with  phimosis :  this 
adhesion  by  pressure  tends  to  dwarf  the  growth  of  the  glans  penis,  and  causes 
accumulation  of  smegma,  which  may  harden  and  act  as  a  foreign  body.  I 
have  frequently  seen  in  cases  of  adherent  prepuce  a  complete  cast  of  hard- 
ened smegma  filling  up  the  groove  behind  the  corona. 

Phimosis  with  adherent  prepuce,  as  has  been  stated  before,  is  almost  always 
present  in  male  infants  at  birth,  but  as  the  child  develops  the  condition 
usually  disappears,  and  in  many  cases  no  symptoms  are  developed  referable 
to  it ;  on  the  other  hand,  there  are  often  mechanical  irritations  and  reflex 
nervous  disturbances  which  can  be  traced  to  the  presence  of  phimosis,  such  as 
malnutrition,  choreic  movements,  paralysis,  convulsions,  nocturnal  incontinence 
of  urine,  dysuria,  prolapsus  of  the  rectum,  and  hernia,  the  latter  conditions  being 
most  frequently  seen  where  there  is  marked  contraction  of  the  preputial  orifice 
and  severe  straining  efforts  are  made  during  micturition.  Adherent  prepuce 
with  retained  smegma  in  young  infants  frequently  produces  priapism,  vesical 
irritation,  defective  nutrition,  and  restlessness  at  night,  which  conditions  are 
usually  relieved  by  exposure  of  the  glans.  In  older  children  the  condition  of 
phimosis  with  adhesions  is  apt  to  give  rise  to  priapism,  and  is  unquestionably 
the  cause  of  the  habit  of  masturbation  in  young  boys.  Bearing  in  mind  these 
facts,  it  seems  the  part  of  wisdom  for  the  physician  to  investigate  the  condi- 
tion of  the  genital  organs  in  all  male  infants,  to  ascertain  the  fact  that  the 
prepuce  and  the  glans  are  separable ;  and  it  is  especially  important  in  any 
obscure  diseases  developing  in  infancy  and  childhood  that  this  examination 
should  not  be  neglected. 

In  cases  where  the  preputial  orifice  is  very  small,  as  in  Fig.  2  (Plate  XXII.), 
the  adhesion  of  the  mucous  layer  of  the  prepuce  to  the  glans  penis  is  usually 
very  firm,  and  as  the  glans  cannot  be  exposed,  the  adhesion  becomes  firmer  as 
the  patient  increases  in  age,  so  that  to  expose  the  glans  it  is  often  necessary  to 
dissect  the  mucous  layer  of  the  prepuce  from  the  glans. 

It  is  an  unquestionable  fact  that  preputial  adhesions  are  separated  spon- 
fi7  1057 


1058  A3fERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

taneously,  and  that  the  condition  of  phimosis  is  outgrown,  and  that  many  cases 
reach  adult  life  without  presenting  any  symptoms  due  to  the  condition  described. 
But  when  we  consider  that  a  very  trivial  operation  in  infancy  will  relieve  the 
condition  which  may  later  gives  rise  to  serious  symptoms,  it  seems  to  me  to  be 
wise  to  stretch  the  prepuce  and  separate  the  adhesions  in  all  cases.  If  phimosis 
still  exists  and  symptoms  are  present,  it  can  be  relieved  later  by  operative 
interference. 

Treatment  of  Adherent  Prepuce. — This  condition  is  best  relieved  by 
stripping  the  glans,  which  is  accomplished  as  follows :  The  foreskin  should  be 
drawn  slowly  backward  until  the  point  of  adhesion  is  reached,  by  grasping  the 
penis  between  the  finger  and  thumb  and  making  traction  upon  the  margin  of 
the  ring  in  this  way :  by  passing  the  end  of  a  silver  probe  around  the  adhesions 
between  the  mucous  membrane  and  the  glans,  they  can  usually  be  separated 
without  difficulty.  When  all  adhesions  have  been  separated  and  any  collec- 
tions of  smegma  about  the  corona  have  been  removed,  which  is  best  accom- 
plished with  the  end  of  a  probe,  the  foreskin  should  be  movable  upon  the  glans. 
The  exposed  surface  of  the  glans  should  then  be  anointed  with  carbolized  oil 
or  boracic-acid  ointment,  and  the  prepuce  again  brought  foi'ward,  care  being 
taken  not  to  keep  the  foreskin  back  for  any  considerable  time,  as  the  condition 
of  paraphimosis  soon  develops,  and  much  difficulty  may  be  experienced  in  its 
reduction.  This  manipulation  should  be  repeated  at  intervals  of  a  few  days, 
and  in  ten  days  or  two  weeks  it  will  be  found  that  no  tendency  to  readhesion 
exists.  When  there  is  very  marked  contraction  of  the  preputial  orifice,  so  that 
the  glans  cannot  be  exposed,  it  is  necessary  to  resort  to  dilatation  or  stretching, 
excision,  or  circumcision  of  the  prepuce. 

Dilatation. — This  method  of  relieving  phimosis  is  accomplished  by  intro- 
ducing into  the  preputial  orifice  the  blades  of  a  pair  of  dressing  or  dissecting 
forceps,  or  forceps  specially  devised  for  the  purpose,  and  separating  the  blades, 
thus  stretching  or  rupturing  the  mucous  membrane  until  the  glans  can  be  freely 
.exposed;  Avhen  this  is  accomplished,  it  should  be  covered  with  carbolized  oil  or 
boracic-acid  ointment,  and  the  foreskin  should  again  be  brought  forward.  The 
manipulation  should  be  repeated  at  intervals  of  two  or  three  days  for  several 
weeks,  until  the  glans  can  be  exposed  without  difficulty.  The  disadvantage  of 
forcible  dilatation  of  the  prepuce  lies  in  the  fact  that  there  is  often  a  consider- 
able amount  of  inflammatory  induration  of  the  mucous  membrane  following  the 
procedure,  and  forcible  dilatation  has  been  followed  by  gangrene  of  the  pre- 
puce. I  have  knowledge  of  one  case  in  which  this  unfortunate  complication 
resulted.  Therefore,  the  procedure  is,  I  think,  not  to  be  generally  recom- 
mended, but,  judiciously  employed  in  connection  with  stripping  of-  the  glans, 
it  is  often  of  advantage ;  but  in  severe  cases  it  is  better  to  resort  to  excision  or 
circumcision. 

Excision. — This  procedure  for  the  relief  of  phimosis  consists  in  first  incis- 
ing the  foreskin  on  the  dorsum  of  the  glans  from  the  preputial  opening  to  the 
corona  glandis;  the  flaps  thus  made,  consisting  of  skin  and  mucous  membrane, 
are  seized  with  forceps  and  trimmed  off"  with  scissors,  so  as  to  make  an  oval 
wound.  In  performing  this  operation  it  is  well  to  introduce  the  end  of  a 
grooved  director  into  the  preputial  orifice  and  pass  it  backward  over  the  dor- 
sum of  the  glans  penis  to  the  corona  glandis ;  the  tissues  upon  the  director  are 
next  divided  with  a  bistoury  or  scissors  to  the  corona  glandis;  the  flaps  result- 
ing are  seized  with  forceps  and  trimmed  off"  with  a  scalpel  or  scissors,  so  as  to 
make  an  oval  Avound,  the  fraenum  being  left  intact ;  a  few  stitches  of  catgut  or 
fine  silk  are  next  introduced  to  hold  the  skin  and  mucous  membrane  together, 
and  the  wound  is  dressed  with  boracic-acid  ointment  spread  on  lint.    The  result 


> 

'A 


PHIMOSIS  AND   PARAPHIMOSIS.  1059 

following  this  operation  is  usually  very  satisfactory,  and  it  will  be  found  most 
serviceable  in  cases  where  the  prepuce  is  indurated  or  oedematous  as  a  result  of 
balanitis. 

Circumcision. — This  operation  in  most  cases  of  phimosis,  and  particularly 
in  congenital  cases,  is  the  one  which  is  to  be  selected  as  securing  the  most  satis- 
factory removal  of  the  redundant  prepuce  and  the  freest  exposure  of  the  glans 
penis.  In  performing  the  operation  of  circumcision  the  foreskin  should  be 
drawn  slightly  forward  and  the  blades  of  a  pair  of  forceps,  preferably  Ricord's 
fenestrated  forceps,  or  a  modification  of  this  instrument,  fenestrated  spring 
forceps  (Fig.  1),  should  be  placed  obliquely  upon  the  foreskin,  so  that  more 

Fig.  1. 


Fenestrated  Spring  Forceps. 

tissue  is  included  in  the  region  of  the  corona  glandis  than  in  the  region  of  the 
frsenum,  care  being  taken  to  see  that  a  sufiicient  quantity  of  skin  is  removed, 
and  that  no  portion  of  the  glans  is  included  in  the  grasp  of  the  forceps. 
Neglect  of  the  former  precaution  often  leads  to  the  production  of  a  secondary 
phimosis  after  healing  has  taken  place,  and  a  subsequent  operation  is  required 
to  expose  the  glans.  I  have  been  called  upon  to  do  a  number  of  secondary 
circumcisions  which  were  necessitated  by  the  operators  having  failed  to  remove 
a  sufficient  quantity  of  the  foreskin  to  expose  the  glans  completely ;  it  is  an 
error  which  inexperienced  operators  are  apt  to  commit.  The  forceps  being 
placed  as  above  described,  a  narrow  bistoury  is  passed  into  the  fenestra, 
and  the  tissues  between  the  blades  are  divided;  or  the  same  purpose  may  be 
attained  by  cutting  with  scissors  close  to  the  forceps.  The  forceps  are  then 
removed  and  the  skin  retracts.  It  will  often  be  found  that  the  mucous  mem- 
brane has  not  been  divided  or  has  only  been  slightly  removed.  If  this  be  the 
case,  it  should  be  divided  upon  the  dorsal  surface  of  the  glans  and  corona  by 
introducing  a  director  and  dividing  the  mucous  membrane  with  bistoury  or 
scissors ;  any  adhesions  to  the  glans  should  be  separated  with  the  end  of  the 
director.  The  triangular  flaps  of  mucous  membrane  thus  resulting  should 
next  be  seized  with  forceps,  and  trimmed  off  with  scissors  to  correspond  to 
the  line  of  the  skin  incision.  There  is  usually  little  haemorrhage,  but  occasion- 
ally the  arteries  of  the  frgenum  or  a  dorsal  artery  or  vein  bleed  freely,  in 
which  case  they  should  be  secured  by  means  of  fine  catgut  ligatures.  To 
secure  prompt  healing  of  the  wound  the  haemorrhage  should  be  perfectly  con- 
trolled before  the  skin  and  mucous  membrane  are  sutured  together.  I  have 
seen  neglect  to  control  the  bleeding  at  the  time  of  operation  give  rise  to  trouble- 
some consecutive  haemorrhage,  resulting  in  great  swelling  of  the  penis  as  the 
blood  escaped  into  the  loose  cellular  tissue ;  and  I  have  also  seen  a  child  almost 
exsanguinated  by  slow  consecutive  hgemorrhage  from  the  artery  of  the  frsenum 
which  had  gone  on  for  hours  after  circumcision.  To  avoid  this  complication, 
I  think  it  is  a  matter  of  the  first  importance  to  check  all  bleeding,  even  if 
insignificant,  at  the  time  of  operation,  and  not  to  depend  upon  controlling  a 
haemorrhage  by  the  final  suturing  of  the  wound,  as  is  often  recommended.  After 
the  mucous  membrane  has  been  trimmed,  the  edges  of  skin  and  mucous  mem- 
brane should  next  be  brought  in  apposition  by  introducing  fine  silk  or  catgut 
sutures.  I  usually  employ  a  fine  chromicized  catgut  suture,  as  it  does  not 
require  subsequent  removal.  The  first  two  sutures  are  introduced,  one  at  the 
frgenum  and  the  other  at  the  middle  line  of  the  dorsum ;  two  more  sutures  on 


1060  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

each  side  are  usually  suflficient.  The  appearance  of  the  parts  immediately 
after  circumcision  in  the  case  already  depicted,  in  which  there  were  firm  ad- 
hesions between  the  mucous  membrane  and  glans,  is  seen  in  the  accompanying 
plate.     (Plate  XXIII.) 

The  surface  of  the  glans  and  the  sulcus  behind  the  corona  should  be  dressed 
with  boracic-acid  ointment  or  carbolized  zinc  ointment,  and  a  dry  dressing  of 
sterilized  or  carbolized  gauze  may  be  wrapped  around  the  penis  to  cover  the 
wound,  or  a  wet  dressing,  consisting  of  boracic  acid,  glycerin,  and  water,  may 
be  employed  in  the  same  manner.  The  dressing  may  be  held  in  place  by  the 
turns  of  a  narrow  roller  bandage  or  by  the  T  bandage  or  by  the  child's  nap- 
kin. Subsequent  dressings  are  made  daily,  and  at  the  end  of  a  week  the  union 
is  generally  complete  in  the  line  of  incision.  Some  oedema  of  the  mucous  mem- 
brane may  persist  for  weeks,  but  it  usually  disappears  in  a  short  time. 


Paraphimosis. 


n.  Paraphimosis. 

This  name  is  given  to  the  condition  in  which  an  abnormally  narrow  pre- 
puce has  been  drawn  up  above  the  corona  glandis  and  remains  irreducible. 
When  this  accident  happens  the  glans  soon  becomes  swollen 
and  oedematous  from  the  constriction  exercised  by  the 
edges  of  the  preputial  orifice,  and,  if  the  condition  is  not 
promptly  relieved,  ulceration  or  gangrene  may  occur. 
Paraphimosis  is  usually  met  with  in  boys  who  retract  the 
prepuce  and  fail  to  replace  it  promptly,  or  may  result  from 
the  trick  of  tying  strings  or  bands  around  the  root  of  the 
penis.  One  of  the  most  aggravating  cases  I  have  ever 
seen  was  caused  by  an  ignorant  nurse  tying  a  string  around 
a  boy's  penis  to  control  nocturnal  enuresis.  I  have  also 
seen  the  condition  resulting  in  young  children  from  the 
bites  of  insects.  "When  paraphimosis  has  existed  for  some 
time,  the  swelling  and  oedema  of  the  glans  and  mucous 
membrane  become  so  marked  that  the  greatest  distortion 
of  the  organ  occurs;    the  appearance  is  well  presented  in  Fig.   2. 

Treatment. — When  seen  early  these  cases 
can  be  quickly  relieved  by  grasping  the  lateral 
folds  of  skin  between  the  thumb  and  finger 
of  the  left  hand,  and  drawing  the  foreskin  for- 
ward at  the  same  time  as  the  thumb  and  fore- 
finger of  the  right  hand  compress  the  glans  and 
push  it  backward  within  the  advancing  ring 
(Fig.  3).  In  cases  where  this  manipulation  does 
not  succeed  minute  punctures  of  the  oedematous 
mucous  membrane  with  a  sharp-pointed  bistoury 
will  often  cause  a  decided  diminution  in  its  bulk 
bv  the  escaped  serum,  so  that  the  above  manip- 
ulation will  then  often  be  followed  by  success. 
Should  this  procedure  fail,  it  is  better  to  anaes- 
thetize the  patient  and  resort  to  operative 
measures.  The  operative  treatment  to  effect  the 
reduction  of  the  paraphimosis  consists  in  intro- 
ducing the  end  of  a  blunt-pointed  bistoury  under 
the  edge  of  the  prepuce  and  divi.ling  it  freely 


Fig.  3. 


Reduciion  of  Paraphimosis. 


PHIMOSIS  AND   PARAPHIMOSIS.  1061 

on  the  dorsum  of  the  glans,  or  the  constricting  tissue  may  be  divided  at  two 
or  three  points.  After  this  has  been  done  the  glans  can  usually  be  reduced 
without  trouble.  •  The  after-treatment  consists  in  the  application  for  a  few  days 
of  a  lotion  of  carbolic  acid,  chloride  of  ammonium,  glycerin,  and  water  until 
all  swelling  has  disappeared.  When  paraphimosis  has  once  occurred,  it  is 
better,  after  the  parts  have  resumed  their  normal  condition,  to  circumcise  the 
patient  and  prevent  the  possibility  of  a  repetition  of  the  accident. 


PART   XI. 


ORTHOPAEDICS. 

By  JAMES  E.   MOORE,  M.  D., 

MINNEAPOLIS. 


Fig.  1. 


Wry  Neck,  or  Torticollis. 

Torticollis  is  a  deformity  of  the  neck  in  which  the  head  is  drawn  down 
toward  the  shoulder  and  the  face  turned  in  the  opposite  direction.  It  may 
be  either  congenital  or  acquired.  The  congenital  cases  are  generally  due  to 
injuries  to  muscles  or  nerves  occurring  at  birth.     Acquired  cases  may  be 

either  traumatic,  paralytic,  compensa- 
tory, cicatricial,  spasmodic,  or  idiopathic 
in  origin.  The  traumatic  variety  is  due 
to  injuries  to  the  muscles,  nerves,  or 
nerve-centres,  and  the  rare  paralytic 
cases  are  similar  in  character,  but  lack 
the  element  of  traumatism.  Compensa- 
tory torticollis  may  be  due  to  curvature 
of  the  spine  or  to  defects  in  the  eyes; 
and  burns  or  scalds  of  the  neck  severe 
enough  to  leave  cicatrices  may  produce 
this  deformity.  Many  cases  are  classed 
as  idiopathic  because  their  cause  is  not 
known. 

Wry  neck  is  therefore  only  a  symp- 
tom of  many  different  conditions.  The 
anatomical  changes  are  chiefly  in  the 
muscles  to  which  the  spinal  accessory 
nerve  is  distributed,  the  sterno-cleido- 
mastoid  being  the  one  usually  affected. 
While  the  condition  may  be  either  acute 
or  chronic,  the  acute  variety  may  be- 
come chronic.  In  chronic  cases  the 
face  becomes  atrophied  on  the  affected 
side  and  the  angle  of  the  nose  with  the 
eyes  is  changed.  Pain  and  elevation 
of  temperature  do  not  occur  except  in 
acute  cases  due  to  inflammation  of  the  muscle. 

Diagnosis. — The  diagnosis  of  this  deformity  can  usually  be  made  from 
inspection,  the  appearance  being  quite  characteristic  (Fig.  1).  Cervical 
Pott's  disease  and  cervical  abscess  should  be  excluded.     In  Pott's  disease 

1062 


Congenital  torticollis. 


ORTHOPAEDICS. 


1063 


Fig.  2. 


the  patient  usually  suiFers,  pain  can  always  be  elicited  by  manipulation, 
motion  is  restricted  in  all  directions,  and  the  face  is  turned  toward  the 
aiFected  muscles.  In  wry  neck  the  face  is  turned  away  from  the  affected 
muscle. 

Cervical  abscess  will  be    accompanied   by  fever  and  pain,  and  can  be 
detected  by  deep  palpation. 

Prognosis. — The  prognosis  is  favorable  under  proper  treatment,  but 
otherwise  there  is  little  tendency  to  recovery.  Acute  cases  due  to  inflam- 
mation, however,  may  recover  promptly  without 
treatment. 

Treatment. — The  treatment  of  torticollis  is  ope- 
rative and  mechanical.  In  a  very  mild  and  com- 
paratively recent  case  mechanical  treatment  alone 
may  suffice,  but  in  severe  chronic  cases  it  will  fail 
unless  preceded  by  an  operation.  In  paralytic  cases 
mechanical  treatment  alone  is  indicated. 

Operative  treatment  of  wry  neck  consists  in  cut- 
ting the  contractured  muscles.  In  the  vast  majority 
of  cases  the  sterno-cleido-mastoid  is  the  only  one  re- 
quiring an  operation.  This  muscle  may  be  cut  either 
by  tenotomy  or  through  an  open  incision.  With 
proper  antiseptic  precautions  the  latter  is  preferable, 
because  the  former  has  been  followed  by  serious  haem- 
orrhage. 

After  the  operation  the  head  must  be  forced  into 
an  over-corrected  position  and  held  there  by  a  plas- 
ter-of-Paris  dressing  or  some  other  appliance. 

The  most  convenient  way  to  hold  the  head  in  the 
over-corrected  position  is  by  means  of  a  plaster  cast 
over  the  head  and  extending  well  down  over  the 
shoulders.  This  dressing  should  be  worn  for  from 
two  to  six  weeks,  according  to  the  severity  of  the  case.  In  mild  cases  this 
will  end  the  treatment,  but  in  severe  or  very  chronic  cases  this  same  or  some 
more  elegant  support  must  be  worn  until  all  tendency  to  relapse  has  disap- 
peared. What  is  known  among  instrument-makers  as  Markoe's  wry-neck 
brace  is  a  very  good  apparatus  (Fig.  2). 


Markoe's  brace  for  torti- 
collis. 


Lateral  Curvature  of  the  Spine,  or  Scoliosis. 

Scoliosis  is  a  deformity  of  the  spine  characterized  by  a  lateral  deviation. 
It  is  very  uncommon  in  early  childhood,  occurring  most  frequently  between 
the  ages  of  eight  and  fifteen.  It  is  rarely  congenital,  most  of  the  early 
curvatures  of  the  spine  being  of  rachitic  origin.  The  curve  is  usually  in 
the  upper  dorsal  region  and  toward  the  right  side  (Fig-  3). 

Btiolog-y. — The  causes  of  lateral  curvature  are  not  well  understood.  No 
inflammation  or  other  pathological  condition  is  known  to  belong  to  this 
deformity.  In  old  cases  the  shape  of  the  bodies  of  the  vertebra  is  changed 
by  pressure.  In  severe  cases  the  worst  part  of  the  deformity  is  due  to  a 
rotation  of  the  vertebrae  upon  each  other. 

Diagnosis. — Aside  from  the  curvature,  there  are  no  subjective  or  objective 
symptoms.  The  diagnosis  must  be  made  from  the  character  of  the  deformity, 
from  the  absence  of  symptoms,  and  by  excluding  other  conditions.  There  is 
no  pain  or  tenderness,  and  the  child  is  usually  in  good  health.    In  early  child- 


1064     A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


hood  the  spine  is  quite  flexible.      The  child  should  he  stripped  and  directed 
to  stand  Avith  its  back  toward  the  physician,  with  the  arms  hanging  down. 

The  ilio-costal  space  on   the   affected   side 

will  be  found  larger  and  of  a  different  shape 

from  that  of  the  opposite  side.      Rachitic 

^fl^^^  \    curves  are  usually  antero-posterior,  and  are 

^^^^^^^  i    accompanied  by  other  characteristic  symp- 

W^^^^^m  toms  of  rickets.      Curvature  due  to  Pott's 

n^^^^^B  disease  is  usually  antero-posterior,  but  when 

^^B^^F  i    it  is  lateral  is  accompanied  by  the  peculiar 

t|f        jg^^    ga^it,  the  inability  to  stoop,  the  pain,  and 

other  characteristic  symptoms. 

Prognosis. — The  prognosis  of  lateral 
curvature  is  good  so  far  as  life  is  concerned, 
but  otherwise  it  is  bad.  There  is  a  per- 
sistent tendency  to  an  increase  of  the  de- 
formity, which  is  very  difficult  to  overcome 
by  any  known  method  of  treatment. 

Treatment. — In  the  early  stage,  while 
the  spine  is  still  flexible,  treatment  is  most 
likely  to  be  beneficial,  but  it  is  far  fiom 
satisfactory  at  any  stage.  Mechanical  sup- 
port is  rarely  helpful  in  these  cases ;  on  the 
contrary,  it  is  likely  to  do  more  harm  than 
good.  In  a  few  exceptional  instances,  where 
the  deformity  is  increasing  very  rapidly,  a 
plaster  or  paper  jacket  will  be  beneficial. 
In  the  vast  majority  of  cases,  however,  the 
greatest  benefit  is  to  be  derived  from  intel- 
ligent gymnastic  exercises  and  massage. 

A  child  can  be  taught  at  a  very  early 
age  to  swing  by  his  hands  and  to  bend  the 
spine  in  the  opposite  direction  from  the 
curvature  or  in  such  a  manner  as  to  unbend  it.  If  a  skilled  masseur  is  not 
at  hand,  the  physician  or  parents  should  unbend  the  spine  daily.  The  child 
should  be  undressed  and  placed  in  such  attitudes  by  the  hands  of  the  attend- 
ant as  will  have  a  tendency  to  overcome  the  deformity.  This  exercise  should 
be  kept  up  for  at  least  fifteen  minutes  every  day.  By  persistent  effort  in 
this  direction  the  deformity  may  be  overcome  in  a  mild  case,  and  in  every 
case  it  may  be  prevented  from  becoming  as  severe  as  it  otherwise  would. 
The  child  should  be  taught  to  avoid  those  attitudes  that  would  naturally  have 
a  tendency  to  increase  the  curvature. 


Loft  scoliosis 


PoTT's  Disease,  or  Tuberculosis  of  the  Spine. 

Pott's  disease  is  a  destructive  disease  of  the  bodies  of  the  vertebrae,  and 
is  tuberculous  in  character.  It  was  first  clearly  described  by  Percival  Pott 
in  1779. 

Etiology. — This  disease  occurs,  in  the  vast  majority  of  cases,  in  childhood. 
The  writer's  experience  leads  hira  to  discredit  the  popular  belief  that  heredity 
is  a  prominent  cause,  for  the  disease  occurs  very  commonly  in  healthy  chil- 
dren of  healthy  parents.  The  parents  usually  ascribe  it  to  some  real  or 
imaginary  injury.     While  it  can  rarely  be  traced  directly  to  an  injury,  every 


ORTHOPEDICS. 


1065 


experienced  orthopaedist  has  met  with  some  cases  that  evidently  originated 
in  this  way.  It  occurs  frequently  as  a  sequel  of  the  exanthemata  and  other 
diseases  of  childhood.  In  the  writer's  experience  measles  is  the  most  fre- 
quent forerunner.  The  disease  usually  begins  in  one  small  spot  near  the 
anterior  part  of  the  body  of  the  vertebra,  but  it  may  begin  in  more  than  one 
vertebra  at  the  same  time. 

Pathology. — The  bodies  of  the  vertebrae  become  gradually  softened  and 
break  down  in  cheesy  debris ;  this  allows  the  spine  to  bend  forward,  caus- 
ing the    characteristic    deformity,    which   is   usually   antero-posterior,    with 

the  convexity  backward.     When  only 
^^^-  ^-  one  vertebral  body  is  affected  the  angle 

of  deformity  is  quite  sharp,  but  is  more 

Fig.  5. 


Dorsal  Pott's  disease.  Characteristic  position  in  dorsal  Pott's  disease. 

obtuse  when  a  number  are  involved.  In  either  case,  however,  the  angle  is 
more  acute  than  that  in  any  other  spinal  disease.  The  intervertebral  disks 
are  destroyed  by  the  granulation-tissue,  but  are  probably  never  the  original 
seat  of  disease,  as  was  once  believed.  When  the  disease  is  in  the  lower  dorsal 
or  lumbar  region,  an  abscess  may  form  and  folloAV  the  psoas  tendon,  pointing 
just  below  Poupart's  ligament.  In  the  cervical  region  a  retropharyngeal 
abscess  may  form.  Paralysis  may  occur  as  a  result  of  pressure  due,  as  a  rule, 
to  thickening  of  the  meninges  by  inflammatory  deposits.  The  bone  does  not 
press  upon  the  cord  even  when  the  deformity  is  marked,  and  the  cord  rarely 
becomes  diseased.  When  recovery  takes  place  the  debris  is  absorbed,  and  the 
vertebrae  are  joined  together  by  bony  formation,  causing  complete  ankylosis. 
Symptoms. — Generally  the  first  symptom  of  Pott's  disease  is  a  disposition 
upon  the  part  of  the  child  to  lie  down  instead  of  playing  about  as  usual.     He 


1066     A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Fig.  6. 


is  restless  at  night,  and  after  a  time  complains  of  pain,  particularly  at  night. 
The  pain  is  usually  located  in  the  abdomen,  and  is  often  accompanied  by 
symptoms  of  indigestion  that  may  be  very  misleading.  The  gait  becomes 
peculiar  and  characteristic,  so  much  so  that  one  accustomed  to  observe  these 
cases  will  readily  recognize  one  on  the  street.  The  child  holds  his  spine 
rigid  and  Avalks  with  great  care,  often  keeping  the  knees  slightly  flexed  to 
lessen  the  jar.  This  restriction  of  motion  or  rigidity  of  the  spine  is  not  alto- 
gether voluntary,  but  is  largely  due  to  involuntary  muscular  spasm — a  symp- 
tom common  to  all  tuberculous  bone-lesions  near  joints.  Deformity  comes  on 
quite  early  ;  it  is  often  the  first,  and  may  be  the  only,  symptom  noticed  before 

bringing  the  child  to  the  physician.  It  usually 
appears  as  a  sharp  projection  or  knuckle  com- 
posed of  one  or  more  spinous  processes. 

This  disease  occurs  most  frequently  in  the 
dorsal  region,  next  in  the  lumbar,  and  least 
often  in  the  cervical  region.  When  it  occurs 
in  the  cervical  region  the  chin  is  thrown  for- 
ward in  a  characteristic  manner ;  the  patient 
may  have  a  choking  sensation  and  experience 
difficulty  in  swallowing ;  at  times  there  is  an 
irritating  cough  and  pain  in  the  chest ;  when 
sitting  the  elbows  are  rested  on  the  arms  of  the 
chair  and  the  head  supported  in  the  hands. 

If  the  disease  is  in  the  dorsal  region  the 
shoulders  are  elevated  and  the  neck  seems  short 
(Fig.  4).  There  is  pain  in  the  abdomen,  which 
becomes  distended,  and  symptoms  of  indigestion 
are  prominent.  The  patient  supports  his  weight 
upon  his  elbows  Avhen  sitting,  and  rests  his 
hands  upon  his  thighs  when  standing  (Fig.  5). 
When  the  lumbar  region  is  affected  the  de- 
formity is  a  lordosis  or  bending  forward,  and  is 
caused  by  contraction  of  the  psoas  muscles.  The 
patient  throws  his  shoulders  back  in  order  to 
keep  his  equilibrium  (Fig.  6).  The  pain  may 
be  in  the  abdomen,  but  is  more  likely  to  be  in 
the  lower  extremities.  The  bladder  and  rectum 
■may  be  irritable. 

Complications. — The  important  complica- 
tions of  Pott's  disease  are  paralysis,  abscess, 
amyloid  changes  in  the  liver  and  kidneys,  and 
tuberculosis  of  the  lungs  and  cerebral  meninges. 
Paralysis  is  of  rare  occurrence  except  in  untreated  cases.  It  may  affect 
both  the  upper  and  lower  extremities,  but  is  usually  confined  to  the  latter. 
It  occurs  most  frequently  with  dorsal  Pott's  disease  and  rarely  affects  the 
sensory  nerves.  Since  the  paralysis  is  due  to  pressure  from  inflammatory 
deposits,  and  not  to  bony  pressure,  the  danger  of  this  complication  does 
not  increase  Avith  great  deformity.  It  may  occur  Avhen  the  deformity  is  very 
slight.  With  this  form  of  paralysis  the  knee-jerk  is  exaggerated  and  ankle- 
clonus  is  marked.  The  bladder  and  rectum  become  affected  when  the  lumbar 
enlargement  of  the  cord  is  involved.  The  muscles  usually  become  soft  and 
flabby  from  disuse.  Rigidity  of  the  muscles  is  a  grave  symptom,  since  it 
indicates  disease  of  the  spinal  cord. 


Lumbar  Pott's  disease :  lordosis. 


ORTHOPEDICS.  1067 

Abscess  may  occur  in  any  region,  but  is  most  common  when  the  disease  is 
in  the  lumbar  region.  A  psoas  abscess  is  rarely  due  to  any  other  cajiise, 
so  it  may  be  considered  as  almost  conclusive  evidence  of  Pott's  disease. 
Lumbar  and  retropharyngeal  abscesses  occur,  but  not  nearly  so  frequently 
as  psoas  abscess.  The  complication  is  not  nearly  so  common  in  children 
as  in  adults,  because  in  the  latter  the  disease  is  more  frequently  located 
on  or  near  the  surface  of  the  bodies  of  the  vertebrae.  It  is  usually  a  late 
symptom  of  the  disease,  and  is  apt  to  be  preceded  by  increased  pain  and 
other  evidences  of  poor  health,  but  occasionally  it  comes  on  so  insidiously 
that  it  is  the  first  symptom  noticed.  These  so-called  abscesses  are,  in  reality, 
rarely  true  abscesses,  because  they,  as  a  rule,  contain  neither  pus  nor  pyo- 
genic germs,  but  they  were  given  the  name  of  cold  abscess  before  their 
pathology  was  understood ;  and  the  name  is  so  well  established  that  it  would 
be  difficult  to  change  it.  The  contents  vary  from  a  thin,  watery  fluid  to  a 
thick,  cheesy  mass.  If  at  any  time  pyogenic  germs  are  introduced  into  a 
cold  abscess,  it  at  once  becomes  a  true  abscess. 

Amyloid  changes  of  the  kidneys  and  liver  are  liable  to  occur  as  a  compli- 
cation in  old  cases  of  Pott's  disease  where  there  have  been  discharging 
sinuses.  They  do  not  differ  in  any  way  from  the  changes  following  prolonged 
suppuration  from  any  cause. 

Pulmonary  tuberculosis  occurs  as  a  complication,  but  less  frequently  in 
children  than  in  adults. 

Tuberculous  meningitis  has  been,  in  the  writer's  experience,  the  most  com- 
mon cause  of  death  in  Pott's  disease.  It  comes  on  late,  beginning  with  very 
severe  headache,  high  temperature,  delirium,  and  other  symptoms  character- 
istic of  meningitis,  and  ends  fatally  in  ten  days  or  two  weeks. 

Diagnosis. — It  is  important  to  make  an  early  diagnosis  of  Pott's  disease, 
in  order  to  begin  intelligent  treatment  and  to  prevent  deformity.  When  a 
child  develops  a  peculiar  gait,  shoAvs  a  disposition  to  lie  about,  or  complains 
of  persistent  pain  in  the  abdomen,  its  spine  should  be  examined.  It  should 
be  stripped  and  made  to  walk  up  and  down  the  room.  If  it  holds  its  head, 
shoulders,  or  arms  in  a  peculiar  manner,  and  walks  as  if  it  were  afraid  to 
move,  Pott's  disease  should  be  suspected.  Place  the  child  prone  upon  a 
table,  flex  the  knees  so  that  the  soles  are  turned  upward,  grasp  the  ankles 
alternately,  and  make  an  effort  to  over-extend  the  thighs.  If  disease  is 
present  in  the  lower  dorsal  or  lumbar  region,  this  effort  at  over-extension 
will  cause  a  spasmodic  jerking  of  one  or  both  thighs  forAvard  toward  the  table. 
This  symptom  is  known  among  orthopedists  as  psoas  spasm,  and  is  consid- 
ered a  valuable  aid  in  diagnosis.  Turn  the  child  upon  its  back,  flex  its 
hips  so  as  to  relax  the  abdominal  muscles,  and  make  deep  palpation  over 
the  abdomen  with  the  points  of  the  fingers.  In  this  way  a  psoas  abscess  may 
be  felt  long  before  it  can  be  seen.  Have  the  child  stand  up,  drop  an  object 
upon  the  floor,  and  ask  him  to  pick  it  up :  if  Pott's  disease  is  present,  he  will 
not  bend  the  spine  and  pick  it  up  as  a  healthy  child  would,  but  will  bend  his 
knees  and  hips  and  crouch  down,  keeping  the  spine  rigid.  This  is  quite 
characteristic  of  Pott's  disease. 

Pain  is  usually  a  prominent  symptom,  beginning  quite  early.  It  is  felt 
at  the  distribution  of  the  spinal  nerves  coming  from  the  seat  of  the  disease 
more  than  in  the  spine.  In  cervical  and  upper  dorsal  disease  the  pain  is 
often  accompanied  by  a  peculiar  grunting  respiration  that  is  very  distinctive. 
The  pain  from  dorsal  disease  is  in  the  abdomen,  and  often  leads  to  mistakes 
in  diagnosis,  for  there  are  usually  other  symptoms  pointing  to  the  digestive 
tract  as  the  seat  of  disease.     When  in  the  cervical  region  this  disease  may  be 


1068     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

mistaken  for  wry  neck.  In  Pott's  disease  the  face  is  turned  toward  the 
affected  muscles,  while  in  wry  neck  it  is  turned  away  from  them,  and  the 
condition  is  not  a  painful  one. 

Deformity  is  the  most  characteristic  symptom  of  a  well-established  Pott's 
disease.  In  all  but  the  lumbar  region  it  is  backward.  Nothing  is  to  be 
learned  by  palpation,  for  there  is  not  even  sensitiveness.  It  is  to  be  differ- 
entiated from  the  deformity  of  rickets.  In  Pott's  disease  the  angle  is  sharp 
and  cannot  be  straightened  out,  while  in  rickets  the  deformity  is  more  of  a 
curve,  and  will  partly  or  entirely  disappear  when  the  child  is  laid  upon  its 
face.     With  a  rachitic  curve  the  other  symptoms  of  rickets  are  present. 

Paralysis  of  Pott's  disease  is  to  be  recognized  by  the  exaggerated  reflexes 
and  by  the  presence  of  the  deformity  and  other  symptoms  of  this  disease. 
The  peculiar  attitudes  the  child  assumes  in  attempting  to  lift  the  weight 
from  the  sore  spine  should  be  remembered.  He  holds  his  head  with  his 
hands  in  cervical  disease,  and  supports  his  weight  on  his  elboAvs  in  dorsal  dis- 
ease. Hip-joint  disease  may  be  suspected  when  psoas  contraction  is  present. 
In  hip-joint  disease,  however,  there  is  tenderness  about  the  joint,  and  motion 
is  restricted  in  every  direction,  while  in  psoas  contraction  from  Pott's  disease 
the  joint  is  not  tender  and  motion  is  restricted  in  extension  only.  In  the 
few  cases  in  which  abscess  is  an  early  symptom  it  may  aid  in  diagnosis. 
Psoas  abscess  should  not  be  mistaken  for  hernia  or  appendicitis. 

Prognosis. — This  disease  is  decidedly  chronic,  the  average  duration  being 
about  three  years.  The  natural  tendency,  however,  is  toward  arrest.  Prob- 
ably 25  per  cent,  of  the  cases  terminate  fatally.  Few  die  from  the  disease 
'per  sg,  but  from  complications,  such  as  tuberculous  meningitis,  phthisis, 
abscess,  and  amyloid  disease  of  the  liver  and  kidneys. 

The  deformity  of  Pott's  disease  has  a  persistent  tendency  to  increase. 
Even  with  the  best  of  treatment  existing  deformity  cannot  be  overcome,  and 
an  increase  cannot  always  be  prevented. 

Abscess  often  runs  a  remarkably  benign  course,  but  it  necessarily  adds 
to  the  gravity  of  the  disease. 

The  paralysis  of  Pott's  disease  ends  in  recovery,  in  the  vast  majority  of 
cases,  within  one  year.      Some  recover  even  after  three  years. 

Treatment. — The  great  principle  in  the  treatment  of  this  disease  is  rest. 
In  tuberculous  disease  of  bone,  nature  will  bring  about  a  cure  in  the  major- 
ity of  cases,  aided  by  rest  alone.  Under  its  influence  abscesses  often  dis- 
appear and  paralyzed  muscles  regain  their  strength.  There  is  little  to  be 
gained  by  the  administration  of  drugs,  save  to  meet  indications  as  they  arise. 
Pain  is  best  relieved  by  rest  secured  by  a  proper  mechanical  appliance. 
Opiates  are  to  be  avoided  in  this  as  in  any  other  chronic  disease,  because 
they  usually  do  more  harm  than  good,  and  are  very  liable  in  the  end  to  add 
to  the  patient's  suffering.  In  many  cases  of  Pott's  disease  the  patient's  gen- 
eral health  is  good.  Drugs  are  to  be  avoided  under  such  conditions.  The 
bowels  should  be  kept  regular,  and  disturbances  of  digestion  met  just  as  if 
Pott's  disease  did  not  exist.  When  the  strength  is  failing,  beef  peptonoids 
and  plenty  of  good  rich  milk  should  be  given,  and  if  at  all  practicable  the 
child  should  be  taken  out  of  doors  and  kept  out  as  many  hours  as  possible. 
In  some  very  severe  cases  the  best  treatment  is  prolonged  rest  in  bed,  sup- 
plemented always  by  a  proper  spinal  support.  It  is  really  surprising  to 
see  how  well  and  strong  these  little  sufferers  become  under  this  treatment, 
but  it  is  only  recommended  when  ambulatory  treatment  cannot  be  employed. 
The  best  means  of  carrying  out  this  plan  is  by  a  piece  of  canvas  stretched 
over  a  light  iron  frame  (Fig.  7).     The  canvas  must  have  an  opening  through 


OR  THOP^DICS. 


1069 


which  a  bed-pan  can  be  used,  and  the  whole  frame  may  be  taken  up  and  the 
child  carried  out  of  doors  if  desired. 

Various  materials  are  employed  for  mechanical  support  in  Pott's  disease. 
The  general  practitioner  can  meet  every  indication  with  the  above-mentioned 

Fig.  7. 


The  stretcher  bed. 


Fig.  8. 


stretcher  splint,  by  plaster  of  Paris,  or  some  form  of  steel  brace.  A  plaster- 
of-Paris  jacket  meets  the  indications  admirably  in  the  lumbar  and  lower 
dorsal  regions.  Objections  are  made  to  it  only  by  those  Avho  do  not  know 
how  to  use  it.  For  the  upper  dorsal  and  cervical  regions  a  steel  brace,  with 
proper  head-piece,  is  the  best  appliance.  A 
plaster  cast  with  a  jury  mast  can  be  used  in 
these  regions,  but  the  writer  has  found  that 
practitioners  with  limited  experience  in  this 
direction  find  it  difficult  to  apply  the  jury  mast 
properly.  A  plaster  cast  should  never  be  ap- 
plied when  sinuses  are  present,  because  it  is 
impossible  to  keep  it  clean  (Fig.   8). 

The  mistake  made  by  inexperienced  persons 
in  applying  a  jacket  is  that  they  get  it  too 
bulky.  It  should  not  be  any  heavier  than  thick 
pasteboard.  For  a  child,  from  four  to  six  plas- 
ter bandages,  four  inches  wide  and  six  yards 
long,  are  sufficient.  Before  applying  the  plas- 
ter a  close-fitting,  armless  knit  shirt  should  be 
put  on  the  child.  The  anterior  superior  spinous 
processes  of  the  ilium  and  the  prominent  spinous 
processes  of  the  vertebrae  should  be  surrounded 
by  rings  of  cotton  or  felt,  so  that  the  cast  will 
not  touch  them.  The  child's  arms  should  be 
lifted  up  and  enough  extension  applied  to  its 
head  to  make  the  spine  as  straight  as  possible. 
It  is  a  mistake  to  lift  the  child  ofi"  its  feet.  The 
ordinary  extension  apparatus  sold  by  all  instru- 
ment-makers is  the  best  appliance,  but  a  very 
satisfactory  one  can  be  improvised  by  an  in- 
genious practitioner.  The  plaster  bandages 
should  be  made  of  the  best  dental  plaster  and 
crinoline ;  commercial  plaster  and  cheese-cloth 
are  not  suitable  materials.  An  ordinary  wash- 
basin will  not  hold  enough  water  to  properly 
moisten  the  bandages ;  a  larger  vessel  should  be 
filled  with  warm  water  and  the  bandages  placed  in  it,  one  at  a  time,  a  sec- 
ond one  being  put  in  just  as  the  first  is  taken  out.  The  roller  should 
be  placed  on  end  in  the  water,  and  as  soon  as  bubbles  cease  to  rise  it  should 
be  taken  out  and  gently  squeezed  between  the  hands  to  remove  the  sur- 


Pla^ter  jacket. 


1070     A3IEEICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


plus  water.  Beginning  well  down  on  the  pelvis,  the  bandage  is  applied 
around  the  body,  with  just  sufficient  tension  to  make  it  fit  comfortably  and 
without  wrinkles.  About  three  turns  should  be  placed  directly  over  one 
another  to  form  the  low  er  end  of  the  cast.  After  this  each  succeeding  turn 
should  lap  over  about  half  the  width  of  the  last  one,  until  the  jacket  reaches 
well  up  under  the  arms,  where  about  three  turns  should  be  applied  directly 
over  one  another.  A  sufficient  number  of  bandages  are  applied  in  this 
systematic  manner  to  make  the  jacket  of  the  desired  strength,  remembering 
that  the  tendency  is  to  make  it  too  heavy.  At  the  lower  end  the  jacket 
should  reach  as  far  down  as  possible  without  interfering  with  the  flexion  of 
the  thighs ;  at  the  upper  end  it  should  not  be  so  tight  under  the  arms  as  to 
be  uncomfortable.  It  is  not  expected  that  the  jacket  Avill  affi^rd  support  by 
pressure  under  the  arms,  but  by  supporting  the  body  as  a  whole.  The  ends 
should  be  trimmed  oflF  to  the  desired  length  before  the  jacket  is  entirely 
hardened.     A  common  pocket-knife  is  the  best  instrument  for  this  purpose. 


Fig.  9. 


Fig.  10. 


The  W'ashburn  spine-brace. 


The  modified  Taylor  brace,  with  liead-piece. 


When  good  plaster  is  used  the  jacket  will  be  solid  enough  to  support  the 
child  by  the  time  the  trimming  is  done.  Each  jacket  can  be  worn  from  one 
to  three  months,  when  it  should  be  replaced  by  a  new  one. 

In  all  cases  of  Pott's  disease  above  the  seventh  dorsal  vertebra  a  head- 
support  should  be  applied,  and  this  is  best  accomplished  by  means  of  a  steel 
brace.  A  steel  brace  can  be  employed  with  great  satisfaction  for  disease  in 
any  part  of  the  spine,  but  it  is  specially  well  adapted  to  the  upper  end.  The 
general  practitioner  will  find  that  the  variety  of  brace  known  and  illustrated 
in  surgical-instrument  catalogues  as  ''Washburn's  brace"  will  give  satisfac- 
tion (Fig.  9).  Braces  with  crutches  under  the  arms  are  to  be  avoided,  because 
the  patient  cannot  bear  sufficient  weight  upon  the  axilla  to  be  of  any  service; 
they  also  cause  the  patient  much  unnecessary  pain,  ami  are  altogether  unsat- 
isfactory (Fig.  10). 

The  AVashburn  brace  acts  upon  the  principle  of  a  lever,  the  weight  being 
at  the  pelvis,  the  fulcrum  at  the  deformity,  and  the  power  at  the  shoulders. 


OBTHOP^DICS.  1071 

It  consists  of  a  padded  steel  pelvic  band,  to  which  are  attached  two  steel 
uprights,  one  on  either  side  of  the  spines  of  the  vertebra,  and  a  cloth  apron, 
which  is  spread  over  the  front  of  the  body,  holding  the  uprights  close 
against  the  back.  To  the  upper  end  of  the  uprights  are  attached  padded 
strips  of  webbing  which  pass  around  under  the  arms  and  buckle  to  a  cross- 
piece  over  the  scapulae,  holding  the  shoulders  back.  The  uprights  are 
padded  opposite  the  deformity.  The  pelvic  band  acts  as  a  fixed  point ;  the 
uprights  make  pressure  upon  the  transverse  processes  of  the  diseased  ver- 
tebme,  and  the  straps  over  the  shoulders,  with  the  aid  of  the  spring  in  the 
steel  uprights,  pull  the  shoulders  back,  thus  lifting  the  weight  from  the 
diseased  bodies  of  the  vertebrae  and  throwing  it  upon  the  healthy  parts. 
The  brace  acts  as  a  splint  does  to  a  broken  leg,  holding  the  whole  spinal 
column  as  one  piece,  thus  securing  the  desired  rest  for  the  diseased  part. 

Should  an  abscess  appear,  so  long  as  it  is  not  large  and  is  causing  no 
symptoms  it  should  be  let  alone.  If,  however,  it  is  increasing  rapidly  in 
size,  if  it  is  causing  symptoms  from  pressure,  or  if  the  patient's  health  is 
failing,  it  should  be  operated  upon.  It  is  far  better  in  any  case  to  let  a  cold 
abscess  alone  than  simply  to  open  it  and  leave  it  to  itself. 

The  writer  has  obtained  the  best  results  by  evacuating  the  abscess  with  a 
trocar  and  cannula,  washing  out  Avith  bichloride  solution  and  injecting  iodo- 
form emulsion.  Every  antiseptic  precaution  must  be  employed  in  this 
operation,  because  the  introduction  of  pyogenic  germs  into  these  cavities, 
causing  a  mixed  infection,  is  a  very  serious  matter.  The  iodoform  emulsion 
should  be  10  per  cent.,  and  from  two  drachms  to  two  ounces  may  be  injected. 
A  second  operation  any  time  after  two  weeks  may  be  necessary. 

The  paralysis  of  Pott's  disease  requires  the  same  care  as  paraplegia  from 
any  other  cause.  The  bladder  and  boAvels  must  be  cared  for  and  bed-sores 
avoided.  The  mechanical  support  must  be  continued.  These  cases  usually 
recover  in  about  a  year,  and,  in  the  writer's  experience,  get  well  just  as 
promptly  without  special  medication. 

Chronic  Joint  Disease. 

It  is  now  well  understood  that  chronic  joint  diseases  are  generally  tuber- 
culous. They  are  ahvays  liable  to  be  followed  by  deformity  and  permanent 
disability,  and  require  mechanical  treatment.  They  are  therefore  classified 
under  the  head  of  orthopaedic  surgery.  The  greatest  advance  made  in  this 
department  of  surgery  is  the  establishment  of  the  fact  that  tuberculosis  of 
bones  and  joints  is  essentially  a  local  disease,  and  should  be  treated  as  such. 
They  very  rarely  prove  fatal,  except  when  they  become  complicated  by  a 
general  tuberculosis  or  a  tuberculosis  of  the  brain,  lungs,  or  some  other  vital 
organ.  The  natural  tendency  of  tuberculous  joint  disease  is  toward  recovery, 
and  when  assisted  by  proper  mechanical  or  operative  treatment  the  prognosis 
is  favorable  in  from  90  to  95  per  cent,  of  the  cases.  The  old  idea  Avas  that 
this  disease  is  constitutional  in  character,  and  it  Avas  treated  accordingly. 
The  belief  still  prevails  that  the  disease  is  hereditary,  but  the  facts  do  not 
support  this  belief,  for  the  children  of  healthy  parents  as  Avell  as  those  of 
diseased  ones  are  subject  to  the  affection.  The  family  history  Avill  not  help 
establish  the  diagnosis,  and  may  even  be  misleading,  because  the  mere  fact 
that  some  ancestor  of  the  child  had  tuberculosis  does  not  prove  that  an  arthritis 
occurring  in  the  child  is  tuberculous.  On  the  other  hand,  the  fact  that  the 
child's  ancestors  AAere  free  from  tuberculosis  does  not  enable  us  to  exclude 
this  affection  in  the  child. 


1072  AMERICAN   TEXT-BOOK   OF   DISEASES    OF   CHILDREN. 

Tuberculous  joint  disease  may  begin  either  as  a  synovitis  or  an  osteitis,  and 
it  is  often  difficult  to  differentiate  between  them.  Fortunately,  the  treat- 
ment is  the  same  in  either  case.  In  children  the  majority  of  cases  begin  as 
an  osteitis,  and  the  tendency  is  for  the  disease  to  extend  to  all  the  tissues  of  a 
joint,  so  that  it  becomes  a  tuberculous  arthritis.  The  great  principle  of  treat- 
ment is  prolonged  rest,  which  is  best  secured  by  some  mechanical  device. 
Usually  when  the  joint  is  kept  perfectly  quiet  for  a  sufficient  length  of  time 
nature  will  bring  about  a  cure.  There  is  no  special  medication  for  this  dis- 
ease. Local  applications  may,  at  times,  help  to  relieve  pain,  but  they  have 
no  curative  effect. 

Hip-joint  Disease. 

The  hip  is  the  most  frequent  seat  of  chronic  joint  disease.  It  is  tuber- 
culous in  character,  and  generally  begins  in  the  head  of  the  femur  near  the 
epiphyseal  line. 

Etiology. — Usually  the  exciting  cause  is  not  known,  but  it  is  certain 
that  in  some  cases  it  is  traumatism.  As  a  rule,  it  is  not  the  puny,  delicate 
child  of  the  family  who  develops  hip-joint  disease,  but  the  active,  stirring 
one — the  one,  in  short,  who  is  most  subject  to  traumatism.  Injury  thus 
causes  a  locus  minoris  resistentice  which  affords  a  culture-field  for  the  tubercle 
bacillus. 

Symptoms. — Generally  the  first  symptom  is  a  limp.  The  child  will  be 
noticed  to  limp  when  it  first  gets  about  in  the  morning,  and  to  get  better  as 
the  day  advances.  Deformity  appears  early,  and  is  usually  flexion  with 
adduction  and  apparent  shortening,  but  it  may  be  flexion  with  abduction 
and  apparent  lengthening  (Figs.  11  and  12).  Atrophy  is  an  early  and  con- 
stant symptom.  Pain  is  apt  to  be  present  early.  It  is  most  marked  on  the 
inner  side  of  the  knee  or  on  the  anterior  surface  of  the  thigh.  It  is  quite 
exceptional  that  it  is  referred  to  the  joint  itself.  Limitation  of  motion  is 
the  symptom  most  depended  upon  by  orthopsedists  in  making  the  diagnosis. 
By  proper  examination  it  may  be  found  at  a  very  early  period.  Involun- 
tary muscular  spasm  is  an  important  symptom  found  upon  manipulating  the 
joint. 

The  general  health  of  the  child  is  often  fairly  good,  but  there  may  be 
emaciation  from  persistent  pain  and  loss  of  sleep.  There  is  no  marked  febrile 
reaction,  although  a  temperature  of  99°  or  100°  F.  is  not  uncommon.  Later 
in  the  disease  an  abscess  may  form,  and  may  appear  at  any  point  about  the 
joint,  but  is  seen  most  frequently  in  front.  It  is  generally  preceded  or 
accompanied  by  an  unusual  amount  of  pain,  but  sometimes  comes  on  so 
insidiously  that  it  becomes  quite  large  before  it  is  noticed. 

Pathology. — If  treatment  is  begun  early  enough,  it  is  possible  to  pre- 
vent the  disease  from  breaking  into  the  joint,  and  thus  save  the  motion  in 
the  limb.  In  many  cases,  unfortunately,  this  has  happened  before  the  child 
is  brought  under  treatment,  and  the  bone  and  other  joint-structures  are 
breaking  down.  The  disease,  unless  prevented  by  proper  treatment,  extends 
to  all  of  the  structures  of  the  joint. 

Diagnosis. — When  a  child  limps  and  complains  of  pain  about  the  knee 
or  hip  a  careful  examination  of  both  the  joints  should  be  made.  It  is  un- 
fortunately a  very  common  experience  of  every  surgeon  to  have  a  child 
brought  to  him  with  well-advanced  hip  disease  which  has  been  diagnosticated 
and  treated  for  rheumatism.  This  mistake  should  never  be  made,  because 
rheumatism  is  an  acute  febrile  disease  usually  affecting  several  joints  at 
once. 


OB  THOPJEDICS. 


1073 


For  examination  the  child  must  be  stripped  of  all  clothing,  and  made 
to  walk  back  and  forth  before  the  examiner,  that  he  may  locate  the  limp.  If 
the  hip  is  affected,  the  patient  swings  the  body  Avhen  stepping  forward 
with  the  affected  limb,  making  as  little  motion  at  that  joint  as  possible.  The 
thighs  should  next  be  measured.  If  hip-joint  disease  is  present,  the  thigh 
on  the  diseased  side  is  from  half  an  inch  to  an  inch  smaller  than  the  other, 
and  the  gluteal  fold  is  usually  absent  as  a  result  of  atrophy  of  the  muscles. 
Older  writers  placed  much  value  upon  deformity  as  a  characteristic  symp- 


FlG.  1], 


Fig.  12. 


Hip-joint  disease  just  beginning,  showing  slight  flex- 
ion and  disappearance  of  gluteal  fold. 


Abduction  and  apparent  lengthening. 


torn,  but  it  is  very  important  to  make  a  diagnosis  before  marked  deformity 
is  present. 

The  child  should  next  be  laid  upon  its  back  upon  a  table  (a  bed  is  too 
soft).  Try  to  bring  the  popliteal  space  of  the  affected  side  and  the  lumbar 
spine  in  contact  with  the  table  at  the  same  time.  If  this  can  be  accom- 
plished with  ease,  hip-joint  disease  can  be  excluded,  because  even  at  an' 
early  stage  some  flexion  is  present,  although  it  may  not  be  noticed  when  the 
child  is  standing ;  and  when  it  is  present  the  popliteal  space  and  lumbar 
spine  cannot  be  made  to  touch  the  table  at  the  same  time.  Place  the  palm 
of  the  hand  first  upon  the  sound  limb  and  gently  roll  it  on  the  table,  then  roll 
the  lame  limb  in  the  same  manner.  If  hip-joint  disease  is  present,  it  will 
require  more  force  to  roll  the  afiiicted  limb,  and  the  limb  will  not  roll  so  far 
on  account  of  the  restriction  of  motion  in  the  hip-joint.     Next  grasp  the 


1074     A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


ankle  of  the  sound  limb  and  flex  the  leg  on  the  thigb  and  the  thigh  upon 
the  body,  noting  the  natural  resistance;  the  hip-joint  should  then  be  put 
through  all  its  natural  motions  to  note  the  amount  of  normal  resistance  and 
to  gain  the  confidence  of  the  child.  The  lame  leg  should  now  be  taken  and 
put  through  the  same  motions,  and  if  hip-joint  disease  is  present,  it  will  re- 
quire more  force  to  flex  and  rotate  the  hip,  and  there  will  be  involuntary 
spasm  of  the  muscles  about  the  hip.  There  is,  in  short,  restriction  of  motion 
and  spasm.  When  this  examination  is  made  with  care  and  gentleness,  these 
signs  can  be  found  at  a  very  early  stage,  and  are  quite  characteristic,  since 
no  other  disease  will  cause  spasm  and  limitation  of  motion  in  every  direction. 
Rough  manipulations  must  always  be  avoided,  because  they  obscure  the  symp- 
toms and  may  do  harm. 

Prognosis. — From  90  to  95  per  cent,  of  cases  of  this  aff'ection  will 
recover  under  treatment,  and  the  majority  will  have  a  useful  amount  of 
motion  in  the  joint.  By  recovery  we  mean  that  the  disease  will  disappear. 
Very  rarely  the  joint  is  left  in  an  almost  perfect  condition.  Usually,  how- 
ever, there  is  some  shortening  and  deformity,  with  more  or  less  permanent 
limitation  of  motion.  In  untreated  cases  the  deformity  is  apt  to  be  great, 
and  complete  ankylosis  is  not  infrequent.  Abscesses  add  to  the  gravity  of 
the  case,  but  do  not  make  recovery  with  a  satisfactory  result  impossible.  The 
length  of  time  required  to  bring  about  a  cure  varies  greatly  in  diff"erent  sub- 
jects ;  a  very  few  will  recover  in  one  year,  many  in  two  and  three  years,  and 
some  continue  for  five  years. 

Treatment. — When  the  diagnosis  is  made  there  must  be  no  delay  in 
beginning  treatment,  for  it  is  only  by  early  detection  and  prompt  treatment 
that  the  best  results  are  obtained.  Medicine  is  of  little  or  no  value  for  the 
disease  per  se,  but  may  be  necessary  to  meet  indications  as  they  arise.  The 
great  point  is  to  secure  perfect  rest  for  the  diseased  joint :  it  must  neither 
move  nor  bear  weight :  this  is  best  accomplished  by  some  mechanical  device. 
Pain  is  best  relieved  by  securing  perfect  rest ;  opiates 
are  to  be  avoided.  An  effort  should  be  made  when  the 
case  is  not  too  chronic  to  overcome  some  of  the  de- 
formity. 

When  the  child  is  suff"ering  severely  a  very  excel- 
lent way  to  begin  treatment  is  to  put  it  in  bed  and 
apply  extension  by  means  of  a  Aveight  and  pulley  until 
the  acute  pain  has  subsided ;  then  some  mechanical  de- 
vice should  be  substituted  and  the  confinement  to  bed 
discontinued.  The  amount  of  weight  required  in  ex- 
tension varies  from  two  to  six  pounds,  or  from  half  a 
brick  to  two  bricks,  according  to  the  age  of  the  child, 
the  object  being  to  secure  continuous  extension.  The 
relief  afforded  is  another  good  gauge  of  the  weight  to 
be  employed,  most  surgeons  erring  in  using  too  much. 
The  weight  is  best  applied  by  means  of  an  ordinary 
Buck's  extension,  as  pictured  in  all  Avorks  on  surgery. 
The  adhesive  straps  should  always  extend  above  the 
knee,  and  the  child  must  not  be  allowed  to  slide  down 
so  as  to  come  in  contact  Avith  the  foot  of  the  bed.  Some 
patients  do  best  if  extension  is  kept  up  by  means  of  an 
extension-brace  throughout  the  treatment,  but  most  cases 
do  equally  well  if  the  joint  is  simply  fixed  Avithout  extension.  The  best  exten- 
sion-brace is  the  long  hip-splint  consisting  of  a  padded  steel  waistband  and  a 


Fig.  13 


Taylor's  long  hip-splint. 


ORTHOPEDICS. 


1075 


long  steel  bar,  capable  of  being  lengthened  or  shortened,  extending  from  the 
waistband  to  a  point  just  below  the  sole  of  the  shoe  (Fig.  13).  Two  perineal 
straps  are  attached  to  the  waistband  upon  which  the  patient  sits  instead  of 
stepping  on  the  foot  of  the  diseased  side.  The  lower  end  of  the  brace  is 
attached  to  the  leg  by  means  of  adhesive  straps  which  have  buckles  attached 
to  them,  and  straps  attached  to  the  horizontal  part  of  the  brace  which  passes 
under  the  foot.  These  straps  are  buckled  into  the  buckles,  and  the  length  of 
the  bar  made  such  that,  when  the  child  stands  upon  the  brace,  the  foot  will 


Fig.  14. 


Fig.  15. 


Taylor's  long  hip-spliat  applied. 


Plaster-of- Paris  splint  for  hip-joint  disease. 


swing  clear  of  the  cross-piece  and  of  the  floor.  The  shoe  on  the  sound  side 
must  be  elevated  so  as  to  make  the  length  of  the  leg  equal  to  the  length  of 
the  brace.  The  perineal  straps  must  be  so  adjusted  that  the  waistband  rests 
between  the  trochanter  and  the  crest  of  the  ilium,  and  so  that  there  is  a 
gentle  pull  upon  the  leg  all  the  while,  forcing  the  head  of  the  femur  away 
from  the  acetabulum.  A  child  can  walk  very  comfortably  upon  a  brace  of 
this  kind  without  the  aid  of  crutches  (Fig.  14). 

A  very  convenient  and  efficient  method  of  treating  hip-joint  disease  is  to 


1076     AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

apply  a  plaster-of-Paris  splint  from  the  ribs  to  the  knee  (Fig.  15).  The  shoe 
on  the  unaffected  side  should  be  elevated  at  least  two  and  a  half  inches,  and 
the  child  should  walk  with  crutches.  The  elevation  of  the  shoe  should 
always  be  sufficient  to  prevent  the  patient  from  bearing  weight  upon  the  lame 
limb,  as  he  is  very  prone  to  do  as  soon  as  it  gets  a  little  better.  The  plaster 
will  last  longer  if  it  is  reinforced  by  light  strips  of  Avood  over  the  fold  of  the 
groin,  where  it  is  most  likely  to  break.  The  splint  should  not  be  heavy,  and 
should  be  changed  every  three  or  six  weeks,  according  to  circumstances. 
Sole  leather  softened  in  cold  water  and  fitted  to  the  body  from  the  ribs  to 
the  knee  makes  a  good  splint.  A  paper  pattern  may  first  be  fitted  and  the 
leather  cut  by  this.  The  softened  leather  can  then  be  fitted  to  the  body  and 
held  there  by  plaster  bandages  until  it  is  perfectly  dry  and  hard.  Particular 
care  must  be  exercised  in  every  case  that  weight  is  not  borne  upon  the 
diseased  limb,  for  a  splint  of  any  kind  would  be  of  little  value  were  the 
patient  allowed  to  use  the  joint.  It  will  be  necessary  to  continue  treatment 
for  from  one  to  three  years,  or  for  six  months  after  all  pain  and  spasm  have 
disappeared.  The  parents  should  be  informed  from  the  first  that  the  treat- 
ment will  necessarily  be  long,  and  that  even  when  the  case  is  doing  well 
there  will  be  acute  exacerbations,  continuing  from  a  few  days  to  as  many 
weeks,  during  which  the  child  will  suffer  more  and  in  every  way  seem  worse. 
During  these  exacerbations  the  treatment  should  be  in  no  way  changed,  save 
that  the  patient  should  be  kept  as  quiet  as  possible. 

An  abscess  may  appear  at  any  time  after  the  first  few  months,  and  always 
adds  to  the  gravity  of  the  disease,  but  it  does  not  follow  that  a  good,  useful 
joint  may  not  be  secured.  As  long  as  an  abscess  is  small  and  is  causing  no 
symptoms  it  should  be  let  alone,  for  it  will  do  no  harm  and  may  disappear 
entirely.  Should  it  increase  rapidly,  should  the  child's  general  health  begin 
to  fail,  or  should  it  give  rise  to  any  decided  symptoms,  it  must  be  evacu- 
ated. Some  very  good  authorities  advise  aspiration,  but  the  writer  has  not 
been  satisfied  with  this.  It  is  better  to  empty  it  through  a  good-sized  cannula, 
and  after  washing  thoroughly  with  a  bichloride  solution  to  inject  from  two 
drachms  to  two  ounces  of  a  10  per  cent,  emulsion  of  iodoform.  It  is  not 
good  surgery  to  open  these  cold  abscesses  and  drain  with  rubber  tubes. 

In  a  very  few  instances  the  disease  will  grow  worse  in  spite  of  the  best 
treatment.  In  these  and  in  some  cases  that  first  come  under  treatment  after 
the  disease  is  well  advanced  the  joint  should  be  excised.  This  operation  is 
indicated  when  the  disease  grows  rapidly  worse  in  spite  of  proper  treatment, 
when  the  child's  health  is  failing  rapidly,  and  when  there  are  sinuses  and 
other  evidences  of  extensive  disease  of  bone.  The  operation  is  not  a  very 
dangerous  one,  and  yields  good  and  at  times  brilliant  results,  for,  as  a  rule, 
in  a  few  weeks  or  months  the  child  recovers.  Unfortunately,  however,  the 
ultimate  results  are  not  nearly  so  good  as  in  cases  treated  mechanically,  and 
the  writer,  while  approving  highly  of  this  operation  under  proper  circum- 
stances, only  recommends  it  when  mechanical  treatment  has  failed  or  cannot 
be  applied. 

Knee-joint  Disease. 

This  disease,  also  called  white  swelling  of  the  knee,  is  a  chronic  tuberculous 
inflammation,  beginning,  in  the  majority  of  cases,  as  an  osteitis  of  the  femur  or 
tibia.     It  begins  more  frecjuently  as  a  synovitis  than  does  hip-joint  disease. 

Etiology. — The  causes  are  the  same  as  hip-joint  and  other  tuberculous 
joint  diseases.  A  traumatism  is  frequently  the  excitant,  but  in  many  cases 
no  such  history  can  be  obtained. 


OR  THOPJEDICS. 


1077 


Pathology. — The  tubercle  bacillus  can  usually  be  found  in  these  cases. 
No  matter  what  tissue  may  be  first  attacked,  the  tendency  is  to  extend  to  all 
the  tissues,  causing  greater  or  less  destruction  of  the  joint.  When  treat- 
ment is  established  at  an  early  date  the  focus  of  disease  may  become  encap- 
sulated. At  a  later  date  very  extensive  disease  may  entirely  disappear  by 
absorption  under  rest  treatment.  The  peculiar  characteristic  white  swelling 
is  due  to  infiltration  of  the  soft  tissues  about  the  joint  with  a  gelatinous 
substance,  which  is  not  tuberculous,  since  no  bacilli  can  be  found  in  it,  but 
which  is  evidently  a  product  of  tuberculosis. 

Symptoms. — This  disease  begins,  as  a  rule,  quite  insidiously.  The  first 
symptoms  are  usually  a  limp  and  slight  pain.  The  joint  soon  loses  its 
normal  appearance  from  filling  up  of  the  depressions  on  either  side  of 
the  patella.  The  swelling  gradually  increases  and  the  knee  becomes  flexed, 
giving  to  the  joint  a  very  characteristic  appearance  (Fig.  16).     At  a  later 


Fig.  16. 


Fig.  17. 


Tuberculous  knee. 


Plaster  cast  properly  applied  to  knee. 


date  the  tibia,  unless  prevented  by  treatment,  becomes  subluxated  back- 
ward. The  pain  may  at  times  become  very  severe,  and  is  usually  worse  at 
night.  Night-cries  frequently  occur.  Atrophy  of  the  limb  above  and  below 
the  knee  is  an  early  symptom.  Limitation  of  movement  and  involuntary 
muscular  spasm  are  always  present.  There  is,  as  a  rule,  little  if  any  general 
rise  of  temperature,  but  the  diseased  knee  is  perceptibly  warmer  than  the 
other  one.  Abscesses  may  form,  generally  appearing  on  the  anterior  inner 
aspect  of  the  knee. 

Diagnosis. — When  a  child  limps  and  complains  of  pain  in  the  knee  he 
should  be  carefully  examined.  It  is  well  to  remember  that  in  hip-joint  dis- 
ease the  pain  is  often  felt  in  or  near  the  knee,  but  then  the  knee  is  not 
swollen  and  its  motion  is  unrestricted.  It  is  well  to  always  examine  both 
joints  carefully.  Place  one  hand  on  each  knee,  and  when  knee-joint  disease 
is  present  a  practised  hand  will  feel  an  increase  of  heat  on  the  affected  side. 


1078    A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Fig.  is. 


Thomas's  knee- 
splint. 


Fig.  19. 


Gentlv  flex  and  extend  the  knee,  and  if    disease  is  present  there  vi'\\\  be 

limitation  of  motion  and  spasmodic  jerking  of  the  muscles.  Upon  measure- 
ment the  aftected  knee  will  be  found  larger  than  the  other, 
and  the  limb,  above  and  below,  will  be  smaller  than  its  fel- 
low. These  symptoms,  together  with  the  history  and  cha- 
racteristic appearance,  will  be  sufficient  evidence  upon  which 
to  base  a  diagnosis  of  tuberculosis  of  the  knee.  This  dis- 
ease should  never  be  mistaken  for  rheumatism,  because  it  is 
mono-articular ;  it  comes  on  slowly  and  is  not  accompanied 
by  fever. 

Prognosis. — With  proper  treatment,  instituted  early,  the 
prognosis  is  good.  Fully  90  per  cent,  recover  with  some 
motion  and  little  deformity.  In  neglected  cases  the  knee 
becomes  ankylosed  in  a  flexed  position  and  the  tibia  is  sub- 
luxated  backward. 

Treatment. — The  treatment  of  this,  as  of  other  tuber- 
culous  bone   disease,   is   prolonged   rest.     Medicines   either 
a   I      internally  or  locally  are  of  little  if  any  value.     It  is  desir- 
I     I     able  to  overcome  existing   deformity   as   early   as  possible. 
■      When  this  is  not  very  marked  the  appliances  used  to  secure 
m      rest  will  also  straighten  the  knee,  but  when  it  is  well  marked 
^       these  will  not  suffice.     When  the  joint  is  not  disorganized, 
and  when  there  are  no  sinuses  or  abscesses,  the  quickest  and 
best  way  is  to  administer  an 
an<'«sthetic  and  straighten 

the  limb  by  manual  force.     Care  must  be 

exercised  not  to  cause  a  subluxation   of 

the  tibia  back^vard  or  a  separation  of  the 

epiphysis    of  either    the    femur    or    tibia. 

Force  must  not  be  used  in  old  cases  with 

abscesses  and  sinuses.     When  the  limb  is 

straight  a  plaster  cast  should  be  applied, 

extending  from  the  malleoli  well  up  to  the 

body  (Fig.   17).     A  short  cast  extending 

only  part  way  up  the  thigh  or  down  the 

leg  is  worse  than  useless.     The  cast  should 

be  applied  next  the  skin  or  over  a  very 

light  roller  bandage,  and  should  never  be 

heavier  than  pasteboard.      The  shoe  on  the 

sound  side  should  be  elevated  two  and  a 

half  or  three  inches,    and   crutches  used. 

The  plaster  should  be  changed  every  ten 

days  or  two  weeks  until  the  deformity  is 

overcome,    and    after    that    about    once    a 

month.     A  good    splint    can  be  made  of 

sole  leather.     It  should  be  soaked  in  cold 

water  until  soft,  and  then  moulded  to  tlie 

limb  by  applying  a  bandage  over  it.     After 

it  dries  it  will  keep  its  shape  indefinitely, 

and  is  light  and  clean.     Leather  is  not  as 

.suitable  as  plaster  before  the  deformity  is 

overcome.     After  many  years  of  experience  with  all  sorts  of  apparatus  the 

writer  prefers  plaster  of  Paris  for  knee-joint  cases. 


Thomas's  knee-splint  applied. 


ORTHOPEDICS.  1079 

A  very  good  knee-splint  is  that  of  Hugh  Owen  Thomas,  which  does  away 
with  crutches  (Fig.  18).  It  consists  of  a  padded  steel  ring  which  surrounds 
the  thigh,  and  two  steel  uprights  extending  from  the  ring  down  to  a  point 
two  or  three  inches  below  the  bottom  of  the  foot,  where  they  are  united  by  a 
smaller  ring.  The  outer  upright  is  longer  than  the  inner  one,  so  the  upper 
ring  rests  against  the  perineum  on  the  inner  side  and  passes  above  the  great 
trochanter  on  the  outer  side.  When  the  child  walks  its  weight  on  the  affected 
side  is  sustained  by  the  ring,  and  thus  taken  from  the  joint  (Fig.  19).  The 
limb  is  fixed  between  the  uprights  by  straps  or  bandages.  The  shoe  on  the 
unaffected  side  must  be  elevated  so  that  this  leg  is  as  long  as  the  brace.  The 
apparatus  must  be  worn  for  a  number  of  months  after  all  symptoms  of  inflam- 
mation have  disappeared.  The  treatment  usually  lasts  from  one  to  three  years. 
When  abscesses  appear  they  are  to  be  treated  as  in  hip-joint  disease. 

In  the  few  cases  that  do  not  yield  to  the  above  treatment  and  in  neglected 
cases  it  will  be  necessary  to  resort  to  operative  treatment.  Excision  of  the 
knee  is  not  to  be  recommended  in  children,  because  it  interferes  with  the 
growth  of  both  the  femur  and  the  tibia,  and  the  result  is  a  very  short,  stiff 
leg  and  one  that  is  very  prone  to  become  deformed.  Erasion,  or  scraping 
out,  is  the  better  operation.  The  joint  should  be  opened  freely  on  both  sides 
of  the  patella,  and  all  diseased  tissue  removed  with  a  bone-scoop  and  scissors. 
If  the  operator  is  assured  that  he  has  removed  all  of  the  diseased  tissue,  and 
that  the  wound  is  aseptic,  after  thoroughly  iodoformizing  the  joint  he  should 
close  the  wounds  and  apply  a  surgical  dressing  and  a  plaster  cast.  If,  how- 
ever, he  is  not  thoroughly  satisfied  that  he  has  removed  all  of  the  disease,  or 
if  the  knee  is  suppurating  to  begin  Avith,  he  should  wash  out  thoroughly 
with  bichloride  solution  and  pack  with  iodoform  gauze.  The  packing  should 
be  kept  up  until  the  wound  closes  by  granulation.  When  the  structures  are 
not  too  badly  diseased  the  joint  may  recover  with  some  motion  after  erasion. 

Disease  of  the  Ankle  and  Tarsus. 

Chronic  inflammation  of  the  ankle  and  tarsus  is  tuberculous  in  character, 
and  is  due  to  the  same  causes  and  has  the  same  pathology  as  hip-  and  knee- 
joint  disease.  It  begins  either  in  the  bones  or  synovial  membrane,  most 
frequently  in  the  former,  the  astragalus  being  the  most  common  location. 
Disease  is  much  less  frequent  in  the  ankle  than  in  the  hip  and  knee. 

Symptoms. — This  disease  is  not,  as  a  rule,  as  painful  as  hip  disease, 
although  it  is  occasionally  very  painful.  The  child  is  first  noticed  to  limp, 
and  upon  examination  limitation  of  motion,  muscular  spasm,  local  heat, 
swelling  of  the  part,  and  atrophy  of  the  calf  .are  found.  The  calf  muscles 
soon  contract,  drawing  the  heel  up  and  producing  deformity.  Enlarged 
veins  can   be  seen  over  the  swelling. 

Diagnosis. — The  ankle  limp  is  peculiar.  The  child  turns  his  toes  out, 
so  as  to  avoid  flexion  of  the  joint,  as  he  steps  forward,  and  advances  the 
inner  side  of  the  foot,  throwing  as  little  weight  upon  the  ball  of  the  foot  as 
possible.  Limitation  of  movement  and  spasm  can  be  demonstrated  by  flex- 
ing and  extending  the  joint.  These  symptoms,  with  those  mentioned  above, 
should  establish  the  diagnosis. 

Prognosis. — In  children  the  prospect  of  recovery  is  good.  Cases  brought 
promptly  under  treatment  frequently  get  Avell  in  from  six  to  nine  months. 

Treatment. — The  proper  treatment  is  prolonged  and  complete  rest.  This 
is  best  secured  by  a  plaster  cast  extending  from  the  points  of  the  toes  to  tlie 
knee.      Crutches  must  be  used,  and  if  the  child  persists  in  bearing  weight 


1080    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

upon  the  foot,  the  souud  foot  must  be  elevated  by  a  high-soled  shoe.  It  is 
of  little  value  to  apply  a  plaster  cast  and  allow  the  patient  to  walk  upon  it. 
The  plaster  should  be  changed  every  three  or  four  weeks,  and  constant  care 
exercised  to  prevent  the  heel  from  drawing  up.  Cases  treated  in  this  manner 
usually  recover  with  a  useful  joint.  Treatment  must  be  continued  for  some 
time  after  all  pain,  heat,  and  muscular  spasm  have  disappeared.  The  Thomas 
knee-splint  is  a  very  good  instrument  for  treating  ankle-joint  disease. 

Operation  is  rarely  satisfactory.  When  the  disease  is  confined  to  one 
bone,  the  removal  of  that  bone  will  yield  a  good  result,  but  when  it  is  more 
extensive,  as  is  usually  the  case,  operation  will  not  yield  as  good  results  as 
rest  treatment.  In  very  extensive  disease  amputation  is  conservative,  for  in 
such  cases  there  is  imminent  danger  of  tuberculous  meningitis  or  pulmonary 
tuberculosis. 

Wrist-joint  Disease. 

Chronic  inflammation  of  the  wrist  and  carpus  is  a  tuberculosis  beginning, 
in  the  majority  of  cases,  in  the  radius.     It  is  quite  a  rare  disease. 

The  causes  and  pathology  are  the  same  as  in  hip-joint  disease. 

Symptoms. — This  is  not  a  very  painful  affection,  as  a  rule,  but  the  joint 
is  quite  sensitive  to  touch  and  motion.  There  are  local  heat  and  swelling,  the 
latter  being  usually  most  marked  on  the  dorsal  surface.  The  arm  becomes 
atrophied,  and  the  thumb  lies  parallel  with  the  fingers  in  quite  a  character- 
istic manner.  The  joint  usually  becomes  flexed  and  motion  is  restricted. 
The  tendon-sheaths  are  very  liable  to  become  involved,  adding  to  the  gravity 
of  the  disease. 

Diagnosis. — The  above-mentioned  features  should  establish  the  diag- 
nosis, since  no  other  disease  gives  rise  to  like  symptoms. 

Prognosis. — The  prognosis  in  wrist-joint  tuberculosis  is  always  grave, 
because  of  the  marked  tendency  to  pulmonary  involvement.  The  wrist  dis- 
ease in  a  child  usually  recovers  promptly  with  a  good,  movable  joint,  but 
the  patient  rarely  lives  out  his  expectancy. 

Treatment. — The  treatment  is  rest,  and  this  is  best  secured  by  a  plaster 
cast  extending  from  the  knuckles  nearly  to  the  elbow.  The  plaster  should 
be  applied  close  to  the  skin,  and  should  be  changed  every  three  or  four 
weeks.  The  hand  must  be  carried  in  a  sling  and  held  halfway  between 
pronation  and  supination.  Operations  in  this  disease  are  very  disappointing, 
and  do  not  yield  nearly  so  good  results  as  the  rest  treatment.  Gouging  and 
scraping  are  not  to  be  recommended. 

Elbow- joint  Disease. 

Tuberculosis  of  the  elbow  is  (piite  a  rare  disease.  Its  causes  and  path- 
ology are  the  same  as  hip-joint  disease. 

Symptoms. — This  disease  is  not  usually  painful,  but  the  joint  is  sensi- 
tive to  motion.  The  first  symptoms  are  generally  flexion  and  limitation  of 
motion.  Swelling  comes  on  gradually,  being  first  noticed  on  either  side  of 
the  olecranon  process.  The  veins  become  enlarged  and  the  elbow  gradually 
assumes  a  spindle  shape.  The  arm  above  and  below  the  joint  becomes 
atrophied.  The  disease  begins  moit  frequently  in  the  olecranon,  and  next 
in  the  humerus. 

Diagnosis. — Recognition  of  the  disease  is  based  upon  the  limitation  of 
motion,  the  peculiar  shape,  and  the  local  heat. 

Prognosis. — For  recovery  the  prognosis  is  good,  but  the  joint  is  very 


ORTHOPEDICS.  1081 

liable  to  aDkylosis  on  account  of  its  peculiar  shape.  Pulmonary  tuber- 
culosis occurs  with  this  less  frequently  than  with  Avrist-joint  disease,  but 
more  frequently  than  with  hip-  or  knee-joint  disease. 

Treatment. — The  joint  should  be  flexed  to  a  right  angle  and  the  hand 
placed  halfway  between  pronation  and  supination,  and  held  there  by  a 
plaster  cast  extending  from  the  wrist  to  the  shoulder.  The  forearm  should 
be  carried  in  a  sling.  The  above-mentioned  position  is  the  one  in  which  the 
arm  would  be  the  most  useful  should  ankylosis  occur.  The  plaster  must 
be  changed  every  three  or  four  weeks,  and  continued  for  some  months  after 
all  symptoms  of  disease  have  disappeared. 

When  the  rest  treatment  fails,  the  joint  should  be  opened  and  the  dis- 
eased tissue  scraped  out.  The  after-treatment  is  the  same  as  after  erasion 
of  the  knee.  There  are  the  same  objections  to  excising  a  child's  elbow  that 
there  are  to  excising  its  knee. 

Shoulder- JOINT  Disease. 

Tuberculosis  of  the  shoulder  is  rare,  especially  so  in  childhood.  It  has 
the  same  causes  and  pathology  as  hip-joint  disease. 

The  symptoms  are  the  same  as  in  tuberculosis  of  the  knee — viz.  heat, 
swelling,  limitation  of  motion,  and  atrophy  of  neighboring  muscles.  The 
swelling  may  be  obscured  by  the  atrophy  of  the  deltoid,  and  the  limitation 
of  motion  will  not  be  so  noticeable  on  account  of  the  mobility  of  the  scapula. 

The  prognosis  is  fairly  good. 

The  treatment  is  rest.  This  is  best  secured  by  binding  the  arm  to  the 
body  by  adhesive  strips  or  bandages.  In  cases  that  do  not  yield  to  rest 
treatment  the  joint  should  be  excised.  Excision  is  followed  by  very  satis- 
factory results. 

Old  Deformities. 

Untreated  cases  of  joint  disease  almost  invariably  result  in  deformity.  At 
the  hip  and  knee  the  deformity  may  be  so  great  as  to  interfere  with  the  useful- 
ness of  the  limb.  These  patients  need  not  be  condemned  to  the  use  of  crutches 
all  their  lives,  for,  no  matter  how  severe  the  deformity,  it  can  be  remedied 
in  some  way.  When  ankylosis  follows  a  tuberculous  disease,  an  effort  to 
restore  motion  in  the  joint  is  unwise,  on  account  of  the  danger  of  lighting  up 
the  disease  again.  When  the  knee  is  ankylosed  in  a  straight  position  it  should 
not  be  disturbed,  but  when  it  is  decidedly  flexed  the  deformity  should  be  over- 
come. If  the  disease  is  well  and  there  is  motion  in  the  joint,  the  limb  can 
usually  be  straightened  by  force  and  held  there  until  the  tendency  to  relapse 
has  disappeared.  The  greatest  difficulty  is  to  overcome  the  subluxation  back- 
ward, but  this  can  be  done  by  mechanical  appliances  made  for  the  purpose. 
When  the  knee  is  firmly  ankylosed  in  a  flexed  position,  it  is  best  straightened 
by  performing  an  osteotomy  just  above  the  condyles  of  the  femur.  The  limb 
should  be  put  in  as  straight  a  position  as  possible,  and  held  there  by  a  plaster 
cast  or  other  splint  until  the  fracture  is  united.  In  extreme  cases  it  may  be 
necessary  to  break  the  tibia  also  just  below  the  epiphysis;  this,  however,  is 
very  rarely  necessary. 

In  neglected  cases  of  hip-joint  disease  there  is  apt  to  be  severe  flexion 
with  adduction  and  practical  shortening.  When  the  disease  is  well  and  there 
is  motion  in  the  joint,  it  may  be  possible,  by  cutting  the  resisting  muscles  sub- 
cutaneously,  to  overcome  a  greater  part  of  the  deformity.     In   very  severe 


1082    AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

deformity  or  when  ankylosis  exists  the  deformity  is  best  overcome  by  perform- 
ing an  osteotomy  just  below  the  trochanters.  It  may  be  necessary  to  cut  some 
of  the  muscles,  even  when  an  osteotomy  is  performed,  before  the  limb  can  be 
brought  into  the  desired  position.  The  thigh  should  be  brought  down  parallel 
with  its  fellow  and  held  there  by  a  plaster-of-Paris  cast  extending  from  the 
toes  well  up  on  the  ribs,  or  by  means  of  Buck's  extension.  After  about  six 
weeks  the  child  can  begin  to  walk  on  crutches,  and  will  soon  be  able  to  use  the 
afflicted  limb.  It  should  be  remembered  that  none  of  these  cases  need  go  un- 
relieved, for  the  treatment  is  not  dangerous  and  is  very  satisfactory. 

Ankylosis  following  tuberculous  disease  is  not  due  to  keeping  the  joint  in 
one  position  so  long  by  means  of  apparatus,  but  to  the  ravages  of  the  disease. 
Nature,  in  her  effort  to  bring  about  a  cure,  sometimes  finds  it  necessary  to 
unite  the  joint  surfaces  by  bone  to  secure  a  strong  limb.  When  joints  suffer- 
ing from  disease  are  not  kept  at  rest  by  apparatus,  they  are  most  likely  to 
become  ankylosed,  while  a  healthy  joint  may  be  kept  at  rest  indefinitely  with- 
out beinsr  thus  affected. 


Congenital  Dislocation-  of  the  Hip. 


Fig.  20. 


Double  congenital  dislocation  of  hip,  showing 
extreme  lordosis. 


This  is  not  a  very  common  afiection, 
but  one  that  is  pretty  certain  to  come 
under  the  observation  of  every  practi- 
tioner. The  dislocation  is  usually  upon 
the  dorsum  of  the  ilium,  but  a  few  cases 
have  been  reported  in  which  it  was  for- 
ward. It  is  usually  on  but  one  side,  but 
may  be  double. 

Etiology. — There  are  two  classes  of 
cases — one  in  which  the  dislocation  is  due 
to  a  traumatism  at  or  before  birth,  and 
the  other  in  which  there  is  a  lack  of  de- 
velopment of  the  acetabulum.  Heredity 
seems  to  have  some  bearing,  because  nu- 
merous instances  are  on  record  in  which 
mother  and  child  were  both  afflicted  in 
this  way.     It  is  more  common  in  girls. 

Symptoms. — The  deformity  is  very 
liable  to  be  overlooked  until  the  child 
begins  to  walk,  when  it  will  be  noticed 
that  it  has  a  peculiar  wabbling  gait. 
Upon  examination  the  limb  is  found 
short,  adducted,  and  flexed,  just  as  in  a 
dislocation  occurring  later  in  life.  When 
the  deformity  is  double  there  is  marked 
lordosis  (Fig.  20).  The  trochanter  is 
above  N^laton's  line.  The  movement  is 
free  in  every  direction  except  abduction. 
There  is  no  pain,  but  the  child  tires  easily 
and  the  joint  may  be  sore  after  severe 
exercise. 

Diagnosis. — The  diagnosis  is  easy 
when  the  examiner  knows  that  there  is 
such  a  thing  as  a  congenital  dislocation. 


ORTHOPEDICS.  1083 

It  is  often,  mistaken  for  hip-joint  disease.  This  should  not  occur,  because 
atrophy,  pain,  and  muscular  spasm  are  absent.  There  is,  as  a  rule,  limitation 
of  motion  in  but  one  direction — abduction.  The  crucial  test  for  dislocation  is 
made  by  placing  the  child  upon  its  unaffected  side  and  drawing  Ndlaton's  line 
from  the  tuberosity  of  the  ischium  to  the  anterior  superior  spine  of  the  ilium. 
This  line  passes  just  above  the  great  trochanter  in  a  normal  joint,  but  when 
dislocation  is  present  the  trochanter  is  some  distance  above  the  line. 

Prognosis. — As  a  rule,  the  deformity  continues  about  the  same  through 
life ;  it  never  improves ;  occasionally  it  grows  progressively  worse.  Parents 
should  be  advised  that  the  child  will  not  be  able  to  do  heavy  work  or  to  be 
much  on  its  feet. 

Treatraent. — Mechanical  treatment  is  not  to  be  recommended,  because  it 
has  been  faithfully  tried  by  competent  men  and  has  failed  to  cure  or  afford 
material  benefit.  The  majority  of  cases  are  better  oif  without  treatment.  In 
exceptional  instances,  when  the  limb  is  too  weak  or  too  badly  deformed  to  ren- 
der good  service,  an  operation  is  indicated.  This  consists  in  scooping  out  the 
rudimentary  acetabulum,  which  always  exists,  trimming  the  head  of  the  bone 
to  the  proper  shape,  and  reducing  the  dislocation.  The  operation  should  only 
be  undertaken  by  an  experienced  surgeon,  because  of  the  dangers  from  sepsis 
and  shock.  An  expert  reduces  the  danger  of  the  former  to  the  minimum  by 
his  technique,  and  of  the  latter  by  his  speed. 

Club-foot. 

There  are  four  principal  varieties  of  club-foot — talipes  varus,  in  which  the 
bottom  of  the  foot  is  turned  inward ;  talipes  valgus,  in  which  the  bottom  of 
the  foot  is  turned  outward ;  talipes  equinus,  in  which  the  toes  point  down- 
ward ;  and  talipes  calcaneus,  in  which  the  heel  points  downward.  As  a  rule, 
two  forms  are  associated,  when  the  deformity  is  indicated  by  combining  the 
names  of  the  varieties  entering  into  it.  Equino-varus  is  by  far  the  most 
common  form.      Club-foot  is  usually  congenital,  but  may  be  acquired. 

Etiology. — Acquired  talipes  is  caused  by  traumatisms,  burns,  bone  disease, 
or  paralysis.  Paralysis  due  to  poliomyelitis  produces  the  majority  of  cases 
of  acquired  talipes. 

Many  theories  have  been  advanced  as  to  the  origin  of  congenital  club-foot, 
but  none  have  been  proven.  The  laity  believe  in  maternal  impressions  as  a 
cause,  but  the  majority  of  the  profession  place  little  value  upon  this  theory. 
In  short,  the  etiology  is  undetermined. 

Patholog-ical  Anatomy. — All  of  the  tissues  take  part  in  the  malforma- 
tion. Bones  are  misshapen,  ligaments  are  shortened,  and  muscles  contracted, 
and  it  is  impossible  to  say  which  is  the  primary  lesion. 

Symptoms  and  Diagnosis. — The  diagnosis  is  self-evident,  and  the  symp- 
toms are  the  peculiarity  in  appearance  and  gait. 

Prognosis. — The  prognosis  of  acquired  talipes  depends  upon  the  cause. 
Those  cases  due  to  paralysis  are  the  least  promising,  but  even  in  these  some 
good  can  be  accomplished.  Almost,  if  not  quite,  all  cases  of  congenital  club- 
foot can  be  cured  by  proper  treatment. 

Treatment. — The  time  to  begin  treatment  is  as  soon  as  the  child  is  born. 
At  this  very  early  date  the  foot  must  be  repeatedly  forced  into  as  nearly  the 
normal  position  as  possible  with  the  hands.  The  nurse  should  be  instructed 
to  repeat  this  many  times  a  day.  After  four  or  six  weeks  the  radical  treat- 
ment should  begin. 

When  the  deformity  is  double,  as  is  very  often  the  case,  both  feet  should 


1084    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

be  treated  at  once.  There  are  two  prime  indications  to  be  met ;  first,  to 
overcome  the  deformity,  and,  second,  to  hold  the  foot  in  the  corrected  position. 
There  are  many  "ways  of  meeting  these  indications,  but  in  this  brief  article  the 
writer  will  describe  only  those  that  have  been  most  satisfactory  in  his  expe- 
rience. 

The  deformity  should  be  overcome  as  quickly  as  possible  without  resorting 
to  undue  violence.  In  very  young  patients  this  can  be  accomplished  in  the 
majority  of  cases  by  the  surgeon's  hands  alone.  Later  it  may  be  necessary 
to  cut  tendons  and  fascia,  and  in  exceptional  cases  to  remove  portions  of  bone, 
but  it  is  very  rarely  indeed  that  bone  operations  are  required  in  children. 

In  order  to  decide  upon  the  treatment  of  a  given  case  the  foot  should  be 
grasped  by  the  hands  of  the  surgeon  and  an  efibrt  made  to  overcome  the 
deformity.  If  the  foot  can  be  brought  into  the  normal  position  without  much 
force,  no  operation'  is  needed,  since  a  cure  can  be  accomplished  by  holding  the 
foot  in  the  corrected  position  by  some  mechanical  appliance. 

When  the  foot  cannot  be  placed  in  the  normal  position,  on  account  of  bands 
of  fascia  or  shortened  tendons,  these  must  be  cut  subcutaneously.  A  very 
common  mistake  made  in  ti'eating  club-foot  is  to  perform  tenotomies  and  then 
apply  some  form  of  club-foot  shoe.  This  almost  invariably  results  in  failure. 
The  operation  should  simply  be  looked  upon  as  the  preliminary  treatment,  for 
it  is  only  by  persistent  and  long-continued  care  that  satisfactory  results  can 
be  obtained.  A  club-foot  shoe  can  be  used  to  advantage  to  prevent  a  relapse 
after  the  deformity  has  been  overcome,  but  as  a  means  of  treatment  it  will 
lead  to  disappointment. 

To  overcome  the  deformity  the  patient  should  be  anesthetized  and  an  effort 
made  to  force  the  foot  into  the  desired  position  by  the  surgeon's  hands.  It  is 
always  necessary  to  over-correct  the  deformity.  If  the  foot  can  be  forced  into 
an  over-corrected  position  and  held  there  by  very  slight  pressure,  no  cutting 
will  be  necessary.  If  it  is  found  to  be  impossible  to  overcome  the  deformity, 
or.  having  overcome  it.  to  hold  it  there  by  light  pressure,  the  tendons  or  fascia 
offering  the  resistance  should  be  cut  subcutaneously.  After  the  cutting  the 
foot  should  be  forced  into  the  over-corrected  position  and  held  there.  In 
some  cases  considerable  pressure  is  required.  Many  machines  have  been  in- 
vented for  the  purpose,  but  the  writer  has  been  able  to  accomplish  the  desired 
end  with  his  hands  alone.  It  may  be  necessary  to  use  all  the  strength  in  one's 
hands,  but  this  can  be  done  Avith  perfect  safety  so  long  as  the  pressure  is  made 
upon  the  foot.  Care  must  be  exercised  not  to  apply  too  much  force  to  the 
lower  end  of  the  leg,  lest  it  be  broken.  In  some  cases  it  will  be  found  impos- 
sible to  overcome  all  of  the  deformity  at  one  sitting.  In  these  the  foot  should 
be  held  in  the  best  attainable  position  for  a  few  days,  when  another  effort 
should  be  made  to  straighten  it. 

The  most  convenient  method  of  holding  the  foot  in  the  corrected  position 
is  by  means  of  a  plaster-of-Paris  bandage.  One  experienced  in  the  use  of 
plaster  may  apply  it  directly  to  the  skin,  but  one  with  limited  experience 
should  apply  it  over  a  stocking  or  roller  bandage.  The  plaster  should  be 
light  and  smoothly  applied.  The  foot  should  be  held  in  the  corrected  position 
while  the  plaster  is  being  applied  and  until  it  is  well  hardened.  It  is  a  grave 
error  to  apply  plaster  and  make  pressure  while  it  is  setting,  for  sloughing  is 
liable  to  follow.  It  should  always  be  remembered  that  the  plaster  is  to  meet 
the  second  indication,  and  not  the  first.  Only  the  best  bandages,  made  from 
the  finest  dental  plaster,  should  be  used,  the  poorer  grades  being  so  slow  setting 
that  they  will  cause  great  annoyance  and  sometimes  failure.  When  the  de- 
formity has  been  over-corrected  the  plaster  may  be  left  on  for  a  month  before 


ORTHOPEDICS. 


1085 


chnnging.  It  should  be  reapplied  until  all  tendency  to  relapse  has  disap- 
peared, a  period  usually  of  several  months.  After  a  time  a  heavier  cast  may 
be  applied  and  the  child  allowed  to  walk  upon  it.  When  the  deformity  is 
thoroughly  overcome,  and  not  till  then,  a  club-foot  shoe  or  walking  shoe 


Fig.  21. 


Fig.  22. 


^5B|!!lil|||fL 

lii'iffisii 


Retention  shoe  for  preventing  relapse  in  club-foot. 


Walking  shoe  for  equino-varus. 


should  be  used.  Fig.  21  shows  a  retention  shoe,  which  answers  an  excellent 
purpose  applied  over  an  ordinary  baby  shoe.  It  is  not  intended  for  a  walking 
shoe,  but  is  to  be  worn  after  the  plaster  has  been  removed  and  before  the 
child  has  learned  to  walk.     In  an  older  child  it  may  be  used  at  night  only. 


Fig.  23. 


Talipes  equino-varus. 


Fig.  22  shows  a  walking  brace  to  be  attached  to  a  heavy-soled,  close-fitting  laced 
shoe.     It  should  be  made  to  lock  at  the  joint,  so  that  the  toes  cannot  drop. 

A  child  is  not  free  from  danger  of  relapse  until  it  is  walking  fairly  upon 
the  bottom  of  its  foot.      "  Half  cures  are  no  cures ;"  and  always  relapse. 


108^    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Talipes  Equino-varus. — Of  the  special  varieties,  equino-varus,  a  combi- 
nation of  varus  and  equinus,  is  by  far  the  most  common  (Fig.  23).  It,  in  fact, 
comprises  the  vast  majority  of  cases  of  club-foot.  In  this  variety  the  tibialis 
anticus,  tibialis  posticus,  tendo  Achillis,  and  plantar  fascia  may  require  cutting. 
The  tendo  Achillis  should  not  be  cut  until  the  varus  is  overcome,  as  it  fixes 
the  heel  while  the  foot  is  being  straightened.  In  severe  cases  that  will  not 
yield  to  the  above-outlined  treatment  it  may  be  necessary  to  resort  to  open 
incision  or  Phelps's  operation. 

Open  Incision. — This  operation  must  be  done  under  the  strictest  aseptic 
conditions.  After  applying  an  Esmarch's  bandage  an  incision  is  made  extend- 
ing from  just  in  front  of  the  inner  malleolus  well  across  the  bottom  of  the  foot, 
down  to  the  bone,  cutting  everything  that  prevents  the  foot  from  straightening. 
The  foot  is  now  forced  into  an  over-corrected  position,  a  piece  of  rubber  tissue 
placed  over  the  wound,  and  a  surgical  dressing  and  plaster  cast  applied. 
This  dressing  should  remain  for  a  month  unless  change  is  indicated  by  a  rise 
of  temperature.  When  the  wound  is  healed  a  walking  shoe  (Fig.  22)  should 
be  applied.  The  same  care  to  prevent  a  relapse  is  required  after  this  as  after 
other  methods  of  treatment. 

Other  special  varieties  of  club-foot  are  to  be  treated  upon  the  principles 
above  laid  down. 

Paralytic  Deformities. 

The  most  common  paralytic  deformities  are  those  resulting  from  an  attack 
of  poliomyelitis  or  infantile  spinal  paralysis.  These  cases  can  be  diagnosed 
from  the  blue  atrophied  appearance  of  the  limb  and  from  the  history.  Both 
upper  and  lower  extremities  may  be  involved,  but  those  of  the  lower  are  the 
only  ones  for  which  much  can  be  done.  Several  forms  of  club-foot,  due  to 
paralysis,  are  met  with.  The  treatment  of  these  cases  is  not  nearly  so  satis- 
factory as  that  of  congenital  club-foot,  because  certain  groups  of  muscles  are 
hopelessly  paralyzed.  Sometimes  one  muscle  of  a  group  may  be  quite  strong, 
while  the  others  are  functionless.  In  some  of  these  cases  tendon  anastomosis 
may  be  performed,  and  the  tendons  of  the  paralyzed  muscles  united  to  the 
tendon  of  the  healthy  one,  making  it  do  the  work  of  all.  When  all  the  mus- 
cles in  front  of  the  leg  are  powerless,  the  tendons  may  all  be  shortened  and 
the  joint  stiflFened  by  removing  the  joint-cartilages,  thus  making  a  useful 
stiff  foot. 

When  the  extensors  of  the  leg  are  paralyzed,  making  the  knee-joint  limp 
and  useless,  the  knee  may  be  excised  and  a  useful,  stiff  leg  procured.  The 
only  hope  of  relief  in  some  cases  in  which  the  paralysis  is  about  the  hip-joint 
is  from  mechanical  support,  and  that  is  not  very  encouraging.  No  case  of 
this  kind  should  be  given  up  as  hopeless,  however,  until  it  has  been  carefully 
examined  by  an  expert  orthopaedist. 

Another  class  of  paralytic  deformities  are  those  resulting  from  infantile 
cerebral  paralysis  or  spastic  palsy.  These  children  do  not  walk  at  the  usual 
age,  and  have  a  spasmodic  jerking  of  many  of  the  muscles.  In  many  cases 
there  is  also  a  lack  of  mental  development.  By  judicious  tenotomies  and  me- 
chanical supports  some  of  these  cases  can  be  greatly  benefited,  although,  as  a 
class,  the  outlook  is  discouraging.  They  also  should  have  the  benefit  of  skilled 
attention,  for  some  of  them  can  be  straightened  and  taught  to  walk,  notwith- 
standing the  fact  that  they  have  gone  several  years  past  the  age  when  chil- 
dren usually  gain  the  power  of  locomotion. 


OB  THOP^DICS. 


1087 


Rachitic  Deformities. 

Every  bone  in  the  body  may  become  deformed  from  rickets,  but  the  spme 
and  the  bones  of  the  lower  extremities  are  the  only  ones  of  interest  from  an 
orthopaedic  standpoint.  Rachitic  curvatures  of  the  spine  are  usually  antero- 
posterior, and  are  to  be  diiferentiated  from  other  curvatures  by  the  fact  that 
when  the  child  lies  down  all  or  a  greater  part  of  the  deformity  disappears,  and 
by  the  presence  of  other  characteristic  symptoms  of  rickets.  A  rachitic  curve 
of  the  spine  is  usually  a  long,  even  curve,  offering  quite  a  contrast  to  the 
sharp,  angular  curve  of  Pott's  disease  (Fig.  24). 

Fig.  24. 


Rachitic  spine. 

The  prognosis  in  these  cases  is  usually  good.  The  spine  should  be 
straightened  and  held,  until  the  bones  have  become  hardened,  by  some  of 
the  appliances  recommended  for  Pott's  disease. 

Bow-legs  is  one  of  the  most  common  rachitic  deformities  (Fig.  25).  In 
children  under  four  years  of  age  the  legs  can  be  gradually  straightened  by  braces 
(Fig.  27);  after  this  age  the  bones  are  usually  too  hard  to  be  so  influenced. 
When  the  deformity  is  very  slight,  interference  is  unnecessary,  since  the  nat- 
ural tendency  is  to  grow  straighter ;  when  well  marked  and  the  child's  bones 
are  hardened,  it  is  necessary  to  break  the  bones  to  straighten  them.  This  can 
be  easily  and  safely  done  by  means  of  an  osteoclast.  The  limbs  are  then  put 
up  in  plaster  of  Paris,  just  as  for  a  simple  fracture,  and  after  five  or  six  weeks 
the  child  will  be  well.     The  bones  may  also  be  broken  by  means  of  hammer 


1088    AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


anrl  chisel,  but  it  is  not  so  safe  as  osteoclasis.     In  practised  bands,  bowever,  it 
is  good  treatment. 

Fig.  25. 


Mild  knock-knee. 

Knock-knee,  or  genu  valgum,  is  cbaracterized  by  an  undue  prominence 


OB  THOP^DICS. 


1089 


of  the  inner  condyle  of  the  femur  (Fig.  26).  It  may  be  single  or  double. 
When  the  knees  are  brought  together  the  inner  malleoli  of  the  ankle-joints 
will  not  touch,  as  they  should.  In  severe  cases  there  is  usually  some  lateral 
motion  in  the  knee-joint  due  to  the  stretching  of  the  internal  lateral  ligaments. 
In  young  children,  before  the  bones  have  hardened,  this  deformity  may  be  en- 


FiG.  27. 


Fig.  28. 


Bow-leg  braces. 


Knock-knee  braces. 


tirely  overcome  by  means  of  braces  (Fig.  28),  but  in  older  children  the  femur 
should  be  broken  just  above  the  condyles  by  means  of  a  mallet  and  osteotome, 
and  the  limbs  put  up  straight  in  plaster  of  Paris.  After  six  weeks  the  bone 
will  be  firm.  Done  under  proper  aseptic  precautions,  this  is  a  safe  and  satis- 
factory operation. 


PART    XII. 


DISEASES  OF  THE  SKIN. 

By  W.  a.  HARDAWAY,  A.  M.,  M.  D., 

St.  Louis. 


In  a  general  way  it  may  be  said  that  the  child  and  the  adult  are  subject  to 
very  nearly  the  same  diseases  of  the  skin  ;  nevertheless,  a  close  scrutiny  will 
show  that  certain  differences  exist,  both  of  kind  and  degree,  that  are  worth 
attentive  consideration.^ 

In  the  first  place,  owing  to  the  greater  vulnerability  of  the  skin  in  children, 
inflammatory  disorders  of  all  sorts  take  on  a  more  acute  aspect  than  with  the 
grown  person,  and,  for  the  same  reason,  mechanical  irritants  are  more  apt  to 
be  productive  of  mischief.  Then,  again,  the  frequent  gastro-intestinal  dis- 
orders of  infancy  increase,  in  an  indirect  way,  the  tendency  to  inflammatory 
and  erythematous  cutaneous  processes.  Although  the  influence  of  dentition 
is  much  overrated  as  an  etiological  factor,  it  remains  true  that  the  nervous 
erethism  set  up  by  the  eruption  of  teeth  may  be  regarded  as  a  complicating 
agency  of  importance  in  certain  cases.  As  regards  special  diseases,  Diday  shows 
that  congenital  syphilis  develops  generally  in  the  first  three  months  of  life ; 
ichthyosis  may  be  congenital  or  show  itself  between  the  ages  of  three  and  six ; 
eczema  is  more  common  during  the  first  five  years  than  at  any  other  period ; 
impetigo  contagiosa  is  a  disorder  of  childhood  ;  ringworm  of  the  scalp  is  essen- 
tially a  disease  of  the  young,  and  so  is  pediculosis  capillitii ;  pemphigus  is  not 
infrequently  encountered  in  children  ;  and  lupus  vulgaris  usually  begins  early  in 
life.  On  the  other  hand,  by  way  of  contrast,  it  may  be  stated  that  acne  is 
rare  before  puberty ;  tinea  versicolor  is  an  aff"ection  of  the  adult ;  epithelioma 
is  uncommon  before  the  fortieth  year,  and  children  rarely  have  essential 
pruritus.  These  comparisons  might  be  much  extended,  but  enough  has  been 
shown  for  practical  purposes.^ 

In  this  article,  owing  to  necessary  limitations  of  space,  only  those  disorders 
of  the  skin  most  common  to  children  will  be  considered  at  any  length  ;  rare 
diseases,  or  those  whose  nosological  positions  are  still  uncertain,  will  not  be 
noticed  at  all  or  only  in  the  briefest  manner. 

'  In  the  preparation  of  this  article  the  writer  is  under  especial  obligations  to  the  papers  on 
dermatology  by  various  authors  in  Keating's  Ci/dopcedia  of  the  Diseases  of  Children,  and  to 
Crocker's  Text-book  of  Skin  Diseases.  Thanks  are  also  due  Dr.  C.  F.  Hersman  for  much  valuable 
assistance. 

^  See  writer's  article,  "  Locality  and  Age  in  the  Diagnosis  of  Skin  Diseases,"  St.  Louis  Clini- 
cal Record,  Nov.,  1875. 

1090 


DISEASES    OF   THE   SKIN.  1091 

DISORDERS  OP  THE  GLANDS. 

SEBACEOUS  GLANDS. 

Seborrhcea. 

Seborrhcea  is  a  functional  disease  of  the  sebaceous  glands,  characterized 
by  excessive  secretion,  which  is  discharged  upon  the  integument  in  the  form 
of  oily,  scaly,  or  crusted  material.  There  are  two  varieties — viz.  sehorrhoea 
oleosa  and  sehorrhoea  sicca  ;  in  the  first  condition  the  secretion  is  fluid  or  oily, 
and  in  the  second  it  is  dry  and  scaly.  As  the  vernix  easeosa  of  the  new-born 
it  may  be  regarded  as  physiological.  Both  forms  of  sehorrhoea  may  be  present 
in  the  same  patient,  or,  on  the  other  hand,  the  distinction  between  them  may 
be  hard  to  define.  The  disease  may  be  present  on  any  part  of  the  body  save 
the  palms  and  soles.  A  slight  amount  of  sehorrhoea  of  the  scalp  is  often  seen 
during  the  first  month  of  infancy,  and  the  frantic  efibrts  to  get  rid  of  this 
almost  normal  secretion  frequently  leads  to  an  annoying  and  rebellious  eczema. 
Sometimes  the  secretion  forms  a  thick  crust  and  extends  over  the  forehead  and 
adjacent  parts.  Unless  the  skin  has  become  irritated  by  the  decomposition  of 
the  secretion,  it  will  be  found  cool  and  even  paler  than  normal.  In  older 
children  both  the  dry  form,  the  so-called  pityriasis  capitis,  and  the  oily  variety 
are  not  infrequently  observed,  and,  as  in  the  adult,  give  rise  to  a  dry,  lack- 
lustre state  of  the  hair  or  comparative  baldness. 

According  to  Crocker,  the  disease  is  often  seen  in  strumous  children  in  the 
form  of  small  shining  scales  situated  upon  the  trunk  and  limbs,  and  generally 
coexisting  with  lichen  scrofulosis.  Excessive  secretion  of  sebum  at  the 
umbilicus,  on  the  glans  penis,  the  inner  surface  of  the  prepuce,  and  the  sulcus 
in  the  male,  and  about  the  labia  and  clitoris  in  the  female,  is  common  in  ill- 
cared-for  children,  and  as  a  consequence  of  decomposition  produces  a  most 
sickening  odor  and  sets  up  an  acute  dermatitis.  Hebra  and  others  regard  ich- 
thyosis congenita  as  a  sehorrhoea. 

Under  the  term  seborrhoeal  eczema  Unna  includes  not  only  the  dry  sehor- 
rhoea of  the  body  (lichen  circumscriptus)  common  to  adults,  but  those  forms  of 
eczema  in  children  situated  upon  the  eyelashes  and  other  regions.  This 
question  cannot  be  discussed  here,  but  it  is  proper  to  remark,  as  long  since 
pointed  out  by  Kaposi,  that  sehorrhoea  is  a  very  common  provocative  of  eczema, 
and  that,  therefore,  the  latter  disorder  is  often  encountered  in  regions  richly 
supplied  with  oil-glands. 

Etiology. — Among  the  common  causes  of  sehorrhoea  in  children  may  be 
mentioned  various  disorders  of  nutrition  arising  from  struma,  ansemia,  gastric 
and  intestinal  disorders,  and,  more  directly,  inattention  to  personal  hygiene. 
Unna  regards  sehorrhoea  as  an  inflammatory  afi"ection  of  the  sweat-glands,  and 
Brooke  thinks  it  is  of  parasitic  origin. 

If  long  continued,  the  glands  are  apt  to  undergo  atrophy,  but  in  the  begin- 
ning the  disorder  is  purely  functional.  The  secretion,  examined  microscopic- 
ally, is  seen  to  consist  of  epithelial  scales,  amorphous  granular  material,  and 
free  oil-globules  and  fat. 

Diagnosis. — This  ofi"ers  few  difficulties.  On  the  scalp  the  disease  is  differ- 
entiated from  eczema  by  the  absence  of  marked  itching  and  infiltration  of  the 
skin  and  by  the  greasy  character  of  the  scales.  The  scales  in  psoriasis  are  not 
greasy,  but  dry,  and  are  arranged  in  more  or  less  isolated  mortar-like  heaps 
scattered  over  the  scalp.  Oily  sehorrhoea  of  the  body  is  easily  recognized : 
the  dry  form  should  be  difi"erentiated  from  eczema,  psoriasis,  ringworm,  and 
pityriasis  rosea.     (See  articles  on  these  diseases.) 


10^2  A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Prognosis. — Infantile  seborrhoea  is  usually  very  amenable  to  proper  treat- 
ment. 

Treatment. — The  internal  treatment  is  entirely  symptomatic,  and  consists 
in  the  removal  of  any  apparent  derangement  of  the  health.  Minute  doses  of 
sulphide  of  calcium  have  been  recommended,  but  the  writer  has  seen  no  benefit 
from  its  use.  Mothers  should  be  warned  against  the  fine-toothed  comb  and 
other  hai'sh  measures  in  their  efforts  to  cleanse  the  heads  of  their  babies. 
Instead,  the  crusts  should  be  soaked  off  with  free  applications  of  olive  oil, 
and  then  kept  clean  with  Eichoff 's  superfatted  thymol  soap ;  but  if  the  skin  is 
at  all  tender,  it  is  better  to  keep  the  parts  anointed  with  a  little  vaseline  for  a 
short  while.  Seborrhoea  of  the  body  is  managed  in  the  same  general  way,  but 
if  the  secretion  is  persistent — and  this  holds  equally  good  for  the  scalp — it  is 
well  to  apply  once  or  twice  daily  the  following  ointment : 

^.  Sulphuris  prsecip gr.  x-xx. 

Acidi  salicylici gr.  v— x. 

Vaselini §j. — M. 

Sig.  Local  use.     To  be  further  diluted  if  too  active. 

Resorcin,  carbolic  acid,  white  precipitate,  and  tannin  are  also  good  remedies. 

Seborrhoea  of  the  umbilicus  and  of  the  genitals  requires  absolute  cleanli- 
ness and  the  local  application  of  alum  or  tannin  washes.  In  all  cases,  if  tlie 
disease  has  set  up  much  dermatitis,  soothing  and  antipruritic  treatment  will 
be  required.     (See  Eczema.) 

Comedo. 

Comedo  is  a  disorder  of  the  sebaceous  glands  in  which  their  excretory  ducts 
are  plugged  with  inspissated  sebum  mixed  with  epithelial  cells.  These  so-called 
flesh-worms  or  black-heads  are  generally  slightly  elevated,  pinpoint  to  pinhead 
in  size,  and  can  be  expressed  as  a  filiform  mass  when  pressure  is  made  at  the 
sides  of  the  lesions.  Sometimes  the  comedo  is  slightly  depressed,  and,  instead 
of  the  usual  black  color,  may  have  a  yellowish  or  even  bluish  tint.  The  usual 
seats  of  comedones  are  the  face,  neck,  chest,  and  back. 

Ordinarily,  comedones  are  not  seen  before  puberty ;  but  some  years  ago 
Crocker  called  attention  to  cases  occurring  in  the  children  of  the  poor  in  sum- 
mer. According  to  this  observer,  they  appear  on  the  upper  part  of  the  fore- 
head and  corresponding  parts  of  the  occiput  in  boys  above  three  years,  on  the 
temples  in  girls,  and  on  the  cheeks  in  infants.  They  are  densely  packed  and 
often  grouped,  and  accompanied  by  seborrhoea  of  the  scalp.  Warmth  and 
moisture  seem  to  be  the  exciting  causes.  T.  C.  Fox  has  made  similar  obser- 
vations. 

Treatment. — Cleanliness  and  the  free  use  of  soap  and  water  are  all  that  is 
required  in  the  way  of  preventive  treatment.  To  remove  the  comedones  when 
present,  friction  with  a  green-soap  lather  is  usually  efiicacious : 

^.  Saponis  olivse  prgep.,  vel  saponis  viridis  .    .    .    §j. 

Alcoholis fdj- 

Aquae q.  s.  ad  f  liv. — M. 

Sig.  Apply  with  flannel  rag. 

In  some  cases  it  may  be  necessary  to  express  the  plugs  with  a  comedo- 
extractor. 


DISEASES    OF   THE  SKIN.  1093 

Acne. 
Although  Chambord  and  others  have  reported  a  few  cases  of  acne  in  young 
children,  practically  the  disorder  does  not  make  its  appearance  until  puberty. 
The  acne  due  to  the  ingestion  of  the  iodides  and  bromides  and  to  the  use  of  tar 
is  not  a  true  form  of  the  disease. 

Milium. 

Milia  are  small  white  or  yellowish  papules,  varying  in  size  from  a  pinhead 
to  a  split  pea,  that  occur  for  the  most  part  under  the  eyes,  on  the  forehead,  and 
over  the  cheeks.  It  is  a  tolerably  common  afiection  in  infants,  and  constitutes 
the  strophulus  alhidus  of  Willan. 

Etiology. — The  etiology  is  not  always  clear  when  occurring  in  infancy. 
Milia  are  often  congenital.  They  also  follow  in  the  wake  of  other  diseases — 
namely,  pemphigus,  lupus,  erysipelas,  etc.  They  are  usually  regarded  as  due 
to  retention  in  one  or  several  of  the  acini  of  an  oil-gland,  but  Robinson  thinks 
that  two  causes  may  be  operative  in  their  production :  in  one  instance  "  it  is  a 
case  of  miscarried  embryonic  epithelium  from  a  hair-follicle  or  from  the  rete," 
while  in  milia  following  pemphigus,  lupus,  etc.,  the  contents  consist  of  fatty 
epithelium  and  cholesterin,  the  epithelium  being  often  arranged  in  concentric 
layers  around  a  central  fat-nucleus. 

Prognosis. — Favorable. 

Treatment. — The  electrolytic  puncture,  as  originally  suggested  by  the 
writer,  is  not  demanded,  nor  would  it  be  tolerated,  in  infantile  cases.  More  or 
less  vigorous  friction  with  soap  and  water  is  all.  that  is  needed. 

S'WEAT    G-LANDS. 

Hyperidrosis. 

Hyperidrosis  is  a  functional  aifection  of  the  sweat-glands,  giving  rise  to 
hypersecretion  of  their  contents.  It  may  be  acute  or  chronic,  general  or  local, 
limited  or  excessive  in  amount.  Universal  hyperidrosis  is  usually  symptomatic, 
occurring  in  connection  with  acute  febrile  states  or  dependent  upon  general 
diseases  of  a  debilitating  character,  such  as  phthisis,  rickets,  etc.  In  the  last- 
named  disease,  however,  the  sweating  is  most  abundant  about  the  head.  Gen- 
erally in  babies  the  profuse  local  and  general  sweating  is  induced  by  injudicious 
clothing  and  excessive  heating  of  living  apartments,  and  when  these  unhygienic 
conditions  are  kept  up,  intertrigo  and  eczema  are  not  infrequent  sequelae  about 
the  genitals  and  between  the  folds  of  the  skin.  Generalized  eruptions  of 
sudamina  from  the  same  causes  are  also  encountered. 

Hyperidrosis  of  the  palms  and  soles  and  axillae  often  develops  during  child- 
hood, and  sometimes  is  clearly  congenital  and  occasionally  hereditary  ;  but  it 
does  not  follow  that  all  of  these  localities  are  involved  at  the  same  time,  for 
usually  the  disorder  is  limited  to  one  region  or  the  other,  the  palms  and  soles 
being  more  apt  to  suffer  together.  When  the  palms  and  soles  are  affected — 
that  is,  if  the  sweating  be  at  all  abundant — the  skin  becomes  sodden  and 
macerated,  and  from  the  feet  the  odor  is  often  disgusting.  This  condition, 
known  as  bromidrosis,  is  more  frequent,  however,  in  the  adult. 

Etiology. — Aside  from  the  more  or  less  physiological  sweating  due  to  high 
temperature,  faulty  innervation  apparently  plays  the  chief  role  in  hyperidrosis. 
Cutler  regards  it  as  a  functional  affection  of  the  sympathetic  system.  Foetid 
perspiration  is  due  to  the  presence,  according  to  Thin,  of  the  bacterium 
fostidum. 


1094  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Prognosis. — Sweating  of  the  feet  is  more  controllable  than  that  of  other 
parts.      Upon  the  whole,  the  prognosis  of  hyperidrosis  should  be  guarded. 

Treatment. — The  treatment  of  general  sweating  is  based  upon  the  causal 
indications,  and  need  not  be  dwelt  upon  here.  The  debilitating  sweating  about 
the  head  in  children  mav  be  much  mitigated  by  directino;  them  to  lie  on  hair 
pillows  instead  of  the  usual  feathers.  Among  specific  remedies  may  be  men- 
tioned belladonna,  atropine,  agaricin,  and  ergot ;  but  their  effect  at  best  is  only 
temporary.  Crocker  highly  extols  precipitated  sulphur,  given  in  milk,  twice  a 
day.  If  it  proves  too  laxative,  it  may  be  combined  with  the  compound  chalk- 
and-cinnamon  powders. 

The  local  applications  are  numerous.  Among  the  most  satisfactory  are  a 
1  per  cent,  solution  of  quinine  in  alcohol,  belladonna  salve  or  liniment,  tannin 
dissolved  in  bay  rum  (gr.  viij  to  fsiv),  salicylic  acid  in  alcohol  (oj-fsiv),  and 
various  dusting  powders,  composed  of  zinc,  starch,  boracic  and  salicylic  acids. 
For  sweating  of  the  hands  Pringle  recommends  pure  silicic  acid  (terra  silicea). 
For  foul-smelling  perspiration  of  the  feet  dusting  the  stockings  with  boracic 
acid  is  valuable.  The  following  powder,  as  suggested  by  Van  Harlingen,  is 
to  be  commended : 

^.  Pulv.  acidi  salicylic 3ij. 

Pulv.  zinci  carb.  praecip 3ij. 

Pulv.  magnesise  ustge 3ij. 

Pulv.  amyli Svijss. 

Pulv.  talci 3x. — M. 

Sig.  Dusting  powder. 

Hebra's  plan,  although  troublesome,  is  eminently  successful.  Briefly,  it 
consists  in  wrapping  the  feet  and  toes,  the  latter  separately,  in  cloths  spread 
with  diachylon  ointment,  which  should  be  changed  twice  daily,  and  the  parts 
rubbed  dry  before  each  reapplication.  This  should  be  kept  up  for  two  weeks, 
water  being  absolutely  interdicted  during  the  treatment.  Strapping  the  parts 
evenly  and  firmly  with  soap  or  lead  plaster  often  suffices. 

Miliaria. 

Miliaria,  lichen  tropicus,  or  prickly  heat,  is  an  acute  inflammatory  affection 
of  the  sweat-glands,  resulting  in  papular,  vesico-papular,  vesicular,  and  even 
pustular,  lesions.  It  is  a  very  common  disorder  in  young  children,  and  is 
usually  seated  upon  the  trunk,  although  the  face  and  other  parts  of  the  body 
are  also  attacked.  The  subjective  symptoms  are  very  annoying,  and  consist 
of  sensations  of  intolerable  burning  and  stinging.  The  rash  comes  out  sud- 
denly,  often  after  profuse  sweating,  and  generall}^  subsides  in  a  few  days  with 
slight  desquamation ;  but  if  the  cause  is  kept  up  successive  crops  will  appear. 
According  to  the  lesion  present — and  this  apparently  depends  upon  the  inten- 
sity of  the  process — the  eruption  has  been  variously  designated — viz.  m.  vesic- 
ulosa or  rubra  (the  "red  gum  "  of  the  nursery),  vi.  papulosa  or  prickly  heat, 
etc.  The  non-inflammatory  variety  is  m.  crystallina  or  sudamina.  Furuncu- 
losis  and  eczema  are  not  infrequent  secjuelae  of  neglected  or  ill-treated  cases. 

Etiology. — Intense  heat  is  the  common  factor,  and  therefore  miliaria  is 
most  frequently  encountered  in  summer.  Sudamina  are  noted  in  connection 
with  states  of  general  debility  and  in  febrile  disorders,  but  also  as  a  consequence 
of  excessive  sweating.  In  sudamina  the  sweat  collects  between  the  deepest 
laminae  of  the  horny  layer ;    the  sweat-duct  is  obstructed,  with    consequent 


DISEASES   OF   THE  SKIN,  1095 

rupture  of  the  wall  and  formation  of  a  vesicle.  In  miliaria  there  is  vascular 
congestion  about  the  ducts,  increased  secretion,  and  more  or  less  effusion  into 
and  about  the  sudoriparous  organs. 

Diagnosis. — Sudamina  are  non-inflammatory  in  character ;  which  fact, 
taken  in  connection  with  the  history  of  the  case,  will  be  sufficient  for  their 
differentiation  from  varicella.  The  lesions  of  eczema  papulosum  are  larger 
than  those  of  miliaria  papulosa,  are  more  persistent,  and  the  pruritus  is  more 
intense.  The  vesicles  of  vesicular  eczema  are  more  closely  set  than  those  of 
vesicular  miliaria ;  they  rupture  readily  (in  miliaria  the  vesicular  contents 
usually  dry  up  without  rupture)  and  give  rise  to  the  peculiar  sticky  discharge. 

Treatment. — In  relapsing  cases  tonics  are  sometimes  demanded,  and  more 
especially  change  of  climate.  Ordinarily,  attention  to  diet,  which  should  be  of  a 
plain,  non-stimulating  sort,  with  proper  clothing  and,  at  the  height  of  the  attack, 
some  mild  refrigerant  mixture,  is  all  that  is  required  in  a  general  way. 
Children  in  summer  should  be  kept  well  powdered  with  borated  talcum  or 
similar  preparation  as  a  preventive  measure.  During  the  outbreak  the  speed- 
iest relief  is  secured  from  the  use  of  the  calamine-and-zinc  lotion  : 

^.  Zinci  oxidi %m. 

Pulv.  calaminae  praep 9iv. 

Glycerini f§j. 

Liq.  calcis f^vij. — M. 

Sig.  Shake  and  mop  on  freely. 

If  the  itching  be  intense,  from  two  to  five  minims  of  carbolic  acid  may  be  added 
to  each  ounce  of  the  mixture. 

Anderson's  dusting  powder  is  useful : 

I^.  Pulv.  amyli 3vj. 

Zinci  oxidi Siss. 

Pulv.  camphorse 3ss. — M. 

Sig.  Dusting  powder. 


INFLAMMATIONS. 

Erythema  Simplex. 

In  simple  erythema  the  skin  presents  variously-sized,  diffused  or  circum- 
scribed, hypersemic  lesions  that  fade  temporarily  upon  pressure,  and  are  usually 
without  sensible  elevation  above  the  surrounding  surface.  Subjective  symp- 
toms are  trivial,  and  consist  for  the  most  part  of  slight  burning  and  tingling, 
or  they  may  be  absent  entirely.  An  altogether  unnecessary  confusion  has 
enveloped  this  subject,  owing  largely,  perhaps,  to  errors  in  diagnosis,  but  also, 
to  some  degree,  it  has  arisen  from  the  cumbersome  and  pedantic  nomenclature 
which  has  been  applied  to  comparatively  insignificant  differences  in  the  appear- 
ances of  the  lesions.  Simple  erythema  may  be  conveniently  divided  into  two 
main  classes — namely,  idiopathic  erythema  and  symptomatic  erythema. 

Idiopathic  Erythema. 

This  variety  of  the  disorder  is  excited  by  the  influence  of  external  irritants 
acting  upon  the  skin,  and  passes  readily  into  a  true  inflammatory  state.     Ery- 


1096  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

thema  ealoricum  is  set  up  by  the  agency  of  heat  and  cold ;  erythema  traumat- 
icum  arises  fi'om  pressure,  rubbing,  etc. ;  and  erythema  venenatum  is  produced 
by  the  action  of  animal  and  vegetable  poisons.  Two  other  forms  of  erythema, 
both  very  common  in  children,  are  e.  intertrigo  and  e.  pernio,  or  chilblain. 

Erythema  Intertrigo. — Intertrigo  usually  occurs  in  the  groins,  in  the  folds 
of  the  neck  in  fat  babies,  and  wherever,  in  fact,  the  skin  surfaces  come  in  con- 
tact ;  and  it  is  all  the  more  readily  induced  by  the  irritation  of  the  sweat-secre- 
tion and  by  urinary  and  faecal  discharges.  Intertrigo  is  always  at  first  a  simple 
hyperemia  of  the  skin,  but  when  neglected  the  skin  becomes  hot  and  ten- 
der, the  epidermis  macerated,  a  profuse,  malodorous,  muciparous  discharge  is 
present,  and  in  bad  cases  Assuring,  and  even  ulceration,  may  occur. 

The  eruption  is  very  common,  at  times  appearing  suddenly,  and,  under 
simple  treatment,  disappearing  again  as  rapidly ;  but  if  maltreated  it  may  run 
a  long  course.    In  some  instances  it  is  symptomatic  of  grave  internal  disorders. 

Intertrigo  naturally  occurs  most  frequently  in  summer,  but  this  is  by  no 
means  the  rule  with  children.     Relapses  are  frequent. 

Diag-nosis. — Intertrigo  is  easy  to  recognize.  Tilbury  Fox  says  it  is  to 
be  distinguished  from  eczema  by  the  nature  of  the  characteristic  discharge, 
which  does  not  stiifen  linen.  The  erythematous  syphilide  of  infancy  is  apt 
to  attack,  like  intertrigo,  the  buttocks  and  genital  regions ;  but,  aside  from 
the  color  and  the  general  concomitants  of  syphilis,  the  diagnosis  is  facilitated 
by  remembering  that  intertrigo  confines  itself  to  the  region  of  the  diaper  ; 
the  syphilide  runs  down  toward  the  heels. 

Treatment. — The  preventive  treatment  demands  absolute  cleanliness,  the 
use  of  a  bland  soap  (Eichoff's  superfatted  thymol  soap,  for  example)  and  a 
simple  dusting  powder,  such  as  oxide  of  zinc  and  lycopodium  (3ij-3vj).  For 
the  curative  treatment  it  is  necessary  to  keep  the  parts  separated  by  the  inter- 
position of  thin  layers  of  absorbent  cotton,  and  to  apply  some  remedy  that  is 
both  astringent  and  antiseptic.     The  following  is  a  good  example  of  a  powder: 

]^.    Thymol g^'-  j- 

Pulv.  zinci  oleatis 5j. — M. 

Sig.  Dusting  powder. 

A  modification  of  Lassar's  paste  serves  an  excellent  purpose,  besides 
thoroughly  protecting  the  surfaces  from  irritating  discharges : 

^.  Acidi  salicylici gi"-  x. 

Bismuthi  subnitratis 

Amy li da  siij . 

Ung.  aq.  rosae q.  s.  ad  §j. — M. 

Sig.  Smear  gently  over  the  afiected  parts. 

Of  late  the  writer  has  used  Pick's  paste  with  much  satisfaction : 

I|i.  Pulv.  tragacanthge gr.  xv. 

Glycerini       TlXxxiv. 

Aquae f5j. — M. 

This  makes  a  transparent  adhesive  dressing,  called  by  its  originator  iinimen- 
tum  exsiccans.  By  adding  to  it  10  per  cent,  of  oxide  of  zinc  and  1  per  cent, 
of  carbolic  acid  there  will  result  a  most  admirable  preparation. 

Erythema  Pernio,  or  Chilblain. — Chilblains  are  prone  to  occur  in  chil- 


DISEASES   OF   THE  SKIN.  1091 

dren  with  poor  circulation,  and  especially  in  weakly,  ansemic  girls.  The  lesions 
consist  of  erythematous  patches  of  various  sizes  and  shapes,  and  attack  by  pref- 
erence the  heels,  toes,  sides  of  the  feet,  fingers,  knuckles,  ears,  and  tip  of  the 
nose.  The  spots  are  light  red  in  the  beginning,  but  later  on  become  bluish - 
red.  The  burning  and  itching  that  accompany  their  development  are  much 
aggravated  by  warmth.  The  surface  of  the  patches  in  bad  cases  may  vesicate 
and  result  in  the  formation  of  large  blebs,  possessing  serous  or  sero-sanguin- 
olent  contents ;  or  the  parts  may  become  denuded  and  slough. 

Treatment. — The  internal  treatment  is  symptomatic,  but,  as  most  of  tbe 
cases  occur  in  the  weakly,  tonics  and  general  hygienic  measures  are  urgently 
demanded.  Woollen  stockings  and  loose  shoes,  without  elastic  sides,  are  to  be 
preferred,  and  the  habit  of  "  toasting  "  at  fires  and  registers  is  to  be  prohibited. 
Friction  with  snow  or  cold  water  should  be  tried  in  threatening  cases,  and  after- 
ward soothing,  somewhat  astringent,  lotions  prescribed,  such  as  the  lotion  of 
zinc  and  calamine.  Pick's  paste  is  also  useful  at  this  stage.  Later,  if  the 
erythematous  condition  has  become  fully  developed,  stimulating  local  treatment 
becomes  necessary. 

The  unbroken  surface  may  be  painted  with  iodine  or  with  oil  of  peppermint, 
pure  or  diluted.     Jackson  recommends — 

^.   01.  cajuputi 

Liq.  ammon.  fort da  f^ij. 

Lin.  saponis  comp f.^iij- — M. 

Sig.  Local  use. 

In  very  chronic  patches  Pringle  recommends  painting  with  a  solution  of 
nitrate  of  silver  (gr.  xvj)  in  spirits  of  nitrous  ether  (f  5J),  or  a  5  per  cent,  solution 
of  salicylic  acid  in  traumaticin.  Ulceration  and  sloughing,  when  they  occur, 
should  be  treated  on  general  surgical  principles. 

Symptomatic  Erythema. 

The  symptomatic  erythemata  are  very  numerous  and  are  due  to  a  great 
variety  of  causes.  It  is  well  for  the  practitioner  to  remember  that  many  general 
diseases — e.  g.  variola,  diphtheria,  measles,  scarlatina,  and  vaccinia — are  often 
preceded,  accompanied,  or  followed  by  erythematous  rashes.  The  scarlatini- 
form  rash  that  is  not  infrequently  seen  in  connection  with  septicasmia,  the 
puerperal  state,  etc.  is  also,  according  to  Crocker,  an  accompaniment  of  malarial 
disorders  in  children.  However,  it  is  necessary  to  bear  in  mind  that  quinine 
in  susceptible  subjects  induces  an  erythematous  rash.  Various  other  drugs 
are  capable  of  evoking  congestions  of  the  skin. 

Erythema  Infantile. — This  form  of  erythema,  also  called  roseola  infantilis, 
is  comparatively  frequent,  and  possesses  an  importance  out  of  proportion  to  its 
severity  on  account  of  the  confusion  in  diagnosis  to  which  it  gives  rise.  Tem- 
porary congestions  of  the  skin  are  quite  common  in  teething  children  and  in 
those  suffering  from  alimentary  derangements.  The  eruption  is  usually  rose- 
olous  ;  that  is  to  say,  made  up  of  variously  sized  and  shaped  patches  and  blotches 
having  a  general  resemblance  to  the  rash  of  measles.  Much  of  what  is  called 
"scarlatina"  is  undoubtedly  this  symptomatic  erythema.  Accompanying  the 
eruption  there  is  usually  some  slight  elevation  of  temperature,  together  with 
some  redness,  without  swelling,  of  the  palate  and  fauces. 

This  infantile  erythema  is  an  ephemeral  affair,  and  its  only  importance  is 
of  a  negative  sort.     The  diagnosis,  however,  is  at  times  difficult  to  the  inex- 


1098  A3IERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

perienced.  It  is  to  be  differentiated  from  scarlet  fever  by  the  fact  that  in  the 
latter  affection  there  is  a  high  temperature,  great  heat  of  skin,  glandular 
engorgement,  the  characteristic  state  of  the  tongue  and  throat,  and  the  location 
of  the  eruption — symptoms  that  are  absent  in  infantile  erythema — while  the 
catarrhal  prodromal  stage,  the  fever,  the  maculo-papular  rash  on  the  mucous 
membranes  and  the  skin,  are  significant  of  measles,  and  not  of  erythema. 
Rotheln  is  manifestly  the  result  of  contagion,  two  or  more  children  in  the 
family  perhaps  being  simultaneously  attacked :  the  glands  behind  the  neck  are 
apt  to  be  swollen,  the  eruption  is  less  evanescent  and  is  more  papular  than 
erythematous. 

New-born  babies  are  often  attacked  with  an  eruption  made  up  of  minute 
red  papules  seated  on  a  hyperremic  base,  Avhich  may  be  made  to  fade  away 
under  pressure.  The  back  and  chest  are  the  usual  sites  of  the  rash.  It  lasts 
but  a  few  days,  and  disappears  w'ith  slight  desquamation.  The  mucous  mem- 
branes are  not  involved,  and  there  is  no  fever. 

Treatment. — The  internal  treatment  of  the  various  erythemata  is  purely 
symptomatic.  A  little  calamine  lotion  or  a  dusting  powder  is  all  that  is 
required  locally. 

Erythema  Multiforme. 

Erythema  multiforme  is  an  exudative  affection  of  the  skin  in  which  various 
erythematous,  papular,  vesicular,  bullous,  tubercular,  and  nodose  lesions  may 
appear  separately  or  coincidently.  Preceding  the  outbreak  of  this  eruption, 
the  patient  may  experience  more  or  less  malaise,  gastric  disturbance,  sore  throat, 
rheumatic  pains,  and  fever.  Crocker,  who  has  paid  much  attention  to  the  skin 
diseases  of  children,  says  that  the  fever  and  general  symptoms  are  more  marked 
in  them  than  in  the  adult,  the  lesions  are  more  severe,  and  when  vesicles  form 
their  contents  are  prone  to  become  purulent  and  leave  cicatrices.  However, 
the  lesions  are  not  so  apt  to  be  multiform.  There  are,  nevertheless,  exceptions 
to  this  rule,  for  often  the  general  symptoms  are  insignificant,  especially  when 
the  eruption  is  limited  in  extent. 

The  local  subjective  symptoms  consist  mainly  of  sensations  of  burning  and 
tinglincj. 

When  the  disease  assumes  the  erythematous  form,  the  fading  of  the  centre 
of  the  patch  leaves  a  ringed  appearance  that  has  been  called  e.  annulare  ; 
or  concentric  rings,  one  forming  within  the  other,  will  leave  in  their  wake,  as 
the  effusion  becomes  absorbed,  a  variety  of  different  colors,  thus  justifying  the 
rather  fanciful  term  of  e.  iris;  or  these  advancing  rings,  meeting  others, 
become  broken  into  various  lines,  producing  e.  gyratum ;  or,  made  up  of 
widely  diffused  patches  with  an  abrupt  and  sharply-defined  border,  it  is  called 
e.  marginatum.  As  usually  seen,  however,  the  disease  makes  its  appearance 
in  the  form  of  discrete  or  aggregated  flat  papules,  varying  in  size  from  a  pin- 
head  to  a  split  pea ;  in  color  they  are  bright  red  or  purplish.  Often  the 
lesions  are  considerably  larger  [e.  tubo'culatum),  in  which  case  they  have  a 
deeper  or  violaceous  hue  that  is  quite  characteristic.  Vesicles  or  bullae  may 
form  in  connection  with  any  of  the  above-mentioned  lesions,  thus  constituting 
e.  vesiculosum  and  e.  huUosum. 

The  backs  of  the  hands  and  feet  are  common  sites  of  the  eruption,  par- 
ticulai'ly  for  the  papular  and  tubercular  types ;  but  the  Avhole  surface  is  often 
involved.  Slight  desquamation  and  pigmentation  may  occur  as  sequelae.  The 
usual  duration  of  the  disorder  is  from  two  to  four  weeks  ;  but  the  general 
symptoms  usually  abate  at  the  appearance  of  the  eruption.  Relapses  are 
common,  especially  in  the  spring,  and  in  a  few  rare  instances,  reported  by  Fox, 


{ 


DISEASES   OF   THE  SKIN.  1099 

Jackson,  and  the  writer,  the  disease  has  relapsed  at  irregular  periods  for  many 
years. 

Many  authorities  look  upon  erythema  iris  and  erythema  nodosum  as  inde- 
pendent affections,  but  the  writer  regards  them  as  clearly  allied  to,  if  not  iden- 
tical with,  erythema  multiforme. 

Herpes  Iris. — It  is  usually  symmetrical,  and  occurs  preferentially  on  the 
backs  of  the  hands  and  feet,  but  especially  the  former.  There  may  be  one  or 
more  patches ;  sometimes  the  whole  body  is  affected,  even  the  mucous  mem- 
branes. The  eruption  consists  of  an  erythematous  base,  upon  which  is  seated  a 
conical  vesicle ;  both  vesicle  and  areola  increase  in  diameter,  and  presently  the 
outer  border  of  the  latter  is  elevated  into  an  annular  ring  by  fresh  effusions, 
while  the  central  vesicle  undergoes  absorption  and  leaves  in*^  its  stead  a  pur- 
plish stain.  Here  the  process  may  terminate,  or  else  successive  rings  may 
form,  and  the  various  shades  of  color  thus  produced  give  the  rather  fanciful 
rainbow  effect.     Various  other  modifications  have  been  noted. 

Erythema  Nodosum. — Before  the  eruption  is  developed  the  patient  may 
complain  of  the  general  symptoms  observed  in  connection  with  other  types  of 
e.  multiforme.  The  lesions  consist  of  isolated,  painful,  inflammatory  nodes 
that  vary  in  size  from  a  hickory-nut  to  an  egg  or  orange.  They  are  usually 
red  at  first,  but  as  they  decline  take  on  the  various  shades  of  a  common  bruise. 
They  may  be  well  or  ill  defined,  and  are  at  first  hard  and  tense,  but  later  become 
softer,  thus  closely  simulating  abscesses.  The  favorite  site  of  the  eruption  is 
the  front  of  the  legs,  but  it  may  appear  elsewhere.  Sensations  of  burning 
and  tingling  are  usually  present.  The  disorder  may  last  two  to  four  weeks. 
Kelapses  are  not  infrequent. 

Etiology. — The  various  types  of  erythema  multiforme  avoid  the  extremes 
of  life  as  a  rule  ;  the  ages  between  ten  and  thirty  are  most  obnoxious  to  its 
attacks.  It  seems  to  occur  as  the  result  of  the  most  diverse  causes — e.g. 
changes  of  temperature,  disorders  of  digestion,  as  sequelae  of  vaccination,  in 
connection  with  epidemic  influenza  (la  grippe) ;  and,  as  regards  e.  nodosum, 
it  apparently  bears  some  etiological  relationship  to  rheumatism.  The  explana- 
tion would  seem  to  be  that  these  various  erythemata  are  of  angeio-neurotic 
origin,  and  that  under  favoring  conditions  toxic  and  other  agents  influencing  the 
central  nervous  system  produce  these  explosions  in  the  vascular  and  nervous 
organs  of  the  skin. 

The  rash  is  undoubtedly  due  to  a  vaso-motor  disturbance,  inducing  the 
usual  phenomena  of  inflammation,  with  a  variable  amount  of  exudation. 
Haemorrhage  into  the  lesions  also  occurs. 

Diagnosis. — Erythema  multiforme  is  to  be  distinguished  from  urticaria  by 
the  stability  of  the  eruption,  the  greater  variety  of  the  eruptive  elements,  and 
the  less  degree  of  itching.  The  papules  of  papular  eczema  are  smaller,  more 
pointed,  last  longer,  and  are  intolerably  pruritic.  The  nodes  of  syphilis 
should  not  be  confounded  with  e.  nodosum.  Attention  to  the  history  of  the  ■ 
case,  the  possibility  of  ulceration,  and  other  concomitants  of  syphilis  should 
sufficiently  emphasize  the  differences. 

Prognosis. — In  the  majority  of  cases  the  prognosis  is  favorable.  Under 
no  circumstances  is  the  disease  dangerous  to  life,  but  the  relapses  are  not 
always  easy  to  control. 

Treatment. — The  prodromic  symptoms  of  erythema  multiforme  should  be 
treated  on  general  principles.  There  is  no  specific  remedy  for  the  disease  as  a 
whole.  Hygienic  measures  and  tonics  are  demanded  in  the  anaemic  and  stru- 
mous. In  rheumatic  cases  the  salicylates  are  indicated.  The  calamine-and- 
zinc  lotion,  with  or  without  the  addition  of  a  little  carbolic  acid,  is  a  good  local 


1100  AMERICAN  TEXT-BOGK  OF  DISEASES  OF  CHILDREN. 

application.  In  e.  nodosum  the  legs  should  be  kept  elevated,  and  the  same 
lotion  applied,  or  a  lead-and-opium  wash.  For  e.  tuberculatum  of  the  hands 
the  unguentum  vaselini  plumbicum  (see  under  Eczema),  spread  on  muslin  and 
neatly  bound,  gives  relief. 

Relapsing  Scarlatiniform  Erythema  (Fereol). 

Under  the  title  of  "erytheme  scarlatiniforme  desquamatif  recidivant"  Fereol 
and  Besnier  describe  a  form  of  disease  that  occurs  in  children  and  young  adults, 
and  which  really  should  be  discussed  along  with  the  other  varieties  of  exfoli- 
ative dermatitis.  Usually,  after  a  prodromic  stage  of  one  or  two  days,  in  which 
the  patient  feels  unwell  and  has  slight  fever,  a  scarlatiniform  erythema  appears, 
first  on  the  trunk,  and  in  a  few  hours,  or  perhaps  not  for  a  couple  of  days,  it 
spreads  over  the  whole  body.  In  some  cases  the  rash  is  localized  to  particular 
parts  of  the  sui'face,  or  it  may  be  widely  diffused,  but  with  areas  of  normal  skin 
between  the  patches.  The  oral  mucous  membranes  are  also  injected.  There 
is  some  burning  and  itching  present,  but  the  skin  remains  supple  and  shows 
no  infiltration.  After  a  few  days — one  or  two — the  process  comes  to  an  end, 
and  free  desquamation  occurs.  At  the  end  of  a  week  or  two  the  disease  has 
generally  run  its  course ;  on  the  other  hand,  there  may  be  repeated  recrudes- 
cences and  the  disorder  may  be  kept  up  for  weeks.  Relapses  are  frequent, 
especially  after  vicissitudes  of  weather  or  from  other  general  or  local  exciting 
causes.     It  is  non-contagious  and  does  not  occur  epidemically. 

Diagnosis. — The  distinction  between  this  affection  and  scarlatina  is  at 
times  difficult ;  but  in  scarlet  fever  the  prodromic  symptoms  are  usually  more 
severe,  the  eruption  comes  out  first  on  the  neck,  chest,  and  flexures  of  the 
joints,  the  fauces  are  tumid,  the  tongue  has  the  strawberry -like  appearance, 
the  glands  at  the  angles  of  the  jaw  are  swollen,  and,  finally,  desquamation  does 
not  occur  nearly  so  soon.  As  additional  points  it  may  be  remembered  that 
this  disorder  usually  gives  the  history  of  relapses,  and  that  it  is  neither  due 
to  nor  causes  contagion. 

Treatment.-^— This  should  be  directed  toward  the  miticjation  of  the  general 
and  local  symptoms — namely,  antipyretics  and  soothing  inunctions. 

Eczema. 

Eczema  is  an  inflammatory,  non-contagious  disease  of  the  skin,  character- 
ized by  multiformity  of  lesion  and  the  presence,  in  varying  degrees,  of  itch- 
ing, infiltration,  and  discharge.  It  may  be  acute,  subacute,  or  chronic,  and 
undergoes  various  secondary  changes,  such  as  scaling,  crusting,  fissuring,  and 
dense  thickening  of  the  skin.  It  was  formerly  held  that  eczema  was  invari- 
ably a  vesicular  disease,  and  that,  therefore,  the  other  types  which  it  presents 
represented  other  diseases,  such  as  impetigo,  lichen,  etc.  We  now  fully  recog- 
nize the  fact  that  it  is  a  truly  protean  affection  in  its  manifestations,  although 
possessing  a  pathological  unity  in  its  essential  features  that  is  unmistakable. 
This  view  has  been  very  fruitful  from  the  standpoints  of  diagnosis  and  treat- 
ment. So  far  from  eczema  being  a  vesicular  disease,  it  may  run  its  course 
without  the  appearance  of  a  single  vesicle.  On  the  contrary,  the  disorder  is 
characterized  by  a  polymorphous  eruption,  consisting  of  erythema,  papules, 
vesicles,  and  pustules.  All  of  these  lesions  are  not  necessarily  present  at  the 
same  time,  although  to  a  limited  extent  they  may  be,  and  one  form  of  ele- 
mentary eruption  may  become  transformed  into  another ;  but,  as  a  rule,  one 
or  another  of  them  may  so  predominate  as  to  establish  the  anatomical  general 


DISEASES    OF    THE   SKIN.  1101 

type  of  the  eczema ;  as,  for  exjample,  eczema  erytliematosum,  e.  papulosum,  e. 
vesiculosum,  e.  pustulosum. 

In  practice,  however,  the  disease  is  more  often  encountered  in  its  subacute 
or  chronic  phases,  and  a  brief  consideration  of  these  secondary  changes  will  be 
necessary. 

Eczema  rubrum  or  madidans  may  develop  out  of  any  of  the  elementary 
types  of  the  disease,  and  consists  of  a  raw,  red,  and  weeping  surface,  the  result 
of  exposure  of  the  rete,  due  to  shedding  of  the  upper  layers  of  the  epithelium. 
The  itching  is  very  severe.  This  form  of  eczema  is  common  on  the  faces  of 
children.  Scaly  or  squamous  eczema  may  also  follow  upon  any  of  the  element- 
ary forms  of  the  disease.  It  appears  mostly  in  patches  of  variable  size,  which 
are  red,  scaly,  and  infiltrated ;  and  finally,  owing  largely  to  situation  or  dura- 
tion of  the  disease,  the  eczematous  surface  may  become  of  board-like  hardness, 
or  warty,  or  cracked  and  fissured. 

The  chief  subjective  symptom  present  in  eczema  is  itching  ;  in  fact,  it 
constitutes  the  disease.  The  pruritus  will  vary  considerably  in  degree,  some- 
times being  slight  and  easily  tolerated,  or,  again,  it  may  be  agonizing  in  its 
intensity. 

Eczema  bears  a  close  resemblance  to  catarrhal  states  of  the  mucous  mem- 
branes, both  in  its  tendency  to  repeated  relapses  and,  objectively,  in  its  habit 
of  exudation  or  discharge.  This  exudation  has  the  property  of  stiffening 
and  slightly  staining  linen  or  cotton  fabrics  with  which  it  comes  in  contact.  It 
is  not  correct  to  assert  that  eczema  is  invariably  a  "  wet  disease,"  for  some  cases 
may  remain  dry  throughout ;  nevertheless,  even  a  papular  or  erythematous 
eczema  may  be  made  to  weep  through  the  influence  of  scratching  or  other 
irritation. 

Although  eczema  in  children,  especially  in  those  under  five  years,  is  a  very 
common  disease,  the  writer  fails  to  see  wherein  it  differs  essentially  from  the 
same  disorder  occurring  in  the  adult,  although  this  opinion  is  one  very  com- 
monly entertained.  Such  differences  as  exist  are  rather  of  causation  and  loca- 
tion than  in  clinical  expression.  In  a  general  way,  it  may  be  said  that  eczema 
occupies  certain  situations  more  often  in  the  child  than  in  the  adult — the  scalp 
and  face,  for  example — and  that  the  eruption  is  more  acute,  of  a  more  inflam- 
matory type.  All  of  the  elementary  lesions  of  the  disease — e.  g.  erythema, 
papules,  vesicles,  and  pustules — are  seen  in  children,  and  often  a  commingling 
of  them  all,  although  it  must  be  allowed  that  pustular  eczema  is  of  more  fre- 
quent occurrence  in  children  than  in  adults.  Eczema  rubrum  and  eczema 
squamosum  are  frequent,  but  leathery-like  infiltration  is  relatively  uncommon. 

Among  other  features  of  importance  connected  with  infantile  eczema  may 
be  noted  secondary  glandular  swellings,  cutaneous  abscesses,  particularly  in  the 
scalps  of  ill-nourished,  strumous  children,  and  post-eczematous  furunculosis. 
The  implication  of  the  lymphatics,  those  in  the  neck  being  principally  involved, 
as  a  result  of  eczema  capitis,  was  formerly  regarded  as  a  sure  indication  of 
scrofula ;  and  in  eczema  occurring  after  vaccination,  with  coincident  glandular 
swelling,  it  was  held  as  proof  positive  of  the  introduction  of  struma  by  the 
inoculated  lymph.  As  a  matter  of  fact,  this  adenitis  is  purely  sympathetic, 
and  is  more  apt  to  occur  from  the  irritation  set  up  by  pediculi.  It  is  excep- 
tional for  the  glands  to  suppurate. 

A  brief  summary  of  some  of  the  more  characteristic  features  of  the  eczema 
of  children  will  now  be  appropriate. 

Generalized  eczema  is  uncommon  in  childhood,  although  there  may  be 
present,  scattered  over  the  body  and  limbs,  infiltrated  patches  of  variable  size, 
sometimes  scaly  or  composed  of  aggregated  papules  exhibiting  moist  and  exco- 


1102  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

riated  surfaces.  The  disease  also  attacks  the^  hands,  feet,  and  legs  and  the 
flexures  of  the  joints.  Eczema  intertrigo,  or  that  form  of  the  disease  found  in  the 
groin  and  between  other  opposing  surfaces  of  skin,  is  frequent,  but  not  attended 
with  much  itching.  The  surfaces  are  very  red  and  moist,  and  are  apt  to  emit 
a  most  disagreeable  odor  ;  moreover,  the  eruption  may  spread  from  these  locali- 
ties to  the  contiguous  portions  of  the  thighs,  back,  and  abdomen.  The  writer's 
experience  is  in  agi'eement  with  that  of  Bulkley  in  regarding  the  face  as  the 
region  most  frequently  first  affected.  The  primary  lesions  are  usually  papules, 
which  run  together  to  form  exuding,  reddened  and  crusted  patches  that  are 
intolerably  itchy.  In  this  situation  the  disease  is  more  prone  to  relapse  than 
elsewhere,  as  every  varying  condition  of  the  system  is  promptly  reflected  upon 
a  part  especially  rich  in  its  vascular  and  nervous  supply.  A  very  common 
starting-point  also  is  the  scalp,  where  it  is  often  evoked  by  the  nurse  or 
mother  in  the  eff"ort  to  clear  away  the  sebaceous  secretion  that  clings  to  the 
new-born  infant.  From  this  region  it  may  spread  to  the  forehead,  ears,  and 
face,  and  the  well-known  picture  of  the  typical  crusta  lactea,  or  milk  crust, 
is  presented.  The  itching  is  excessive,  and  the  little  suff'erers,  if  old  enough, 
make  frantic  efforts  to  get  relief  by  scratching ;  while  infants  will  rub  the  face 
and  head  against  the  pillow  or  the  mother's  breast.  In  neglected  cases 
eczema  rubrum  is  soon  developed. 

Etiology. — Eczema  is  one  of  the  most  common  of  all  skin  diseases,  and 
it  is  most  frequent  during  childhood.^  Even  within  this  period — nay,  up  to 
the  tenth  year — the  disease  is  most  frequently  developed  during  the  first  five 
years,  and,  according  to  Crocker's  statistics,  one-third  of  all  cases  in  children 
begin  within  the  first  year  of  life. 

Leaving  out  of  consideration  for  the  present  the  essential  nature  of  the  ecze- 
matous  process,  it  may  be  said  that  eczema  is  a  catarrhal  inflammation  of  the  skin, 
which  may  be  evoked  by  a  great  number  of  exciting  agencies,  both  internal 
and  external.     With  children  these  influences  are  often  sufficiently  obvious. 

It  is  not  uncommon  to  find  that  eczematous  parents  have  eczematous  chil- 
dren, but,  nevertheless,  the  disease  is  not  inherited  in  the  sense  that  syphilis 
is;  it  is  rather  the  transmission  of  a  predisposed  and  vulnerable  skin  than  the 
inheritance  of  a  diathesis.  The  ill-nourished  and  strumous  are  especially  prone 
to  eczema,  particularly  of  the  pustular  type,  Avith  swollen  glands,  ciliary 
blepharitis,  and  otorrhoea  as  concomitants ;  and  such  children,  according  to 
Unna,  may  subsequently  develop  local  or  general  tuberculosis.^  It  will  be 
found  equally  true  that  depressing  influences  of  all  sorts,  unhygienic  suiTound- 
ings,  insufficient  or  improper  food,  both  for  the  child  and  the  nursing  mother, 
may  be  regarded  as  causative  factors  of  no  slight  importance.  It  is  no  uncom- 
mon thing  for  eczema  to  follow  in  the  wake  of  the  eruptive  fevers,  especially 
measles,  in  this  latter  instance  often  assuming  the  form  of  eczema  tarsi. 
Vaccination  is  often  held  responsible  for  inducing  eczema,  but  so  also  may 
the  operation  of  piercing  the  ears  for  earrings. 

As  stated  above,  various  dietetic  errors  induce  the  disease  by  provoking 
gastric  and  intestinal  disorders.  The  mother's  milk  may  be  of  an  inferior 
quality  from  lack  of  proper  nourishment  on  her  part,  or  it  may  be  at  fault 
from  too  great  indulgence  in  rich  food  and  stimulating  liquids.     Over-feeding 

^  In  the  writer's  practice,  out  of  a  total  of  6724  cases  of  skin  disease  of  all  classes,  there 
were  2148  patients  with  eczema,  or  31.40  per  cent.  In  .3000  ca.ses  of  eczema  analyzed  by  Bulkley, 
907  occurred  during  the  first  ten  years  of  life,  and  676  of  these  were  observed  in  children  five 
years  old  and  under ;  that  is,  one-quarter  of  the  whole  number  could  be  regarded  as  infantile. 

■■''This  latter  statement  must  be  taken  with  many  reservations,  at  least  from  the  .standpoint 
of  American  experience ;  for  many  tubercular  children  never  develop  eczema  at  all,  and  many 
children  with  so-called  tuberculous  eczema  never  get  tuberculosis. 


rjjATJli    JLJ^^lV. 


^'L 


it  t'^>>^vV'^/ 


^>;y#^ 


ECZEMA   RUBRUM 


DISEASES    OF    THE  SKIN.  1103 

is  more  apt  to  evoke  eczema  than  under-feeding  in  children.  Very  few  chil- 
dren are  properly  fed,  and  it  is  no  uncommon  thing  to  find  very  young  infants 
allowed  everything  that  appears  on  the  table.  The  writer  has  long  maintained 
that  oatmeal  is  a  pernicious  food  for  the  eczematously  disposed,  especially  the 
hastily-cooked  article  reinforced  by  rich  cream  and  great  quantities  of  sugar. 
Jamieson  of  Edinburgh  doubts  that  oatmeal  in  itself  can  initiate  an  eczema, 
but  he  thinks  it  is  quite  probable  that  it  can  light  up  an  imperfectly  cured 
eczema  or  perpetuate  one  already  existing,  as  any  other  cause  of  eczema  may. 

Spoon-fed  babies  are  more  apt  to  develop  eczema  than  those  nursed  by 
healthy  mothers,  but  here  also  it  is  to  be  remembered  that  they  are  liable  to 
disorders  of  the  alimentary  canal. 

The  local  and  reflex  irritations  of  the  eruption  of  teeth  plays  no  inconsid- 
erable role  among  the  exciting  ca.uses  of  eczema,  but  to  regard  teething  as  the 
sole  cause  of  the  disease  is  unscientific,  and  the  reassuring  advice  often  given 
that  the  disease  will  recover  after  teething  is  frequently  not  fulfilled. 

Any  form  of  external  irritant  may  provoke  an  eczema — e.  g.,  cold,  heat, 
bad  soap,  hard  water,  rough  under-garments,  etc.  Seborrhoea  is  a  prolific 
source  of  the  disease,  and  the  efibrt  to  remove  the  seborrhoeal  exudation,  espe- 
cially from  the  scalp  of  infants,  is  perhaps  one  of  the  most  common  causes  of 
the  disease  in  that  situation.  The  agency  of  micro-organisms  is  probable, 
especially  in  localized  forms  of  the  aifection  where  the  cutaneous  secretions 
have  undergone  decomposition. 

From  the  foregoing  considerations  it  will  be  seen  that  there  is  no  one  cause 
for  eczema.  Whatever  the  essential  nature  of  the  disease  may  be,  it  is  obvious 
that  the  eczematous  subject  has  a  specially  vulnerable  and  susceptible  skin,  and 
that  under  given  conditions  the  disorder  may  be  evoked  by  any  cause,  internal 
or  external,  that  will  arouse  this  susceptibility. 

Diagnosis. — Papular  urticaria,  the  so-called  lichen  urticatus,  bears  a 
general  resemblance  to  papular  eczema.  In  lichen  urticatus  the  papules  are 
larger  and  more  discrete,  and  the  presence  of  the  ordinary  urticarial  wheal 
may  be  detected  at  some  period  of  the  case  ;  moreover,  the  urticarial  papules 
never  run  together  to  form  the  characteristic  scaling,  infiltrated,  and  weeping 
patch  of  eczema. 

Scabies  and  eczema  are  usually  confounded  by  the  inexperienced.  Both 
itch  severely,  and  in  both  multiform  lesions  may  be  present ;  but  in  scabies 
contagion  can  nearly  always  be  made  out,  the  other  children  in  the  family  or 
the  mother  being  similarly  affected,  and  the  eruption  occupies  certain  preferen- 
tial localities — namely,  between  the  fingers,  the  flexor  surfaces  of  the  wrists 
and  arms,  including  the  axillae,  the  lower  part  of  the  trunk,  both  before  and 
behind,  and  in  older  boys  the  penis.  In  children  of  some  age  the  eruption 
will  not  be  found  on  the  face  or  feet,  but  in  infants  both  of  those  regions  may 
be  affected.  It  is  safe  to  say  that  a  generalized  multiform  itchy  eruption,  occu- 
pying portions  of  the  body  that  are  normally  moist  and  warm,  either  from  the 
pressure  of  garments  or  from  contact  of  contiguous  parts,  is  almost  necessarily 
scabies.  The  characteristic  burrow,  or  cuniculus,  is  more  readily  demonstrated 
in  the  child  than  in  the  adult. 

Various  forms  of  the  syphilide,  especially  the  papular  and  pustular,  are 
liable  to  be  confounded  with  eczema.  In  general  it  may  be  said  that  the  spe- 
cific eruption  is  most  apt  to  be  seen  about  the  mouth,  nose,  and  genitals,  and 
that  the  individual  lesions  are  larger,  less  acute  in  aspect,  and  of  a  darker  color, 
besides  often  presenting  a  circular  arrangement.  The  weazened  appearance  of 
the  child,  the  presence  of  snuffles,  and  the  discovery  of  mucous  patches  are 
important  aids  in  diagnosis.     Moreover,  syphilitic  eruptions  do  not  itch. 


1104:  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Pediculosis  capillitii  bears  some  resemblance  to  pustular  eczema  of  tlie 
scalp,  but  the  dermatitis  is  usually  confined  to  the  occiput,  whereas  eczema 
is  apt  to  involve  the  Avhole  head,  and  a  little  search  will  easily  discover  the 
pediculi  or  their  nits. 

The  possibility  of  confounding  eczema  with  rin^^worm  and  favus  should  be 
borne  in  mind.  (See  those  diseases.) 

Treatment. — Before  entering  upon  the  subject  of  treatment  it  is  Avell  to 
take  notice  of  the  opinion  still  lingering  among  the  laity,  and  occasionally 
entertained  by  physicians,  that  the  cure  of  the  disease  may  be  attended  with 
the  most  serious  consequences.  This  apprehension — a  revival  of  the  old 
humoralistic  theory  of  peccant  humors — both  modern  science  and  accumulated 
experience  unite  in  pronouncing  absolutely  baseless.  Hebra  acutely  suggested 
that  when  the  protest  against  a  cure  comes  from  a  medical  man,  it  is  quite 
likely  that  it  is  due  to  foilure  on  his  part  to  effect  it. 

In  the  matter  of  internal  medication  it  may  be  distinctly  stated  that  there 
are  no  specifics  for  the  affection.  In  every  instance  a  searching  investigation 
must  be  made  for  possible  exciting  causes  or  probable  complications.  Routine 
is  to  be  avoided  and  each  case  managed  on  its  merits. 

It  not  infrequently  happens  that  the  little  patient  is  in  apparently  perfect 
general  health,  the  disorder  being  due  to  external  causes,  and  no  treatment 
beyond  the  necessary  local  applications  is  demanded.  Even  in  such  cases 
proper  attention  to  diet  Avill  prove  beneficial,  and  all  the  more  beneficial  if  a 
connection  can  be  established  between  the  eruption  and  dietetic  errors.  If  the 
child  is  being  suckled,  the  mother  should  abstain  from  stimulating  foods  and 
drinks,  but  if,  on  the  other  hand,  she  is  ill-nourished  and  anaemic,  her  condi- 
tion should  receive  appropriate  attention.  As  regards  the  child  itself,  if  old 
enough  to  be  fed,  the  strictest  attention  should  be  paid  to  the  character  of  the 
food  and  to  the  time  and  frequency  of  meals.  The  usual  stuffing  with  unwhole- 
some and  indigestible  food  should  be  strictly  forbidden,  and  the  physician  will 
find  it  wise  to  write  out  carefully  prepared  diet  tables.  The  writer  has  long 
been  in  the  habit  of  using  the  admirable  tables,  prepared  for  different  ages,  to 
be  found  in  Dr.  Louis  Starr's  valuable  work  on  the  diseases  of  the  digestive 
organs  in  children.  We  would  reiterate  the  statement,  already  made  above, 
that  oatmeal,  especially  when  served  with  cream  and  sugar,  is  harmful  to  ecze- 
matous  children.  Corn  grits  with  salt  and  butter  are  just  as  nutritious  and 
apparently  harmless. 

The  condition  of  the  alimentary  canal  must  be  strictly  inquired  into,  so 
that  constipation,  gastric  and  intestinal  catarrhs,  or  other  complicating  disorders 
may  receive  proper  attention.  An  occasional  minute  dose  of  calomel  will  prove 
useful  in  nearly  all  cases.  Anaemic  and  strumous  children,  who  usually  suffer 
from  pustular  eczema,  are  much  benefited  by  the  use  of  iron,  particularly  the 
syrup  of  the  iodide,  and  some  form  of  cod-liver  oil.  A  favorite  and  agreeable 
method  of  administering  the  oil  is  as  follows : 

]^.   01.  morrhujB •     ....  fsiv. 

Pancreatiui  saccharati 3J. 

Pulv.  acaciiB q.  s. 

Glyceriti  hypophosphit f.?iv. 

Syr.  calcis  lactophosphatis 

Aquae da  fsiv. 

Olei  gaultheriffi gtt.  xxx. — M. 

Sig. — From  a  teaspoonful  to  a  dessert-spoonful,  according  to  age,  three 
times  a  day,  after  meals. 


DISEASES    OF   THE  SKIN.  1105 

The  habit  of  prescribing  arsenic  in  all  cases  of  eczema  is  almost  a  matter 
of  routine  "svith  most  physicians.  Notwithstanding  excellent  authority  to  the 
contrary  ("Wilson,  Bulkley),  the  "writer  must  insist  that  this  is  bad  practice. 
The  drug  should  never  be  given  in  acute  attacks,  and  its  beneficial  effects, 
even  in  chronic  types  of  the  disease,  are  by  no  means  constant.  Its  chief 
value  is  in  the  dry  and  scaly  forms  of  eczema.  Before  giving  arsenic  at  all,  it 
is  absolutely  necessary  to  see  that  the  digestive  functions  are  unimpaired. 
Children  bear  relatively  larger  doses  than  adults.  Erasmus  Wilson,  "who  "was 
a  great  advocate  of  the  employment  of  arsenic  in  infantile  eczema  after  a 
proper  eliminative  treatment  "with  mercury,  recommends  t"wo  minims  of  Fo"wler's 
solution  for  a  child  from  a  month  to  a  year  old,  to  be  repeated  three  times  a 
day  "with,  or  immediately  after,  meals : 

I^.  Vini  ferri f^ss. 

Liq.  potassii  arsenitis ITLxxxij. 

Syr.  tolutani f^ss. 

Aquae  anethi fgj. — M. 

Sig.   One  teaspoonful  three  times  a  day.^ 

As  a  general  thing,  the  various  local  measures  should  be  sufficient  to  allay 
itching  and  procure  sleep,  but  at  times  it  is  necessary  to  resort  to  internal 
medicines.  Any  form  of  opium  is  inadmissible,  as  it  increases  the  pruritus. 
Small  doses  of  phenacetin  are  of  value  in  allaying  restlessness,  and  it  appears 
to  have  no  ill  effect  on  the  eruption.  Quinine  is  particularly  recommended  by 
Dr.  Pye-Smith  as  an  antipruritic — a  half  grain  for  a  child  of  one  year  an  hour 
before  bedtime,  a  grain  at  t"wo  years,  and  five  grains  at  the  age  of  fifteen. 
Where  a  rebellious  eczema  is  probably  due  to  reflex  irritation,  the  result  of  a 
tight  prepuce,  circumcision  or  other  methods  of  uncovering  the  glans  should 
be  recommended. 

The  local  treatment  of  eczema  is  of  the  utmost  importance ;  perhaps,  taking 
all  the  facts  into  consideration,  of  more  importance  than  any  direct  internal 
medication ;  for,  as  the  "writer  has  expressed  it  else"where,  in  quite  a  large 
number  of  cases  internal  remedies  are  not  demanded  at  all,  either  because  the 
disease  is  due  to  entirely  local  agencies,  or  because  the  internal  exciting  cause 
has  ceased  to  be  operative,  and  there  remains  only  the  effects,  "which  may  be 
got  rid  of  by  topical  means. 

In  order  to  determine  the  character  and  stage  of  the  disease,  it  is  a  pre- 
requisite that  all  scales,  crusts,  and  other  secondary  products  be  removed. 
Poultices  should  be  avoided,  as  a  rule,  but  free  inunctions  with  a  bland  oil  will 
generally  suffice  for  this  purpose.  The  rule  that  an  eczema  should  never  he 
washed  is  absolute.  The  habit  of  daily  washing  eczematous  surfaces  is  per- 
nicious in  the  extreme,  and  is  the  principal  reason  of  the  apparent  rebellious- 
ness of  these  cases  to  treatment.  Even  after  recovery  is  seemingly  established 
the  use  of  an  indifferent  soap  will  speedily  provoke  an  exacerbation.^  When 
the  eruption  is  at  its  height  it  is  better  to  let  the  parts  go  unwashed,  or  a  little 
warm  milk  and  water  Avill  ansAver  the  purposes  of  cleanliness  sufficiently. 

The  principles  underlying  the  local  treatment  of  eczema  are  in  reality  very 
simple.  When  the  disease  is  acute,  soothing  remedies  should  be  applied ;  when 
subacute,  they  may  be  made  somewhat  astringent ;  and  when  the  chronic  stage 

'  In  the  writer's  judgment  such  large  doses  of  arsenic  as  recommended  by  Wilson  should 
be  administered  -n-ith  great  caution,  if  at  all. 

^  The  best  soaps  kno"svn  to  the  writer  are  the  superfatted  kinds  made  in  Germany.  Eichoffs 
thymol,  or  Kinderseife,  is  an  excellent  toilet  article. 
70 


iiOQ  A mi:bicax  text-book  of  diseases  of  children. 

is  established,  a  suitable  degree  of  stimulation  is  demanded.  Some  few  of  the 
many  topical  applications  used  in  eczema  will  now  be  described,  together  with 
their  special  indications,  and  the  subject  will  be  concluded  with  a  brief  consid- 
eration of  the  regional  forms  of  the  disorder. 

Lotions. — Sedative  and  somewhat  astringent  lotions  are  useful  in  acute 
eczema.  Preparations  of  lime-water  and  opium  and  solutions  of  soda  or  borax 
may  be  employed  for  this  purpose,  but  the  calamine-and-zinc  lotion  is  the  most 
valuable  of  all  such  applications.  (See  Miliaria.)  It  should  be  applied  by 
means  of  cheesecloth  cut  into  strips  and  bound  on  with  a  neat  bandage. 
If  the  itching  be  severe,  from  two  to  five  minims  of  carbolic  acid  may  be  added 
to  each  ounce  of  this  mixture. 

Lotions  of  carbolic  acid  are  often  indispensable  to  allay  the  tormenting 
pruritus  : 

^.  Acidi  carbolici f^ss. 

Glycerini Tllx. 

Alcoholis foj. 

Aquae q.  s.  ad  fsiv. — M. 

Sig.  Local  use  ;  apply  several  times  a  day. 

This  may  be  used  alone  or  in  conjunction  with  other  measures. 

Chronic  infiltrated  patches  of  limited  extent  may  be  made  to  heal  under 
brisk  friction  with  a  tar-and-soap  solution  : 

I^.   01.  cadini foij- 

Saponis  viridis 

Alcoholis da  f sij . — M. 

This  may  be  quickly  rubbed  in,  then  washed  oflF  with  water,  and  the  parts 
covered  over  with  unguentum  vaselini  plumbicum  spread  on  cloth.  The  neces- 
sity for  such  stimulating  treatment  does  not  often  arise  with  children. 

Powders. — In  general  acute  erythematous  eczema  and  in  the  forms  of  the 
disease  found  between  folds  of  the  skin,  powders  are  sometimes  useful,  but  as 
a  rule  other  measures  serve  a  better  purpose : 

R.  Pulv.  amyli 3v. 

Zinci  oxidi ojss. 

Pulv.  camphors 3ss. — M. 

Sig.  Dust  on  with  a  puflf. 

I^.   Thymol gr.  j. 

Pulv.  zinci  oleatis oj- — M* 

This  is  a  good  formula  in  mild  cases  of  eczema  intertriofo. 

Ointments. — Salves  are  of  especial  value  where  there  is  crusting  and 
exudation,  and  since  most  cases  are  seen  by  the  physician  at  this  stage,  it  fol- 
lows that  they  are  more  used  than  all  other  preparations  together.  To  secure 
success  it  is  necessary  that  the  ingredients  should  be  fresh  and  that  the  oint- 
ment should  be  thoroughly  prepared.  Soothing  salves  should  always  be  spread 
on  suitable  strips  of  muslin  and  bound  on  the  parts,  but  when  stimulation  is 
desired  the  remedy  may  be  rubbed  in  with  the  finger.  AVhen  it  is  desired 
merely  to  protect  the  parts  with  a  bland  unguent,  the  unguentum  aquK  rosae  is 
very  beneficial :  a  little  bismuth  (3 ij—5J)  may  be  added  with  advantage.  To 
increase  its  astringency  and  to  allay  pruritus  the  following  combination  may  be 
advised : 


DISEASES    OF   THE  SKIN.  1107 

B^.  Bismuthi  subnitratis giv. 

Zinci  oxidi 3ss. 

Acidi  carbolic! HfLx. 

Vaselini gij. — M. 

A  standard  preparation  of  great  value  is  the  unguentum  vaselini  plum- 
bicum : 

I^.  Emplastri  diachyli Iss. 

Vaselini gss. — M. 

These  should  be  melted  together  by  gentle  heat  and  stirred  until  cold.  In 
subacute  and  moderately  thickened  eczema,  and  in  the  pustular  form  of  the 
disease,  there  are  few  better  preparations. 

In  the  great  majority  of  cases  of  eczema  in  children,  as  ordinarily  encoun- 
tered— that  is  to  say,  cases  in  the  subacute  stage  with  slight  infiltration  and 
intense  itching — there  is  nothing  comparable  to  the  zinc-and-tar  salve: 

^.  Zinci  oxidi .  3j. 

Ung.  picis  liquidse 3ij. 

Ung.  aquae  rosas • gij. 

Lanolini 3iv. — M. 

Sig.  Local  use. 

This  should  be  applied  on  strips  of  muslin,  but,  as  children  will  not  usually 
submit  to  the  face-mask  or  other  bandaging,  it  does  almost  as  well  to  smear  it 
on  gently  with  the  finger  repeatedly  during  the  day  and  night.  To  get  good 
results  with  this  ointment  it  is  absolutely  essential  that  the  prescription  should 
go  to  a  pharmacist  accustomed  to  the  preparation  of  ointments.  Under  the  use 
of  this  ointment,  so  promptly  does  it  relieve  itching,  the  writer  has  been 
enabled  in  a  large  measure  to  abstain  from  the  harsh  methods  of  physical 
restraint  sometimes  advocated.^ 

It  is  a  safe  rule  even  in  seemingly  chronic  eczema  to  commence  with  one 
of  the  milder  preparations,  but  if  the  case  prove  obstinate,  we  may  then  proceed 
to  more  stimulating  applications,  as  follows : 

I^.   Hydrarg.  ammoniati gr.  x— xv. 

Liq.  carbonis  detergentis tllxx— f^ss. 

Lanolini gj. — M. 

Sig.  Apply  two  or  three  times  daily. 

^.   01.  rusci 3SS-J. 

Ung.  zinci  oxidi 5j. — M. 

Sig.  To  be  rubbed  into  the  parts. 

^  Bulkley  {Eczema  and  its  Management)  makes  the  following  sensible  remarks  on  the  appli- 
cation of  ointments :  "  The  first  application  of  any  ointment  may  be  resisted  by  the  child,  and 
may  seem  not  to  give  relief;  but  if  a  suitable  application  has  been  selected,  and  if  it  is  renewed 
as  often  as  it  falls  off  or  is  brushed  off,  relief  will  soon  be  obtained,  and  the  child  who  first 
resisted  the  application  will  shortly  crave  it.  This  matter  of  the  constant  protection  day  and 
night  of  eczematous  surfaces  from  the  irritating  action  of  the  air  and  external  contact  must  be 
insisted  upon,  and  carried  out  at  all  hazards  with  rigid  severity.  Attendants  will  often  neglect 
it,  and  the  application  will  often  be  intentionally  removed  in  anticipation  of  the  visit  of  the 
physician,  or  when  inconvenient  on  account  of  ordinary  matters  of  daily  life.  A  single  neglect, 
for  even  a  short  period,  followed  by  scratching  and  irritation  of  the  skin,  can  result  in  more 
damage  than  can  be  repaired  by  long  treatment."  It  may  be  added  that  a  single  washing  of  an 
eczematous  skin  will  be  equally  injurious. 


\\0d>  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Pastes. — These  preparations  are  very  useful  when  there  is  neither  too 
much  crusting  nor  too  great  infiltration ;  moreover,  they  are  very  valuable 
when  an  adhesive  and  protective  application  is  required,  as  they  are  not  readily 
scratched  oft'  or  Avashed  away  by  secretions.  They  find  their  principal  utility 
in  irritable  papular  and  erythematous  patches  and  in  eczema  intertrigo.  Las- 
sar's  well-known  formula  is  as  follows  : 


I^.  Acidi  salic3dici 3ss. 

Zinci  oxidi 

Amyli da  3vj. 

Vaselini sij. — M. 

A  small  amount  of  tar  may  be  added  to  secure  greater  stimulation. 
This  paste  is  also  valuable  : 

^.  Resorcini gr.  x-3j. 

Lanolini 3ij. 

Vaselini 3ij. 

Zinci  oxidi 

Pulv.  amyli aa  3ij. — M. 

Pick's  linimentum  exsiccans  naay  also  be  mentioned  under  this  head  : 

!^.  Pulv.  tragacanth gr.  xv. 

Glycerin! ITtxxiv. 

Aquse fsj. — M. 

The  writer  is  in  the  habit  of  adding  to  this  10  to  15  per  cent,  of  oxide  of  zinc 
and  1  per  cent,  of  carbolic  acid  or  3  to  5  per  cent,  of  tar.  Thus  combined, 
this  preparation  is  of  the  greatest  merit,  particularly  in  cases  similar  to  those 
mentioned  as  suitable  for  pastes  in  general.  The  various  glycerin  jellies  have 
been  almost  entirel}^  discarded  in  its  favor. 

Plasters. — The  plaster  and  salve  mulls  of  Unna,  made  by  Beiersdorf  of 
Hamburg,  are  very  beneficial  in  suitable  cases.  The  salve  mulls  are  made  by 
incorporating  the  required  remedy,  such  as  lead,  mercury,  zinc  etc.,  with  a 
base  made  of  benzoated  suet  and  lard,  and  spread  on  one  or  both  sides  of 
undressed  muslin.  The  plaster  mulls  are  made  of  gutta-percha  faced  with  some 
adhesive  substance  containing  the  remedy,  and  backed  with  muslin.  The  salve 
mulls  may  be  used  in  subacute  cases  when  a  fixed  dressing  is  necessary  ;  the 
plaster  mulls  are  to  be  employed  only  when  there  is  considerable  infiltration. 
In  these  latter  cases  the  writer's  modification  of  Pick's  soap  plaster  does  just 
as  well,  and  is  much  less  expensive : 

^.  Empl.  plumbi 3xxv. 

Pulv.  saponis 9iv. 

Aquae q.  s. 

Vaselini 3v. 

Camphorae gr.  xx. 

Acidi  salicylic! gr.  x-xx. — M. 

Sig.   Spread  on  strips  of  muslin  and  change  once  a  day. 

This  plaster  serves  an  excellent  purpose  for  thickened  patches  of  eczema  on  the 
hands  and  feet. 


DISEASES    OF   THE  SKIN.  1109 

Paints. — Fixed  dressings  made  with  collodion  or  solution  of  gutta-percha 
are  of  limited  range  of  application,  but  may  occasionally  be  used  to  advantage  : 

I^.   01.  rusci 3SS-J. 

Collodii,  vel  liq.  gutta-perchse fij. — M. 

Sig.  Apply  with  camel's-hair  pencil. 

This  may  be  painted  on  chronic  patches  of  eczema  about  the  mouth,  both  to 
secure  the  healing  effect  of  the  tar  and  the  protective  action  of  collodion  or 
gutta-percha. 

Prognosis. — The  prognosis  of  infantile  eczema  is  generally  favorable,  pro- 
vided the  nature  of  the  disease  and  the  fundamental  principles  of  treatment 
are  thoroughly  understood.  That  it  is  prone  to  relapse,  like  all  catarrhal 
inflammations,  when  exposed  to  the  manifold  exciting  causes  that  are  capable 
of  evoking  it,  must  be  admitted ;  but  with  patience  and  perseverance,  and  the 
hearty  co-operation  of  parents  in  the  general  management,  the  physician  is 
usually  rewarded  in  his  efforts.  While  it  is  true  that  the  tendency  to  relapse 
decreases  with  age,  the  assurance  often  given  that  the  disease  will  disappear  at 
certain  specified  periods — for  example,  at  the  cessation  of  dentition — is  not 
borne  out  by  experience.  There  is  a  small  minority  of  cases  of  eczema  that 
almost  justifies  the  term  "  malignant."  In  such  cases  the  disease  commences  in 
childhood  and  recurs  with  greater  or  less  frequency  during  life.  Fortunately, 
they  are  rare. 

Treatment  of  the  Regional  Forms  of  Eczema. — Eczema  of  the  Scalp. 
— Remove  crusts  if  present,  and  clip  the  hair.  If  the  eruption  is  acute,  apply 
almond  or  olive  oil  with  1  per  cent,  of  carbolic  or  salicylic  acid.  A  bismuth 
salve  (3j-§j)  is  also  soothing.  After  subsidence  of  the  inflammatory  symptoms 
the  tar-and-zinc  ointment  (^,.  Zinei  oxidi,  3j  ;  Ung.  picis  liq.,  Ung.  aq.  ros(e, 
da  3ij  ;  Lanolini,  3iv. — M.)  makes  the  best  application.  In  children  with  little 
or  no  pain  the  ung.  vaselini  plumbicum,  spread  on  muslin,  is  efficacious.  For 
scaly  eczema  salicylic  acid  and  sulphur  give  speedy  result  (I^.  Acidi  sali- 
ci/lici,  gr.  X ;  Sulphuris  prcecip..,  3ss ;  Vaselini.,  ij. — M.).  If  the  eczema  is 
secondary  to  pediculosis,  the  pediculi  and  their  nits  must  be  first  destroyed. 

Eczema  of  the  Ears. — The  calamine-and-zinc  lotion  (^.  Zinci  oxidi,  gss  ; 
Pulv.  calamine  prcep..,  9iv  ;  Grlycerini,  f|j  ;  Liq.  calcis,  f^vij. — M.)  is  the  most 
suitable  application  for  acute  eczema  of  the  auricle.  Strips  of  cheese-cloth 
should  be  Avet  with  this  solution  and  bound  over  the  parts.  The  unguentum 
vaselini  plumbicum  spread  on  muslin  is  well  adapted  for  subacute  and  chronic 
cases.  The  cracked,  infiltrated  condition  found  behind  the  ears  is  frequently 
cured  after  a  brisk  friction  with  the  tincture  of  green  soap  (^i.  Saponis  viridis, 
Alcoholis,  da  giv. — M.),  followed  by  the  lead-and-vaseline  salve.  (The  reader 
is  referred  to  another  section  of  this  work  for  the  treatment  of  eczema  of  the 
auditory  canal.) 

Eczema  of  the  Face. — The  calamine-and-zinc  lotion  affords  the  best  results 
for  very  acute  erythematous  eczema  of  this  region.  In  children,  however,  the 
disease  usually  begins  more  insidiously,  and  when  first  seen  the  parts  are  gen- 
erally raw  and  weeping  and  covered  with  crusts.  These  latter  may  first  be 
removed  by  oil  inunctions  or  the  immediate  application  of  the  ung.  vaselini 
plumbicum  spread  on  muslin.  This  ointment  may  be  continued,  or  the  tar- 
and-zinc  salve  above  given  may  be  substituted  for  it,  or  else  used  from  the 
beginning.  As  stated  above,  this  is  by  far  the  best  application  for  almost 
all  forms  of  infantile  eczema.  Of  course  the  amount  of  tar  may  be  increased 
or  diminished  according  to  the  effect.     In  slight  patches,  or  toward  the  end  of 


1110  A 3fIJBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

a  more  pronounced  case,  Pick's  paste  (see  above)  with  oxide  of  zinc  and  tar 
may  be  smeared  over  and  allowed  to  dry  on.  This  makes  a  valuable  protective 
dressing,  which  is  not  readily  scratched  oflF.  Lassar's  paste  is  also  of  use 
under  these  circumstances.  When  it  is  necessary  to  employ  an}-  of  the  oint- 
ments above  mentioned,  it  is  best,  if  the  child  will  allow  it,  that  the  muslin 
strips  upon  Avhich  the  salve  is  spread  be  kept  in  place  by  a  light  skeleton 
mask.  This  is  not  necessary  for  the  pastes.  Chronic  infiltrated  areas  may  be 
treated  tAvo  or  three  times  a  day  by  Avorking  in  a  little  mercurial-and-tar  salve 
(I^.  Hydrarg.  aimnoniati,  gr.  x;  Liq.  carhonis  deterg.,  TTLxv-f^ss ;  LanoUni, 
§j. — M.).  Eczema  about  the  mouth  is  slow  to  heal,  owing  to  the  movements  of 
the  parts  and  the  trickling  of  saliva  and  food  over  the  inflamed  surfaces. 
Here  some  form  of  fixed  dressing  is  indicated  (I^.  Olei  rusci,  3ss ;  Collodii, 
f^j),  or  one  of  the  adhesive  pastes  just  mentioned. 

Eczema  of  the  Lids. — Eczema  of  the  surface  of  the  lids  is  usually  of  the 
erythematous  type,  and  generally  demands  soothing  measures,  such  as  the 
ointment  of  cold  cream  with  a  little  oxide  of  zinc  added  to  it.  Eczema  tarsi 
occurs  mostly  in  strumous  children,  and  is  a  common  sequela  to  the  eruptive 
fevers.  Internally  cod-liver  oil  and  iron  are  invaluable,  and  locally  the  yellow- 
oxide-of-mercury  ointment  is  especially  beneficial  (I^.  Hydrarg.  oxidi  fiav., 
gr.  ij— viij  ;    Vaselini,  5j. — M.). 

Eczeyna  of  the  Umbilicus. — The  disease  in  this  region  is  often  secondary 
to  seborrhoea,  and  is  very  intractable.  Ung.  vaselini  plumbicum  makes  a  good 
application,  but  it  is  usually  best  to  add  five  or  ten  grains  of  salicylic  acid  to 
each  ounce.  Unna's  diachylon  salve  mull  is  also  to  be  advised.  Duhring 
suggests  an  ointment  of  oleate  of  zinc  and  calomel.  Boracic  acid  is  also 
useful. 

Eczema  Intertrigo. — As  a  prophylactic  measure  infants  should  be  kept 
well  dusted  with  some  bland  borated  powder  in  those  parts  liable  to  the  dis- 
order ;  that  is,  in  the  genital  organs,  under  the  neck,  and  in  the  axillae.  When 
the  disease  has  become  established,  the  affected  surfaces  should  be  washed  as 
little  as  possible,  and  protected  with  Lassar's  paste  (Bf,.  Acidi  salicylici,  gr. 
x;  Zinci  oxidi,  Pulv.  amyli,  da  3ij  ;  Vaselini,  q.  s.  ad  %}. — M.).  Pick's  lini- 
mentum  exsiccans,  with  10  per  cent,  oxide  of  zinc  and  1  per  cent,  carbolic 
acid,  is  perhaps  even  better. 

Eczema  occurring  in  other  regions  of  the  body  requires  no  special  descrip- 
tion, and  should  be  treated  upon  the  general  principles  set  forth  in  the  fore- 
going sections  of  this  article. 

Lichen  Planus. 

As  ordinarily  encountered,  lichen  planus  consists  of  an  eruption  of  slightly 
umbilicated,  broad,  flat,  glazed,  purplish-red  papules  with  an  angular  outline. 
The  papules  may  remain  discrete,  or  they  may  be  arranged  in  groups,  lines,  or 
bands.  By  coalescence  of  the  lesions,  variously  sized,  elevated,  and  sharply 
defined  patches  decked  with  thin  scales  may  be  formed.  The  lesions  leave  in 
their  wake  atrophic  spots  and  distinct  pigmentation.  Pruritus  is  sometimes 
slight  or  it  may  be  very  intense. 

The  eruption  is  generally  bilateral,  and  the  usual  sites  of  predilection  are 
the  flexor  surfaces  of  the  wrists,  flanks,  lower  part  of  the  abdomen,  around  the 
knees,  and  on  the  calves.  The  face  is  usually  exempt.  The  mucous  mem- 
branes may  also  be  implicated. 

The  disease  is  rare  in  children,  but  Crocker  describes  an  infantile  form  as 
follows  :   "  The  eruption  comes  out  acutely  in  groups,  each  papule  of  which  is 


DISEASES   OF   THE  SKIN.  1111 

sometimes  acuminate  at  first,  but  the  top  seems  to  die  doAvn  and  a  scale  comes 
off,  leaving  a  smooth,  shining,  angular  papule,  of  a  brighter  red  than  usual, 
though  it  may  get  a  purplish  tint  subsequently.  It  may  be  on  the  limbs  or 
trunk,  or  both,  is  attended  with  considerable  itching,  and  gets  well  in  a  few 
Aveeks  with  the  help  of  a  soothing  application."  Rickets  was  present  in  some 
cases,  conjunctivitis  and  miliaria  in  others,  while  still  others  were  in  apparent 
health. 

Etiology. — The  causes  of  lichen  planus  are  obscure.  In  the  acute  infantile 
form  Crocker  thinks  that  a  sudden  chill  while  in  a  profuse  perspiration  is  the 
exciting  acjencv. 

Diagnosis. — If  the  characteristic  and  typical  features  of  the  lichen-planus 
papule  be  kept  in  mind,  it  is  not  easy  to  make  a  mistake  in  diagnosis.  Even 
when  the  lesions  have  run  together  into  patches,  a  few  outlying  angular  umbil- 
icated  papules  may  be  discovered.  "When,  as  sometimes  happens,  the  usual 
papular  eruption  is  accompanied  by  an  acute  erythematous  rash,  the  diagnosis 
must  be  held  in  abeyance  for  the  time  being. 

Prognosis. — Xeglected  cases  are  prone  to  run  an  indefinite  course,  but  with 
proper  treatment  a  favorable  issue  may  be  expected. 

Treatment. — In  acute  cases  attention  to  diet  and  gentle  laxatives  and 
diuretics  may  be  beneficially  prescribed ;  and  locally,  calamine-and-zinc  lotion, 
with  a  little  carbolic  acid  for  the  itching,  will  often  speedily  remove  the  erup- 
tion. In  chronic  cases  Fowler's  solution,  Avith  or  without  iron,  is  of  great  value. 
For  external  application  tar  in  some  form  is  of  most  benefit.  The  following 
lotion  does  good: 

^.   Saponis  olivse  praep Biv. 

Olei  rusci 

Glycerini da  f^j. 

Olei  rosmarini f^iss. 

Alcoholis q.  s.  ad  fsviij. — M. 

Sig.  Rub  in  Avith  a  piece  of  flannel. 

A  weak  tar  ointment  Avith  mercury  is  also  serviceable : 

!^.   Hydrargyri  ammoniati  .........  gr.  x. 

Liq.  carb.  detergentis f^ss. 

Lanolini §j. — M. 

Sig.  Apply  twice  daily. 

Wilson  recommended  a  bichloride-of-mercury  lotion,  and  Unna  extols  an 
ointment  of  carbolic  acid  and  mercury. 

Psoriasis. 

Psoriasis  is  a  chronic  inflammatory  disease  of  the  skin,  exhibiting  lesions 
of  various  sizes  having  red  bases  covered  with  white  dry  scales.  The  disorder 
attacks  the  extensor  surfaces  by  preference,  especially  in  the  neighborhood  of 
the  elbows  and  knees,  but  it  is  also  found  elsewhere  on  the  body,  and  almost 
invariably  on  the  hairy  scalp.  It  is  almost  always  symmetrical.  The  lesions 
of  psoriasis  make  their  flrst  appearance  as  minute  pinhead-sized  spots  of  con- 
gestion that  are  slightly  elevated  and  surrounded  by  normal  integument.  The 
eruption,  although  discrete,  is  usually  made  up  of  multiple  spots,  which  enlarge 
peripherally  to  the  size  of  large  or  small  coins.     The  papules  may  then  remain 


1U2 A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

isolated,  or  they  may  run  together,  and  in  this  way  form  patches  of  different 
sizes  and  shapes,  but  possessing  a  general  circular  arrangement.  Various 
terms  are  used  to  designate  the  manifold  shapes  and  sizes  the  psoriatic  lesion 
may  assume — viz.  :  p.  punctata^  p.  guttata,  p.  tmmnmlaris,  p.  circinata  or 
orbicularis,  p.  gyrata,  and  p.  diffusa.  Psoriasis  nummularis,  or  the  coin-like 
form,  is  perhaps  the  most  common  variety ;  but,  whatever  the  shape  or  the 
dimension  of  the  lesions,  the  essential  clinical  features  of  the  disease  remain 
unaltered.  The  lesions  are  infiltrated,  and  sharply  defined  against  the  unaffec- 
ted skin,  and  they  are  covered  with  shining,  mother-of-pearl,  imbricated,  easily- 
detached  scales,  which  upon  being  scraped  off"  show  a  punctate  bleeding  surface. 

The  eruption  has  no  discharge  feature,  and  itching  is  either  entirely  absent 
or  very  slight.  The  patches  usually  disappear  by  central  involution,  and  in 
this  way  rings  and  segments  of  circles  may  form.  The  eruption  upon  its  dis- 
appearance leaves  no  traces  of  its  previous  existence,  except  that  there  may  be 
slight  pigmentation  on  the  legs.  The  disorder  is  rare  on  the  palms  and  soles, 
but  the  nails  are  usually  rough  and  brittle.  The  extension  of  the  eruption 
from  the  scalp  to  the  forehead  in  the  shape  of  a  band  along  the  border  of  the 
hair  is  quite  common.  The  hair  suffers  no  permanent  injury,  and  even  tem- 
porary alopecia  is  unusual.  Children  rarely  suffer  from  the  more  pronounced 
forms  of  the  disease :  in  them  the  eruption  is  mostly  discrete,  and  made  up  of 
small  lesions  rather  generally  distributed  over  the  body.  The  elbows,  knees, 
and  scalp  are  the  parts  commonly  first  attacked. 

Psoriasis  is  essentially  a  chronic  aff"ection,  although  at  times  having  an 
acute  aspect.  Repeated  relapse  is  the  rule  ;  in  some  cases,  indeed,  the  patient 
is  practically  never  entirely  free  of  the  eruption,  but  usually  longer  or  shorter 
periods  intervene  between  the  outbreaks.  It  is,  as  a  rule,  worse  in  winter  than 
in  summer.  It  not  infrequently  temporarily  disappears  during  the  course  of 
acute  diseases. 

Etiology. — Psoriasis  is  common  to  both  sexes  and  to  all  conditions  of  life. 
In  this  country  it  represents  about  3  per  cent,  of  all  cases  of  skin  disease.  The 
disorder  makes  its  first  appearance  during  childhood  more  frequently  than  is 
generally  supposed.  It  is  not  contagious.  In  many  cases  the  fact  of  hereditary 
transmission  is  readily  established.  The  disease  has  been  observed  in  connec- 
tion with  gout  and  rheumatism,  and  it  may  follow  in  the  wake  of  scarlatina, 
varicella,  and  vaccinia.  In  fact,  our  knowledge  of  its  essential  nature  is  obscure, 
and  we  may  assume,  as  in  the  case  of  eczema,  that  the  psoriatic  possesses  a 
specially  vulnerable  skin,  and  that  his  disorder  may  be  evoked  by  a  great 
variety  of  widely-differing  agencies.  It  may  be  added  that  Lang  regards  psori- 
asis as  due  to  a  special  parasite,  while  Polotebnoff"  looks  upon  it  as  avaso-motor 
neurosis.     The  histological  investigations  are  contradictory. 

Diagnosis. — Seborrhoea,  eczema,  and  syphilis  are  the  diseases  that  bear 
the  closest  resemblance  to  psoriasis.  In  seborrhoea  of  the  scalp  the  scales  are 
greasy  and  yellowish,  and  not  dry  and  white,  as  in  psoriasis,  and  the  eruption 
does  not  take  the  form  of  bands  and  patches,  as  in  the  latter  disease  ;  more- 
over, seborrhoea  affecting  the  scalp  may  be  limited  to  that  region,  whereas 
psoriasis  of  the  scalp  will  occur  in  connection  with  the  same  eruption  on  the 
elbows  and  knees  and  other  parts  of  the  body.  Seborrhoea  of  the  body  is  not 
necessarily  symmetrical,  and  is  found  particularly  about  the  sternal  and  inter- 
scapular region,  Avhile  psoriasis  is  nearly  always  symmetrically  disposed,  and 
affects  the  elbows  and  knees  in  addition  to  other  parts  of  the  body.  The 
character  of  the  scales  is  the  same  as  in  seborrhoea  of  the  scalp,  and  they  differ 
altogether  from  those  found  in  psoriasis. 

Scaly  or  squamous  eczema  in  patches  sometimes  strongly  simulates  psoriasis. 


PLATE  XXV 


PSORIASIS. 
(From  the  Collection  of  Geo.  H.  Fox,  M.  D.) 


DISEASES    OF    THE  SKIN.  1113 

but  the  patches  of  eczema  are  not  symmetrically  arranged,  occur  on  the  flexor 
rather  than  the  extensor  surfaces,  and  the  scales  are  light,  tenacious,  and  do  not 
show  a  punctate  bleeding  surface  when  removed ;  besides,  eczema  itches 
markedly,  and  thei'e  is  usually  a  history  of  discharge. 

The  scaling  syphilides  are  not  unlike  psoriasis  in  a  superficial  way.  The 
history  of  the  case  must  always  be  taken  into  consideration,  and  the  presence 
of  concomitant  symptoms  noted.  The  scales  of  the  squamous  syphilide  are 
dirtier-looking  and  more  adherent  than  in  psoriasis,  and  the  patch  is  usually 
more  infiltrated.  Again,  the  fact  that  psoriasis  is  almost  always  found  on  the 
elbows  and  knees  on  both  sides  of  the  body,  and  that  the  syphilide  observes  no 
such  localization,  is  to  be  kept  in  mind. 

Prognosis. — The  prognosis  as  to  permanent  cure  is  unfavorable,  but  it  is 
usually  easy  to  remove  the  eruption  temporarily. 

Treatment. — Beyond  remedying  obvious  defects  of  health  and  instituting 
a  rational  system  of  diet,  the  internal  treatment  of  psoriasis  in  children  is  mainly 
restricted  to  the  use  of  arsenic,  which  in  this  disease  is  of  undeniable  value. 
As  voung  children  tolerate  relatively  larger  amounts  than  adults,  it  may  be 
given  in  considerable  doses  without  inconvenience.  If  the  patient  is  an?emic, 
it  mav  advantageously  be  combined  with  iron.  (See  formula  under  head  of 
Eczema.)  If,  however,  the  eruption  is  acute,  the  use  of  arsenic  should  be 
deferred  until  the  disease  has  assumed  a  less  inflammatory  aspect. 

Before  undertaking  the  local  treatment  it  is  necessary  to  remove  the  scales 
thoroughly  from  the  patches.  In  recent  outbreaks  this  is  best  accomplished 
by  means' of  warm  soda  baths,  followed  by  inunctions  with  vaseline.  These 
m'easures  will  sometimes  alone  be  sufficient  for  the  removal  of  the  eruption.  If 
the  disease  has  existed  for  some  time,  the  scales  may  be  taken  ofi"  by  scrubbing 
with  soap  and  water  or  by  means  of  friction  with  salicylic  acid  and  alcohol 
(Sj  to  f  Siv). 

Chrysarobin  is  by  far  the  most  efficacious  remedy  in  psoriasis,  but  it  must 
be  used'very  cautiously  with  children,  as  it  sets  up  so  much  irritation.  When 
the  eruption  is  sparse  the  following  pigment  may  be  tentatively  employed: 

E«.   Chrysarobini gr.  xx. 

Acidi  salicylici gr.  xx. 

Liq.  gutta-perchffi foj- — M. 

Sig.  Apply  with  camel's-hair  pencil. 

This  may  be  painted  on  every  fourth  day,  a  bath  being  taken  at  the  end  of  this 
period  and  before  each  reapplication.  If  this  causes  too  much  dermatitis,  its  use 
should  be  intermitted  for  a  season.  The  chrysarobin  is.  however,  too  severe 
for  some  skins,  and  other  remedies  should  be  tried.  Bulkley  recommends  the 
following  application : 

'S^.  Acidi  carbolic! gi'-  "^"• 

(vel  Resorcini,  gr.  x). 

Bismuthi  subnit. 3ss. 

Ung.  hydrarg.  ammon oj~y- 

Ung.  aq.  rosa5 q.  s.  ad§j. — M. 

Sig.  To  be  rubbed  into  affected  parts. 

For  delicate  skins  it  may  need  to  be  made  weaker. 

Greenough  suggests  the  employment  of  a  tar  lotion  consisting  of  equal 
parts  of  alcohol,  glycerin,  and  oil  of  cade.  This  prescription  may  also  be  con- 
siderably diluted. 


1114:  A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Among  other  remedies  may  be  mentioned  thymol,  naphthol,  salicylic  acid, 
sulphur,  and  the  mercurials. 

Psoriasis  of  the  scalp  is  best  treated  with  an  ointment  of  tar  and  mercury  : 

I|i.   Hydrarg.  ammoniati .    .  gr.  x. 

Liq.  carbonis  detergentis 1TLxx. 

Lanolini SJ- — M. 

Sig.  Local  use. 

It  is  first  necessary,  however,  to  remove  the  scales  with  a  green-soap  shampoo, 
consisting  of 

I|i.  Saponis  olivae  prsep.  (Bagoe)  .... 

Spt.  odorati da  oiv. — M. 

Sig.   Shampoo. 

For  psoriasis  of  the  face  nothing  succeeds  so  well  as  a  salve  of  white  pre- 
cipitate : 

^.   Hydrarg.  ammoniati gr.  x-xx. 

Ung.  aq.  rosse §j. — M. 

Sig.  Local  use. 

Pemphigus. 

Pemphigus  is  a  very  rare  disorder.  It  is  characterized  by  the  appearance 
of  successive  crops  of  variously-sized  blebs.  It  may  be  acute  or  chronic,  but  as 
ordinarily  encountered  it  runs  a  chronic  course.  It  is  customary  to  speak  of 
two  principal  forms  of  the  disease — viz.  p.  vulgaris  and  p.  foliaceus — but  the 
nomenclature  is  encumbered  with  an  infinite  number  of  sub-varieties,  partly 
dependent  upon  the  clinical  appearances  of  the  lesions,  and  largely  also  on  the 
imagination  of  the  observers. 

Pemphigus  Vulgaris. — Constitutional  symptoms  are  rare,  but  when  the  erup- 
tion is  widespread  each  outbreak  may  be  preceded  by  a  chill.  The  blebs  usually 
appear  first  as  minute  vesicles,  but  soon  reach  the  maximum  dimensions.  They 
are  oval  or  hemispherical,  tense,  and  vary  in  size  from  a  pea  to  an  orange,  but 
more  generally  are  the  diameter  of  a  hazelnut  or  Avalnut.  They  may  arise  on 
normal  skin,  or  they  are  preceded  at  the  point  of  eruption  by  a  degree  of 
erythema.  The  contents  of  the  lesions  are  at  first  clear,  but  gradually  become 
turbid,  and  sometimes  even  purulent.  The  life  of  a  bleb  is  from  two  to  ten 
days ;  it  rarely  ruptures  spontaneously,  but  desiccates  with  a  thin  dry  crust. 
After  the  fall  of  the  crust  the  site  of  the  bulla  shows  slight  excoriation,  and 
lastly  more  or  less  pigmentation. 

Pemphigus  may  occur  on  any  part  of  the  body,  but  is  more  frequent  on  the 
face,  limbs,  and  trunk.  The  mucous  membranes,  including  the  alimentary  and 
respiratory  tracts,  may  also  be  attacked.  In  the  mild  forms  of  the  disease  the 
eruption  may  be  kept  up  by  successive  crops,  more  or  less  continuous  or  markedly 
intermittent,  for  weeks  or  months ;  but  in  malignant  pemphigus  death  may 
ensue  in  a  few  weeks. 

As  to  the  existence  of  an  acute  pemphigus  there  has  been  considerable 
difference  of  opinion.  Undoubtedly  there  has  been  much  confusion  of  diag- 
nosis in  this  regard,  and  instances  of  bullous  erythema,  urticaria,  varicella, 
etc.  have  been  so  classified ;  but  the  writer  has  convinced  himself,  from  obser- 


DISEASES    OF   THE   SKIN.  1115 

vations  made  in  infants'  asylums  and  elsewhere,  that  an  eruption  bearing  the 
clinical  features  of  pemphigus  and  running  an  acute  course  really  occurs 
among  children.  So  good  an  observer  as  Crocker  agrees  in  this  opinion,  and 
says  that  there  are  grades  of  severity  in  the  acute  pemphigus  of  infants,  from 
the  mild,  usual  type  to  cases  in  which  those  attacked  die  in  a  few  days.  On 
the  other  hand,  many  of  the  so-called  cases  of  pemphigus  contagiosa  undoubt- 
edly represent  varicella  bullosa  and  impetigo  contagiosa  (Crocker). 

Pemphigus  foliaceus  is  rare  even  in  adults,  but  Jamieson  reports  a  case  in  a 
child  which  followed  the  ordinary  form.  In  this  type  of  the  disease  the  bullae 
are  flaccid,  with  cloudy  contents,  and  display  a  sticky  secretion  when  their 
covers  are  removed.  The  whole  body  eventually  becomes  involved,  and  after 
a  time,  when  the  bullous  stage  has  passed  away,  the  surface  has  the  appearance 
of  an  exfoliative  dermatitis. 

Etiology. — The  disease  is  equally  common  in  both  sexes,  and  is  met  with 
far  more  frequently  in  children  than  in  grown  persons.  Pemphigus  has  been 
observed  in  connection  with  a  variety  of  different  conditions,  such  as  diseases 
of  the  nervous  system,  disorders  of  nutrition,  after  local  injury,  etc.  It  also 
occurs  in  the  apparently  healthy.  An  hereditary  tendency  to  the  malady  has 
been  noted,  and  septic  influences  recognized.  Morbid  changes  in  the  cord 
and  the  peripheral  nerves  have  been  discovered  in  some  cases. 

Diagnosis. — The  mere  occurrence  of  blebs  does  not  constitute  pemphigus, 
for  lesions  of  this  character  are  encountered  in  erythema,  erysipelas,  scabies, 
syphilis,  urticaria,  and  as  the  result  of  traumatism  ;  but  in  all  these  instances 
the  history  of  the  case  and  the  concomitant  symptoms  will  usually  establish  the 
points  of  diff"erence. 

Prognosis. — The  prognosis  must  be  guarded,  as  it  is  difiicult  to  forecast  the 
ultimate  outcome  of  any  case ;  still,  in  children  at  least  and  in  the  more  acute 
forms,  a  favorable  termination  may  be  expected. 

Treatment. — In  acute  pemphigus  an  endeavor  should  be  made  to  discover 
the  exciting  cause  or  causes  of  the  disease,  and  to  meet  such  complications  as 
may  arise  in  its  course.  In  the  chronic  form  of  the  disorder  the  strength 
should  be  maintained  by  suitable  nourishment.  So  far  as  direct  medication  is 
concerned,  arsenic  is  the  chief  reliance.  It  should  be  given  in  full  doses, 
freely  diluted  and  frequently  administered.  According  to  Bulkley,  the 
quantity  of  the  drug  should  be  fearlessly  increased  until  the  disease  yields  or 
until  it  causes  diarrhoea  or  other  evidences  of  disagreement.  Opium,  an 
excellent  remedy  in  itself  for  pemphigus,  according  to  Hutchinson,  may  be 
combined  with  the  arsenic,  or,  if  the  latter  is  not  tolerated,  it  may  be  given 
alone.  Fowler's  solution  and  the  deodorized  tincture  of  opium  are  the  best 
preparations  of  the  respective  remedies. 

Locally,  the  tense  blebs  may  be  punctured  at  their  bases,  so  as  to  allow 
their  roofs  to  form  a  protective  covering  over  the  excoriated  surfaces  beneath. 
Cloths  dipped  in  lime-water  and  linseed  oil,  to  which  may  be  added  1  per  cent, 
of  carbolic  acid,  make  a  good  application. 

The  calamine-and-zinc  lotion  is  sometimes  grateful,  or  a  powder  of  oxide 
of  zinc  and  lycopodium  may  be  dusted  on  and  covered  with  cotton  -wool.  Raw 
surfaces  may  be  dressed  with  the  following  salve  : 

^.  Zinci  oxidi Bj. 

Ung.  aq.  rosse 3ij. 

Lanolini 3vj. — M. 

Two  or  three  drops  of  carbolic  acid  may  be  added  to  each  ounce  of  this  oint- 
ment. 


lUQ  AMUmCAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Herpes  Simplex. 

This  affection,  variously  known  by  the  names  of  herpes  facialis,  herpes 
febrilis,  fever  blisters,  and  cold-sore,  is  an  acute  inflammatory  disorder  char- 
acterized by  the  eruption  of  one  or  more  groups  of  vesicles  seated  upon  red- 
dened bases.  The  vesicles  come  out  abruptly,  usually  being  preceded  by  sen- 
sations of  burning  and  tingling.  Their  contents  are  at  first  clear,  but  presently 
— that  is,  in  a  day  or  two — become  puriform,  and  the  lesions  dry  up  into  light- 
brown  crusts  which  show  no  loss  of  substance  upon  being  detached.  The  whole 
process  occupies  eight  or  ten  days. 

The  favorite  sites  of  the  eruption  are  the  lips,  the  angles  of  the  mouth,  and 
anywhere  on  the  face  below  the  forehead.  The  mucous  membranes  may  also 
be  attacked.  Herpes  simplex  is  usually  symptomatic  of  febrile  disorders,  and 
is  often  preceded  by  chilly  sensations ;  in  other  cases  it  is  due  to  gastric  dis- 
turbances or  is  produced  by  local  irritation.  Repeated  recurrence  is  not  an 
uncommon  feature. 

Diagnosis. — This  offers  no  difficulties. 

Treatment. — Regulation  of  the  diet  and  appropriate  remedies  for  gastro- 
intestinal disturbances  are  demanded  in  recurrent  cases,  but  if  there  are  no 
obvious  causal  indications,  small  doses  of  Fowler's  solution  will  probably  do 
good.  Herpes  symptomatic  of  general  febrile  states  requires  no  treatment 
other  than  that  for  the  exciting  cause.  Locally,  the  vesicles  should  be  pro- 
tected from  rupture,  and  this  is  best  accomplished  by  painting  them  over  with 
flexible  collodion  or  mopping  on  the  calamine-and-zinc  lotion. 

Herpes  Zoster. 

Herpes  zoster,  zona,  or  shingles,  is  an  inflammatory  disease  of  the  skin 
which  is  characterized  by  grouped  vesicles  seated  on  reddened  bases  and  fol- 
lowing the  distribution  of  cutaneous  nerves.  Although  the  eruption  most 
frequently  occurs  around  the  trunk  in  the  course  of  the  intercostal  nerves, 
it  is  well  to  remember  that  it  may  develop  anywhere  else,  so  that,  for  example, 
according  to  the  anatomical  seat  of  the  disorder,  it  will  be  designated  as  z. 
capillitii,  z.  froyitalis,  z.  ophthalmicus,  z.  nuehce,  z.  facialis,  etc. 

Before  the  eruption  of  the  vesicles  the  patient  may  complain  of  considerable 
pain  in  the  part  to  be  attacked,  or  there  may  be  slight  febrile  reaction.  The 
lesions  vary  in  size  from  a  pinhead  to  a  split  pea,  and  by  the  coalescence  of 
one  or  more  vesicles  a  quite  considerable  bulla  may  be  formed.  Their  contents 
are  at  first  serous,  in  rare  cases  hsemorrhagic,  but  presently  become  puriform. 
It  is  characteristic  of  herpetic  vesicles  that  they  do  not  rupture  spontaneously, 
but  in  the  course  of  some  ten  days  to  three  weeks  they  desiccate  into  brown 
crusts,  Avhich,  falling  off,  exhibit  a  reddened  surface  and  not  infrequently  slight 
loss  of  substance.  In  children  the  neuralgic  pain  may  entirely  cease  when 
the  eruption  appears,  or  in  severe  attacks  it  may  persist  throughout. 

In  nearly  every  instance  the  eruption  is  unilateral,  and  but  rarely  recurs. 
Zoster  is  usually  a  descending  interstitial  neuritis  of  the  spinal  ganglion,  but 
Kaposi  points  out  that  it  may  be  of  cerebral,  spinal,  ganglionic,  or  peripheral 
origin. 

Etiology. — Zoster  is  very  common  in  young  people,  and  is  perhaps  most 
prevalent  in  the  spring  and  autumn  of  the  year.  It  is  contended  by  some 
authorities  that  this  affection  should  be  classed  with  the  acute  infectious  dis- 
eases. Hutchinson  thinks  that  zoster  is  prone  to  develop  during  an  arsenical 
treatment. 


PLATE  XXVI. 


HERPES    ZOSTER 


DISEASES   OF   THE  SKIN.  1117 

Diagnosis. — The  recognition  of  an  ordibary  case  of  shingles  presents  no 
difficulties  :  the  grouped  vesicles  following  the  distribution  of  cutaneous  nerves, 
the  neuralgic  pain,  etc.  are  sufficiently  patent  symptoms.  There  are  two  points, 
however,  worth  remembering — viz.  first,  that  zoster  occurs  elsewhere  than 
around  the  trunk  ;  and,  secondly,  that  sometimes  there  are  abortive  forms — 
that  is,  merely  reddened  patches  or  clustered  papules  that  do  not  become 
vesicular ;  but  in  both  instances  the  grouping  and  distribution  of  the  eruption 
are  the  same,  as  is  also  the  pain. 

Prognosis. — In  children  the  prognosis  of  zoster  is  always  favorable. 

Treatment. — Zoster  is  an  acute  self-limited  disease,  which,  however,  runs 
a  very  variable  course,  and  conclusions  as  to  the  value  of  internal  medication  in 
its  treatment  are,  therefore,  usually  fallacious.  It  is  idle  to  attempt  to  abort 
an  attack  by  remedies  in  our  possession,  and  such  treatment  is  restricted  to  the 
relief  of  pain.  As  a  rule,  children  suffer  but  little  inconvenience  in  this  latter 
regard,  and  a  few  appropriate  doses  of  phenacetin  at  night  are  all  that  is 
required. 

Some  writers  believe  that  it  is  possible  to  limit  the  amount  and  duration  of 
the  eruption  by  local  measures.  Duhring  advises  a  weak  galvanic  current,  and 
Leloir  praises  pure  alcohol  or  alcoholic  solutions  of  certain  drugs  for  this  pur- 
pose : 

^.  Alcoholis  (90  per  cent.) fij. 

Resorcini 5j. — M. 

^.  Alcoholis  (90  per  cent.) fij. 

Menthol gr.  xv. 

Ext.  cannabis  Indicse gr.  xxv. — M. 

Pads  made  of  wadding  are  to  be  wet  with   these  solutions   and   frequently 
applied. 

The  essential  point  of  treatment  is  to  prevent  the  vesicles  from  rupture. 
Flexible  collodion,  with  or  without  a  little  morphia,  makes  an  excellent  pro- 
tective dressing  and  gives  marked  relief.  Pick's  paste,  the  linimentum 
exsiccans,  is  also  excellent  when  made  as  follows : 

I^.   Zinci  oxidi gr.  xlviii. 

Acidi  carbolici tTLx. 

Tragacanthse gr.  xxiv. 

Glycerini TtLx. 

Aqu^ fii.— M. 

Sig.  Smear  gently  over  the  parts,  and  allow  to  dry  on. 

Various  bland  dusting  powders,  such  as  oxide  of  zinc,  corn  starch,  and 
rice  powder,  are  also  useful.  It  is  well  to  protect  the  parts  with  absorbent  cot- 
ton and  a  bandage  to  prevent  friction.  Ointments  should  never  be  prescribed, 
as  they  are  prone  to  macerate  the  vesicles  and  thus  produce  ulceration.  Should 
ulceration  occur,  it  may  be  treated  on  general  surgical  principles.  Persistent 
neuralgia  following  zoster  is  very  unusual  with  children,  but,  should  it  super- 
vene iron  and  arsenic  may  be  given  internally  and  galvanism  applied  locally. 

Impetigo  Contagiosa. 

Impetigo  contagiosa  is  an  acute  contagious  disease  of  the  skin  characterized 
by  the  appearance  of  vesico-pustules  or  bullae.     In  some  cases  the  eruption  is 


1118  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

preceded  by  slight  fever,  but  mere  often  this  symptom  is  absent.  Crocker  is 
authority  for  the  statement  that  in  the  febrile  cases  the  eruption  appears  in 
successive  groups  for  about  a  week,  but  that  when  unattended  by  elevation  of 


Fig.  1. 


Impetigo  Contagiosa  (after  Lesser). 


temperature  the  cutaneous  manifestations  are  more  limited,  and  the  course  of 
the  affection  is  less  definite. 

The  lesions  begin  as  small,  isolated,  acuminate  vesicles  that  slowly  increase 
to  the  size  of  a  split  pea  or  silver  quarter-dollar,  that  are  surrounded  for  a  short 
time  by  a  slight  erythematous  halo.  The  contents,  at  first  serous,  soon  become 
sero-purulent,  and  the  fully-formed  flat  or  slightly  umbilicated  vesico-pustule 
dries  to  a  thin,  straw-colored  granular  crust.  As  by  this  time  the  erythematous 
ring  around  the  lesions  has  faded  away,  the  crusts  have  the  appearance  of  being 
'•  stuck  on"  (T.  Fox).  When  the  crusts  drop  oif  the  underlying  surface  is  red 
and  has  the  appearance  of  a  burn,  but  there  is  no  loss  of  substance. 

Jackson  calls  attention  to  another  variety  of  the  disease,  in  which  the 
lesions  consist  of  large  blebs  of  an  irregular  oval  shape  and  several  inches  long, 
but  usually  other  typical  forms  are  found  elsewhere. 

Impetigo  contagiosa  is  generally  seen  on  the  fixce  and  hands.  The  lesions 
may  be  discrete  or  else  coalesce  into  patches.  Itching  is  not  marked.  The 
disorder  runs  no  special  course ;  it  may  last  two  or  three  Aveeks,  or  by  repeated 
auto-inoculations  a  considerably  longer  time. 

Etiolog-y. — Children  are  the  usual  subjects.  It  is  contagious,  and  often 
many  children  in  the  same  house  or  neighborhood,  especially  among  the  indigent, 
are  simultaneously  attacked.  The  writer  has  known  of  dozens  of  cases  in  a 
single  poor  settlement.  It  is  apt  to  appear  in  summer.  A  number  of  different 
fungous  elements  have  been  described  as  occurring  in  the  crusts,  but  definite 
results  are  lacking.  By  some  authorities  the  affection  has  been  ascribed  to 
pus-inoculation  from  any  source,  but  the  clinical  facts  do  not  bear  out  this  con- 


DISEASES    OF   THE  SKIN.  1119 

tention.  Its  connection  v.'itli  vaccinia  has  been  remarked,  but  this  is  perhaps 
accidental. 

Diagnosis. — The  presence  of  large,  generally  discrete,  slightly  umbilicated, 
non-pruritic  vesico-pustules,  occurring  on  the  lower  part  of  the  face  or  on  the 
hands,  is  generally  sufficiently  distinctive  for  purposes  of  diagnosis.  Bearing 
these  symptoms  in  mind,  it  is  usually  easy  to  exclude  pustular  eczema,  chicken- 
pox,  and  pemphigus.  Even  when  the  lesions  have  run  together  into  patches, 
or  the  large  bullous  form  predominates,  a  few  at  least  of  the  more  usual  vesico- 
pustules  may  be  found. 

Prog-nosis. — Favorable  under  proper  treatment. 

Treatment. — The  removal  of  the  eruption  is  comparatively  easy.  A  weak 
preparation  of  mercury  generally  suffices  : 

!^J.   Hydrarg.  ammoniati gr.  x— xv. 

Ung.  zinci  oxidi 5J. — M. 

Sig.  Apply  to  lesions  after  removal  of  the  crusts. 

To  prevent  auto-inoculation  it  is  a  good  plan  to  smear  boric-acid  paste  over 
the  intervening  skin : 

^.  Acidi  boraci 3ss. 

Pulv.  amyli Sij. 

Zinci  oxidi 3ij. 

Vaselini q.  s.  ad  gj. — M. 

Dermatitis  Exfoliativa  Neonatorum. 

Ritter  has  called  attention  to  a  severe  form  of  exfoliative  dermatitis  that 
occurs  between  the  second  and  fifth  weeks  of  life.  It  is  apparently  non-con- 
tagious and  unaccompanied  by  fever.  The  affection  begins  around  the  mouth 
as  an  erythema,  ai>d  extends  to  the  rest  of  the  body.  The  surface  has  the  ap- 
pearance of  an  extensive  burn,  and  the  epidermis  exfoliates  after  some  amount 
of  fluid  has  accumulated  beneath  it.  In  some  cases  the  eruption  resembles  an 
eczema,  in  others  a  pemphigus  ;  or,  again,  when  it  is  limited,  it  is  dry  through- 
out, and  the  skin  becomes  infiltrated  and  fissured.  The  whole  process  lasts 
about  a  week.  Often  it  is  followed  by  eczema,  furunculosis,  and  gangrenous 
processes.  Death  results  in  one-half  the  cases.  Ritter  regards  the  disorder  as 
of  septic  character,  while  Behrend  thinks  it  is  merely  a  foliaceous  pemphigus. 
The  treatment  is  symptomatic. 

Other  forms  of  exfoliative  dermatitis  may  occur  in  children  either  as  primary 
or  secondary  processes,  but  they  are  unusual.  Relapsing  scarlatiniform  erythema, 
which  is  in  reality  an  acute  exfoliative  dermatitis,  has  been  already  described. 

Dermatitis  Gangrenosa  Infantum. 

G-antrrene  of  the  skin  is  not  uncommon  in  strumous  and  syphilitic  chil- 
dren, especially  following  in  the  wake  of  chicken-pox  and  vaccination,  and 
also  developing  from  simple  pustular  affections.  The  disorder  varies  in 
intensitv :  in  some  instances  the  gangrenous  patches  are  widespread  and 
numerous,  with  high  temperature  and  a  rapid  lethal  ending,  or,  on  the  other 
hand,  there  may  be  present  a  series  of  small  pustules,  each  of  which  sloughs 
and  leaves  a  small  scar,  and  the  disease  may  be  prolonged  indefinitely  by 
successive  crops  (Pringle).     As  stated  elsewhere,  T.  C.  Fox  regards  the  vari- 


1120  Alfl^BICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cella-prurigo  of  Hutchinson  as  in  reality  a  form  of  urticaria.  Secondary  gan- 
grene of  the  skin  is  comparatively  rare  in  this  country,  even  in  the  infant  asy- 
lums, and  the  "writer  has  never  met  with  a  case  in  private  practice. 

Treatment. — The  general  treatment  consists  in  the  administration  of  ton- 
ics, such  as  iron,  quinine,  and  the  hypophosphites,  with  cod-liver  oil.  Good 
food  and  proper  hygienic  surroundings  are  essential  adjuncts.  Locally,  it  is 
necessary  to  employ  the  usual  antiseptic  dressings. 

Urticaria. 

Urticaria,  nettlerash,  or  hives,  is  characterized  by  evanescent  eflBorescences 
called  wheals  or  pomphi,  which  come  out  suddenly,  retain  their  forms  for  a 
few  minutes  or  several  hours,  and  as  suddenly  disappear,  leaving  no  trace 
behind.  The  lesions  usually  vary  in  size  from  a  pea  to  the  diameter  of  the 
finger-nail,  or  they  may  be  much  larger.  Wheals  are  generally  oval  or 
circular  in  shape,  but  also  occur  in  bands  or  streaks,  and  observe  no  special 
grouping.  They  are  somewhat  elevated  above  the  general  surface,  are  flat,  and 
present  a  sense  of  resistance  to  the  touch.  They  are  usually  white  in  the  cen- 
tre and  bright-red  or  pink  at  the  periphery.  The  mucous  membranes  may 
also  be  attacked.  The  eruption  is  accompanied  by  intense  burning,  itching,  and 
tingling.  There  may  be  considerable  febrile  disturbance  accompanying  the 
outbreak  in  the  skin  in  acute  cases,  or  there  may  be  a  day  or  two  of  malaise, 
with  coated  tongue  and  other  evidences  of  indigestion,  before  the  rash  appears. 
Sometimes  no  deviation  from  the  normal  condition  can  be  detected. 

The  type  of  the  disease  most  commonly  seen  in  young  children  is  the  papu- 
lar— urticaria  papulosa  or  lichen  urticatus.  In  these  instances,  as  a  result  of 
the  inflammatory  eff"usion,  a  small  solid  papule  remains  after  the  disappearance 
of  the  more  evanescent  wheal.  In  many  cases  the  urticarial  element  is  not 
manifest  to  a  casual  inspection,  and  the  only  visible  lesions  are  white  or  pale- 
red  miliary,  scratched  papules,  more  or  less  discretely  scattered  over  the  sur- 
face. The  eruption  is  accompanied  by  intense  itching,  usually  worse  at  night. 
Interspersed  among  the  papules,  various  crusted  and  excoriated  lesions,  the 
result  of  scratching,  may  be  detected. 

T.  C.  Fox  says  that  while  the  usual  lesion  is  papular,  it  may  be  vesicular, 
pustular,  or  bullous  as  a  result  of  the  evolution  of  the  lesion  itself,  and  not  as 
a  secondary  result  of  irritation.  He  claims,  moreover,  that  Bateman's  lichen 
urticatus,  Hutchinson's  varicella-prurigo,  the  infontile  prurigo  of  the  English, 
and  many  of  the  papular,  vesicular,  and  pustular  rashes  following  vaccination, 
should  be  included  as  phases  of  infantile  eczema. 

In  addition  to  the  usual  form  of  the  disease  just  described,  several  other 
varieties  are  observed.  The  titles  are  suflficiently  descriptive — viz.  urticaria 
papulosa,  II.  tuberosa,  u.  vesiculosa  or  bullosa,  u.  Jicemorrhagica,  and,  in  cases 
artificially  produced  by  scratching  or  other  irritation,  u.  factitia. 

Etiology. — The  exciting  causes  are  very  numerous,  and  may  be  of  central, 
peripheral,  or  reflex  character,  acting  upon  the  vaso-motor  system.  The  wheal 
is  probably  brought  about  by  a  spasmodic  contraction  of  the  capillaries,  which 
in  return  is  followed  by  relaxation  and  consequent  serous  effusion.  Among 
the  local  causes  may  be  mentioned  bites  of  insects,  coarse  under-clothing,  and, 
in  fact,  irritants  of  any  sort. 

Gastro-intestinal  derangement  occupies  the  first  place  among  the  indirect 
causes  of  urticaria.  Many  foods  have  a  bad  reputation  in  this  regard,  such  as 
oatmeal,  buckwheat  cakes,  pork,  pastry,  and  especially  strawberries.  Intes- 
tinal worms  often  excite  the  disease  in  children.     Malaria  is  known  to  set  up 


DISEASES    OF   THE  SKIN.  1121 

an  intermittent  type  of  the  disorder.  Many  medicines  also  induce  it,  especially 
the  preparations  of  cinchona.  While  it  is  true  that  in  dispensary  practice  the 
papular  urticaria  of  infancy  is  often  caused  by  bites  of  insects  and  other  irri- 
tating local  influences,  the  writer  believes  that  the  majority  of  cases  are  due  to 
gastro-intestinal  disturbances  the  result  of  injudicious  diet. 

Diagnosis. — The  ordinary  type  of  urticaria  is  readily  recognized.  Occa- 
sionally, when  the  eruption  occupies  the  greater  part  of  the  body  in  continuous 
sheets  and  with  accompanying  fever,  scarlatina  may  be  suggested  ;  but  the  his- 
tory of  the  case,  the  absence  of  the  scarlatinal  throat  implication,  and  the  dis- 
covery of  isolated  urticarial  wheals  somewhere  on  the  body  will  usually  clear  up 
the  diagnosis. 

Papular  urticaria,  especially  if  commingled  with  ecthymatous  lesions,  bears 
a  close  likeness  to  scabies  ;  but  the  localization  of  the  eruption  in  the  latter 
disease,  the  absence  of  burrows,  and  the  freedom  of  other  members  of  the  same 
family  from  a  similar  eruption  furnish  sufficient  grounds  for  the  distinction. 

Prognosis. — The  prognosis  of  the  acute  cases  is  favorable  if  properly 
managed.  Papular  urticaria  is  exceedingly  obstinate  often  lasting  for  months, 
but  even  these  cases  eventually  get  well. 

Treatment. — In  all  cases  the  cause  must  be  assiduously  sought  out,  and, 
if  possible,  removed.  Acute  attacks  are  generally  due  to  gastric  disturbance 
from  injudicious  diet,  and  a  brisk  emetic,  followed  by  a  laxative,  will  be  apt  to 
bring  about  a  speedy  recovery.  The  more  persistent  attacks,  kept  up  by 
repeated  exacerbations,  are  rare  in  children.  Above  all,  the  diet  must  be  care- 
fully regulated.  Quinine  is  of  much  value  when  malaria  is  suspected.  Phena- 
cetin  will  often  cut  short  an  attack.  The  usual  empirical  remedies,  such  as 
atropine,  ergot,  pilocarpine,  and  salicylate  of  sodium,  are  scarcely  demanded. 

In  the  chronic  papular  form  it  is  first  necessary  to  remove  all  sources  of 
external  irritation,  and,  secondly,  to  clearly  indicate  the  proper  method  of  diet 
to  be  pursued.  Constipation  should  be  relieved,  and  appropriate  remedies 
prescribed  for  any  gastric  irregularity  that  may  be  present. 

There  is  a  great  variety  of  measures  recommended  for  the  local  treatment. 
Among  the  household  remedies  may  be  mentioned  lotions  of  soda,  vinegar 
(pure  or  diluted),  and  the  application  of  cologne-water  or  other  spirits.  The 
calamine-and-zinc  lotion,  as  previously  given,  with  carbolic  acid  (gr.  ij  to  f  si)  is 
especially  valuable.    Menthol  in  solution  (^ss-f^iv)  is  also  a  good  antipruritic. 

In  lichen  urticatus  the  same  preparations  may  be  employed.  Fox  recom- 
mends the  folloAving : 

^.  Liq,  plumbi  subacetatis fiss. 

Liq.  carbonis  detergentis f^ijss. — M. 

Sig.  Add  a  teaspoonful  to  a  pint  of  water. 

The  same  authority  advises  a  dilute  white-precipitate  ointment  or  paste  for  the 
pustular  form. 

Urticaria  Pigmentosa. 

This  is  a  rare  form  of  disease,  only  a  few  cases  having  been  observed  in  this 
country.  It  begins  within  the  first  six  months  of  life  in  the  form  of  wheals 
that  come  out  suddenly,  singly  or  in  numbers.  The  lesions  are  brownish-red, 
split-pea  sized  tubercles,  and  in  the  beginning  are  surrounded  by  a  delicate  pink 
areola  ;  subsequently,  however,  they  increase  in  size  and  assume  a  buff  color. 

The  course  of  the  disease  is  chronic,  and  while  the  first  lesions  ai'e  under- 
going involution  new  ones  are  constantly  forming,  so  that  all  the  varied  stages 
71 


IV22  AMERICAN  TEXT- BO  OK  OF  DISEASES  OF  CHILDREN. 

can  be  seen  at  the  same  time.  Urticaria  pigmentosa  affects  principally  the 
trunk  and  neck,  then  the  head,  face,  and  limbs.  It  may  or  may  not  itch. 
In  the  pruritic  variety  factitious  urticaria  is  common.  The  disease  is  usually 
arrested  at  puberty. 

The  cause  of  the  affection  is  unknown,  and  the  treatment  purely  symp- 
tomatic. 

Pityriasis  Rosea. 

Pityriasis  rosea  is  a  trivial  disorder,  its  only  special  importance  arising 
from  the  liability  to  confound  it  with  grave  affections.  It  is  claimed  by 
some  writers  that  the  cutaneous  eruption  is  preceded  by  some  elevation  of 
temperature,  but  this  symptom  is  by  no  means  constant.  Brocq  states  that 
he  has  observed  that  the  more  general  eruption  is  preceded  by  a  single  patch 
that  makes  its  appearance  about  the  Avaist,  neck,  or  arm.  The  lesions  in  the 
beginning  are  minute  pinkish  papules,  which  soon  enlarge  into  circular  or 
oval  macules  having  slightly  depressed  centres  and  a  defined  raised  border. 
They  are  covered  with  somewhat  greasy  yellowish  or  yellowish-white  scales. 
When  the  patches,  by  peripheral  extension,  have  reached  a  diameter  of 
one-half  to  three-quarters  of  an  inch,  the  centre  assumes  a  yellow-parch- 
ment hue,  while  the  extending  scaly  margins  are  distinctly  I'eddish.  The 
patches  may  remain  discrete,  or  they  may  run  together  and  produce  irregular 
gyrate  areas  :  these  bizarre  outlines  are  also  formed  by  the  central  recovery  and 
peripheral  extension  of  the  single  lesions.  The  skin  is  but  little  thickened, 
and  pruritus  is,  as  a  rule,  insignificant.  The  eruption  is  usually  found  on  the 
trunk,  but  it  may  migrate  over  the  body  generally  with  the  exception  of 
exposed  parts.  Papules,  ringed  patches,  and  patches  that  are  undergoing 
involution  may  be  present  at  one  and  the  same  time.  The  disorder  is  self- 
limited,  and  tends  to  spontaneous  recovery  in  from  two  weeks  to  two  months. 

Etiolog-y. — English  and  continental  writers  state  that  this  affection  prin- 
cipally attacks  young  children,  but  this  is  not  true  in  the  writer's  experience, 
although  he  has  been  brought  much  in  contact  with  the  skin  diseases  of  infiints 
and  young  persons.  It  occurs  in  quasi-epidemics,  especially  in  the  spring  and 
fall,  but  considerable  differences  of  opinion  exist  as  to  its  contagiousness,  and 
neither  has  its  parasitic  nature  been  satisfactorily  demonstrated. 

Diagnosis. — Pityriasis  rosea  is  distinguished  from  the  scaling  circinate 
syphilide  by  its  more  inflammatory  color  and  the  absence  of  pigmentation  ; 
besides,  along  with  the  syphilide  would  be  found  other  evidences  of  syphilis. 
Its  resemblance  to  seborrhoea  of  the  body  is  superficially  close,  but  in  sebor- 
rhoea  the  eruption  is  usually  found  only  over  the  sternum  and  between  the 
shoulders,  while  in  pityriasis  rosea  it  is  not  so  limited  ;  moreover,  the  scales  of 
seborrhoea  are  thicker  and  greasier,  and  there  is  often  a  history  of  considerable 
chronicity.  Pityriasis  rosea  differs  from  ringworm  in  its  wider  distribution, 
the  absence  of  papules,  vesicles,  or  pustules  from  the  borders  of  the  patches, 
and  the  absence  of  the  tricophyton  fungus  in  the  scales. 

Prognosis. — The  disease  undergoes  spontaneous  arrest  within  from  a  fort- 
night to  two  or  three  months. 

Treatment. — Internal  treatment  is  useless ;  indeed,  treatment  of  any  sort 
is  unpromising.  The  calamine-and-zinc  lotion  is  agreeable  when  itching  is  a 
symptom,  and  ointments  of  sulphur  and  boracic  acid  may  be  prescribed.  A 
pigment  of  salicylic  acid  has  seemed  to  be  serviceable : 

I^.  Acid,  salicylici gr.  x-xv. 

Liq.  gutta-perchse     . f5j. — M. 


DISEASES   OF   THE  SKIN.  1123 

Prurigo. 

Prurigo  is  a  chronic  inflammatory  disease  of  the  skin  characterized  by 
an  eruption  of  pale  papules  accompanied  by  severe  itching.  This  disease 
begins  in  infancy,  the  lesions  first  consisting  of  urticarial  wheals,  to  which 
the  papules  succeed.  The  papules  are  quite  small,  and,  as  it  Avere,  bur- 
ied in  the  skin,  so  that  they  are  more  easily  felt  than  seen  ;  their  color  is  in 
the  beginning  that  of  the  surrounding  skin,  but  in  time,  as  the  result  of 
scratching,  they  become  of  a  darker  hue.  The  most  noticeable  feature  of 
prurigo  is  the  intense  itching,  which  at  times  becomes  unbearable.  The  dis- 
ease is  most  marked  upon  the  extensor  aspects  of  the  limbs,  w^hile  the  flexor 
surfaces,  the  genitals,  the  scalp,  and  the  face  are  rarely  attacked. 

Various  secondary  changes  in  the  skin  are  to  be  noted,  such  as  infiltration, 
pigmentation,  desquamation,  etc.  A  severe  form  of  the  malady  (prurigo  ferox) 
is  marked  by  intercurrent  attacks  of  wheals,  severe  dermatitis,  pustulation, 
scabbing  and  deep  pigmentation,  and  enlargement  of  the  lymphatic  ganglia, 
especially  those  of  the  groin. 

In  a  few  cases  prurigo  directly  causes  death  by  the  constant  worry  and  loss 
of  sleep,  setting  up  a  condition  of  marasmus  ;  but  usually  it  is  not  fatal. 

Etiology. — By  some  writers  prurigo  is  regarded  as  a  neurosis  of  the  skin. 
Others  do  not  admit  it  is  an  entity,  but  think  it  only  a  group  of  symptoms 
caused  by  the  action  of  various  irritants  upon  a  sensitive  skin.  Prurigo  is 
mainly  found  among  the  poor,  who  cannot  have  its  earlier  manifestations  treated. 
The  disease  is  not  so  rare  in  this  country  as  it  was  at  one  time  supposed, 
a  number  of  cases  having  been  recently  reported  by  Zeissler. 

Diagnosis. — Unless  the  whole  course  of  the  disease  be  taken  into  consider- 
ation, together  with  the  lesions  actually  present  at  any  one  time,  there  is  danger 
of  confounding  prurigo  with  eczema,  scabies,  and  pediculosis.  Careful  atten- 
tion to  the  history  and  to  the  situation  of  the  lesions  will  usually  enable  a 
diagnosis  to  be  made. 

Prognosis. — Tne  earlier  in  a  case  treatment  is  begun,  the  better  the  chance 
of  cure.  In  cases  of  very  long  standing,  though  a  cure  may  not  be  efi'ected, 
the  condition  may  be  much  benefited. 

Treatment. — The  diet  should  be  carefully  regulated,  all  those  articles  which 
are  calculated  to  provoke  a  nettle-rash  being  eliminated. 

The  general  health  will  often  demand  tonics  and  cod-liver  oil.  Some  cases 
seem  to  have  improved  under  arsenic.  Bromide  of  potassium,  carbolic  acid, 
cannabis  Indica,  and  the  salicylates  have  been  used  for  their  effect  upon  the 
itching.  Pilocarpine  and  atropine  are  both  well  recommended,  but  since  they 
act  best  when  given  hypodermatically,  they  are  rarely  ever  used  in  children. 

Locally,  bathing  in  quite  w'arm  baths,  followed  by  the  inunction  of  an 
ointment,  will  probably  yield  the  best  results.  The  ointment  may  contain  tar, 
sulphur,  naphthol,  or  salicylic  acid  in  quantities  varying  with  the  condition 
of  the  patient. 

FURUNCULUS. 

A  furuncle  is  a  circumscribed  phlegmonous  inflammation  occurring  about 
a  hair-follicle  or  a  gland  of  the  skin.  The  appearance  of  a  boil  may  be 
preceded  by  a  slight  tingling  or  itching  of  the  skin.  In  a  short  time 
a  small  red  papule  will  be  noticed,  which  is  very  sensitive  to  pressure  and 
is  accompanied  by  a  burning  sensation.  The  skin  immediately  around  the 
papule  becomes  hard  and  swollen,  and  thus  a  hemispherical  nodule  is  formed, 
varying  in  size  from  a  pea  to  a  walnut.     The  color  of  the  boil  itself  is  a 


U2i  A3fEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

dull  red  or  purplish,  while  the  skin  in  the  immediate  neighborhood  is  of  a 
brighter  red.  The  furuncle  at  this  stage  is  firm  and  hard  to  the  touch,  very 
tender,  and  accompanied  by  a  dull  throbbing  pain.  Within  a  week  or  ten 
days  pus  accumulates  in  the  boil,  and  if  it  is  not  opened  the  skin  ruptures, 
giving  exit  to  a  more  or  less  free  discharge.  Lying  in  the  centre  of  the  fur- 
uncle is  now  exposed  the  core,  a  whitish  necrotic  mass,  which  if  left  alone 
comes  away  of  itself  in  a  few  days.  As  soon  as  the  pus  is  evacuated  the  pain 
in  a  boil  ceases,  and  when  the  core  has  separated  the  hardness  in  the  surround- 
ing skin  gradually  disappears,  while  the  small  cavity  remaining  fills  by  granu- 
lation. A  scar  results,  which  is  at  first  of  a  violaceous  hue,  but  in  time  becomes 
white.  Occasionally  a  boil  stops  short  of  suppuration  and  resolves :  this  is 
known,  in  popular  parlance,  as  a  blind  boil. 

Furuncles  may  occur  singly,  or  numJoers  may  be  on  the  body  at  the  same 
time.  In  some  cases  the  affection  is  indefinitely  prolonged  by  the  appearance  of 
one  crop  after  another,  constituting  the  condition  known  as  furunculosis.  Boils 
may  occur  on  any  part  of  the  body  except  on  the  palms  and  soles.  In  children 
they  are  common  on  the  back,  the  head,  the  eyelids,  and  in  the  axilla.  When 
a  boil  occurs  in  a  ceruminous  gland  in  the  auditory  canal,  there  is  great  pain 
on  account  of  the  denseness  of  the  tissues  in  that  region. 

When  boils  are  single  or  in  small  numbers,  there  is,  as  a  rule,  no  constitu- 
tional disturbance,  but  in  furunculosis  appetite  and  flesh  may  be  lost,  while 
sleep  is  disturbed  by  the  pain. 

A  furuncle  always  commences  about  a  hair-follicle,  a  sebaceous  gland,  or  a 
sweat-gland.  The  severe  inflammation  causes  the  death  of  the  follicle  or 
gland,  which  then  constitutes  the  core. 

Etiology. — Boils  may  be  the  result  of  local  injury,  such  as  bruising  or 
pressure,  as  on  the  buttocks  from  prolonged  sitting.  They  often  occur  in 
depraved  conditions  of  health,  as  after  scarlatina  or  measles.  In  summer  they 
often  accompany  prickly  heat.  Boils  are  contagious  under  certain  conditions, 
such  as  sleeping  in  the  same  bed  with  a  person  aifected.  They  may  arise  dur- 
ing the  course  of  any  pruritic  disease,  probably  from  inoculation  of  the  skin 
by  scratching.  The  pus  from  a  boil  will  produce  other  boils  if  inoculated  upon 
another  part  of  the  body  or  upon  another  person.  The  virus  may  be  carried 
from  one  person  to  another  by  flies.  These  facts,  together  with  the  observation 
that  pus-cocci  are  always  found  in  boils,  seem  to  warrant  the  conclusion  that  the 
disease  is  due  to  the  presence  of  a  micro-organism. 

Diagnosis. — The  only  disease  of  infancy  with  which  furuncle  is  apt  to  be  con- 
founded is  that  rare  syphiloderm  described  by  Barlow,  in  which  several  circum- 
scribed abscesses  in  the  skin  occur ;  but  here  the  inflammatory  symptoms  will 
be  less  severe,  other  symptoms  of  syphilis  will  be  present,  while  the  abscesses 
possess  no  core.  In  children  carbuncle  is  a  rare  affection,  and  can  be  differ- 
entiated from  furuncle  by  the  fact  that  it  has  several  centres  of  suppuration, 
which  in  turn  become  so  many  openings. 

Prognosis. — The  prognosis  of  furunculus  is,  as  a  rule,  favorable.  Whenever 
suppuration  occurs  permanent  scarring  is  the  result.  In  furunculosis  the 
prognosis  must  be  guarded,  as  in  some  cases  successive  crops  of  boils  occur  in 
spite  of  the  best-directed  therapeutic  efforts. 

Treatment. — In  the  treatment  of  furuncle  the  first  step  is  to  look  for  and 
to  correct  any  condition  of  general  health  which  mi^ht  act  as  a  predisposing 
cause.  All  local  conditions  which  may  be  presumed  to  favor  the  development 
of  boils  should  be  removed. 

Various  remedies,  such  as  yeast,  sulphide  of  calcium,  hypophosphite  of 
sodium,   have  been  advised  for   internal  administration    in  the  treatment  of 


DISEASES    OF   THE  SKIN.  1125 

furuncle,  but  their  effect  upon  the  local  condition  is,  to  say  the  least,  proble- 
matical. A  great  many  different  drugs  have  been  recommended  as  possessing  the 
power  to  abort  boils  :  the  apex  may  be  cauterized  with  a  solid  stick  of  nitrate 
of  silver  ;  Guigeot  advises  painting  with  tincture  of  iodine  till  quite  a  thick 
layer  covers  the  boil ;  boric  acid  in  saturated  solution  may  be  frequently 
sprayed  upon  the  affected  surface,  and  by  this  means  some  authorities  claim 
excellent  results  ;  the  following  formula  is  given  by  Jamieson : 

I^.  Tr.  iodi .    .    .  f3j. 

Acidi  tannici 3ss. 

Pulv.  acacise 3ss. — M. 

This  mixture  is  to  be  painted  upon  the  boil  and  the  surrounding  skin  in 
successive  layers,  each  one  being  allowed  to  dry  before  the  next  is  put  on,  till 
a  thick  coating  is  obtained.  Unna's  carbolic-acid-and-mercury  plaster  will 
sometimes  cause  a  boil  to  disappear  :  a  piece  of  the  mull  a  little  larger  than  the 
boil,  with  its  centre  cut  out  to  avoid  pressure  on  the  sensitive  apex,  should  be 
applied,  and  renewed  every  twenty-four  hours.  Hypodermatic  injections  into 
and  around  the  boil,  as  well  as  electrolytic  puncture,  may  succeed  in  arresting 
the  process,  but  these  methods  are  too  painful  to  be  of  use  in  children. 

One  of  the  best  methods  of  treating  a  boil  consists  in  applying  a  pledget  of 
absorbent  cotton  saturated  with  2J  per  cent,  carbolic-acid  solution,  over 
Avhich  is  placed  a  piece  of  rubber  tissue  large  enough  to  cover  the  cotton  and 
a  small  area  of  the  surrounding  skin ;  even  if  this  does  not  prevent  suppura- 
tion, it  will  be  found  to  give  relief. 

Poultices  in  their  ordinary  forms  are  to  be  entirely  discarded,  as  they  favor 
the  development  of  other  boils  around  the  ones  to  which  they  are  applied. 

The  skin  for  some  distance  around  a  furuncle  should  be  frequently  anointed 
with  an  antiseptic  ointment,  to  prevent  the  inoculation  of  the  neighboring  hair- 
follicles.     The  following  is  an  appropriate  formula : 

;^i.  Acidi  boraci gr.  xx. 

Zinci  oxidi ,^ij. 

Lanolini |j. — M. 

As  soon  as  pus  is  collected  in  a  boil  a  free  opening  should  be  made,  the 
cavity  washed  out  with  some  antiseptic  solution,  then  dusted  with  iodoform,  and 
an  antiseptic  dressing  applied. 

In  the  treatment  of  furuncles  in  the  auditory  canal,  Cholewa  recommends 
inserting  into  the  ear  a  plug  of  absorbent  cotton  which  has  been  moistened 
with  a  20  per  cent,  solution  of  menthol  in  olive  oil.  Spencer  inserts  a  cotton 
plug,  having  first  applied  to  the  boil  an  ointment  of  extract  of  arnica,  extract 
of  belladonna,  and  morphine. 


HEMORRHAGES. 

Purpura. 


The  term  "purpura"  is  applied  to  certain  conditions  in  which  haemor- 
rhages occur  in  the  skin  or  mucous  membranes.  The  lesions  of  purpura  may  be 
of  a  bright  red  or  of  a  livid  bluish  hue.  They  do  not  disappear  upon  pressure. 
The  individual  haemorrhages  vary  much  in  size,  and  from  this  fact  various 
names  have  been  applied  to  them,  as  petechise,  where  the  extravasations  occur 


112Q  A3£ERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

in  the  form  of  minute  points  ;  vi bices,  where  they  occur  as  streaks  ;  ecchymose?, 
where  they  occur  as  larger  spots  or  blotches.  At  times  haemorrhages  are  com- 
bined with  other  lesions  of  the  skin  ;  thus  we  may  find  blood  effused  into  a 
papule  or  a  bulla.  Occasionally  blood  finds  its  way  into  the  sweat-glands, 
whence  it  is  extruded  along  with  the  perspiration,  giving  to  it  a  hsemorrhagic 
appearance — haematidrosis. 

Haemorrhages  occur  in  the  skin  under  such  manifold  conditions  that  any 
classification  upon  an  etiological  basis  is  impossible.  Clinically,  three  forms 
are  found  with  sufficient  frequency  to  warrant  a  description  as  special  diseases. 
The  mildest  form  in  which  the  affection  occurs  is  known  as  purpura  simplex. 
The  person  affected  is  usually  in  good  health  when  the  disease  manifests  itself: 
the  lesions  appear  suddenly  upon  any  part  of  the  body — in  children  especially 
about  the  neck,  upper  portion  of  the  trunk,  and  arms.  The  eruption  is  com- 
monly made  up  of  petechige,  though  streaks  and  larger  spots  may  also  occur. 
The  haemorrhages  usually  remain  discrete,  and  when  sufficiently  copious  may 
cause  a  slight  elevation  of  the  skin.  The  duration  of  the  disease  is  prolonged 
by  the  repeated  appearance  of  fresh  crops  of  the  lesions.  Each  crop,  as  resorp- 
tion occurs,  passes  through  the  different  changes  in  color  that  we  remark  in  a 
bruise.  There  are  no  subjective  symptoms.  The  condition  is  most  likely  to  be 
confounded  with  flea-bites. 

In  purpura  rheumatica  the  extr-avasation  of  blood  into  the  skin  constitutes 
the  most  remarkable  feature  of  the  disease,  and  for  this  reason  it  is  classed 
among  haemorrhages.  The  appearance- of  the  skin  affection  is  preceded  by 
malaise  ;  pain  in  the  joints  is  complained  of,  and  frequently  swelling  may  be 
detected.  After  a  day  or  two  a  petechial  eruption  shows  itself  upon  the  sur- 
face. In  its  general  characters  this  eruption  does  not  differ  from  the  lesions 
found  in  purpura  simplex,  except  that  there  is  a  tendency  to  localization  about 
the  affected  joints.  The  disorder  may  be  indefinitely  prolonged  by  relapses,  and 
sometimes  passes  into  a  condition  simulating  purpura  hasmorrhagica.  The 
heart  may  become  implicated  during  the  course  of  the  malady,  with  a  resulting 
lesion  of  the  valves.  Henoch  and  Couty  have  described  a  form  of  purpura 
which  occurs  most  frequently  in  children,  and  is  characterized  by  pains  in  the 
joints,  vomiting  and  intestinal  pain,  and  a  localized  oedema  of  the  skin. 
(See  Purpura  Haemorrhagica.)  While  purpura  rheumatica  is  at  its  height 
there  is  often  a  moderate  rise  in  temperature. 

The  most  severe  form  in  which  purpura  occurs  is  as  purpura  haemorrhagica 
(morbus  Werlhofii).  In  this  affection  we  find,  in  addition  to  the  phenomena 
of  purpura  simplex,  bleeding  from  various  mucous  membranes  and  haemor- 
rhages into  various  internal  organs.  The  disease  may  develop  suddenly  or  be 
preceded  by  symptoms  of  an  indefinite  kind,  such  as  headache,  loss  of  appetite, 
lassitude,  etc.  The  haemorrhages  into  the  skin  are  frequently  larger  than 
those  found  in  purpura  simplex,- and  effusion  of  blood  occurs  also  in  the  mucous 
membranes,  as  indicated  by  its  escape  from  the  mouth,  nose,  anus,  vagina,  and 
urethra.  Bleeding  occurs  also  in  the  parenchyma  of  the  organs,  and  when  the 
brain  is  thus  affected  speedy  death  may  result.  The  serous  cavities  often  con- 
tain blood. 

The  disease  is  usually  accompanied  by  a  moderate  fever.  When  the  amount 
of  blood  lost  is  not  large,  recovery  may  follow,  but  relapses  are  not  uncommon. 

For  purpura  haemorrhagica  as  it  occurs  in  the  new-born  the  designation 
purpura  neonatorum  has  been  given.  The  disease  hardly  warrants  a  special 
description,  since  it  presents  symptoms  similar  to  those  found  in  purpura 
haemorrhagica,  its  only  point  of  distinction  being  that  it  occurs  within  the  first 
few  days  of  life. 


DISEA8ES    OF   THE  SKIN.  1127 

Etiology, — In  those  cases  in  whicli  haemorrhage  into  the  skin  is  merely  a 
secondary  or  symptomatic  phenomenon  a  cause  for  the  affection  can  often  "be 
ascribed.  Illustrations  of  such  cases  would  be  the  purpura  that  often  occurs 
with  the  specific  fevers,  as  measles,  scarlatina,  and  malaria ;  or  where  certain 
drugs,  such  as  quinine  or  iodide  of  potassium,  have  been  ingested  ;  or  in 
cases  where  we  may  be  able  to  determine  some  decided  obstruction  to  the  blood- 
current,  as  some  valvular  heart  trouble  ;  or  where  a.  congenital  or  acquired 
weakness  of  the  vessel-walls  may  be  supposed  to  exist,  as  in  haemophilia, 
rickets,  or  syphilis.  In  those  cases  in  which  the  effusion  of  the  blood  seems 
to  constitute  the  chief  feature  of  the  disease  the  etiology  is  far  from  being 
definitely  determined.  In  that  form  which  manifests  itself  in  the  new-born 
babe  it  has  been  supposed  that  the  violent  changes  which  then  occur  in  the 
circulation  may  account  for  the  phenomenon.  Of  late  years  the  presence  of 
various  forms  of  micro-organisms  has  been  invoked  to  explain  the  occurrence 
of  purpura.  Petrone  injected  blood  from  patients  with  purpura  into  rabbits, 
and  produced  a  general  haemorrhagic  state.  Letzerich  found  a  bacillus  which, 
injected  in  pure  culture  into  rabbits,  occasioned  haemorrhages.  Several  other 
investigators  have  made  somewhat  similar  observations.  Hanot  and  Luzet 
found  in  the  body  of  a  foetus,  the  mother  of  which  was  dead  of  purpura,  strep- 
tococci of  identical  characteristics  with  those  found  in  the  mother.  These 
observations,  though  as  yet  too  recent  to  be  wholly  relied  upon,  serve  to  show 
that  there  may  be  certain  cases  of  purpura  which  are  acute,  infectious  diseases; 
and  this  assumption  is  corroborated  by  the  clinical  history  in  some  instances. 

Diagnosis. — The  diagnosis  of  purpura  rarely  presents  any  difficulty,  as 
the  lesions  differ  from  those  caused  by  inflammatory  conditions  in  not  disap- 
pearing under  pressure.  A  fleabite  differs  from  a  petechia  in  having  a  central 
point,  indicating  its  traumatic  origin.  Scurvy  may  be  distinguished  from  pur- 
pura haemorrhagica  by  the  fact  that  it  is  caused  by  a  diet  deficient  in  vege- 
tables, that  it  attacks  more  than  one  of  those  so  situated,  and  that  in  it  we  find 
a  spongy  condition  of  the  gums,  loosening  of  the  teeth,  and  brawny  swelling 
of  the  limbs. 

Prognosis. — Care  must  be  exercised  in  giving  an  opinion  as  to  the  course 
and  ultimate  result  even  in  simple  cases  of  purpura,  as  the  complications  which 
may  arise  are  manifold.  As  a  rule,  the  simple  forms  recover,  though  the  attack 
may  be  prolonged  by  relapses.  The  prognosis  in  purpura  haemorrhagica  is 
always  grave. 

Treatment. — Mild  cases  of  purpura  will  require  no  special  treatment.  In 
all  cases  rest  in  bed  is  of  prime  importance,  as  in  this  way  further  haemor- 
rhage is  best  guarded  against.  When  the  haemorrhages  from  the  mucous  cav- 
ities threaten  danger,  an  effort  should  be  made  to  arrest  them  by  means  of 
tampons,  hot  and  cold  water,  or  a  spray  of  perchloride  of  iron  or  other  as- 
tringent. In  the  way  of  drugs  to  be  administered  internally,  turpentine, 
acetate  of  lead,  dilute  sulphuric  acid,  ergot,  and  iron  have  the  best  reputation. 
A  combination  that  has  proved  of  service  to  the  writer  is  the  followi»ng : 

^.  Ext.  ergotae  fid 

Tr.  ferri  chloridi, da  f  §ss. — M. 

Sig.  Three  to  ten  drops  in  water,  t.  d. 

In  purpura  rheumatica  the  salicylates  may  benefit  the  affection  of  the 
joints. 


112S  AMUBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

HYPERTROPHIES. 

Lentigo. 

The  affection  known  as  lentigo,  or  freckles,  consists  in  the  appearance, 
mostly  upon  exposed  surfaces,  of  variously-shaped,  usually  small,  yellow, 
brownish,  or  black  spots.  Freckles  are  most  common  on  the  hands  and 
face,  but  may  occur  on  covered  parts.  As  a  rule,  the  affection  appears  in 
the  second  decade  of  life,  though  Wilson  mentions  congenital  cases.  The  spots 
are  prone  to  become  darker  and  more  numerous  in  the  summer,  while  in  the 
winter  they  may  almost  disappear.  In  its  pathology  a  freckle  is  a  circum- 
scribed hyperpigmentation  situated  in  the  rete. 

Etiology. — Lentigo  is  rarely  seen  before  the  sixth  or  seventh  year.  It 
affects  especially  those  of  a  light  complexion.  Exposure  to  the  effects  of  sun- 
light is,  by  universal  consent,  the  most  common  cause,  though,  that  it  is  not 
the  only  one  is  shown  by  the  occurrence  of  freckles  on  parts  not  exposed. 

Treatment. — Freckles  may  be  temporarily  removed  by  many  stimulating 
ointments  and  lotions.     One  of  the  best  of  the  former  is — 

^.  Hydrarg.  ammoniati     . 3J' 

Bismuthi  subnit 3j- 

Ung.  aq.  rosae 5J- — M. 

Sig.  Apply  at  night. 

In  cases  where  the  pigment  is  very  black,  pricking  each  freckle,  very 
superficially,  with  a  needle  attached  to  the  negative  pole  of  the  galvanic  bat- 
tery often  hastens  its  disappearance. 

Freckles,  though  they  have  disappeared,  are  prone  to  return  under  exposure 
to  exciting  causes. 

Ichthyosis. 

Ichthyosis  is  a  congenital  disease  characterized  by  dryness  and  scaliness 
of  the  skin,  and  at  times  by  the  development  of  thickened  Avarty  patches. 
Two  principal  varieties  are  described,  though  their  difference  is  of  degree 
and  not  of  kind.  Ichthyosis  simplex  affects  the  general  surface,  but  is  often 
most  marked  on  the  extensor  sides  of  the  limbs.  Often  there  is  only  to 
be  noticed  a  dryness  and  scaliness  of  the  skin,  with  small  papules  due  to  an 
accumulation  of  horny  cells  in  the  hair-follicles.  In  more  severe  cases  a  thick- 
ening of  the  skin  exists  and  painful  fissures  may  occur.  Large  scales  form 
on  the  surface,  which  get  to  be  of  a  dark  color  from  accumulations  of  dirt ; 
and  from  their  being  somewhat  of  a  diamond  shape  may  give  the  skin  a  re- 
semblance to  the  hide  of  an  alligator.  The  face,  scalp,  palms,  and  flexor  sur- 
faces are  apt  to  be  but  little  involved,  the  disease  in  these  parts  manifesting 
itself  as  a  branny  desquamation.  The  hair  is  often  harsh  and  without  lustre, 
and  the  nails  rough  and  brittle.  Both  sweat  and  sebaceous  matter  are  deficient 
in  quantity.     The  condition  grows  better  in  summer  and  worse  in  winter. 

In  ichthyosis  hystrix  there  is  present  in  localized  areas  an  exaggeration  of 
the  condition  just  described  :  the  skin  is  rough  and  bark-like,  or  may  be  covered 
by  actual  spines,  due  to  a  papillary  hypertrophy  in  addition  to  the  thickening 
of  the  epidermis.  The  usual  sites  for  ichthyosis  hystrix  are  the  back,  the 
neck,  and  the  extremities.  The  lesions  may  be  distributed  along  the  course  of 
a  nerve.  Occasionally  ichthyosis  is  present  at  birth,  but,  as  a  rule,  it  first 
manifests  itself  after  some  months  or  even  a  couple  of  years. ^ 

'Sometimes  ichthyosis  exists  at  birth,  or  in  the  premature;   the  "  harlequin  foetus"  of 


DISEASES    OF   THE  SKIN.  1129 

Though  the  disease  remains  through  life,  the  general  health  is  entirely  un- 
affected. The  most  striking  microscopical  changes  are  thickening  of  the 
epidermis,  with  more  or  less  hypertrophy  of  the  papillary  layer  of  the  cutis. 

Btiolog-y. — The  only  recognized  factor  in  the  etiology  of  ichthyosis  is 
heredity.  It  is  apt  to  recur  in  successive  generations  of  the  same  family, 
though  this  is  not  always  the  case. 

Diagnosis. — The  diagnosis  will  be  easy  if  the  history  be  considered  along 
with  the  characteristic  appearance  of  the  disease. 

Prognosis. — The  disease  persists  through  life,  but  does  not  show  any 
detrimental  effect  on  the  health. 

Treatment. — Arsenic  and  pilocarpine  have  been  recommended,  though  in 
the  experience  of  the  Avriter  they  exert  no  permanent  influence  on  the  malady. 
The  local  treatment  is  of  importance,  since  by  it  much  relief  may  be  given. 
In  mild  cases  frequent  warm  baths,  followed  by  inunctions  with  glycerin  or 
lanoline,  suffice.  In  cases  of  greater  severity  it  is  advisable  to  use  alkaline 
baths.  Duhring  recommends  that  some  simple  ointment  be  rubbed  on  ;  after 
this  has  remained  a  few  hours  a  hot  bath  with  green  soap  is  given,  and  then 
rinsing  in  simple  water,  after  which  ointment  is  again  applied.  The  following 
ointment  is  recommended : 

I^.  Adipis  benzoati ^j. 

Glycerini tilxl. 

Vaselini §ss. — M. 

Sig.  Apply  after  bathing. 

Various  authors  recommend  the  following  ointment  for  constant  use : 

I^.  Potassii  iodidi Bj. 

Glycerini 3j. 

Adipis  benzoati 

01.  bubuli da  |ss. — M. 

Sig.  Rub  in  once  a  day. 

Naphthol  in  5  per  cent,  ointment,  with  the  use  of  naphthol  soap,  is  advised 
by  Kaposi.  Sulphur  or  ichthyol  (one  drachm  to  an  ounce  of  vaseline)  may  be 
used  as  a  daily  inunction.  In  ichthyosis  hystrix  large  horny  growths  must  be 
removed  by  the  knife  or  other  surgical  means.  Smaller  patches  may  be  treated 
by  the  application  of  salicylic-acid  plaster  mulls,  as  devised  by  Unna,  or  a 
solution  of  the  same  drug  in  collodion  or  traumaticin: 

!^,  Acidi  salicylici 3j-3iss. 

Traumaticini oj- — M. 

Sig.  Apply  every  two  or  three  days  after  removing  the  application  pre- 
viously made. 

MoLLUscuM  Epitheliale. 

Molluscum  epitheliale  is  a  comparatively  rare  affection.  The  lesions  are 
from  a  pinpoint  to  a  pea  in  size,  according  to  the  duration  of  the  disease. 
They  form  little  tumors,  usually  sessile,  varying  in  color  from  white  to  a  decided 
pink,  often  semitransparent,  resembling  wax,  and  presenting  at  one  point  on 

English  writers.     The  body  is  covered  with  plates  of  fatty  epidermis  separated  by  furrows. 
If  these  children  are  born  alive,  they  succumb  in  a  few  days. 


IISO  AMEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  surface  a  pit  or  umbilication  indicating  the  situation  of  a  follicle.  Through 
this  orifice  on  firm  pressure  a  milky  fluid  may  be  sometimes  squeezed,  ihe 
lesions  are  generally  few  in  number,  and  most  frequently  occur  on  the  face,  on 
the  eyelids,  cheeks,  and  chin.  They  may  be  found  in  other  regions,  as  the 
neck  breast,  or  <Tenitals.  After  the  tumors  have  attained  their  lull  size  they 
may  remain  stationary  for  an  indefinite  time,  or  become  inflamed  and  undergo 
spontaneous  cure  by  suppuration.  Subjective  symptoms  are  absent  in  mollus- 
cum  epitheliale.  As  to  the  anatomical  changes  present  there  are  various 
opinions  Virchow  considers  that  the  process  begins  as  a  hyperplasia  ot  the 
hair-follicles,  while  Leloir  and  Vidal  support  the  older  view,  that  the  tumor  is 
the  result  of  changes  occurring  in  sebaceous  glands. 

Etiology.— The  aff"ection  is  commoner  among  children  than  adults,  it 
is  without  .doubt  contagious.  As  to  the  cause  of  the  malady  there  is  much 
diff"erence  of  opinion,  Neisser  and  others  believing  it  to  be  the  result  oi  some 
form  of  coccidia ;  Wickham  contending  that  molluscum  epitheliale  is  a  cuta- 
neous psorospermosis;  while  Piff-ard  is  among  those  who  hold  that  the  patho- 
logical process  at  the  basis  of  the  disease  is  a  corneous  degeneration  ot  the 

epithelium.  ,  .  ,  .       i  j      .i. 

Diagnosis.— No  other  aff'ection  of  childhood  is  apt  to  be  confounded  with 

molluscum  epitheliale.  -,  ^      ^     •       xi 

Treatment.— The  little  tumors  may  be  successfully  treated  by  laying  them 
open  with  a  knife  and  pressing  out  the  contents ;  the  base  should  then  be 
touched  with  nitrate  of  silver.  Electrolysis  also  may  be  used  in  the  treatment 
of  molluscum  epitheliale,  each  lesion  being  transfixed  several  times  by  a  slender 
steel  needle  attached  to  the  negative  pole  of  a  galvanic  battery.  In  a  few  days, 
if  the  operation  has  been  successful,  the  tumors  shrivel  up,  and  eventually  dis- 
appear :  if  this  result  is  not  attained  bv  the  first  sitting,  the  operation  must  be 
repeated.  Jamieson's  method  of  touching  each  tumor  with  pure  carbolic  acid, 
and  then  painting  over  it  with  flexible  collodion,  is  said  to  be  efi"ective» 

Verruca. 
Warts  represent  papillary  hypertrophies,  and  present  great  variations  in 
appearance :  they  mav  be  congenital  or  acquired.  They  may  occur  upon 
any  portion  of  the  body  in  numbers  or  singly,  though  exposed  surfaces, 
such  as  the  hands  and  face,  seem  their  favorite  sites.  Various  names  have 
been  applied  to  the  different  clinical  manifestations  of  verruca.  Verruca 
vul<raris  occurs  most  often  on  the  hands  of  children  as  one  or  more  elevations 
from  a  pinhead  to  a  large  pea  in  size,  of  the  natural  color  of  the  skm  or  ot  a 
dark  hue,  with  a  smooth  or  rough,  shagreen-like  surface;  verruca  digita  is 
usually  found  on  the  scalp,  and,  as  the  name  implies,  presents  one  or  more 
finger-like  projections  from  the  skin,  caused  by  an  unusual  outgrowth  ot  indi- 
vidual papillse ;  verruca  acuminata  is  found  in  such  parts  as  are  kept  damp 
and  warm  and  are  subject  to  the  irritating  influences  of  discharges,  as  about 
the  crenitals  or  anus :  this  wart  occurs  as  a  vascular  growth,  sessile  or  peduncu- 
lated, of  a  reddish  or  purplish  color,  and  is  frequently  accompanied  by  an 
offensive  purulent  discharge.  Various  other  more  or  less  fanciful  names  have 
been  applied  to  diff'erent  forms  of  warts,  but  their  importance  is  not  suthcient 
to  warrant  description  here. 

No  matter  how  difi"erent  the  outward  form  of  verrucfe  may  be,  microscop- 
ically they  consist  of  exaggerated  papillary  growths  covered  by  epidermis  more 
or  less  thickened. 

Etiology.— The  etiology  of  warts  is  enveloped  in  obscurity :  some  torms 


PLATE  XXVII. 


MOLLUSCUM   EPITHELIALE 


DISEASES    OF   THE  SKIN.  1131 

seem  to  be  contagious ;  and  an  explanation  for  this  clinical  fact  is  offered  by 
various  observers,  "who  have  found  micro-organisms — sometimes  micrococci, 
sometimes  bacilli,  sometimes  psorosperms — in  the  affected  tissues. 

Diagnosis. — The  only  other  disease  of  childhood  with  which  verruca  may 
be  confounded  is  that  rare  form  of  lymphangioma  circumscriptum  in  which  the 
dilated  lymph-spaces  are  covered  and  concealed  by  warty  growths.  Here 
careful  examination  will  demonstrate  that  the  seeming  warts  contain  lymph- 
like fluid. 

Treatment. — Recently  Epsom  salts  in  sufficient  doses  to  cause  two  or  three 
evacuations  a  day  has  been  said  to  bring  about  rapidly  a  cure  of  warts :  this  is 
endorsed  by  good  authority,  but  the  writer  has  had  no  experience  of  it. 

Where  children  can  be  induced  to  endure  the  pain,  the  wart  may  be  caused 
to  disappear  by  transfixing  it  one  or  more  times  with  the  needle  attached  to 
the  negative  pole  of  a  galvanic  battery. 

One  of  the  best  topical  remedies  is  a  saturated  solution  of  salicylic  acid  in 
alcohol  painted  on  once  or  twice  a  day ;  or  this  formula  may  be  used : 

]^.  Acidi  salicylici 3ss. 

Collodii fsj.— M. 

Sig.  Paint  on  the  wart  every  other  day. 

Sometimes  powders  kept  dusted  over  the  affected  area  will  bring  about  a 
cure  ;  this  powder  is  as  good  as  any  : 

^.   Pulv.  zinci  oleatis Iss. 

Bismuthi  subnit §ss. — M. 

Sig.  Dust  on  the  part. 

Nearly  all  of  the  various  caustics  have  been  used  to  remove  warts,  but  the 
methods  mentioned  are  equally  effective  and  much  safer. 

N^VUS    PiGMENTOSUS. 

By  the  term  ^'- ncevus  pigtnentosus,"  or  mole,  is  meant  a  circumscribed 
deposit  of  pigment  in  the  skin,  which  may  be  congenital  or  may  develop 
at  a  later  period.  The  size  of  moles  varies  from  a  pinhead  to  a  bean,  and 
in  some  instances  a  large  part  of  the  body  is  involved.  The  most  frequent 
sites  of  naevus  pigmentosus  are  the  neck,  face,  and  back.  The  color  of  moles 
varies  from  a  light  brownish-yellow  to  black.  Hyperpigmentation  may  be  the 
only  pathological  condition  present,  or  this  may  be  accompanied  by  other  ana- 
tomical changes  :  these  differences  in  structure  have  given  rise  to  special  names, 
such  as  ncevus  spilus,  where  a  simple  smooth  deposit  of  pigment  exists :  ncevus 
verrucosus,  where  the  surface  is  warty  and  uneven ;  ncevus  pilosus,  where  the 
mole  is  covered  with  hairs. 

Moles  are  of  importance  from  a  cosmetic  point  of  view,  and  because,  in 
later  years,  they  may  undergo  a  malignant  change.  Anatomically,  a  mole  is  a 
collection  of  pigment  in  the  rete,  often  accompanied  by  an  increase  in  the  con- 
nective tissue  of  the  skin. 

Etiology. — No  cause  for  the  appearance  of  neevus  pigmentosus  has  yet  been 
certainly  ascertained.  The  fact  that  moles  sometimes  occur  scattered  along  the 
course  of  a  nerve  seems  to  point  to  a  neurotic  origin  in  some  cases. 

Prognosis. — Pigmentary  nsevi  persist  through  life,  only  rarely  disappear- 
ing spontaneously.     Where  practicable,  it  is  best  to  remove  them,  because 


1132  AMJEBICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  the  possibility  of  a  cancerous  or  sarcomatous  growth  originating  from  the 
moles  as  life  advances. 

Treatment. — Electrolysis  offers  the  best  method  of  removing  moles  of 
ordinary  size.  A  needle  attached  to  the  negative  pole  of  a  galvanic  battery  is 
introduced  into  the  mole  at  several  points  till,  in  the  judgment  of  the  operator, 
a  sufficient  amount  of  destruction  is  accomplished.  To  avoid  scarring  it  is  best 
not  to  attempt  to  complete  the  removal  at  one  sitting.  For  the  minutiae  of  the 
operation  the  reader  must  be  referred  to  works  in  which  the  subject  is  treated 
more  fully,  as  space  is  not  here  afforded.  Electrolysis  presents  advantages  in 
the  removal  of  large  naevi,  as  there  is  no  haemorrhage,  and  scarring  is  less  than 
by  most  other  methods.  The  operation  is,  however,  tedious,  as  a  number  of 
sittings  are  required  for  the  larger  growths.  When  time  is  an  element  in  treat- 
ment, excision  with  the  knife  gives  the  most  satisfactory  results.  It  is  not 
good  practice  to  attack  moles  with  caustics,  as  the  results  are  less  favorable 
than  by  the  methods  mentioned,  while  a  malignant  change  may  possibly  be 
provoked. 

Sclerema  Neonatorum. 

Sclerema  neonatorum  manifests  itself  as  an  induration  and  stiffening  of 
the  skin  in  new-born  children.  The  disease  may  be  congenital,  but  when 
this  is  the  case  the  children  are  usually  still-born.  More  frequently  the 
trouble  develops  within  the  first  few  days  of  life.  The  skin  of  the  legs  is 
usually  first  attacked,  and  successive  portions  of  the  integument  are  affected  till 
the  whole  surface  has  become  involved.  Occasionally  the  disease  begins  in  the 
cheeks  and  spreads  downward.  At  first  the  skin  is  of  a  whitish,  waxy  appear- 
ance, and  feels  thick  when  pinched  between  the  fingers  :  but  as  the  malady 
advances  a  livid  hue  is  developed,  and  the  skin  becomes  adherent,  so  that  it  can 
no  longer  be  picked  up.  "When  the  process  is  fully  developed  the  child  lies 
rigid,  with  no  perceptible  motion  save  that  due  to  its  feeble  respirations.  The 
joints  are  not  readily  flexed,  and  the  child  may  be  picked  up  by  the  legs  and 
held  out  horizontally ;  the  jaws  are  so  stiff  that  nursing  is  impossible.  The 
pulse  decreases  to  60  per  minute  :  the  respirations  are  slow  and  shallow  ;  and 
the  temperature  is  below  the  noi'mal  by  two  or  three  degrees  :  under  such  con- 
ditions life  cannot  long  persist,  and  is  genei'ally  extinguished  in  five  or  six  days. 

Sclerema  neonatorum  was  until  the  time  of  Parrot  confused  with  oedema, 
which  may  occur  in  the  new-born  from  various  causes.  Parrot  makes  the 
essence  of  the  disease  a  drying  up  or  desiccation  of  the  skin ;  he  denies  that 
there  is  a  true  sclerosis.  Langer  attributes  the  stiffness  of  the  integument  to 
solidification  of  the  subcutaneous  fat ;  in  infants  the  fat  becomes  solid  at 
89.6°  F..  while  in  adults  this  occurs  at  a  temperature  lower  than  32°F.  If  by 
any  depressing  cause  the  infants  temperature  is  sufficiently  reduced,  the  fat 
solidifies,   and  sclerema  neonatorum  is  the  result. 

Etiology. — The  disease  is  most  common  in  those  born  prematurely.  Any 
conditions  which  depress  the  general  health,  such  as  congenital  heart  affections, 
bronchitis,  diarrhoea,  exposure  to  cold.  etc..  seem  to  act  as  predisposing  causes. 

Diagnosis. — Sclerema  neonatorum  is  distinguished  from  oedema  by  the 
fact  that  the  skin  is  stiff  and  unyielding,  and  that  there  is  no  pitting  on  pres- 
sure. (For  the  differential  diagnosis  between  sclerema  neonatorum  and  sclero- 
derma the  reader  is  referred  to  the  article  on  the  latter  subject.) 

Prognosis. — The  disease  is  nearly  always  fatal.  Encouragement  is.  how- 
ever, offered  by  the  few  cases  that  have  recovered. 

Treatment. — An  effort  should  be  made  to  bring  the  temperature  of  the 
child  to  the  normal  by  enveloping  it  in  cotton  wool,  or,  better,  by  placing  it  in 


DISEASES   OF   THE  SKIN.  1133 

an  incubator.  As  nursing  is  impossible,  nourishment  must  be  maintained  by 
other  methods.  Milk  with  brandy  may  be  administered  per  rectum  or  by 
means  of  a  catheter  passed  into  the  stomach  through  the  nose.  Money  reports 
success  in  two  cases  by  inunctions  of  mercury. 

Scleroderma. 

Clinically,  scleroderma  presents  itself  as  a  thickening  and  induration  of 
the  skin.     A  limited  area  or  the  whole  surface  may  be  involved. 

The  disease  may  occur  on  any  part  of  the  body,  but  shows  a  preference  for 
the  upper  portions — the  head,  the  thorax,  or  the  upper  extremities.  The  malady 
may  come  on  acutely,  and  in  a  few  days  involve  the  entire  surface ;  but  more 
commonly  the  progress  is  so  slow  that  the  person  affected  does  not  notice  the 
presence  of  the  disease  till  the  skin  is  already  hard  and  stiff.  Sometimes  the 
real  infiltration  is  preceded  by  oedema.  When  fully  developed  the  affected 
area  is  to  the  touch  dense,  hard,  and  will  not  pit  on  pressure.  The  skin  can- 
not be  picked  up  from  the  underlying  structures,  nor  slid  about,  as  in  the  nor- 
mal state.  The  diseased  area  is  usually  on  the  same  level  with  the  healthy 
integument,  and  passes  so  gradually  into  it  that  no  line  of  demarcation  can  be 
seen.  Generally,  the  surface  is  somewhat  paler  than  normal,  though  it  may  be 
a  uniform  or  mottled  brown  from  increased  pigmentation  :  it  is  most  often 
smooth  and  shining,  with  the  markings  of  the  natural  skin  obliterated,  but  in 
some  instances  it  is  scaly.  Around  the  border  of  the  area  there  is  sometimes 
a  zone  of  hypersemia.  The  movement  of  all  the  parts  affected  is  limited  by  the 
rigid  skin,  so  that  the  face  is  expressionless,  the  neck  cannot  be  easily  turned, 
respiration  is  hindered,  and  the  joints  are  not  readily  flexed.  Sensation  may 
be  increased  or  diminished,  but  pressure  on  the  diseased  skin  is  acutely  pain- 
ful. The  mucous  membranes  may  become  involved,  as  may  also  the  muscles. 
Having  persisted  in  this  stage  for  an  indefinite  time,  the  affected  skin  may 
become  normal,  or  it  may  pass  into  the  second  or  atrophic  stage.  It  then  becomes 
thin,  parchment-like,  of  a  dull-white  color,  with  telangiectic  vessels  showing 
here  and  there,  and  is  stretched  tensely  over  the  underlying  structures.  The 
pressure  thus  caused  brings  about  atrophy  of  the  tissues  beneath,  so  that  the 
face  may  resemble  a  skull  with  only  the  skin  stretched  over  it,  and  the  limbs 
seem  made  up  of  only  skin  and  bones.  Various  distortions  of  the  hands  and 
extremities  occur,  and  ulceration  over  bony  prominences  is  common. 

During  the  course  of  scleroderma,  endocarditis  and  pericarditis  may  develop. 
There  is  frequently  no  disturbance  in  health  till  the  disease  has  persisted  for  a 
long  time,  when  a  state  of  marasmus  may  appear  and  death  result.  In  chil- 
dren the  disease  is  prone  to  run  an  acute  course,  and  does  not  so  often  ter- 
minate in  atrophy.  The  denseness  of  the  skin  in  scleroderma  is  due  to  an 
increase  in  the  connective-tissue  elements.  The  changes  are  found  chiefly  in 
the  corium  and  subcutaneous  tissue.  There  is  at  times  an  increase  of  pigment 
in  the  rete.  Around  the  vessels  are  found  masses  of  cells  the  exact  origin  of 
which  is  unknown.  In  a  case  examined  by  Mdry  there  was  a  development  of 
connective  tissue  in  the  muscles  of  the  limbs  and  in  the  heart. 

Etiology. — The  cause  of  scleroderma  is  not  known.  Obstruction  of  the 
lymph-channels  has  been  suggested,  but  this  remains  an  hypothesis.  Various 
observers  have  detected  lesions  of  the  central  or  peripheral  nervous  system  in 
connection  with  scleroderma.  The  disease  seems  to  have  followed  exposure  to 
cold,  and  it  has  been  remarked  after  erysipelas. 

Diagnosis. — The  only  disease  of  childhood  with  which  the  first  stage  of 
scleroderma  can   be   confounded  is  sclerema   neonatorum  :    here  the  time  of 


11S4:  AlfUBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

development  will  suffice  to  distinguish,  as  the  youngest  child  in  whom  sclero- 
derma has  been  reported  was  thirteen  months  old. 

In  the  atrophic  stage  scleroderma  most  resembles  Kaposi's  disease,  but  the 
history  of  scleroderma,  which  begins  as  a  thickening  of  the  skin,  Avill,  in  most 
cases,  differentiate  it  from  this  affection,  which  begins  with  pigmentation  and 
atrophy.     (For  other  points  of  difference  see  Kaposi's  Disease.) 

Prognosis. — It  is  impossible  to  give  an  opinion  as  to  the  result  when  the 
case  is  seen  in  the  first  stage.     When  atrophy  has  occurred  it  is  permanent. 

Treatment. — The  body  should  be  clothed  with  flannel,  and  exposure  to 
cold,  which  always  seems  to  aggravate,  guarded  against.  The  general  nutri- 
tion should  be  cared  for  by  a  generous  diet  and  the  exhibition  of  cod-liver  oil 
and  tonics.  Hot  baths  often  give  comfort  to  the  patient.  The  suppleness  of 
the  skin  may  be  increased  by  vigorous  inunctions  of  oil.  Massage  has  seemed 
of  service  in  some  cases.  The  constant  current  has  been  recommended  by 
some  authors,  and  in  a  circumscribed  patch  of  scleroderma  in  an  adult  Brocq 
used  electrolysis  with  apparent  improvement. 

MORPHCEJA. 

The  affection  of  the  skin  known  by  the  name  "morphoea"  is  thought  by 
some  dermatologists  to  be  only  a  circumscribed  scleroderma.  However  this 
may  be,  the  disease  presents  enough  clinical  peculiarities  to  entitle  it  to  a 
separate  description. 

The  lesions  of  morphoea  consist  of  variously  sized  spots,  streaks,  or  bands 
with  sharply-defined  bordei's  surrounded  by  a  zone  of  dilated  capillaries,  which 
zone  is  often  of  a  violet  hue.  The  affected  area  is  frequently  of  a  waxy-Avhite 
color,  so  that  it  has  been  likened  to  a  piece  of  old  ivory  let  into  the  skin,  but  at 
times  the  color  may  be  pinkish,  yellow,  brown,  purple,  or  even  black.  The 
patches  are,  as  a  rule,  not  raised  above  the  level  of  the  surrounding  skin.  Gen- 
erally, the  surface  is  smooth  and  the  skin  is  not  adherent  to  the  underlying 
tissues,  so  that  it  may  readily  be  picked  up,  when  it  is  found  to  be  slightly 
thickened ;  sometimes  in  one  part  of  a  patch  there  exists  thickening,  while 
in  another  the  skin  is  thinner  than  normal.  The  disease  occurs  frequently  upon 
the  breast,  and  may  affect  any  part  of  the  body.  Sometimes  several  patches 
are  grouped  along  the  course  of  a  nerve.  At  times  the  disease  presents  itself 
as  a  number  of  small  atrophic  pits  in  the  skin. 

The  subjective  symptoms  are  insignificant,  being  limited  to  slight  itching. 
Occasionally,  the  centre  of  a  patch  will  be  insensitive. 

The  disease  persists  for  months  or  years,  and  then  may  disappear,  leaving 
the  skin  normal ;  or  the  final  result  may  be  an  atrophy  of  the  skin,  and  even 
deeper  structures.  Crocker  found  in  the  earlier  stages  of  morphoea  a  consider- 
able infiltration,  in  the  corium,  of  cells  which  later  become  connective  tissue, 
and  by  their  contraction  cause  atrophy  of  the  blood-vessels  and  glands. 

Etiology. — The  disease  may  occur  at  any  age  beyond  two  years.  It  is 
thought  by  many  to  be  a  neurotic  affection,  and  certain  facts  lend  countenance 
to  this  belief,  as  its  occurrence  with  other  disturbances  of  the  nervous  system, 
such  as  hemiatrophia  facialis,  canities,  alopecia  areata,  etc.,  and  its  being  often 
distributed  along  a  nerve-trunk. 

Diagnosis. — Leucoderma  differs  from  morphoea  in  not  presenting  any 
alteration  in  the  texture  of  the  skin,  there  being  simply  an  absence  of  pig- 
ment. The  atrophic  spots  of  leprosy  show  marked  an?esthesia,  and  the  con- 
comitant symptoms  will   aid  in  the  diagnosis.     Keloid  is  more  vascular  and 


DISEASES   OF   THE  SKIN.  1135 

denser  than  morphoea,  is  redder,  and  its  lesions  present  the  well-known  claw- 
like processes. 

Prognosis. — Although  morphoea  has  a  tendency  toward  recovery  in  the 
course  of  time,  with  no  permanent  damage  to  the  skin,  yet  in  view  of  the  cases 
followed  by  atrophy  the  prognosis  must  be  somewhat  guarded. 

Treatment. — Xo  internal  medication  has  any  effect  on  the  lesions  of  mor- 
phoea, and  thus  far  local  remedies  may  be  said  to  be  equally  futile. 


ATROPHIES. 

Albinism. 


x\lbixism  is  a  congenital  absence  of  pigment :  it  may  be  total  or  partial. 
"When  general,  not  only  the  skin,  but  also  the  hair,  the  iris,  and  the  choroid 
lack  their  normal  coloring  matters.  Persons  thus  affected  are  termed  albinos, 
and  present  the  well-known  characteristics  of  a  pink  skin,  Avhite  hair,  and  pink 
irides.  Frequently  nystagmus  may  be  observed  in  albinos,  from  the  irritating 
effect  of  the  light  upon  the  unsheltered  retinae,  ihese  persons  are  often  poorly 
developed,  both  physically  and  mentally.  Albinos  are  quite  frequently  the 
offspring  of  negro  parents. 

Partial  albinism  is  most  common  among  negroes,  and  occurs  as  limited 
areas  in  which  the  pigment  of  the  skin  is  absent.  Should  these  areas  be  found 
in  hairy  regions,  the  hair  also  lacks  its  coloring  matter.  In  rare  cases  partial 
albinism  spontaneously  recovers  by  a  new  deposit  of  pigment  in  the  affected 
part. 

Leucoderma. 

Leucoderma  is  an  acquired  diminution  of  the  pigment  of  the  skin.  It 
usually  occurs  as  one  or  more  round  or  irregular-shaped  areas,  in  which  the  skin 
is  of  a  much  whiter  color  than  the  surrounding  integument.  Such  patches  of 
skin  vary  in  size  from  a  quarter  of  an  inch  in  diameter  up  to  several  inches, 
and  their  borders  are  strongly  defined  from  the  healthy  skin  by  a  line  of  abnor- 
mally deep  pigmentation  which  surrounds  the  leucodermic  plaque.  Hairs  grow- 
ing on  the  affected  areas  may  be  white  or  may  retain  their  natural  color. 
Save   for  the  absent  pigment  the  diseased  skin  is  quite  normal. 

Leucoderma  is  generally  symmetrical,  and  occurs  most  frequently  on  the  neck, 
face,  backs  of  the  hands,  and  about  the  hips.  The  disease  tends  to  slowly 
progress,  till  in  the  course  of  time  the  whole  body  may  become  involved. 
When  leucoderma  has  thus  extended  over  a  whole  member,  it  is  often  thought 
to  have  recovered,  as  the  contrast  with  the  healthy  skin  can  no  longer  be 
remarked.  As  a  matter  of  fact,  the  pigment  is  rarely  if  ever  restored.  The 
disease  appears  to  grow  worse  in  summer,  because  at  this  season  the  pigment  of 
the  normal  skin  becomes  darker. 

Etiology. — Leucoderma  usually  develops  between  the  ages  of  ten  and 
thirty,  though  the  writer  has  seen  it  in  a  child  four  years  old.  Beyond  the 
fact  that  the  malady  seems  to  be  due  to  some  disturbance  in  innervation,  noth- 
ing is  known  as  to  its  etiology.  It  is  sometimes  secondary  to  other  diseases, 
such  as  morphoea.  alopecia  areata,   and  eczema. 

Diagnosis. — From  the  congenital  absence  of  pigment  known  as  partial 
albinism  leucoderma  is  distinguished  by  its  history,  its  symmetry,  and   its  pro- 


llSeAMUBICAJV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

gressive  tendency.  From  raorphoea  it  will  be  differentiated  by  the  fact  that  in 
the  former  disease  there  is  a  change  in  the  structure  of  the  skin.  From  the 
white  spots  which  occur  in  nerve-leprosy,  leucoderma  can  be  told  by  the  fact 
that  the  macules  of  leprosy  are  antesthetic  and  often  scaly. 

Prognosis. — There  is  little  hope  of  recovery,  though  in  time,  by  the  spread 
of  the  disease,  the  effect  is  rendered  less  startling. 

Treatment. — No  drug,  either  internally  or  locally,  has  any  effect  upon  the 
disease.  The  most  that  can  be  done  is  to  remove  the  hyperpigmented  border 
and  thus  relieve  the  contrast.  (For  the  various  means  of  accomplishing  this 
see  Treatment  of  Lentigo.)  Tatooing  or  staining  the  patches  with  walnut- 
juice  may  be  tried  where  the  cosmetic  effect  must  be  cared  for. 


Fig.  2. 


Alopecia  Areata. 

Sometimes,  after  certain  premonitory  symptoms,  such  as  headache  or  burn- 
ing or  itching,  the  hair  is  lost  from  the  scalp  in  one  or  more  circumscribed 
spots ;  more  frequently,  however,  these  sensations  are  absent,  and  the  patient's 
attention  is  first  attracted  by  the  peculiar  and  striking  areas  of  baldness.  The 
patches  are  usually  quite  white  and  perfectly  smooth,  and  give  the  appearance 
of  slight  depression.  There  may  be  one  or  many  bald  spots,  and  they  may 
vary  in  size  from  a  dime-piebe  to  that  of  the  palm,  the  larger  areas  usually 
resulting  from  coalescence  of  the  smaller  ones.  Sometimes  the  loss  of  hair  is 
general,  but  this  must  be  rare  in  children.  The  disorder  runs  a  chronic  course. 
It  may  persist  from  a  few  months  to  several  years.  When  recovery  sets  in,  the 
returning  hairs  are  white  and  downy,  but  gradually  attain  their  normal  size 
and  color. 

Etiology. — The  disease  is  comparatively  frequent  in  children.  It  is  some- 
times  noted  to  occur  after  various   illnesses,  but  more  often   there  is  no  such 

history.  A  blow  on  the  head,  or,  in 
the  adult,  persistent  neuralgia,  is  occa- 
sionally apparently  responsible  for 
limited  areas  of  the  disease.  By  some 
authorities  it  has  been  regarded  as  con- 
tagious (Hillier  and  others),  but  cer- 
tainly in  the  majority  of  instances  this 
is  not  so,  and  it  is  likely  that  the  re- 
corded cases  of  such  character  are 
susceptible  of  some  other  explanation. 
Neither  has  the  parasitic  theory  been 
maintained.  The  writer  is  in  agreement 
with  most  dermatologists  in  looking 
upon  alopecia  areata  as  a  trophoneurosis. 
Diagnosis. — The  disease  is  so  strik- 
ino;  that  its  recognition  is  a  matter  of 
little  difficulty.  Ringworm  of  the  scalp 
bears  the  closest  resemblance,  but  in 
this  latter  affection  the  patches  are  not 
smooth  and  fflistening,  but  are  covered 
with  grayish  scales,  and  scattered  over 
the  surface  are  to  be  seen  the  stumps  of  broken-off  hairs  ;  besides,  if  any  doubt 
arise,  the  microscope  will  soon  settle  the  question.  Favus,  syphilis,  and  cer- 
tain forms  of  folliculitis  would  also  be  differentiated. 

Prognosis. — The  alopecia  areata  of  young  people  generally  tends  to  spon- 


Alopecia  Areata. 


DISEASES    OF   THE   SKIN.  1137. 

taneous  recovery,  although  undoubtedly  much  hastened  by  appropriate  treat- 
ment. 

Treatment. — There  is  no  special  internal  treatment  beyond  attention  to 
any  obvious  defects  of  the  general  health.  In  rebellious  cases  small  doses  of 
arsenic  might  be  tried.  Locally,  the  demand  is  for  thorough  and  persistent 
stimulation.     The  following,  briskly  rubbed  in  twice  a  day,  is  useful : 

!^.  Acidi  salicylic 9j. 

Sulphuris  pr^ecipitati 3j. 

Vaselini • |j. 

Olei  rosse      q.  s. — M. 

Equal  parts  of  tincture  of  cantharides  and  glycerin  serve  an  equally  good 
purpose.  Pilocarpine  in  ointment  or  the  fluid  extract  of  jaborandi  in*^  lotion 
may  be  advised.  Galvanic  stimulation  with  a  metallic  brush  (negative  pole)  is 
also  to  be  recommended.  In  obstinate  cases  blistering  limited  regions  at  a 
time  with  cantharidal  collodion  gives  excellent  results. 


NEW  GROWTHS. 

Kaposi's  Disease. 


This  disease,  which  is  also  known  as  xeroderma  pigmentosum  and  angioma 
pigmentosum  et  atrophicum,  develops  in  the  first  year  of  life,  frequently 
as  an  erythema,  upon  the  disappearance  of  Avhich  small,  variously  colored  pig- 
ment-spots, resembling  freckles,  are  noted.  Sometimes  tbe  pigmentation  is  the 
first  morbid  change  observed.  In  a  short  time  small  atrophic  spots  begin  to 
appear,  and  as  the  atrophy  advances  vascular  telangiectases  of  various  sizes 
develop,  which  may,  in  severe  instances,  form  small  elevated  blood-tumors. 
Often  warty  growths  are  seen  arising  from  the  pigmented  spots.  As  the 
malady  progresses  the  atrophic  skin,  by  contraction,  may  cause  marked  defor- 
mities. Ulcers  are  prone  to  form,  and  these  or  the  warty  growths  referred  to 
may  be  the  starting-point  for  malignant  tumors  which  often  terminate  the 
patient's  life.  The  most  frequent  sites  of  the  malady  are  those  parts  which  are 
habitually  exposed — the  face,  neck,  hands,  and  feet. 

Kaposi's  disease  is  essentially  an  atrophy  of  the  skin  beginning  in  the 
papillary  body  and  epidermis.  The  tumors  which  are  associated  with  this 
process  are  usually  described  as  epitheliomata,  though  some  observers  found 
papillomata  and  sarcomata. 

Diag-nosis. — The  atrophic  stage  of  some  cases  of  scleroderma  most 
resembles  the  disease  under  consideration,  but  the  history  of  the  two  affections 
is  entirely  different. 

Prognosis. — The  prognosis  is  in  all  cases  bad,  for  after  the  malignant 
growths  have  once  developed  the  patient  has  only  a  few  years,  at  the  most,  to 
live. 

Treatment. — No  internal  medication  has  any  effect  upon  this  disease.  The 
ulcers  should  be  treated  on  general  surgical  principles,  and  the  tumors  removed 
at  as  early  a  date  as  possible. 

N^vus  Vascularis. 

The  affection  known  as  n?evus  vascularis  consists  in  a  congenital  new- 
growth  of  blood-vessels,  which  may  be  manifest  at  birth  or  may  show  itself 


1138  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

at  a  later  period.  The  clinical  picture  will  vary  much  according  to  the  size 
of  the  vessels  involved  and  the  presence  or  absence  of  implication  of  other 
structures,  such  as  the  connective  tissue,  hair-follicles,  or  fatty  tissue. 

As  usually  seen,  niBvus  vascularis  consists  of  spots  of  various  sizes,  in  color 
from  a  pale  red  to  a  bluish  hue,  not  raised  above  the  skin,  disappearing  largely 
on  pressure,  and  due  to  a  new  formation  of  capillary  vessels.  Sometimes  there 
will  be  only  a  small  pinhead-sized  point,  radiating  from  which  are  numerous 
red  lines  (nievus  araneus) :  at  other  times  areas  as  large  as  the  palm  may  be 
involved  (port-wine  mark).  This  capillary  form  of  nasvus  may  spontaneously 
disappear,  may  remain  stationary,  or  may  increase  rapidly  in  size  till  large 
areas  become  involved.  According  to  Depaul,  one-third  of  the  children  born 
at  the  Clinique  de  la  Faculte  de  M^decine  in  Paris  have  this  form  of  birth- 
mark, but  in  most  cases  the  mark  disappears  within  a  month. 

Often  over  the  surface  of  a  capillary  nsevus  warty  growths  occur,  and  at 
times  small  erectile  vascular  tumors  may  be  seen.  The  most  common  sites  for 
this  form  of  naevus  are  the  face,  scalp,  neck,  arms,  and  genitals. 

When  the  vascular  channels  constituting  the  naevus  are  of  a  larger  size,  we 
find  elevated  areas,  usually  of  a  bluish  color,  often  lobulated,  soft  and  frequently 
fluctuating,  compressible,  but  rapidly  filling  again  when  pressure  is  removed. 
In  such  tumors  pulsation  may  at  times  be  observed.  Nsevi  of  this  form  seem 
sometimes  to  develop  from  the  capillary  variety.  They  vary  in  size  from  a  pea 
to  an  orange,  and  occasionally  attain  enormous  proportions.  In  some  instances 
these  growths  lie  entirely  in  the  subcutaneous  tissue,  the  skin  being  simply 
stretched  over  them,  but  not  altered  otherwise.  Nsevi  of  this  kind  most  often 
occur  on  the  neck  about  the  lower  jaw,  on  the  buttocks,  and  on  the  lower  limbs. 

As  a  rule,  vascular  nsevi  are  not  accompanied  by  any  subjective  symptoms, 
but  in  some  of  the  pulsating  tumors  there  are  neuralgic  pains. 

Naevus,  especially  naevus  vascularis,  consists  of  new-formed  vessels  which 
are  variously  distorted,  being  convoluted  or  varicose.  Sometimes,  from  pressure, 
parts  of  the  intervening  vascular  walls  are  broken  through,  and  irregular  inter- 
communicating chambers  are  formed  (cavernous  tumors  of  some  authors).  In 
connection  with  the  growth  of  the  vessels  there  may  be  an  increased  development 
of  other  elements  of  the  skin — connective  and  fatty  tissue,  glands,  hairs,  etc. 

Etiology. — Maternal  impressions  are  thought  by  some  to  determine  the 
location  of  naevi,  and  such  views  have  been  supported  by  many  instances. 
When  we  consider  how  common  naevus  vascularis  is,  it  does  not  seem  strange 
that  there  should  often  be  an  accidental  coincidence  of  birth-mark  in  the  child 
and  "maternal  impression  "  in  the  parent. 

Diagnosis. — Naevus  vascularis  cannot  readily  be  confounded  with  any  other 
affection  of  the  skin,  and  the  diagnosis  is  easy. 

Prognosis. — The  prognosis  must  be  guarded.  Though  small  naevi  may 
remain  stationary,  or  may  even  disappear  as  the  child  grows  older,  on  the  other 
hand  they  often  increase  rapidly  in  size,  and  this  may  occur  after  the  growth 
has  remained  stationary  for  years :  this  is  especially  true  of  the  prominent  and 
pulsating  naevi. 

Treatment. — For  the  cure  of  the  elevated  or  pulsating  naevi,  when  the 
area  involved  is  of  limited  extent  and  a  reasonable  hope  of  cure  in  a  few 
sittings  may  be  entertained,  the  most  satisfactory  means  is  the  coagulating 
effect  of  electricity.  The  child  must  be  anaesthetized,  as  the  operation  occa- 
sions a  good  deal  of  pain.  A  slender  steel  needle  attached  to  the  negative  pole 
of  a  galvanic  battery  is  thrust  into  the  tumor ;  the  positive  sponge  electrode 
is  then  placed  upon  some  convenient  portion  of  the  child's  body.  The  length 
of  time  the  current  should  be  passed  must  be  determined  by  the  thickness 


DISEASES   OF   THE  SKIN.  Il39 

of  the  skin  and  the  size  of  the  vessels  of  the  tumor.  As  coagulation  occurs, 
a  paling  of  the  tumor  usually  follows.  The  needle  must  be  passed  through 
different  parts  of  the  nsevus ;  the  number  of  times  will  depend  upon  the  size 
of  the  growth.  A  current  from  twenty  to  thirty  cells  of  a  galvanic  battery 
will  suffice.  To  secure  the  complete  cure  a  number  of  sittings  will  generally 
be  required,  and  this  fact  constitutes  the  principal  objection  to  the  method. 
Some  operators  plunge  needles  attached  to  both  the  positive  and  negative  poles 
into  the  tumor,  but  the  writer  prefers  the  method  above  described. 

When  ngevi  of  this  class  are  very  large,  their  treatment  must  be  under- 
taken by  surgical  means,  a  discussion  of  which  is  not  within  the  scope  of  this 
article. 

In  the  treatment  of  the  superficial  ngevi,  where  the  affected  vessels  are  capil- 
laries, electrolysis  is  not  so  satisfactory,  for  if  the  area  involved  be  of  any  extent, 
an  indefinite  number  of  repetitions  of  the  operation  will  be  required,  and, 
moreover,  as  the  vessels  to  be  destroyed  are  so  small  and  so  numerous,  each 
sitting  must  be  of  considerable  length ;  as  the  operation  requires  anaesthesia 
in  young  children,  the  number  of  the  sittings  and  the  length  of  time  employed 
in  each  become  serious  objections  to  its  performance. 

Unless  the  birth-mark  is  very  small,  other  methods  will  be  found  more 
applicable.  Ethylate  of  soda  may  be  painted  over  the  ngevus,  and  when  the 
eschar  thus  formed  has  separated  the  remedy  may  be  reapplied  till  a  cure  is 
effected. 

A  4  per  cent,  solution  of  corrosive  sublimate  in  collodion  is  recommended, 
and  it  is  stated  that  the  resulting-  cicatrix  is  thin  and  smooth. 

Pure  carbolic  acid  may  be  brushed  over  the  neevus  ;  by  several  applications 
a  cure  will  usually  be  effected.  A  host  of  other  escharotics  has  been  recom- 
mended, but  those  mentioned  are  among  the  most  reliable. 

Multiple  puncture  and  incision,  though  strongly  advocated  by  some,  have 
failed  in  the  hands  of  many  careful  operators. 

Lupus  Vulgaris. 

Lupus  vulgaris  is  a  chronic  granuloma  of  the  skin,  depending  upon  the 
presence  of  the  tubercle  bacillus.  It  usually  manifests  itself  in  early  child- 
hood as  small  brownish-red  spots,  which  may  be  a  trifle  depressed  below  the 
skin,  on  a  level  with  the  surface,  or  even  slightly  raised.  Several  such  spots 
are  generally  noticed  in  the  same  neighborhood:  as  they  grow  older  they 
increase  in  size,  while  at  the  same  time  an  infiltration  of  the  skin  occurs : 
they  are  then  of  a  brownish  color,  semi-transparent,  softer  than  the  surround- 
ing tissues,  so  as  to  be  more  readily  broken  down  under  pressure,  and  consti- 
tute what  is  known  as  lupus  tubercles.  These  tubercles  gradually  coalesce 
by  peripheral  extension  to  form  patches  of  a  brownish-red  color,  raised  at 
the  borders,  often  depressed  in  the  centre,  accompanied  by  deep  and  firm 
infiltration  of  the  skin.  The  typical  lupus  tubercles,  which  have  been  likened 
to  masses  of  apple-jelly,  though  they  may  not  be  discoverable  in  such  a  patch, 
may  generally  be  detected  about  its  edges.  After  remaining  in  this  condi- 
tion for  an  indefinite  time,  one  of  two  processes  occurs  in  the  lupus  patch : 
interstitial  absorption  may  take  place,  producing  eventually  a  shining  depressed 
cicatrix  ;  or  the  lupus  tissue  may  break  down,  leaving  ulcers  of  various  shapes 
and  depths,  often  covered  with  crusts  and  having  raised  infiltrated  borders. 
When  healing  takes  place  after  ulceration  the  scars  are  thick  and  rough. 

Various  accidental  features  may  present  themselves  during  the  course  of 
lupus,  which  have  given  rise  to  a  number  of  special  names  ;   thus,  if  warty 


1140  AMERICAN  TEXT- BOOK  OF  DISEASES  OF  CHILDREN. 

growths  are  present  on  the  patch,  the  disease  is  known  as  lupus  verrucosus,  if 
granulations  are  exuberant,  it  is  lupus  hypertrophicus  ;  if  the  borders  advance 
in  a  sinuous  manner,  the  title  lupus  serpiginosus  is  given. 

Lupus  usually  occurs  on  the  face  about  the  nose  and  cheeks,  but  it  may 
attack  any  part  of  the  body  except  the  forehead,  chin,  palms,  soles,  and  penis, 
which  portions  of  the  body  seem  to  be  exempt.  The  mucous  membranes  may 
be  involved,  but  this  is  most  often  by  extension  from  the  adjacent  skin. 
Whole  organs  or  entire  regions  may  ultimately  be  destroyed  by  the  disease, 
but  the  onward  progress  of  lupus  is  so  slow  that  such  ravages  are  usually  not 
witnessed  till  the  patient  is  of  some  age. 

The  course  of  the  malady  is  not  uniform  ;  at  one  period  it  advances  with 
great  rapidity,  and  then  for  long  intervals  it  may  remain  quiescent. 

Various  complications  may  arise  during  the  course  of  lupus :  when  the 
disease  occurs  upon  the  limbs  and  extremities,  the  bones  may  be  destroyed  by 
caries;  erysipelas  sometimes  develops  in  the  lupus  patch,  but  often  exercises  a 
favorable  influence  upon  the  malady  ;  the  inflammatory  processes  accompany- 
ing lupus  may  involve  the  lymph-vessels,  which,  becoming  obstructed,  give  rise 
to  a  condition  resembling  elephantiasis. 

Microscopically,  lupus  tissue  is  made  up  of  a  reticulum  of  fibrous  tissue, 
the  meshes  of  which  are  filled  with  round  cells  and  a  varying  number  of  giant- 
cells.  Some  observers  have  been  able  to  demonstrate  the  presence  of  tubercle 
bacilli,  but  they  usually  occur  in  such  small  numbers  that  their  discovery  is 
difficult. 

Etiology. — Lupus  generally  begins  in  childhood,  and  is  more  common  in 
females  than  in  males.  It  is  stated  by  excellent  observers  that  a  tubercular 
family  history  may  be  obtained  in  a  majority  of  the  cases,  though  compara- 
tively fcAV  of  those  suffering  from  lupus  have  consumption.  The  observations 
of  Koch,  Pick,  Doutrelepont,  and  others  make  it  very  certain  that  lupus 
vulgaris  is  a  tuberculosis  of  the  skin. 

Diagnosis. — The  history  of  the  case  and  the  presence  of  the  lupus  tuber- 
cles generally  make  the  diagnosis  easy.  In  children  the  only  disease  with 
which  it  might  be  confounded  would  be  a  gummatous  syphilide,  and  this  is 
very  rare  in  chiWhood ;  when  a  gumma  appears,  it  goes  through  its  evolutions 
much  more  rapidly  than  lupus,  frequently  breaking  down  into  a  punched-out 
ulcer  with  sharp-cut,  thin  borders,  which  readily  heals  under  appropriate 
treatment. 

Prognosis. — The  progress  of  lupus  is  so  slow  that,  save  in  those  rare 
instances  where  the  disease  involves  a  vital  organ,  death  results  more  often 
from  some  intercurrent  trouble  than  from  the  disease  itself.  If  neglected,  hor- 
rible deformities  occur,  and  even  in  those  cases  where  a  cure  results  from 
treatment,  permanent  and  disfiguring  scarring  is  left. 

The  disease  justly  has  the  reputation  of  being  very  rebellious  to  treatment. 
Perhaps  one  of  the  chief  reasons  for  this  is  that  treatment  to  be  successful 
must  be  so  long  protracted  that  the  patient  becomes  discouraged  ere  it  is  com- 
pleted. 

Treatment. — Lupus  demands  both  constitutional  and  local  treatment. 
The  child  should  be  given  the  most  nutritious  diet ;  plenty  of  fresh  air  and 
sunshine  should  be  recommended ;  the  sleeping  apartment  should  be  well 
ventilated,  and  habits  of  cleanliness  insisted  upon.  The  two  remedies  for 
internal  administration  are  cod-liver  oil  and  the  preparations  of  iodine.  As 
large  doses  of  the  oil  should  be  given  as  can  be  borne  by  the  stomach.  The 
iodide  of  potassium  or  the  syrup  of  the  iodide  of  iron  will  be  found  the  most 
eligible  forms  for  the  administration  of  iodine. 


DISEASES    OF   THE   SKIN.  1141 

Hypodermatic  injections  of  tuberculin,  as  proposed  by  Koch,  have 
not  yielded  the  brilliant  results  at  first  expected  of  the  remedy,  and  the  most 
enthusiastic  can  now  only  claim  for  this  method  of  treatment  a  very  limited 
field. 

The  local  remedies  that  have  been  used  in  lupus  are  so  many  that  merely 
to  enumerate  them  AYould  require  more  space  than  can  here  be  given.  When 
a  case  of  lupus  is  first  seen  it  is  often  of  benefit  to  apply  for  a  time  soothing 
remedies,  as  in  this  way  external  irritation  is  removed  and  it  is  possible  to  see 
what  part  of  the  trouble  is  due  to  the  lupus  and  what  part  to  accidental  inflam- 
matory complications :  for  this  purpose  nothing  is  better  than  unguentum 
vaselini  plumbieum  spread  on  linen  and  changed  twice  a  day.  With  the  idea 
of  destroying  the  tubercle  bacilli,  any  ulcers  present  may  be  dusted  with  iodo- 
form before  the  ointment  is  applied. 

One  of  the  oldest  methods,  and  still  regarded  by  some  as  the  best,  for 
destroying  the  lupus  growth  is  by  the  application  of  the  stick  of  nitrate  of 
silver :  this  is  of  special  use  in  small  patches.  To  be  effectual  the  sharpened 
point  should  be  bored  deeply  into  the  affected  tissues. 

Pyrogallic  acid  is  one  of  the  remedies  most  frequently  used,  and  is  an 
efficient  caustic :  it  may  be  applied  in  the  form  of  a  plaster,  for  which  Duh- 
ring's  formula  is — 

^.   Acidi  pyrogallic gij, 

Emp.  plumbi *  3j- 

Cerati  resinge  comp 3v. — M. 

Sig.   Apply  on  cloth. 

This  plaster  should  be  renewed  every  twenty-four  hours  for  three  days, 
and  then  the  surface  dressed  with  a  simple  oil  dressing  till  the  eschar  is  sep- 
arated. A  mild  mercurial  ointment  then  forms  a  most  excellent  dressinof. 
The  procedure  may  have  to  be  repeated  several  times  before  cicatrization  is 
secured. 

Hebra's  modification  of  Cosme's  paste  often  produces  excellent  results. 
The  formula  is — 

I^.  Acidi  arseniosi gr.  xx. 

Hydr.  sulphuret.  rubri gj. 

Ung.  aq.  rosse  - SJ- — M. 

Sig.  Apply  on  muslin. 

This  should  be  renewed  once  a  day  for  two  or  three  days :  it  should  never 
be  used  on  a  large  surface  at  a  time,  for  fear  of  arsenical  poisoning. 

Unna's  salicylic-creasote  plaster-mull  is  highly  recommended  by  some 
writers :  this  mull  is  prepared  in  strengths  varying  from  5  to  20  per  cent,  of 
salicylic  acid,  with  twice  as  much  creasote ;  the  strength  used  will  depend 
upon  the  age  of  the  patient  and  the  amount  of  infiltration  in  the  lupus  patch. 
A  piece  of  the  mull  sufficiently  large  to  cover  the  area  which  it  is  desired  to 
attack  should  be  applied  each  day  until  enough  destruction  has  been  produced ; 
a  mild  mercurial  ointment  should  be  applied  on  cloth  until  the  healing 
occurs. 

Various  surgical  procedures  have  been  used  in  the  treatment  of  lupus.  Mul- 
tiple linear  scarification  has  been  much  employed  in  the  early  stage  of  the 
disease,  the  tissue  being  minced  as  finely  as  possible  by  numerous  cuts  made 
at  right  angles  to  each  other ;    but  this  method  of  treatment  has  been  largelv 


1142  A3fi:JiICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

superseded  by  other  more  successful  procedures.  It  is  probable  that  when  a 
surgical  operation  is  found  necessary,  scraping  with  Volkmanns  spoon  will  be 
most  satisfactory  :  the  lupus  tissue  is  softer  than  the  healthy  structures,  and  is 
more  readily  broken  down  by  the  curetting.  After  it  is  judged  that  all  the 
diseased  tissue  is  removed,  the  area  operated  upon  should  be  cauterized  with 
an  8  per  cent,  solution  of  chloride  of  zinc  or  with  the  galvano-cautery ;  the 
wound  should  then  be  dressed  in  an  antiseptic  manner.  No  matter  how 
thoroughly  curetting  may  be  done  at  each  sitting,  it  will  usually  have  to  be 
repeated  several  times  before  a  cure  is  effected. 

The  galvano-cautery  or  Paquelin  cautery  may  be  used  to  destroy  the 
lupus  growth :  after  the  tissue  has  been  thoroughly  burned  away,  the  wound 
should  be  dressed  with  a  moist  antiseptic  dressing  till  the  slough  has  sep- 
arated, and  then  dusted  with  iodoform  and  a  dry  dressing  applied. 

When  very  small  nodules  only  are  present,  electrolysis  may  be  used  for 
their  destruction :  the  needle  is  to  be  thrust  into  the  lupus  nodule  and  the 
skin  immediately  surrounding  it  until  it  is  judged  that  sufficient  destruction 
has  been  produced.  After  two  or  three  weeks,  if  the  lupus  process  still  seems 
active,  the  operation  must  be  repeated.  The  tediousness  of  its  use  forms  the 
principal  objection  to  electrolysis. 

Whatever  method  may  be  employed,  the  treatment  must  be  actively  fol- 
lowed, and  the  operations  repeated  again  and  again  as  long  as  any  of  the 
lupus  tissue  remains. 

Scrofuloderma. 

As  to  which  diseases  shall  be  grouped  under  the  term  "scrofuloderma" 
there  is  great  diiference  of  opinion  among  authors.  Three  different  forms  of 
skin  trouble  occur  with  considerable  frequency  in  those  who  are  affected  with 
the  tuberculous  diathesis  ;  these  diseases  will  here  be  considered  as  the  scrofulo- 
dermata  proper. 

The  most  frequent  form  of  scrofuloderma  is  the  ulcerous  lesion  which  is 
often  found  over  tubercular  lymphatic  ganglia,  especially  in  the  neck.  When 
such  an  enlarged  ganglion  begins  to  soften  and  break  down,  the  skin  over  it 
becomes  thinned  and  of  a  violaceous  hue.  Finally,  the  pus  and  necrotic  rem- 
nants of  the  ganglia  break  through  the  skin,  and  an  ulcer  results.  Such  ulcers 
are  round  or  oval,  their  edges  purplish  and  frequently  undermined,  their  floors 
covered  with  pale,  unhealthy  granulations.  A  thin  more  or  less  purulent  fluid 
is  constantly  secreted,  which  dries  into  thin,  light-colored  crusts.  The  progress 
of  these  ulcers  toward  recovery  is  very  slow,  and  when  healing  does  occur 
thick,  ridged  scars  result. 

Duhring  describes  a  scrofuloderm  which  consists  of  one  or  more  large  flat 
pustules  seated  upon  an  inflamed  base.  A  crust,  which  is  thin  and  brown, 
forms  slowly  ;  underneath  is  an  ulcer  which  has  the  "  peculiar  scrofulous  cha- 
racter:" the  scars  are  flat  and  superficial.  The  same  author  describes  an 
eruption  of  small  pustules  which  occurs  on  the  face  and  extremities  in  scrofu- 
lous subjects,  and  leaves  variola-like  scars. 

Another  eruption  which  occurs  usually  in  the  scrofulous  is  the  lichen 
scrofulosorum.  The  disease  consists  of  numerous  pinhead-sized  papules  of  a 
red  or  yellowish  color,  situated  usually  on  the  trunk,  sometimes  on  the  limbs, 
and  not  accompanied  by  itching  or  other  subjective  symptoms.  The  papules 
often  have  a  grouped  arrangement.  Each  papule  is  crowned  by  a  few  thin 
scales.     This  affection  is  very  rare  in  this  country. 

Etiology. — The  scrofulodermata  occur  most  often  in  children.     That  form 


DISEASES    OF    THE   SKIN.  1143 

which  is  found  -with  tuberculous  lymph-ganglia  is  due  to  the  presence  of  the 
tubercle  bacillus. 

Lichen  scrofulosorum  is  an  inflammation  which  commences  about  a  hair- 
follicle  or  sebaceous  gland,  but  Avhether  this  inflammation  is  of  microbic  origin 
is  not  yet  determined. 

Diagnosis. — Scrofulous  ulcers  are  to  be  distinguished  from  those  of  syphilis 
by  the  history,  the  concomitant  symptoms,  and  the  difi'erences  in  appearance 
of  the  ulcers  themselves.  Lichen  scrofulosorum  difi"ers  from  the  other  papular 
rashes  in  that  it  occurs  in  subjects  presenting  evidences  of  scrofula,  and  further 
that  it  is  not  accompanied  by  itching. 

Treatment. — The  therapeutic  efforts  must  be  directed  especially  toward 
bringing  the  general  health  up  to  the  highest  point.  The  best  of  food  and 
out-door  life  and  sufiicient  exercise  will  be  indicated.  Cod-liver  oil,  iron,  and 
some  form  of  iodine  are  the  drugs  most  to  be  recommended.  The  local  treat- 
ment of  the  diseased  glands  and  the  consequent  ulcers  of  the  skin  belong  more 
to  the  realm  of  surgery  than  to  dermatology,  and  the  reader  is  referred  to 
works  on  this  branch  of  medicine  for  full  details  of  the  various  operative  pro- 
cedures. When  the  ganglia  have  not  yet  broken  down  an  ointment  of  iodo- 
form, rubbed  in  several  times  a  day,  is  said  sometimes  to  cause  their  resolution. 
This  ointment  may  be  made  thus : 

^.  lodoformi 3j. 

Vaselini ij. — M. 

In  lichen  scrofulosorum  the  remedy  most  in  favor  is  cod-liver  oil,  given  in 
full  doses  and  also  rubbed  into  the  aff'ected  skin. 

Syphiloderma. 

L^'nder  the  term  syphiloderma  are  included  all  those  manifestations  of 
syphilis  which  occur  upon  the  cutaneous  surface.  In  children  syphilis  is 
almost  exclusively  a  congenital  disease.  In  those  exceedingly  rare  cases  where 
it  is  acquired  it  runs  the  same  course  and  presents  the  same  lesions  as  the 
acquired  disease  in  adult  life.  In  congenital  syphilis,  however,  the  skin  mani- 
festations present  certain  peculiarities  Avhich  place  the  syphilodermata  of  child- 
hood, as  it  were,  in  a  special  class. 

A  foetus  afi"ected  with  syphilis  may  die  in  utero,  and  thus  occasion  an 
abortion  ;  the  pregnancy  may  progress  to  term  and  the  child  be  born  with  the 
signs  of  the  disease  upon  its  body  ;  or  it  may  be  born  apparently  healthy,  and 
the  skin  lesions  of  syphilis  develop  only  after  several  weeks.  At  times  infants 
will  be  seen  presenting  evidences  of  hereditary  syphilis  in  whom  no  actual 
eruption  may  be  found  upon  the  skin,  but  in  whom  the  nutrition  of  the  skin 
is  evidently  affected,  as  it  is  thin  and  dry,  wrinkled,  and  parchment-like. 

The  syphilodermata  are  accompanied  by  the  general  manifestations  of  the 
disease,  such  as  inflammations  of  the  nose  and  larynx,  giving  rise  to  "snuffles" 
and  hoarseness ;  periostitis  and  epiphysitis  of  the  bones ;  loss  of  the  hair  and 
eyelashes ;  iritis,  etc. 

Congenital  syphilis  of  the  skin  presents  itself  as  erythematous,  papular, 
vesicular,  pustular,  bullous,  and  tubercular  eruptions ;  but  it  must  be  remem- 
bered that  these  various  elementary  lesions  may  coexist  in  the  same  subject 
or  be  evolved  from  one  another,  just  as  happens  in  the  acquired  forms  of  the 
disease.  L^pon  the  bodies  of  infants  the  erythematous  sypliiloderm  may  pre- 
sent an  appearance  and  grouping  similar  t,o  the  erythematous  syphilide  as  it 


UUA3Ii:iiICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

occurs  in  acquired  syphilis :  this,  however,  is  not  the  most  common  appearance 
of  this  form  of  eruption.  The  erythematous  rash  usually  begins  about  the  but- 
tocks and  perineum,  or  at  times  about  the  neck,  as  reddish  macules,  which  soon 
coalesce  to  form  sheets  of  yellowish-red,  shining,  often  slightly  moist  skin, 
which  resembles  an  intertrigo.  The  eruption  differs  from  intertrigo  in  that 
it  is  not  confined  to  those  parts  kept  warm  and  damp,  as  by  the  diaper,  but 
extends  both  above  and  below,  being  found  especially  along  the  back  of  the 
thighs  and  legs,  and  even  on  the  soles.  In  regions  where  warmth  and  moist- 
ure  are  not  present  the  rash  is  usually  accompanied  by  a  slight  branny 
desquamation.  While  the  eruption  is  upon  the  body  the  palms  and  soles  may 
be  found  red  and  scaling. 

The  i)apular  sypliiloderm  is  the  next  most  common  rash  of  congenital 
syphilis.  The  papules  are  generally  discreet,  sometimes  grouped,  flat,  more 
rarely  acuminate,  and  may  exist  alone  or  be  combined  with  erythematous  erup- 
tions ;  the  papules  occasionally  scale  slightly,  are  of  the  brownish-red  tint  of 
syphilis,  and  when  of  an  irregular  angular  outline  may  somewhat  resemble  the 
lesions  of  lichen  planus ;  when  they  occur  around  the  mouth  or  anus  or  in 
other  regions  where  they  are  exposed  to  irritation,  they  may  become  trans- 
formed into  mucous  patches  exactly  like  those  which  are  found  with  acquired 
syphilis.  Around  parts  which  are  much  in  motion  the  presence  of  the  papules 
causes  cracks  and  fissures,  which  result  in  scars,  such  as  are  commonly  seen  in 
the  angles  of  the  mouth  and  nose  in  syphilitic  children. 

The  vesicular  lesion,  as  the  primary  form  of  congenital  s^^philis.  is  rarely 
seen  ;  vesicles  are  more  commonly  found  developing  after  some  other  lesion, 
as  upon  papules. 

The  pustular  sypliiloderm  occurring  early  indicates  a  severe  affection  ;  it 
may  be  present  on  any  part  of  the  body,  but  is  usually  most  abundant  on  the 
face,  buttocks,  and  thighs;  about  the  mouth  crusts  are  apt  to  form,  covering 
superficial  ulcers ;  pustules  sometimes  form  around  the  borders  of  the  nails. 
Secondary  suppuration  may  supervene  upon  any  syphilitic  rash,  and  is  to  be 
distinguished  from  the  real  pustular  syphilide.  Barlow  has  described  a  syph- 
ilitic eruption  which  occurs  as  small  cutaneous  abscesses,  resembling  boils,  but 
having  no  cores. 

The  bullous  syphiloderm  occurs  quite  frequently  in  the  first  two  weeks  of 
life,  and  indicates  a  severe  phase  of  the  disease.  The  bullae  nearly  always 
affect  the  palms  and  soles ;  they  may  occur  on  other  portions  of  the  limbs  and 
about  the  lower  part  of  the  lace,  but  often  spare  the  trunk  entirely.  The 
bullous  lesions  develop  upon  dusky-red  areas  as  small  vesicles  or  pustules, 
which  rapidly  grow  to  the  size  of  a  pigeon's  egg  or  larger ;  they  may  be  tense 
or  flaccid,  round  or  irregular  in  outline,  and  are  usually  filled  with  a  cloudy, 
purulent  fluid  which  sometimes  is  blood}'.  When  the  bullae  rupture  a  dark 
broAvnish-red.  somewhat  thickened  base  remains  covered  with  the  remnants 
of  the  roof  of  the  bulla ;  at  times  greenish  crusts  form,  covering  an  unhealthy 
ulcerating  surface.  Death  frequently  follows  this  form  of  syphilis,  though  by 
prompt  and  efficient  treatment  life  may  be  saved. 

The  tubercular  syphilide  is  not  frequent  in  hereditary  syphilis,  and  then  it 
occurs  late,  so  that  it  will  rarely  be  found  in  children.  When  seen,  this  erup- 
tion is  similar  to  that  found  in  the  adult,  and  most  frequently  occurs  on  the 
face  and  anterior  surface  of  the  legs. 

The  gumma  is  a  lesion  not  uncommon  in  hereditary  syphilis,  though  it  is 
usually  a  late  lesion.  Gummata  when  present  exhibit  the  ordinary  signs  of 
these  lesions  as  seen  m  acquired  syphilis,  which  are  so  well  known  as  not  to 


DISEASES   OF   THE  SKIN.  1145 

require  special  description  here.  They  may  occur  upon  any  part  of  the  body, 
singly  or  in  groups. 

Etiology. — Syphilis  occurring  in  children  is  usually  the  result  of  a  pre- 
viously existing  syphilis  in  one  or  both  parents.  The  disease  may  be  transmitted 
by  either  mother  or  father.  If  the  mother  be  syphilitic,  abortion  is  more  likely 
to  occur  than  where  the  disease  is  transmitted  by  the  father,  since  not  only  is 
the  ovum  directly  syphilized  by  her,  but  the  nutrition  of  the  embryo  is  inter- 
fered with  by  the  impaired  state  of  the  parent's  blood.  In  regard  to  the 
question  whether  a  woman  who  is  free  from  syphilis  at  the  time  of  her  impreg- 
nation by  a  healthy  man,  but  who  contracts  the  disease  at  a  later  period  of  her 
pregnancy,  can  then'  infect  her  foetus,  there  is  great  difference  of  opinion. 
The  experiments  of  Pellizzari  go  to  show  that  the  vehicles  of  syphilitic  virus 
are  cells,  or,  at  all  events,  formed  albuminous  bodies.  Under  ordinary  cir- 
cumstances only  the  serum  of  the  blood  of  the  mother  passes  into  the  circula- 
tion of  the  foetus,  and  we  should  not  expect  it  to  become  thus  infected ;  but 
the  writer  can  see  no  reason  why,  if  some  syphilitic  inflammation  occur  in  the 
placenta,  the  cellular  elements  bearing  the  poison  might  not  pass  directly  into 
the  foetus. 

It  seems  to  be  a  fact  founded  on  careful  observation  that  mothers  of  syph- 
ilitic children  who  are  themselves  apparently  healthy  do  not  acquire  the  dis- 
ease from  nursing  and  handling  the  children,  while  healthy  nurses  often  do : 
the  facts  disclosed  by  modern  research  concerning  the  immunity  against  infec- 
tions conferred  by  the  so-called  antitoxins  of  the  blood-serum  of  an  animal 
suffering  from  the  disease,  when  introduced  into  the  blood  of  another  animal, 
are  of  interest  in  this  connection. 

Diagnosis. — In  making  the  diagnosis  of  hereditary  syphilis  a  thorough 
knowledge  of  the  personal  history  of  both  parents  is  of  importance ;  but  in 
the  absence  of  such  knowledge  the  diagnosis  can  usually  be  made  by  attention 
to  the  characteristics  of  the  lesions  as  they  present  themselves  upon  the  child's 
body. 

The  erythematous  syphilide  is  most  apt  to  be  mistaken  for  an  intertrigo 
on  account  of  its  situation,  but  it  differs  in  the  fact  that  it  extends  beyond 
the  regions  which  alone  would  be  involved  in  intertrigo. 

The  bullous  syphilide  may  be  mistaken  for  acute  pemphigus  neonatorum, 
but  it  can  be  distinguished  by  the  facts  that  the  bullse  are  in  the  palms  of  the 
hands  and  upon  the  lower  part  of  the  face,  while  the  trunk  is  left  almost  free, 
and  that  they  are  often  seated  on  an  infiltrated  brownish-red  base  and  contain 
cloudy  serum  or  pus. 

Prognosis. — In  a  general  way  it  may  be  said  that  the  greater  the  length 
of  time  between  the  acquiring  of  syphilis  by  the  parent  and  the  procreation 
of  the  child,  the  better  will  be  its  chances  for  life.  The  date  of  appearance 
of  the  rash  on  the  infant  and  its  severity  will  largely  determine  the  prognosis ; 
thus  a  child  born  with  a  bullous  eruption  will  very  likely  die  in  a  few  days, 
while  one  developing  a  roseola  in  the  second  month  will  probably  survive. 

Treatment. — The  treatment  of  hereditary  syphilis  is  conducted  in  accord- 
ance with  those  principles  which  govern  the  therapy  of  acquired  syphilis  in 
the  adult,  with  such  modifications  as  are  demanded  by  the  age  of  the  patient. 
For  a  very  long  time  efforts  have  been  made  to  introduce  medicaments  into 
the  nursing  infant  along  with  the  mother's  milk  :  for  this  purpose  mercury 
has  been  administered  to  the  mother  even  when  she  gave  no  evidence  of  the 
disease.  Only  the  most  minute  quantity  of  mercury  has  ever  been  discovered 
in  the  milk  under  such  circumstances,  so  that,  save  as  an  accessory  form  of 
treatment,  it  is  not  to  be  recommended. 


1146  AIIEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

The  best  method  of  administering  mercury  to  infants  is  unquestionably  by 
a  modified  form  of  inunction.  The  preparation  best  adapted  for  this  purpose 
is  an  ointment  of  equal  parts  of  unguentum  hydrargyri  and  vaseline.  A  piece 
of  this  as  large  as  a  hazelnut  is  rubbed  into  the  abdomen  of  the  child  night 
and  morning,  and  the  entire  abdomen  is  closely  covered  with  a  white  flannel 
binder.  Once  a  day  the  abdomen  should  be  washed  with  warm  water  and 
white  castile  soap  before  new  ointment  is  applied.  The  same  binder  should  be 
used  continuously,  as  it  becomes  gradually  charged  with  the  ointment,  so  that  it 
produces  a  constant  inunction  with  every  motion  of  the  infant.  In  case  the  skin 
becomes  irritated,  the  application  may  be  temporarily  suspended,  or  inunctions 
given  in  the  usual  way  may  be  substituted  till  the  binder  can  again  be  applied. 

If  there  be  lesions  upon  the  belly  which  will  prevent  the  use  of  the  method 
just  described,  mercury  should  be  administered  by  the  mouth.  Calomel  and 
mercury  with  chalk  are  the  preparations  most  used ;  from  one-eighth  to  one- 
half  grain  of  either  preparation,  made  into  a  powder  with  sugar  of  milk,  should 
be  placed  upon  the  infant's  tongue  just  before  it  is  to  be  nursed,  three  times 
a  day.  Tannate  of  mercury,  in  doses  of  one-twentieth  to  one-eighth  of  a  grain, 
is  prompt  in  its  action,  and  is  said  not  to  be  likely  to  cause  intestinal  disturb- 
ance. The  bichloride  of  mercury  has  many  enthusiastic  advocates.  One  of  the 
best  methods  of  giving  it  is  in  the  form  of  Van  Swieten's  liquid,  the  formula 
of  which  is — 

I^.  Hydg.  bichloridi 1  part. 

Spts.  rectificat 100  parts. 

Aquae 900  parts. — M. 

Five  to  ten  drops  of  this  should  be  given  three  times  a  day. 

The  administration  of  mercury  by  hypodermatic  injection  has  been  in  use 
for  many  years :  it  gives  prompt  results,  and  the  intestinal  tract  is  not  irri- 
tated as  when  the  remedies  are  given  per  os.  As  the  method  partakes  some- 
what of  the  nature  of  a  surgical  operation,  the  parents  nearly  always  raise 
objections  to  its  employment;  its  use  will  therefore  usually  be  confined  to 
those  cases  in  which  the  symptoms  are  very  urgent.  In  the  hypodermatic 
administration  of  mercury  the  bichloride  is  the  most  satisfactory  salt,  and 
should  be  given  in  doses  of  one  one-hundredth  to  one  twentieth  of  a  grain. 

The  use  of  bichloride-of-mercury  baths  is  of  value,  principally  as  an  aid 
to  other  methods  of  giving  the  drug.  Seven  to  thirty  grains,  with  an  equal 
quantity  of  ammonium  chloride,  are  dissolved  in  some  hot  water,  which  is 
added  to  a  bath  consisting  of  eight  gallons  of  warm  water ;  the  child  should 
remain  in  the  bath  from  five  to  ten  minutes,  and  should  then  be  warmly 
wrapped  up ;  the  bath  may  be  repeated  every  second  or  third  day.  If  no 
signs  of  weakness  or  loss  of  appetite  result  and  the  patient  improves,  the  use 
of  the  baths  may  be  continued. 

The  use  of  iodide  of  potassium  is  restricted  to  the  later  manifestations  of 
hereditary  syphilis,  such  as  gummata,  bony  lesions,  -cerebral  affections,  eye  and 
ear  troubles,  etc.  When  thought  necessary,  it  may  be  given  by  itself  in  doses 
of  one  to  five  grains  three  times  a  day,  freely  diluted,  or  it  may  be  prescribed 
with  more  benefit  in  combination  with  mercury  : 

^.  Hydg.  bichloridi gi"-  j- 

Potass,  iodidi 3ss. 

Syr.  aurantii  cort 

Aquse au  fgij. — M. 

Sig.   Five  to  ten  drops,  with  plenty  of  water,  three  times  a  day. 


DI8EASES   OF   THE  SKIN.  1147 

Aside  from  the  specific  treatment  of  syphilis  itself  as  detailed  above,  the 
general  health  of  the  child  should  be  cared  for.  It  should  have  mother's  milk 
if  possible :  when  this  cannot  be  given,  a  young  syphilitic  wet-nurse  should 
be  obtained,  for  a  healthy  woman  by  suckling  a  syphilitic  child  exposes  her- 
self  to  great  risks.  In  the  absence  of  either  one  of  these  means  of  supplying 
nourishment,  cow's  milk,  properly  diluted  to  render  it  as  nearly  as  possible 
like  human  milk,  should  be  given.  It  will  often  be  of  the  utmost  importance 
to  endeavor  to  assist  the  general  nutrition  by  the  administration  of  cod-liver  oil, 
malt,  and  hypophosphites.  If  the  child  be  angemic,  some  preparation  of  iron 
will  be  beneficial ;  it  may  be  given  in  the  form  of  the  saccharated  carbonate, 
or,  if  mercury  be  administered  by  the  mouth,  the  lactate  of  iron  may  be  com- 
bined with  it : 

^.  Hydrarg.  chlor.  mit gr.  iss. 

Ferri  lactatis g^^-  "^• 

Sacchari  albi q.  s. — M. 

Ft.  pulv.  No.  X. 
Sig.   One  to  four  a  day. 

In  whatever  form  mercury  is  given,  its  effect  must  be  closely  watched ; 
upon  the  appearance  of  anaemia  or  intestinal  trouble  or  general  weakness  it 
should  be  temporarily  suspended.  Even  if  the  child  be  doing  well  it  is  always 
best  to  stop  the  drug,  during  the  whole  course  of  treatment,  at  the  end  of 
every  month ;  after  a  week  or  so  it  may  be  again  resumed.  The  treatment 
should  be  continued  for  some  time  after  all  signs  of  syphilis  have  disappeared, 
and  the  patient  should  then  be  constantly  under  the  notice  of  the  physician, 
so  that  at  the  first  sign  of  any  relapse  treatment  may  be  resumed. 

In  the  presence  of  ulcerative  lesions  local  applications  should  be  made; 
after  the  ulcer  is  thoroughly  cleansed  with  some  antiseptic  solution,  it  should 
be  dusted  with  the  following  powder : 

^.  Zinci  oxidi 3iij- 

lodoformi 3ss. 

Hydg.  chlor.  mit " 3ss. — M. 

The  ulcer,  if  discharging,  should  then  be  dressed  with  bichloride  gauze, 
but  if  fairly  dry  unguentum  vaselini  plumbicum  may  be  spread  on  cloth  and 
placed  over  it.  Condylomata  and  mucous  patches  should  be  frequently  washed 
with  a  2  per  cent,  carbolic-acid  solution,  thoroughly  dried,  and  then  dusted 
with  the  same  powder.  In  some  cases  the  use  of  iodoform  excites  a  dermatitis 
of  the  surrounding  skin ;  it  should  then  be  left  out  of  the  formula. 

Affections  of  the  mucous  membranes,  such  as  "snuffles,"  should  be  treated 
by  douches  of  a  2  per  cent,  boric-acid  solution,  and  any  localized  lesions 
touched  with  nitrate  of  silver  in  strengths  appropriate  to  the  condition. 


1148  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

PARASITIC  AFFECTIONS. 

Tinea  Favosa. 

Favus  is  a  vegetable  parasitic  disease  affecting  the  skin  and  its  append- 
ages. It  is  most  common  on  the  hairy  scalp,  though  it  occurs  on  the  gen- 
eral surface,  and  at  times  attacks  the  nails.  On  the  scalp  the  favus  fungus 
grows  in  the  hair-follicle,  in  which  it  gives  rise  to  an  inflammation  which 
often  spreads  to  the  adjacent  tissues.  If  seen  in  the  beginning,  erythem- 
atous, scaly,  itching  patches  will  be  noticed ;  after  a  time  the  scutula  de- 
velop, and  these  are  the  characteristic  clinical  signs  of  the  disease.  At  its 
full  development  the  scutulum  is  a  sulphur-colored,  cup-like  mass,  slightly 


Fig.  3. 


Achorion  Schcenleinii  in  hair-shaft  and  follicle  (after  Kaposi). 

elevated  above  the  surface  of  the  scalp,  surrounding  a  hair  and  dipping  into 
the  follicle ;  these  cups  are  about  an  eighth  of  an  inch  in  diameter.  In  the 
the  course  of  time  the  scutula  touch  each  other  and  become  fused  into  a 
grayish  crust,  which,  firmly  adhering  to  the  base  of  the  hairs,  may  cover  a 
large  portion  of  the  scalp.     The  hairs  in  the  affected  area  become  dry  and 


PLATE  XXVIII. 


TINEA    FAVOSA 


DISEASES    OF    THE  SKIN. 


1149 


lustreless,  and,  as  their  nutrition  is  destroyed  by  the  fungus,  gradually  fall, 
thus  leaving  irregular  more  or  less  bald  areas.  A  peculiar  odor  is  to  be 
detected  in  those  suffering  from  favus,  which  has  been  likened  to  the  odor  of 
a  mouse's  nest.  When  favus  attacks  the  general  surface,  it  usually  commences 
as  vesicles  surrounded  with  inflammatory  areolae  ;  after  a  time  the  characteristic 
scutula  develop  upon  the  skin.  When  the  nails  are  involved  a  yellow  spot, 
in  reality  a  sciitulum,  may  occasionally  be  seen  at  one  point :  more  often,  how- 
ever, the  nails  become  rough,  dry,  brittle,  pitted,  and  gradually  crumble  away. 
When  the  disease  has  existed  upon  the  scalp  for  any  length  of  time,  permanent 
atrophy  and  loss  of  hair  result.  The  affection  generally  begins  in  childhood, 
and,  untreated,  may  persist  for  years  or  throughout  life.  The  subjective  symp- 
toms are  limited  to  a  slight  itching. 

Under  the  microscope  the  scutula  are  seen  to  be  formed  almost  entirely 
of  fungus. 

Etiology. — All  those  conditions  which  depress  the  general  nutrition,  such 
as  bad  food,  foul  air,  and  filthy  surroundings,  predispose  to  favus.  The  dis- 
ease exists  in  many  of  the  lower  animals — cats,  mice,  etc. — and  it  is  likely 
that  it  is  often  conveyed  from  these  to  man.  The  cause  of  tinea  favosa  is  the 
achorion  Schoenleinii  (Fig.  3),  which  invades  the  horny  layers  of  the  epidermis, 
the  root-sheaths  of  the  hair  especially,  and  often  the  hair  itself.  Recently, 
Quincke,  Unna,  and  others  have  separated  the  achorion  Schoenleinii  into  sev- 
eral varieties :  certain  trifling  clinical  differences  in  favus  may  be  accounted 
for  by  the  presence  of  one  or  the  other  of  these  forms. 

Fig.  4. 


Achorion  Schoenleinii  (after  Kaposi). 


Microscopically,  the  fungus  of  favus  is  distinguished  by  the  short  and 
jointed  appearance  of  the  mycelia,  by  the  rarity  of  the  smooth-bordered 
mycelia,  and  by  the  great  number  of  conidia  (Fig.  4).  Unna  states  also  that 
the  mycelia  of  favus  grow  at  right  angles  to  the  strata  of  the  horny  layer  of 
the  epidermis,  while  in  other  fungi  the  direction  is  more  nearly  parallel. 

Diagnosis. — Only  in  the  beginning,  or  after  the  scutula  have  united  into 
a  large  mass  will  the  diagnosis  be  difficult :  here  it  is  necessary  to  distinguish 
favus  from  eczema,  ringworm,  psoriasis,  seborrhoea,  and  lupus  erythematosus. 
The  simplest  way  of  arriving  at  a  definite  diagnosis  is  by  an  appeal  to  the 
microscope. 

Prognosis. — The  prognosis  must  be  given  with  care.     When  upon   the 


1160  A3fi:BICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

scalp,  if  the  disease  has  been  of  long  standing,  there  will  be  permanent  loss 
of  hair.     When  apparently  cured  it  is  prone  to  relapse. 

Treatment. — Whatever  method  of  treatment  may  be  pursued,  it  must  be 
supplemented  by  patience  and  perseverance.  In  recent  cases  the  disease  may 
yield  promptly,  but  in  those  of  longer  duration  treatment  must  be  continued 
for  months.  If  any  depraved  state  of  the  general  health  be  noted,  it  must 
receive  attention.  The  treatment  of  the  disease  itself  is  purely  local.  First, 
the  crust  must  be  removed ;  this  is  best  done  by  cutting  the  hair  short  and 
then  saturating  the  scalp  for  a  night  or  two  Avith  sweet  oil,  when  the  crusts 
may  be  readily  scraped  away  with  a  spatula.  Perhaps  the  most  important  part 
of  treatment  is  epilation,  as  by  this  procedure  not  only  are  masses  of  the  fungus 
actually  removed  with  the  diseased  hair,  but  the  follicle  is  thus  opened  up  and 
more  readily  permits  the  entrance  of  medicaments.  Epilation,  if  practised 
over  a  small  area  at  a  time,  is  not  a  severe  operation,  especially  as  the  hairs 
are  loosened  by  the  disease.  As  soon  as  the  hairs  have  been  removed  the 
following  solution  should  be  applied  : 

I^.  Hydg.  bichloridi gr.  ij— iv. 

Alcoholis f5j. — M. 

This  solution  should  be  mopped  on  the  affected  area  once  a  day,  and  especially 
applied  to  those  parts  that  have  just  been  epilated. 

An  ointment  of  chrysarobin  and  ammoniated  mercury  has  been  useful  in 
the  hands  of  the  writer : 

^.  Chrysarobini 3ss. 

Hydrarg.  ammoniati gr.  xx. 

Yaselini 5J. — M. 

Sig.   Rub  in  well  at  night. 

Chrysarobin  is  prone  to  excite  in  many  persons  an  erysipelatous  inflammation 
of  the  scalp,  and  its  use  therefore  demands  caution  :  it  is  best  to  begin  with 
a  weak  ointment  and  gradually  to  increase  the  strength. 

A  great  number  of  parasiticides  have  been  recommended  by  authors,  among 
them  sulphur,  tar,  carbolic  acid,  salicylic  acid,  sulphurous  acid,  oleate  of  cop- 
per, various  preparations  of  mercury,  etc.  It  will  often  be  found  necessary  to 
vary  the  use  of  these  drugs,  as  they  seem  to  lose  their  effect  after  a  time. 

While  the  diseased  area  is  being  treated  with  these  remedies  the  whole 
scalp  should  be  washed  daily  with  a  saturated  watery  solution  of  boric  acid, 
the  intent  of  this  procedure  being  to  prevent  the  inoculation  of  the  fungus 
upon  new  areas.  Every  two  or  three  days  it  will  be  necessary  to  remove  the 
old  ointment  by  shampooing  with  a  liquid  soap  made  thus : 

]^.  Saponis  oliva  proep., 5iij. 

Alcoholis fsiij- — ^I- 

Sig.  A  tablespoonful  for  each  shampoo. 

After  the  treatment  has  been  continued  till  all  signs  of  the  disease  have 
disappeared,  the  patient  should  be  kept  under  observation  for  several  months, 
and  at  the  first  sign  of  relapse  treatment  should  again  be  actively  instituted. 


DISIJASES   OF   THE  SKIN. 


1151 


Tinea  Trichophytina. 

The  trichophyton  fungus  grows  in  the  skin,  hair,  or  nails  ;  in  each  situ- 
ation it  gives  rise  to  such  peculiar  clinical  phenomena  as  to  merit  a  special 
name.  As  seen  on  the  skin  the  disease  is  known  as  tinea  circinata,  or  ring- 
worm of  the  body.  The  most  common  sites  of  the  eruption  are  the  ex- 
posed surfaces — the  face,  the  neck,  the  hands.  The  first  evidence  of  the 
disease  is  usually  a  small,  faint  red,  slightly  raised,  scaling  spot ;  this  soon 
begins  to  spread  peripherally,  while  at  the  same  time  healing  occurs  in  the 
centre ;  thus  there  is  produced  a  ring  of  small  scaling  papules  enclosing  a 
healthy  area  of  skin.  The  border  goes  on  enlarging  till  it  reaches  the  size 
of  a  dollar,  when  the  disease  may  spontaneously  disappear,  or  remain  station- 
ary for  an  indefinite  time.  Often  there  are  several  such  rings  close  together ; 
as  they  enlarge  their  borders  touch,  and,  disappearing  where  contact  occurs, 
leave  gyrate  figures.  Occasionally  several  rings  may  be  found,  one  Avithin  the 
other.    If  the  inflammation  excited  be  severe,  we  may  see  the  border  composed 

Fig.  5. 


Trichophyton  tonsurans  in  hair-shaft  and  follicle  (after  Kaposi). 

of  vesicles  or  pustules  instead  of  papules.  Occasionally  the  centre  fails  to 
clear  up  as  the  border  grows,  and  thus  plaques  of  reddened,  somewhat  thick- 
ened, scaling  skin  occur.  Rarely  the  disease  involves  the  nails,  when  they 
become  rough,  lustreless,  and  brittle. 

Tinea  tonsurans,  or  ringworm  of  the  scalp,  is  almost  never  found  in  the 
adult,  being  essentially  a  disease  of  childhood.  It  occurs  as  one  or  more  circu- 
lar scaly  patches,  in  which  the  stumps  of  broken  hairs  may  be  seen,  not  lying 
in  one  way,  as  is  natural  to  the  hair  of  the  scalp,  but  pointing  in  all  directions. 
The  color  of  the  affected  scalp  varies,  in  dark  complexions  being  a  dirty  gray, 
while  in  blonds  it  is  a  faint  red.  When  the  hair  becomes  diseased,  it  loses  its 
lustre  and  is  very  brittle,  so  that  it  readily  breaks  ofi".     The  loss  of  hair  in 


I\b2  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

the  patches  is  occasionally  complete,  and  the  scalp  is  left  smooth  and  shining, 
so  that  the  disease  is  indistinguishable  from  an  alopecia  areata.  In  a  rare 
form  of  the  disease,  known  as  tinea  tonsurans  disseminata,  there  occur  scat- 
tered over  the  scalp  small  clumps  of  diseased  hairs.  Sometimes  small  pustules 
may  be  seen  around  some  of  the  hairs  in  an  affected  area  ;  this  resembles  Avhat 
occurs  in  a  more  severe  form  in  kerion,  which  is  an  acute  folliculitis,  giving 
rise  to  a  circumscribed,  doughy  swelling,  studded  over  which  may  be  seen  the 
widely-gaping  diseased  follicles.  When  pressure  is  made  upon  such  a  swelling, 
a  thick  muco-purulent  material  exudes  from  the  follicles,  which  have  usually 
lost  their  hairs. 

Ringworm  of  the  scalp  is  not  accompanied  by  subjective  symptoms. 
Untreated  it  may  continue  indefinitely. 

Etiology. — The  cause  of  ringworm  is  the  trichophyton  fungus.'  It  is  an 
odd  fact  that  it  attacks  the  scalp  almost  always  only  in  children,  while  the 
general  surface  may  be  affected  at  any  age.  The  fungus  exists  in  the  lower 
animals,  and  may  be  transferred  from  them  to  man ;  it  grows  only  in  the  epi- 
dermic structures,  and  is  not  found  in  living  tissues. 

Diagnosis. — Tinea  circinata  must  be  distinguished  clinically  from  syphilis, 
eczema,  psoriasis,  and  seborrhoea.  In  syphilis  the  concomitant  symptoms  will 
generally  suffice  for  differentiation ;  the  border  of  the  circinate  syphilide  is 
more  sharply  defined  and  of  a  darker  red  color  than  the  border  of  ringworm  ; 
the  erythematous  syphilide  is  widely  diffused  and  scaling  is  absent.  In  eczema 
the  itching  forms  a  marked  feature,  and  the  disease,  as  a  rule,  does  not  present 
the  sharply-defined  border  of  tinea  circinata,  Avhile  exudation  and  crusting  are 
more  marked ;  furthermore,  when  tinea  occurs  in  solid  plaques,  so  as  to 
resemble  eczema,  it  is  often  present  simultaneously  on  the  scalp.  The  lesions 
of  the  circinate  form  of  psoriasis  present  a  heavier  scaling,  and  the  disease 
may  often  be  found  occupying  its  characteristic  sites  on  the  knees  and  elbows. 
In  seborrhoea  the  scales  are  thick  and  greasy,  and  on  their  removal .  patulous 
sebaceous  ducts  may  be  seen. 

Tinea  tonsurans  may  be  confounded  with  alopecia  areata  and  eczema,  pso- 
riasis, and  seborrhoea  affecting  the  scalp.  In  eczema  the  patches  are  not  sharply 
limited,  crusting  and  itching  are  present,  and  the  hairs  are  only  matted  to- 
gether, not  broken,  as  in  tinea.  In  psoriasis  the  scales  are  thick  and  abun- 
dant ;  the  hairs  are  not  affected ;  and  the  disease  may  be  found  elsewhere, 
occupying  its  favorite  sites.  Seborrhoea  usually  affects  the  whole  scalp ;  the 
scales  are  greasy  ;  and,  though  the  hair  is  thin,  no  broken  or  twisted  stumps 
are  seen.  Ordinarily  tinea  presents  a  very  different  appearance  from  alopecia 
areata  with  its  smooth  shining  patches  of  perfectly  bare  scalp ;  in  those  cases 
of  tinea  mentioned  above,  which  very  closely  resemble  alopecia  areata,  often 
some  affected  hairs  may  be  discovered  at  the  border  of  the  patches,  and  a 
microscopical  examination  may  reveal  the  true  nature  of  the  disease. 

In  every  case  of  tinea  the  surest  way  of  avoiding  mistakes  is  by  a  micro- 
scopical examination.  Scales  should  be  removed  or  hairs  drawn  and  placed 
in  a  few  drops  of  liquor  potassse  upon  a  slide  and  covered  with  a  cover-glass ; 
after  a  few  hours  the  scales  or  hairs  will  be  rendered  transparent  enough  to 
permit  the  fungus  to  be  seen.  The  trichophyton  fungus  occurs  as  smooth- 
bordered  branching  mycelia,  and  as  conidia,  single  or  in  chains  (Fig.  5) ;  in  the 
hair  both  forms  may  be  found  in  the  inner  root-sheath  and  in  the  substance 
of  the  hair  itself. 

Prognosis. — Ringworm  of  the  body  is  readily  curable.  On  the  scalp  it  may 
last  indefinitely  unless  the  treatment  be  kept  up  with  untiring  patience  and  vigor. 

'  Recently  Sabouraud  and  others  have  described  four  varieties  of  the  trichophyton  fungus. 


DISEASES    OF    THE  SKIN.  1153 

Treatment. — The  treatment  of  tinea  circinata  is  purely  local ;  it  is  usually 
readily  cured.  Often  a  few  applications  of  tincture  of  iodine  will  suffice,  or 
one  of  the  following  ointments  may  be  used  :• 

I^.  Acidi  salicylici gr.  xxx. 

Sulphuris  praecip 3j, 

Vaselini §j. — M. 

Sig.  Rub  into  affected  area  once  or  twice  daily. 

^.  Hydrarg.  ammoniati gr.  xx. 

Lanolini §j. 

Olei  olivse fgij. — M. 

Sig.  Apply  twice  a  day. 

i^.  Cupri  oleatis 3ss— j. 

Vaselini 5j. — M. 

Sig.  Apply  twice  a  day. 

In  the  treatment  of  tinea  tonsurans  the  entire  armamentarium  of  the 
physician  will  sometimes  be  required  to  bring  about  a  cure.  As  a  preliminary 
step  the  hair  should  be  cut  short  and  all  scales  removed.  Epilation,  though 
not  absolutely  necessary,  is  no  doubt  of  assistance,  and  should  be  practised  in 
all  inveterate  cases ;  many  advise  removing  the  hairs  from  the  area  immedi- 
ately surrounding  the  patch  of  tinea,  thus  hindering  its  spread.  During  the 
whole  course  of  treatment  the  head  should  be  washed  daily  with  soap  and 
water,  and  then  sponged  with  a  saturated  solution  of  boric  acid.  In  young 
children,  the  disease  in  the  beginning  will  often  yield  to  a  simple  ointment  like 
the  following  : 

I^.  Sulph.  prgecip 3j. 

TJng.  aq.  rosse 3ij. 

Lanolini S;vj. — M. 

Sig.  Apply  twice  a  day. 

Coster's  paint  may  be  applied  to  the  patch  with  a  stiff  brush  every  four  or 
five  days,  the  formula  of  this  is : 

^.  Iodine 3ij. 

Colorless  oil  of  wood-tar 3v. — M. 

In  an  epidemic  recently  treated,  the  application  of  a  1  per  cent,  aqueous 
solution  of  rosanilin  hydrochlorate,  rubbed  in  well  once  a  day,  served  to  check 
promptly  the  disease  in  its  early  development. 

Of  the  mercurial  preparations,  the  oleate  and  white  precipitate  are  the 
most  efficacious.  They  may  be  prescribed  in  the  form  of  ointments  varying 
from  2  to  5  per  cent. 

In  the  experience  of  the  writer  the  most  valuable  drug  in  the  treatment 
of  chronic  cases  is  chrysarobin.  It  may  be  used  in  the  form  of  an  ointment 
slightly  modified  from  that  recommended  by  Hutchinson  : 

I^.  Chrysarobini 3ss— j. 

Hydrarg.  ammoniati gr.  xx. 

Liq.  carbonis  detergentis TTLxx. 

Lanolini ,^j. 

Olei  olivse f^j. — M. 

Sig.  Rub  in  at  night. 

'73 


1164:  A3fi:BICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Chrysarobin  must  always  be  used  with  caution  ou  account  of  its  tendency  to 
excite  severe  inflammation. 

Crocker  thinks  highly  of  the  use  of  croton  oil  in  cases  of  limited  extent 
in  children  over  six  years  old;  it  may  be  used  in  a  liniment  with  olive  oil, 
1  :  10,  rubbed  into  the  patch  until  inflammation  is  excited ;  or  it  may  be 
pricked  into  the  diseased  follicle  with  a  needle ;  the  suppuration  which  the 
croton  oil  excites  destroys  the  fungus. 

Of  late  much  has  been  said  in  favor  of  the  employment  of  electric  cata- 
phoresis  in  the  treatment  of  tinea  tonsurans.  The  positive  sponge  electrode 
is  saturated  with  a  1  per  cent,  solution  of  corrosive  sublimate  and  applied  to 
the  patch,  while  the  negative  electrode  is  placed  upon  some  other  part  of  the 
body. 

^"hen  the  fungus  has  invaded  only  a  few  follicles  or  remains  in  a  limited 
number  in  spite  of  treatment,  the  electric  needle  may  be  introduced  and  the 
follicle  destroyed. 

In  kerion  the  hairs  should  be  pulled  and  some  soothing  antiseptic  ointment 
applied. 

In  any  case  of  tinea  tonsurans  treatment  is  to  be  actively  continued  as 
long  as  any  hair-stumps  can  be  detected. 


Scabies. 

This  disease  is  not  so  common  in  this  country  as  on  the  Continent.  The 
lesions  seen  in  scabies  are  due  to  the  ravages  of  the  itch  mite  (acarus 
scabiei).     It   is   only  the  female  which    attacks  the   skin,  the  male   merely 

remaining  upon  the  surface.     The 
^^^"-  ^-  female  burrows  under  the  epithelium 

for  the  purpose  of  laying  her  eggs. 
She  lives  about  two  months,  and 
lays  in  this  time  about  fifty  eggs, 
which  hatch  in  two  weeks.  The 
itch-mite  selects  those  parts  of  the 
skin  in  which  to  make  her  burrow 
where  the  epithelium  is  not  very 
dense,  as  between  the  fingers,  flex- 
ures of  the  joints,  axillie,  about  the 
genitals,  etc. 

The  lesions  found  in  scabies  are 
those  directly  due  to  the  presence 
of  the  mite  and  secondary  ones  due 
to  scratching.  The  burrow  is  the 
most  characteristic  lesion.  This 
consists  of  a  small,  fine,  black, 
zigzag  line,  from  one-eighth  to 
one-half  an  inch  long,  lying  just 
beneath  the  upper  layers  of  the 
epidermis.  It  is  often  difl^cult  to 
find  the  burrows,  as  scratching 
and  bathing  destroy  them.  Sometimes  the  acarus  may  be  seen  lying  at 
one  end  of  the  burrow  as  a  small  white  speck. 

The  presence  of  the  itch-mite  excites  various  grades  of  inflammation  : 
papules,  vesicles,  and  pustules  will  be  found  intermingled  on  those  parts  of 
the  body  where  the  skin  is  thin  and  where  warmth  and  moisture  exist.     In 


Female  Acarus  (after  Anderson). 


DISEASES    OF   THE   SKIN. 


1155 


infants  in  arms  the  face  is  often  involved,  as  it  is  kept  warm  by  pressure 
against  the  mother  when  the  child  nurses  ;  the  feet  and  buttocks  may  present 
the  lesions  of  scabies,  as  they  are  protected  by  the  warm  clothing.  Itching 
is  severe,  and  we  usually  find  various  lesions  as  the  result  of  scratching — 
scratch-marks,  crusts,  furuncles,  and  pigmentations.  None  of  the  lesions  of 
scabies  show  any  tendency  toward  grouping,  but  are  scattered  irregularly  over 
the  surface. 

In  severe  cases  nearly  the  whole  body  may  be  involved,  while  in  very  mild 
ones  only  a  few  scattered  papules  or  vesicles  may  exist.  If  not  treated,  the 
disease  may  persist  for  years. 

Etiology. — Though  markedly  contagious,  the  disease  does  not  seem  to  be 
communicated  by  ordinary  contact,  but  only  by  prolonged  exposure,  such  as 
wearing  infected  garments  or  sleeping  in  infected  beds.  No  age,  sex,  or  social 
condition  is  exempt,  but  filth  and  infrequent  bathing  give  the  acarus  a  better 
chance  by  leaving  its  burrow  undisturbed. 

Diagnosis. — Scabies  might  be  mistaken  for  an  eczema,  but  eczema  does 

Fig.  8. 


Fig.  7. 


Larva  (after  Anderson). 


Male  Acarus  (after  Anderson). 


not  present  such  multiformity  of  lesions,  is  not  apt  to  be  so  widely  dissem- 
inated, and  the  individual  elements  are  aggregated  or  grouped.  The  finding 
of  the  burrow,  and  more  especially  of  the  acarus  itself,  is  proof  positive  of 
scabies  (Figs.  6,  7,  8). 

Prog-nosis. — The  prognosis  of  scabies  is  always  favorable. 

Treatment. — The  disease  is  readily  cured  if  the  treatment  be  properly 
carried  out.  Before  any  local  application  is  given  the  patient  should  receive 
a  hot  bath,  with  thorough  rubbing,  using  green  soap.  Probably  the  most 
generally  successful  remedy  in  the  treatment  of  scabies  is  sulphur.  The  fol- 
lowing ointment  should  be  well  rubbed  in  over  all  the  affected  parts  of  the 
body  morning  and  evening  for  three  days ; 

^.  Sulphuris  prsecip 3iij-vj. 

Vaselini §vj. 

01.  rosge q.  s. — M. 

The  same  under-clothing  and  sheets  should  be  used  until  the  treatment  is 
completed ;  then  the  patient  takes  a  hot  bath  with  soap,  puts  on  fresh  under- 
clothes, and  sleeps  between  clean  sheets,  all  that  he  has  previously  used  being 
boiled ;  his  outer  garments  should  be  ironed  with  a  very  hot  iron. 


115Q  AIIUBICAJV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Many  other  remedies  have  been  recommended,  and  a  few  of  the  most  use- 
ful formulcB  are  added : 

I^.  Styracis  liquid! f,lj. 

Adipis 3J- — M. 

Sig.  Rub  in  twice  a  day, 

'Bf,.  Sulphuris  praecip 3j. 

Balsami  Peruv , 3ss. 

Vaselini SJ- — M. 

Sig.  Rub  in  twice  a  day. 

Kaposi  advises  the  use  of  naphthol. 

It  is  of  the  utmost  importance,  no  matter  what  method  of  treatment  may 
be  used,  to  prevent  reinfection  by  attention  to  the  rules  in  regard  to  clothing 
and  bedding  above  laid  down.  If,  when  specific  treatment  is  completed,  the 
skin  remains  inflamed  and  irritable,  some  soothing  ointment  should  be  used ; 
the  following  answers  very  well : 

^.  Zinci  oxidi SJ. 

Ung.  aq.  rosse 3ij. 

Lanolini 3vj. 

Sig.  Apply  as  often  as  necessary. 

Pediculosis. 

In  the  children  of  the  poor  the  head-louse  is  very  common,  and  occasion- 
ally the  pubic-louse  may  be  found  on  the   hairs  of  the  eyebrow  or  on  the 

lashes.     On  the  head  the  louse  (Fig.  9) 

is  most  apt  to  confine  itself  to  the  occip- 
ital region  ;  here  the  irritation  it  causes, 

together  Avith  scratching,  soon  sets  up  a 

dermatitis,  which  may  range  from  a  few 

scattered  pustules  to  a  condition  in  which 

the  whole  region   is   covered   by  crusts 

and  exudes  a  thick,  sticky  liquid,  which 

mats  the  hair  and  by  its  decomposition 

gives  rise  to  a  disagreeable  odor :  this 

purulent    matter    may  be    conveyed    to 

other  parts  of  the  body  upon  the  fingers, 

and    thus  set  up    a   pustular   eruption. 

The  lymph-ganglia  of  the  neck,  which 

communicate  with  the  lymphatic  chan- 
nels of  the  scalp,  are  apt  to  become  enlarged,  tender, 
and  in  poorly-nourished  children  may  suppurate.  If  the 
hair  be  long,  so  that  it  hangs  upon  the  neck,  a  similar 
dermatitis  may  be  caused  in  that  region. 

Whenever  we  find  a  pustular  eczema  confined  to  the 
occipital  region  of  a  child,  we  should  at  once  look  for 
pediculi.  If  these  are  present  only  in  small  numbers, 
it  is  often  easier  to  discover  the  eggs  or  nits  than  the 
louse.  Usually  one  or  tAvo  nits  will  be  attached  to  a 
single  hair,  though  sometimes  many  are  found  upon  one 
shaft ;  they  appear  as  small  white  specks  firmly  attached  to  the  side  of  a 
hair.  They  may  be  mistaken  for  crusts,  but  a  hair  passes  through  the  centre 
of  a  crust,  and  a  crust  may  be  easily  brushed  away,  while  a  nit  is  firmly 


Fig 


Fig.  10. 


Male  Pediculus 

Capitis 
(after  Kuchen- 

meisterj. 


Nits  of  Pediculus  Capitis 
(after  Kaposi). 


DISEASES   OF   THE  SKIN.  1157 

glued  to  the  shaft.  In  the  rare  cases  where  the  pubic  louse  has  infested  the 
eyebrows  or  lashes  of  a  child,  the  most  noticeable  signs  of  its  presence  are  the 
punctate  haemorrhages  in  the  surrounding  skin,  caused  by  the  bite  of  the 
insect.  In  these  regions  the  pediculi  and  their  knits  may  be  found  upon 
the  hairs  close  to  the  skic. 

Etiology. — Pediculosis  is  contracted  by  contact  with  a  lousy  person  or  some 
object  containing  pediculi,  such  as  hats,  caps,  and  other  articles  of  clothing. 

Treatment. — In  children  the  hair  should  be  cut  short  and  the  crusts  soft- 
ened with  olive  oil  and  removed.  The  head  should  then  be  thoroughly  anointed 
with  petroleum,  the  parents  being  warned  not  to  allow  the  child  to  approach  a 
lamp  or  fire  while  the  coal-oil  is  on  the  hair.  The  petroleum,  having  re- 
mained on  all  night,  should  be  washed  off  the  following  morning  with  soap 
and  water.  Two  such  applications,  made  on  successive  nights,  will  kill  the 
pediculi,  but  the  nits  are  more  difficult  to  destroy.  To  remove  them,  in 
cases  where  the  hair  cannot  be  cut  off,  it  should  be  taken  up  in  small  bunches 
and  carefully  sponged  with  vinegar ;  this  softens  the  glue  which  attaches  the 
nits  to  the  hair-shafts,  so  that  they  may  be  readily  removed  with  a  fine-toothed 
comb. 

The  treatment  as  above  detailed,  if  carefully  carried  out,  will  be  found 
entirely  satisfactory.  If  for  any  reason  petroleum  pannot  be  used,  the  follow- 
ing ointment  may  be  applied  for  several  days : 

^.  Hydrarg.  ammoniati gr.  xx. 

Vaselini §j. — M. 

Whatever  method  of  treatment  may  be  used,  a  dermatitis  will  still  remain, 
which  should  be  treated  by  soothing  ointments. 


PART    XTII, 


DISEASES  OF  THE  EAR. 

By  B.  ALEXANDER  RANDALL,  A.  M.,  M.  D. 

Philadelphia. 


The  organ  of  hearing  is,  in  its  normal  function,  one  of  the  most  important 
of  the  body,  especially  in  the  child,  since  it  is  the  seat  of  the  sense  which  is 
second  to  the  sight  only,  if  at  all,  as  the  link  between  the  individual  and  his 
fellows,  and  through  the  help  of  which  a  very  large  part  of  his  education  is 
acquired  and  his  value  as  a  worker  made  available.  Loss  of  hearing  reacts 
sadly  upon  most  adults  in  cutting  them  off  from  easy  intercourse,  and  is  very 
apt  to  engender  a  suspicious  and  discontented  frame  of  mind ;  while  in  the 
child  it  is  still  more  serious,  since  it  bars,  to  a  greater  or  less  degree,  so  many 
channels  of  learning,  sympathy,  and  practical  usefulness  before  they  have 
even  begun  to  convey  their  wealth  to  the  forming  mind. 

The  diseases  of  the  ear  are  of  great  importance,  also,  because  of  their 
frequency  and  seriousness — facts  which  are  all  too  little  understood  or  accepted 
— for  they  endanger  life,  as  well  as  function,  much  oftener  than  do  the  more 
noticed  lesions  of  the  eye,  which  are  probably  little  more  numerous.  They 
are  far  more  insidious  and  readily  overlooked  in  children  than  in  adults,  since 
complaint  is  rarely  made  of  any  subjective  symptom  except  pain;  and  only 
slowly  will  parents  generally  appreciate  that  the  alleged  "  slowness "  or 
"stupidity"  of  children,  and  their  habit  of  "asking  over  again,"  are  due  to 
a  real  physical  infirmity.  Add  to  this  the  weighty  fact  that  in  childhood  are 
quietly  laid  the  foundations  for  most  disqualifying  and  steadily  progressive 
forms  of  deafness,  which  are  little  amenable  to  later  treatment,  and  the 
importance  becomes  manifest  of  their  recognition  at  the  earlier  period,  when 
they  can  be  successfully  combated. 

Embryologically,  the  organ  of  hearing  arises  in  three  distinct  portions,  the 
first  being  the  otic  vesicle,  which  forms  as  a  pouch  from  the  epiblastic  surface, 
develops  to  form  the  labyrinth,  and  becomes  distinctly  nerve-tissue  in  part 
and  intimately  connected,  by  the  auditory  nerve,  with  the  brain  ;  the  second 
is  the  mucous  cavity,  extending  out  and  back  from  the  pharynx  in  the  line  of 
the  closed  second  branchial  cleft  to  form  the  Eustachian  tube  and  tympanic 
cavity,  including  the  so-called  mastoid  antrum  and  the  communicating  cells ; 
while  the  third  portion  is  a  cutaneous  projection  and  pouch  growing  outward 
and  in,  respectively,  to  form  the  auricle  and  the  external  auditory  meatus. 
Mesoblastic  tissues  remain  as  barriers  between  these  parts,  yet  serve  to  link 
them  together — the  tympanum  having  the  drumhead  with  the  malleus  separating 
it  from  the  external  ear,  and  the  bony  labyrinth-capsule  with  the  membranes 
of  the  fenestra  constituting  the  division  betAveen  it  and  the  internal  ear. 

Physiologically    and    pathologically,    this    distinction    is  maintained;   the 

1158 


DISEASES   OF   THE  EAR.  1159 

internal  ear  remaining  as  the  sound-receiving  apparatus,  in  contrast  to  the 
conducting  apparatus  external  to  it :  and  disease  shows  that  the  labyrinth 
inclines  to  share  in  brain  disorders  ;  the  tympanum  remains  part  of  the  upper 
air-passages,  involved  in  most  of  the  lesions  of  that  tract ;  while  the  external 
ear  suffers  little  except  from  the  disorders  of  the  cutaneous  surface.  Clinical 
work,  likewise,  maintains  the  divisions  thus  defined,  and  our  methods  of  study 
fall  largely  into  the  three  forms  of  topical,  pneumatic,  and  acoustic  meavSures 
according  as  the  external,  middle,  or  internal  ear  is  aimed  at.  Treatment  of 
the  aural  disorders  is  principally  on  the  same  lines  ;  and,  in  spite  of  the  incom- 
pleteness of  the  demarcation  in  some  instances,  this  forms  the  most  natural 
and  advantageous  division  of  our  subject. 

In  the  study  and  treatment  of  the  ear  in  children  some  care  is  generally 
requisite  as  to  the  holding  of  the  patient.  If  small,  he  is  usually  best  held 
in  the  lap  of  an  adult,  as  the  mother,  with  head  resting  upon  her  breast  and 
the  ear  to  be  examined  turned  toward  the  physician.  One  arm  passes  around 
the  child's  waist  from  behind  and  holds  the  hands,  while  the  other  is  ready  to 
steady  the  head  or  meet  any  other  requirement.  Some  throwing  back  and 
twisting  of  the  head  may  be  expected ;  but  the  physician's  hand  in  drawing 
and  holding  the  auricle  outward,  backward,  and  down  or  up,  as  the  config- 
uration of  the  parts  may  demand,  can  take  points  of  counter-pressure  for  his 
hand  upon  the  child's  head  and  do  much  to  steady  it.  In  mopping  and  other 
manipulations  the  movements  of  the  child  should  be  followed  as  closely  as 
possible,  especially  if  the  ear  is  painful,  for  much  roughness  and  restraint  may 
be  thus  avoided.  The  active  struggles  and  screaming  of  a  child  cease  most 
acceptably  in  many  instances  as  the  applicator  actually  enters  the  ear,  and 
perfect  quiet  is  maintained  until  it  is  withdrawn,  as  though  the  child,  in 
anticipation  of  something  awful,  were  reserving  its  powers  to  do  justice  to  the 
occasion.  With  older  children  quiet  can  often  be  obtained  by  allowing  them 
to  stand  or  sit  free,  while  the  examination  is  directed  first  to  the  unaffected 
ear,  the  nose,  and  the  throat,  and  they  are  plied  with  questions,  jesting  as  well 
as  serious.  Moderate  stillness  yielded  spontaneously  is  generally  better  than 
that  which  can  be  enforced  by  the  efforts  of  three  or  four  strong  adults,  and 
considerable  patience  in  winning  confidence  and  obedience  will  usually  prove 
good  policy ;  but  if  restraint  has  to  be  enforced,  it  should  be  as  overAvhelming 
as  possible,  so  as  to  demonstrate  the  futility  of  resistance  and  the  real  gentleness 
of  the  treatment,  for  it  is  generally  fright  or  wilfulness,  rather  than  pain,  that 
is  the  disturbing  element.  Facility  in  the  measures  of  examination  and 
treatment,  especially  without  instrumental  aids,  counts  for  a  great  deal,  since 
every  speculum,  tongue-depressor,  or  other  instrument  may  be  an  object  of 
terror  as  well  as  a  probable  source  of  discomfort.  The  unaided  view  into  a 
canal  may  be  restricted  and  incomplete,  yet  if  the  light  spot  can  be  seen  and 
no  redness  is  visible  along  the  handle  of  the  malleus,  tympanic  inflammation 
may  be  excluded ;  and  flakes  of  epidermis,  etc.  along  the  walls  may  then  be 
let  alone,  which  would  be  pushed  up  before  a  speculum  and  require  removal 
before  any  view  could  be  obtained. 

Affections  of  the  External  Ear. 

The  external  ear,  although  tangible  and  prominent,  is  far  less  important  for 
our  consideration  than  the  middle,  and  furnishes  hardly  25  per  cent,  of  aural 
work  ;  and  the  labyrinth  suffers  so  rarely  that  less  than  10  per  cent,  of  ear 
diseases  affect  it,  leaving  the  mucous  membrane  of  the  tympanum  to  bear  the 
responsibility  of  quite  two-thirds  of  all  aural  disorders.     Yet  access  to  the 


1160  A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

deeper  structures  is  partly  through  the  auditory  canal,  and  the  disorders  and 
study  of  this  portion  may  best  be  first  considered. 

The  auricle,  as  a  skin-covered  projection  of  fibro-cartilage,  is  open  to  ready 
inspection  and  palpation  for  its  study,  and  its  position  exposes  it  to  trauma  as 
well  as  to  various  cutaneous  aflections.  Its  congenital  malformations  of  distor- 
tion, reduplication,  or  defect  ai'e  of  interest  rather  as  curiosities  than  as  path- 
ological conditions,  and,  except  for  appearance'  sake,  rarely  concern  the  aural 
surgeon.  Supernumerary  auricles  or  auricular  appendages  may  be  removed 
if  conspicuous  ;  the  persistence  of  the  branchial  cleft,  as  the  so-called  ••  aural 
fistula,"'  may  call  for  a  tiny  plastic  operation  to  close  it;  huge  auricles  may  be 
brought  to  more  reasonable  dimensions  by  the  excision  of  a  wedge-shaped  seg- 
ment, or  veiy  prominent  auricles  may  be  fastened  more  closely  in  by  excising 
a  crescentic  flap  behind  them.  These  are  mere  matters  of  surgical  common 
sense.  Minuteness  of  the  auricle  or  absence,  congenital  or  traumatic,  may 
tempt  the  surgeon  to  plastic  efforts  ;  but  it  must  be  remembered  that  without 
cartilaginous  framework  any  semblance  of  an  auricle  is  quite  hopeless,  and  that 
transplanting  of  cartilage,  except  from  the  adjacent  meatus,  has  always  proven 
a  failure.  Upon  the  hearing,  these  conditions  are  practically  without  influence, 
and  any  rash  experimentation  is  unjustifiable. 

The  habit  of  piercing  the  ears  for  ear-rings  is  responsible  for  some  of  the 
lesions  of  the  auricle,  aside  from  the  tearing  of  the  lobules  from  traction  upon 
them ;  for  the  services  of  an  itinerant  vender  of  ear-rings  are  sometimes  followed 
by  a  surprising  group  of  cases  of  abscess  of  the  lobule,  apparently  aff'ecting  in 
a  neighborhood  every  little  girl  who  had  not  previously  been  subjected  to  the 
rather  barbarous  custom.  Although  usually  limited  and  without  diffused  infec- 
tion, these  abscesses  deserve  some  surgical  care,  for  their  healing  may  be  slow 
and  disfiguring.  The  infiltration  may  be  of  less  passing  nature,  and  there  may 
result  a  fibroid  or  so-called  keloid  tumor,  which  tends  to  groAv  rather  persist- 
ently and  to  recur  after  removal.  These  are  rather  uncommon,  except  in  the 
neorro.  The  malignant  tumors  are  too  rare,  even  in  adult  life,  to  demand  notice. 
Dermoid  cysts,  probably  congenital,  may  occur  in  the  sulcus  behind  the  auricle, 
and  cyst-like  perichondritic  effusions  or  haematomata  may  fill  the  concavities  of 
its  anterior  aspect  as  the  result  of  trauma. 

The  inflammatory  lesions  of  the  auricle  are  almost  always  of  an  eczematous 
character.  Herpes  is  rarely  met  and  hardly  distinguished  with  certainty,  except 
by  the  occurrence  of  severe  pain  for  hours  or  days  before  the  visible  lesions. 
True  erysipelas  is  very  rare,  though  not  infrequently  simulated  by  a  severe 
eczema.  Specific  lesions  may  take  almost  any  form,  though  generally  pustular 
or  rupial. 

Eczematous  Ixflammatioxs. — These  are  usually  secondary  to  some  irri- 
tant, such  as  an  excoriating  purulent  discharge  from  the  tympanum ;  and  the 
main  measure  of  treatment  is  protection  from  the  cause,  which  should  be  re- 
moved if  possible.  The  eczema  is  generally  marked  in  the  furrow  back  of 
the  auricle,  where  Assuring  may  be  deep  and  inveterate,  and  cicatrization 
may  bind  the  auricle  tightly  down  upon  the  mastoid ;  but  fissures  of  the 
lobule  and  intertragus  notch  may  be  deep  and  disfiguring.  The  dyscrasia, 
conveniently  though  vaguely  termed  "•  strumous,"  is  apt  to  underlie  and 
strongly  influence  the  condition  ;  and  similar  lesions  of  eyelids,  nares.  and  lip 
are  apt  to  be  present,  with  swelling  or  suppuration  of  the  adjacent  glands.  For 
its  cure  eczema  often  demands  long,  varied,  and  laborious  treatment.  Internally 
such  tonics  as  cod-liver  oil,  hypophosphites,  and  iodide  of  iron  are  called  for, 
with  close  attention  to  the  hvcrienic  surroundings.  The  diet  must  be  regulated, 
the  perversions  of  appetite,  which  have  often  been  encouraged  by  giving  cakes 


DISEASES   OF   THE  EAR.  1161 

and  candy  to  still  the  fretful  child,  must  be  corrected,  tea,  coiFee,  and  other 
ina^jpropriate  food  forbidden,  and  simple  but  generous  nourishment  given. 
Locally,  cleansing  to  the  verge  of  meddling  is  called  for  as  often  as  the  lesions 
become  crusted,  since  healing  is  generally  tardy  or  absent  beneath  the  inspis- 
sated discharge.  Alkaline  solutions  or  peroxide  of  hydrogen  will  soften  the 
crusts  and  permit  their  removal  with  little  violence,  and  while  all  rude  hand- 
ling is  detrimental,  it  is  generally  less  so  than  permitting  the  pathological  tissue 
to  remain  bathed  in  pus  and  protected  from  medication  beneath  its  incrustation. 
Any  of  the  many  lauded  measures  may  prove  promptly  successful  or  largely 
futile,  but  a  routine  treatment,  with  a  bland  calomel  ointment  (gr.xx— xl.  ad 
vaseline  ij),  has  usually  served  me  excellently.  In  the  very  moist  forms  free 
painting  with  silver  nitrate  may  make  a  better  beginning,  and  drying  powders, 
such  as  boric  acid,  may  be  used  on  the  eczema,  as  well  as  in  the  suppurating 
tympanum  from  which  the  irritation  has  often  proceeded.  The  ichthyol  oint- 
ment has  decided  value  in  reducing  the  swollen  lymph-glands,  and  may  be  well 
used  upon  the  infiltrated  aural  surfaces,  especially  after  visible  lesions  are  about 
gone,  yet  there  remains  a  rigidity,  Avhich  is  often  a  useful  diagnostic  sign. 

FuRUisrcLE. — Circumscribed  inflammation  of  the  external  canal  is  less 
common  in  childi'en  than  in  adults,  who  are  more  inclined  to  scratch  the  irri- 
tated and  itching  surfaces  caused  by  eczema.  Yet  it  is  met  at  times,  as  is  a 
similar  lesion  of  the  auricle.  Its  painfulness  raises  its  importance  beyond  any- 
thing due  to  its  influence  upon  the  function,  although  it  may  close  the  canal  by 
swelling  in  a  way  to  muffle  hearing  and  to  conceal  and  possibly  seriously 
obstruct  a  deeper  suppuration.  Diagnosis  may  remain  uncertain,  and  call  for 
treatment  as  though  a  tympanic  lesion  were  certainly  present.  Cleansing  with 
hvdrogen  peroxide,  rubbing  in  of  a  salve  of  the  yellow  oxide  of  mercury,  and 
firm  pressure  by  a  conical  cotton  pledget,  will  generally  secure  prompt  resolu- 
tion ;  but  sometimes  this  cannot  be  borne,  and  must  be  substituted  by  the 
rather  agreeable  and  pain-relieving  hot  douche.  The  poultice  or  moist  warmth 
in  any  form  is  to  be  deprecated,  and  the  warmth  or  actual  heat  furnished  by  a 
salt-bag  or  hot-water  bottle  must  be  relieved  of  any  macerating  effect  by  the 
thorough  drying  of  the  ear  after  douching.  No  single  measure  is  as  valuable 
in  aural  treatment  as  this  hot  douche,  serving  as  it  does  to  clean  away  secre- 
tion, to  reduce  swelling  by  relieving  stasis,  and  to  soothe  the  pain  ;  and  it  is  as 
applicable  to  the  acute  tympanic  inflammation  as  it  is  to  the  external  suppura- 
tion of  the  canal,  md  is  especially  appropriate  in  the  mixed  cases.  Any  sort 
of  syringe,  gently  used,  will  serve,  the  bulb  and  nozzle  of  soft  rubber  being 
often  best ;  but  a  medicine-dropper  or  a  teapot  will  do  nearly  as  well,  and  the 
temperature  should  be  as  high  as  the  patient  can  be  induced  to  bear.  Careful 
use  of  the  cotton-carrier,  under  illumination  by  the  forehead  mirror,  should 
follow,  if  possible,  in  order  to  remove  the  moisture,  to  press  out  secretion  from 
any  open  furuncle,  to  disclose  and  possibly  dislodge  any  cerumen  mass  or  un- 
suspected foreign  body  (recent  or  long  present)  which  may  be  hidden  beyond 
the  swelling,  and,  as  a  probe,  to  demonstrate  the  most  swollen  and  tender  point 
as  a  preliminary  to  incision.  It  can  also  seek  for  uncovered  bone  beneath  a 
discharging  opening  ;  for  it  must  not  be  forgotten  that  the  furuncle  may  lead 
to  caries  of  the  wall  of  the  canal ;  and,  still  more  important,  that  burrowing 
of  pus  from  deeper  localities,  in  antrum  or  attic,  may  appear  externally  as  fur- 
uncle-like lesions.  The  knife  may  shorten  treatment  and  is  indicated  to  release 
pus,  but,  without  prejudice  to  the  result,  it  can  often  be  dispensed  with,  to  the 
patient's  great  mental  relief.  "When  used,  the  smaller  and  sharper  the  blade 
the  better,  a  cataract  knife-needle  being  admirably  suited  to  this  and  similar 
incisions,  which   may  be  almost  painless  when  pointing   is  well  marked.     A 


1162  AMERICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREX. 

series  of  furuncles  is  to  be  expected,  and  prognosis  and  treatment  given  accord- 
ingly. Whether  to  be  ascribed  to  dvscrasia  and  demanding  tonics,  or  regarded 
as  a  matter  of  microbic  auto-inoculation  to  be  combated  h\  rigid  antisepsis, 
both  local  and  general  measui-es  are  indicated  to  forestall  or  control  this 
tendency. 

Cerumen  Impaction. — This  is  also  much  less  common  in  the  child  than 
in  later  life,  associated  as  it  so  often  is  with  a  chronic  tympanic  catarrh.  It  is 
almost  invariably  a  sign  of  lessened,  not  increased,  secretion  of  wax,  with  change 
in  its  consistency,  so  that  it  tends  to  mass  in  dark  scales  or  lumps  instead  of 
passing  constantly  out  in  tiny,  light,  unnoticed  flakes.  Those  who  suffer  are 
often  victims  of  misplaced  efforts  at  cleanliness,  for  Nature  is  given  no  chance 
to  displace  the  material  as  it  forms,  but  meddlesome  attempts  to  hasten  the 
process  push  back  and  pack  inward  the  emerging  masses.  The  epithelium 
seems  to  grow  most  rapidly  at  the  centre  of  the  drumhead,  and  to  tend  to  push 
outward  from  this  point  to  the  margins  and  then  along  the  meatus  walls :  so  an 
outward  march  of  the  lining  skin  and  all  that  rests  upon  it  is  generally  discern- 
ible, the  slow  progress  of  which  is  aided,  as  the  exit  is  approached,  by  the 
movements  of  the  jaw.  Many  have  probably  felt  at  times  a  little  tickling  in 
the  ear,  and  found  that  a  wax-flake  had  been  ejected  by  the  spring  of  hairs 
upon  which  it  had  been  pressed.  The  movements  of  the  auricle,  also,  whether 
accidental  or  by  its  own  muscles,  serve  to  dislodo^e  any  clinging  masses.  Formed, 
as  the  cerumen  is.  only  in  the  outer  two-thirds  of  the  canal,  it  can  only  by 
interference  be  pressed  into  the  deeper  parts,  although  the  epidermal  debris 
which  serves  to  increase  the  collection  can  arise  in  the  neighborhood  of  the  tym- 
panic membrane.  So  long  as  the  mass  does  not  absolutely  occlude  the  canal, 
sound-waves  may  pass  through  an  invisible  crevice  and  the  hearing  remain 
perfect ;  but  the  hygroscopic  mass  can  easily  swell,  if  only  through  atmospheric 
moisture,  and  thus  give  rise  to  sudden  deafness.  If  there  has  been  displace- 
ment of  the  mass,  as  in  the  movements  of  the  head  upon  the  pillow,  pressure 
upon  the  drumhead  or  other  sensitive  point  may  also  be  suddenly  caused,  with 
most  varied  and  possibly  severe,  reflex  attacks  of  vertigo,  coughing,  or  symp- 
toms of  more  remote  and  inexplicable  character.  The  unsuspected  presence  of 
these  masses  should  never  be  forgotten,  and  both  ears  looked  into,  not  only  in 
aural  patients,  but  in  all  nasal  and  many  other  obscure  cases. 

Treatment. — This  consists  in  syringing  away  the  collection  with  hot  water. 
Previous  instillations  of  oil  or  glycerin  are  to  be  deprecated  as  I'arely  useful  and 
not  always  harmless  :  and  medicinal  additions  to  the  svrinjrino:  fluid  do  little,  if 
anything,  to  increase  its  efficiency.  Plain  water  is  about  as  good  a  solvent  of 
cerumen  as  can  be  found,  and  its  value  increases  with  its  temperature.  At  the 
same  time,  the  dizziness  or  faintness  which  syringing  oftener  than  other  aural 
manipulations  is  apt  to  cause  is  less  probable  or  severe  if  the  fluid  be  Avarm. 
The  water  must  be  thrown  with  well -controlled  and  well-directed  force  :  so  the 
canal  must  be  straightened  by  traction,  illuminated  with  the  forehead  mirror, 
and  the  stream  directed  along  one  wall,  especially  up  and  back,  in  the  attempt 
to  insinuate  it  beside  the  mass.  The  syringe  is  to  be  emptied  with  gently 
increasing  force,  and  after  the  first  ounce  or  so,  the  fluid  ought  to  be  stained 
with  dissolved  cerumen,  the  softened  lumps  should  follow,  and  soon  the  re- 
sidual mass,  softened  and  reduced  in  size,  appears  in  the  exit,  and  may  be 
hastened  out,  if  it  clings  there,  by  a  touch  of  the  probe.  If  fair  employment 
of  the  syringe  has  not  been  thus  successful,  with  good  illumination  and  a  steady 
hand  the  mass  may  be  touched  with  a  probe,  such  as  the  cotton-carrier,  and 
gently  loosened,  when  the  syringing  will  probably  succeed.  "When  the  epidermal 
element  is  large  and  the  solubility  correspondingly  small,  considerable  instru- 


DISEASES    OF   THE  EAR. 


1163 


mentation  may  be  needful ;  but  it  takes  a  skilful  hand  to  employ  forceps  or 
curette  safely  or  effectively.  A  small  sharp  spoon  is  a  most  useful  instrument, 
for  with  it  a  channel  can  be  excavated  in  the  centre  or  side  of  the  mass,  por- 
tions displaced  so  as  to  be  easily  grasped  and  withdrawn  by  the  forceps,  or  the 
whole  engaged  and  adroitly  extracted.     Yet  it  is  decidedly  dangerous,  and  the 


Fig.  1. 


The  Aural  Syringe  in  Use. 

blunt  ear-spoons  more  so  than  the  sharp  ones,  since  the  operator  is  apt  to  pre- 
sume upon  the  supposed  innocuous  character  of  the  former.  First  and  last,  and 
often  between-times,  the  syringing  is  to  be  relied  upon  as  the  really  appropriate 
measure ;  and,  well  used,  it  will  rarely  need  much  help  in  securing  complete 
removal  of  impacted  cerumen  at  the  first  sitting.  On  clearing  the  canal  some  con- 
gestion of  the  walls  and  drumhead  is  usually  seen,  with  excoriation,  perhaps, 
if  the  pressure  of  the  mass  has  been  ill  borne  or  the  manipulation  rough  in  re- 
moval. The  canal  should  be  gently  dried  with  absorbent  cotton  on  the  cotton- 
carrier,  any  excoriated  surfaces  lightly  dusted  with  boric  acid,  and  the  exit 
filled  with  a  flake  of  cotton  in  order  to  exclude  the  dust  and  too  rapid  move- 
ment of  the  air.  A  repeated  visit  should  be  called  for,  to  make  sure  of  prompt 
restoration  to  normal ;  while  any  tympanic  catarrh  should  be  appropriately 
treated  at  the  first  as  well  as  later  visits. 

Foreign  Bodies  in  the  auditory  canal  owe  their  importance  almost  solely 
to  the  utter  misapprehension  with  which  they  are  regarded  and  the  maltreat- 
ment to  which  the  ear  is  often  subjected  on  their  account.  They  are  rare, 
and  generally  of  no  importance  if  let  alone ;  but  the  panic  with  which  they  are 
frequently  regarded  by  patient  and  parent  is  too  often  fostered  by  the  almost 
breathless  haste  with  which  the  physician  undertakes  heroically  to  remove  them- 


1164  AJIJEBICAJV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

Placed  in  the  canal  with  little  pressure,  kept  in  place  often  only  by  the  force 
of  gravity,  the  foreign  body  may  be  ready  to  fall  out  spontaneously  as  soon  as 
the  ear  is  directed  downward  so  as  to  permit  it.  Shaking  or  jarring  of  the 
head  may  greatly  aid  this,  and  rotary  rubbing  in  front  of  the  tragus  will  often 
serve  to  coax  an  intruder  out.  The  jaw  condyle  presses  upon  the  canal  and 
narrows  it,  so  the  mouth  should  hang  open,  and  the  meatus  should  be  drawn 
outward  and  back  to  straighten  it.  The  syringe,  with  Avarm  water,  is  the 
proper  instrument  for  the  removal  of  the  great  majority  of  foreign  bodies,  not 
excepting  seeds  and  such  bodies  as  will  swell  if  long  soaked.  Swelling  of 
the  canal-walls  through  irritation  or  injury  in  rash  attempts  at  removal  ma;y 
preclude  prompt  success  by  this  means :  if  so,  the  hot  irrigation  will  be  of 
value  to  reduce  it.  The  canal  may  be  dried  with  absorbent  cotton  and  the 
body  dehydrated  with  alcohol  or  glycerin  if  maceration  or  germination  is  feared, 
a  drying  powder,  such  as  boric  acid,  dusted  in,  and,  unless  urgent  symptoms 
should  arise,  further  intervention  delayed  until  a  more  favorable  occasion. 
It  is  important,  however,  to  preface  any  attempt  with  an  explanation  of  the 
intention  to  do  only  a  limited  amount  of  intervention  because  of  the  danger  of 
overdoino- ;  for  this  will  come  with  better  grace  and  find  readier  acceptance 
before  a  non-success.  The  temperature  and  general  condition  must  be  closely 
watched  if  expectancy  is  attempted  and  brain-symptoms  looked  for ;  but  it 
great  violence  has  been  done,  delay  is  both  safe  and  advisable.  Nearly  "half 
of  the  foreign  bodies  noted  as  found  in  our  clinics  have  been  present  longer  or 
shorter  times  without  the  knowledge  of  patient  or  friends. 

Accurate  diagnosis  is  of  course  a  prerequisite  to  any  intervention,  and  this  will, 
as  usual,  be  much  aided  by  inspection  of  the  fellow-ear.  Thus  Ave  can  learn  the 
probable  size  and  form  of  the  canal,  the  pre-existence  of  eczema  or  other  irrita- 
tion Avhich  may  have  led  to  the  introduction  of  the  foreign  body,  and  other 
valuable  points.  Not  very  infrequently  a  foreign  body  is  really  present  in  the 
fellow-ear,  either  because  one  has  been  placed  in  each  ear,  or  because,  in  the 
panic  over  the  case,  its  true  location  has  been  forgotten.  The  cases  are  far  too 
numerous  where  harsh  or  destructive  efforts  at  extraction  have  been  blindly 
made  in  the  wrong  ear  or  in  one  from  which  the  intruder  had  already  fallen 
out.  The  presence  and  the  nature  of  a  mass  to  be  removed  must,  therefore, 
be  decided,  although  in  some  instances  blood  or  SAvelling  in  a  maltreated  ear 
may  preclude  certainty  of  diagnosis.  The  hearing  should  be  tested  by  speak- 
ing or  whispering  questions  or  commands  into  each  ear,  better  with  the  other 
one  closed  with  a  finger-tip ;  since  retention  of  good  hearing  is  of  good  omen 
as  to  the  incompleteness  of  impaction  and  the  uninjured  condition  of  the  tym- 
panum— points  of  great  prognostic  importance.  The 
Fig.  2.  syringe  should  be  used  gently  at  first,  and  so  directed 

as  to  seek  a  passage  past  the  body  if  visible  and  local- 
ized, the  upper  back  wall  of  the  canal  being  gener- 
ally the  best  along  Avhich  to  throAV  the  stream.  Much 
ingenuity  has  been  w^asted  in  trying  to  float  up  Avith 
mercury  a  foreign  body  too  heavy  to  be  readily  lifted  by 
the  stream  of  Avatei',  when  the  mere  inclining  the  ear 
(loAvnAvard  Avhile  syringing  would  have  far  more  effect- 
TOEY  Canal  of  a  Child,  ually  enlisted  the  aid  of  gravity.  This  position  is  aAvk- 
ure  usually  found  at  jinic-  Ward  and  need  not  be  attempted  at  first,  until  syringing 
inm,s"'^p^ortfons,*^amV"fife  ^^^^  ^^^^  Vainly  tried  in  the  ordinary  f\ishion.  Here, 
inclination  of  'the  drum-     as  in  all  syrino;infr,  Avork  under  good  illumination  A\'ith 

head.        Although      quite       ^i         n        ^         ^         •  ■  ^  t     •      ^  ^  c 

movable  in  the  canal,  the     the  lorehcad  miiTor  IS  Strongly  advisablc ;  tor  syring- 
by^vioient^tractimr"  °"^^     ing  may  Avholly  fail  when  blindly  used,  though  perfectly 


DISEASES    OF    THE  EAR.  1165 

competent  if  intelligently  employed,  and  the  Trell-straiglitened  canal  is  as  neces- 
sary for  success  as  in  inspection.  When  ^vell  seen,  yet  immovable  by  a  strong 
and  well-directed  stream  of  water,  a  gentle  touch  of  the  probe  may  do  good 
service,  if  the  patient  is  quiet  and  tractable ;  for  much  may  thus  be  learned 
as  to  the  impaction,  and  perhaps  the  body  rotated  into  better  position  or  dis- 
engacred. 

If  space  beside  the  body  can  be  seen  and  vigorous  syringing  has  failed  to 
move  it,  a  delicate  wire-loop  may  be  passed  beyond  it  and  serve  as  an  efficient 
yet  gentle  tractor.  But  all  use  of  instruments  is  dangerous,  even  in  hands 
well  accustomed  to  precisely  these  manoeuvres,  and  should  rarely  be  attempted 
except  under  ether,  and  then  with  great  caution.  Almost  no  form  of  forceps 
is  to  be  commended,  since  they  are  apt  to  injure  the  walls  and  push  the  body 
deeper  in  the  attempt  to  grasp  it ;  and  slipping,  as  they  so  often  will,  even 
when  fairly  and  firmly  placed,  they  are  almost  sure  to  drive  the  intruder 
deeper.  Yet  some  wholly  unsuitable  pair  of  forceps,  thrust  into  the  canal  of 
an  unansesthetized  and  struggling  child,  on  the  mere  suspicion  of  a  foreign 
body,  without  aid  of  illumination,  is  rather  generally  the  first  resort  of  the 
practitioner  who  has  little  experience  in  aural  work,  and  scarcely  enough 
knowledge  of  the  anatomy  not  to  share  the  "lay"  fear  that  the  body,  unless 
I'emoved  at  any  cost,  may  work  its  own  way  into  the  brain.  The  risk  of  brain 
lesion  is  indeed  great  when  the  ear  is  subjected  to  such  an  attack,  for  there 
may  be  no  foreign  body  there  to  be  encountered,  and  the  ossicles  or  any  other 
normal  structures  may  fall  victims  to  the  heroic  resolve  not  to  retire  empty- 
handed.  If  present,  the  body  will  probably  be  driven  through  the  drum- 
head into  the  tympanum,  with  more  or  less,  destruction  of  the  ossicles;  and  the 
numerous  fatal  results  on  record  give  ghastly  but  incomplete  evidence  of  the 
seriousness  of  the  situation.  If  such  an  impaction  in  the  tympanum  has  oc- 
curred, and  the  air-douches  through  the  Eustachian  tube  and  syringing 
through  the  meatns  both  fail,  little  place  remains  for  expectancy  or  gentle 
measures.  Only  in  cases  with  no  fever  or  disquieting  symptoms  can  the 
brush  of  glue  be  allowed  to  attach  itself  to  the  mass,  or  delicate  skilful  trac- 
tion by  instruments  be  tried  in  the  eifort  to  dislodge  the  body.  It  is  actually 
safer  and  simpler  to  dissect  the  auricle  and  cartilaginous  canal  forward,  and 
work  with  free  view  in  the  short,  broad  bony  canal,  chiselling  away  the  upper 
back  wall  if  greater  space  is  needed,  than  to  do  unknown  and  more  serious 
damage  to  the  deeper  structures  in  the  effort  to  work  through  the  natural  pas- 
sage. The  fact  that  this  operation  has  not  been  more  often  done  since  it  was 
proposed  argues  little  for  the  manual  skill  of  aural  and  other  surgeons,  and 
much  against  their  wisdom  and  judgment. 

Caeies  of  the  Wall  of  the  ArDiTORT  Caxal  may  occur  apparently  idio- 
pathically,  and  cause  much  enlargement  through  loss  of  tissue.  The  granulation 
tissue  formed  is  sometimes  redundant,  and  the  healing  process  may  cause  fibrous 
stenosis  or  division  of  the  canal  by  a  membranous  septum  across  it.  Bony 
outgrowths  may  also  arise,  congenital,  perhaps,  in  origin,  yet  increasing  later, 
and  may  narrow  and  close  the  canal. 

CoxGEXiTAL  Atresia,  or  defect  of  the  meatus,  may  be  met,  with  or  with- 
out malformation  of  the  auricle.  Operation  may,  with  difficulty,  secure  patu- 
lency  in  cases  where  the  closure  is  by  soft  tissues  ;  but  the  formation  or  freeing 
of  a  canal  closed  by  bone  is  a  serious  and  often  unsuccessful  measure.  Good 
bone-conduction  must  be  present  as  evidence  of  a  useful  labyrinth ;  and  the 
hearing  by  way  of  the  Eustachian  tubes  may  be  as  good  as  the  case  admits 
of;  so  these  passages  are  to  be  kept  in  as  open  a  condition  as  possible.  The 
proper  location  of  the  auditory  canal  is  to  be  determined  by  the  mastoid  process, 


1166  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

for  the  auricle  may  be  widely  displaced  ;  and  as  absence  of  the  tympanum  may 
render  nugatory  all  efforts,  drilling  or  such  procedures  can  be  attempted  only 
with  great  caution. 

Affections  of  the  Middle  Ear. 

Inflammation  of  the  Middle  Ear,  arising,  as  it  generally  does,  from  a  nasal 
origin  by  Avay  of  the  Eustachian  tube,  may  involve  any  or  all  portions  of  the 
tract,  from  the  pharyngeal  mouth  of  the  tube  to  the  remotest  cells  of  the  mas- 
toid. It  is  readily  distinguished  into  acute  and  chronic,  with  a  few  interme- 
diate forms,  and  the  types  of  catarrhal  and  suppurative,  which  are  distinct  and 
strongly  contrasting  in  the  chronic  inflammations,  are  with  less  certainty  dis- 
tinguishable in  the  acute.  Localized  subdivisions  can  be  made,  a  fortiori,  as 
the  brunt  of  the  attack  falls  on  the  tube,  drumhead,  or  mastoid,  or  the  disease 
tends  to  cling  there,  as  salpingitis,  myringitis,  or  mastoid  periostitis,  etc.  ;  yet 
such  nomenclature  can  be  strictly  applied  in  few  cases,  and  rarely  Avith  profit, 
especially  if  taken  to  mean  that  adjacent  parts  are  free  from  implication.  The 
gravity  of  all  the  severer  middle-ear  inflammations  lies  in  the  facts  of  the  prox- 
imity of  very  important  structures  like  the  labyrinth,  the  meninges,  and  the 
great  blood-vessels,  and  that  to  a  large  extent  the  lining  mucous  membrane  is 
practically  the  periosteum,  and  readily  causes  the  dependent  bone  to  share  its 
inflammation  or  its  destruction.  What  would  elsewhere  in  the  air-passages  be 
a  mere  superficial  mucous  ulcer  may  here  lay  bare  the  bone  to  carious  or  necrotic 
process.  The  intricacy  of  the  tract  also  hampers  the  escape  of  the  secretions 
and  degenerated  products ;  and  retention  of  these  maintains  and  increases  the 
disease  at  the  focus,  often  gives  rise  to  most  excruciating  suffering,  and  may 
lead  to  penetration  of  septic  material  in  most  dangerous  directions. 

Acute  Simple  Inflammation  of  the  Middle  Ear. — This  usually  origi- 
nates in  a  coryza  by  an  extension  of  the  process  up  the  Eustachian  tube  ;  for  as 
this  entire  tract  is  essentially  a  part  of  the  upper-air  passages,  its  involvement  is 
as  natural  as  that  of  the  pharynx.  Bathing,  especially  in  the  surf,  with  penetra- 
tion of  the  water  into  the  naso-pharynx  and  tubes,  is  responsible  for  many  cases, 
some  of  which  are  ascribed  to  the  action  of  the  cold  water  in  the  external  canal ; 
and  the  improper  use  of  the  nasal  douche  or  syringe  is  fairly  blamed  for  a  fur- 
ther series  of  cases,  sometimes  disastrous.  Intranasal  surgery  has  not  infre- 
quently such  a  sequence,  and  all  too  often  the  aural  inflammation  takes  on  the 
suppurative  character.  All  of  the  exanthemata,  including  typhoid,  are  very 
apt  to  give  rise  to  it,  and  its  symptoms  are  likely  to  be  ascribed  to  the  general 
condition  or  be  masked  by  it ;  so  routine  investigation  of  the  ears  is  called 
for  in  such  cases.  The  prime  symptom  is  usually  earache ;  and  the  prevalent 
error  of  regarding  this  as  an  entity  instead  of  a  sjanptom,  and  combating  it  by 
narcotics  instilled  into  the  ear,  instead  of  striking  at  the  underlying  inflamma- 
tion, is  responsible  for  many  unhappy  results.  Neuralgias  of  the  ear  are  rare, 
and  while  points  of  reflex  irritation  may  be  suspected  and  sought  in  teeth,  ton- 
sils, and  other  neighboring  structures,  it  is  only  after  careful  investigation,  prov- 
ing the  uninflamed  condition  of  the  aural  tract,  that  a  painful  condition  should 
be  set  down  as  otalgia.  Usually  in  children  some  fever  is  present,  there  is  ten- 
derness elicited  by  pressure  on  the  tragus  or  traction  on  the  auricle,  and  inspec- 
tion will  show  a  congested  and  perhaps  distended  condition  of  the  drum- 
head. 

It  is  important  here  to  correct  misapprehensions  as  to  the  drum-mem- 
brane in  childhood,  which  have  been  fostered  by  some  of  the  authorities. 

The  tympanic  membrane  and  the  annulus  in  which  it  is  set  are  upon  the  sur- 


DISEASES    OF    THE   EAR. 


1167 


face  of  the  skull  in  infancy,  open  to  view  when  the  soft  structures  have  been 
removed,  and  revealing  the  nearly  horizontal  inclination  of  the  drumhead  : 
hence  the  impressions  that  the  tympanic  membrane  is  more  superficial  and  more 
horizontal  in  infancy.  Neither  is  true ;  for  the  canal  is  about  thirty  millimetres 
long,  as  in  the  adult,  with  a  membranous  portion  where  the  tympanic  scroll 
later  forms  the  bony  canal;  and  removal  of  the  bony  canal  in  adults  shows  that 

the  two  drumheads  main- 
tain  identically  the  same 
inclination  to  each  other 
as  in  infants.  Much  as  is 
the  growth  of  the  temporal 
bones  and  their  separation 
by  the  occipital,  the  plane 
of  the  tympanic  mem- 
brane, like  its  size,  is 
unaltered  after  birth.  An 
anatomical  point  which 
lends  color  to  the  error 
has  much  practical  im- 
portance. The  direction  of 
the  adult  canal  is  upward 
as  it  passes  inward,  while 
the  auricle  falls  downward 
and  forward,  and  must  be 
drawn  up  and  back  to 
straighten  the  cartilagin- 
portion  (Fig.  3).  In  infancy  the  auricle  is  above  the  tympanum, 
the  flaccid  canal  is  pressed  against  the  upward-curving  surface  of 
squama,  and  can  be  straightened  only  by  drawing  it  doivn  and  out 
4).       Long,  narrow,  and  readily  collapsing,  the  infant  meatus   gives 


Schematic  Vertical  Section  of  Adult  Ear,  showing  direction  of  the 
auditory  canal  and  the  length  of  the  bony  portion. 


ous 
and 
the 
(Fig. 


Fig, 


but  a  poor  view  of  the  drumhead,  even  when  correctly  straightened ;  and 
the  distinction  between  back  wall  and  drum- 
membrane  is  unrecognized,  unless  shown  by 
the  normal  coloration.  In  an  inflajned  ear 
the  practised  eye  is  often  puzzled  to  find  land- 
marks or  make  a  certain  diagnosis,  and  one 
less  expert  is  apt  to  make  insufficient  attempt 
to  discern  details — too  soon  discouraged  be- 
cause the  picture  is  not  unmistakable.  Yet 
the  triangular  light  spot  on  the  lower  ante- 
rior portion  of  the  drumhead  ought  to  be  visible 
in  every  healthy  ear,  and  from  its  absence  or 
alteration  valuable  data  can  be  easily  obtained 
as  to  the  position  and  surface.  The  malleus 
handle  ought  to  be  distinguishable,  and  any 
congestion  will  show  first  and  last  in  the  plexus 
along  its  posterior  margin.  Distention  of  the 
tympanic  membrane  generally  shows  up  and  back,  and  the  color  indicates  the 
character  of  the  collection,  being  generally  greenish  if  filled  with  serum  or 
mucus — -yellowish,  if  purulent ;  while  the  thinness  of  the  sac  usually  reveals 
whether  only  a  bleb  or  the  whole  thickness  is  protruded.  Inflation  of  the 
tympanum,  if  successfully  accomplished,  generally  alters  the  appearances  ;  thus 
giving  evidence  of  the  patulency  of  the  Eustachian  tube  and  a  new  view  of  the 


Schematic  Vertical  Section  of  the  Ear  of 
an  Infant,  showing  the  usual  direction 
and  length  of  the  auditory  canal. 


1168  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tympanic  condition,  with  a  clear  surface  line  to  the  contained  fluid,  perhaps, 
or  bubbles  moving  in  it.  The  pneumatic  speculum  may  do  similar  service 
in  clearincr  obscure  details,   Avhether  inflation  succeeds  or  fails. 

Concrestion,  serous  exudation,  and  hypersecretion  of  mucus  are  the  usual 
stages  of  the  affection  ;  and  imperfect  drainage  by  the  Eustachian  tube  consti- 
tutes a  cause  for  retention  and  pressure.  In  the  absence  of  septic  infection 
and  consequent  suppuration,  there  is  little  danger,  except  to  the  hearing,  in 
adults  ;  but  with  children  the  barriers  are  too  thin  and  imperfect  to  protect  the 
meninges  and  other  important  structures  from  involvement,  and  most  severe 
brain-symptoms,  Avhich  are  not  always  merely  reflex,  may  arise  in  cases  where 
the  collection  is  simply  mucus.  Stupor,  hemiplegia,  convulsions,  opisthotonos, 
and  other  indications  of  meningeal  or  cerebral  inflammation  may  occur,  with 
little  to  direct  attention  to  the  ear  ;  and  marvellous  improvement  may  be  gained, 
as  though  by  magic,  from  relief  of  the  pressure,  either  by  freeing  the  Eusta- 
chian tube  or  bv  incising  the  tense  drumhead.  For  diagnosis,  as  well  as  treat- 
ment,  therefore,  the  nares  should  be  sprayed  free  of  any  mucus,  the  pharynx 
vault  and  tube-mouths  mopped  with  the  curved  cotton-carrier  passed  above  the 
velum,  and  the  inflation  tried  with  the  Politzer  bag.  If  no  voluntary  ai\i 
be  given  by  the  child  in  puflBngout  the  cheeks,  saying  "  Huck,"  or  swallowing, 
a  cry  will  often  be  as  helpful ;  and  often  the  short,  wide,  flaccid  tube  opens 
readily  without  special  assistance.  A  quick,  spontaneous  movement  of  the 
hand  to  the  ear  will  often  tell  of  the  passage  of  air  to  the  tympanum ;  and  as 
this  may  be  painful,  its  first  employment  should  be  gentle,  Avith  force  increased 
when  needed.  No  harm  is  likely  to  result,  even  should  the  increased  pressure 
cause  rupture  of  the  tympanic  membrane,  for  this  can  happen  only  when  it  is 
about  to  occur  spontaneously. 

Exit  of  the  secretion  by  its  normal  drainage-channel  may  be  impossible 
because  of  tubal  SAvelling  or  from  the  tenacious  character  of  the  mucus,  and 
incision  of  the  drumhead  may  be  demanded  in  order  to  give  relief.  This 
should  be  a  simple  and  harmless  measure,  yet  its  pain  is  often  severe  enough  to 
forbid  its  needless  performance.  It  may  cause  injury  to  the  stapes  or  the  inner 
tympanic  wall  if  done  with  a  stab,  and  has  been  known  to  open  the  head  of 
the  jugular;  and  it  may  convert  a  non-suppurating  into  a  septic  inflammation 
if  all  the  requirements  of  asepsis  are  not  secured  and  maintained.  It  must  be 
done,  of  course,  under  good  illumination,  and  should  generally  be  preceded  by 
delicate  use  of  the  probe  in  order  to  let  touch  assist  sight  in  getting  the  true 
relations.  The  most  protruded  portion  of  the  membrane  should  usually  be 
chosen,  and  the  needle-point  inserted  for  a  distinct  cutting  motion,  avoiding 
any  contact  with  the  ossicles  or  inner  wall.  The  oblique  position  of  the  drum- 
head must  be  clearly  borne  in  mind,  and  a  hand  skilled  in  aural  procedures  is 
generally  requisite.  Inflation  of  the  tympanum  should  follow,  if  possible  ;  and 
hot  syringing  of  the  canal  will  remove  the  blood  and  evacuated  secretion,  allay 
the  pain,  and  serve  to  favorably  stimulate  the  inflamed  tissues  and  inaugurate 
resolution.  The  canal  should  then  be  gently  dried  and  protected  by  a  flake 
of  cotton  or  wool,  and  a  pad  of  the  same  laid  on  outside  in  unfavorable  weather. 
The  same  result  can  commonly  be  gained  without  incision,  and,  unless  the 
symptoms  are  urgent,  the  little  operation  had  better  be  delayed.  The  hot 
syringing  can  impress  the  tympanum,  controlling  the  pain  and  other  symptoms, 
about  as  fully  and  favorably  Avith  the  drumhead  intact.  Nasal  treatment, 
aided  by  the  shrinking  effect  of  cocaine,  can  generally  free  the  Eustachian  tube 
and  fairly  maintain  its  patulency ;  and  dry  heat,  as  by  a  hot-water  bottle,  can 
increase  the  comfort  and  further  the  cure.  The  hot  douching  should  be  fre- 
quently employed,  and  if  drying  be  done  with  reasonable  care,  no  undue  mace- 


DI8EA8ES   OF   THE'  EAR.  1169 

ration  need  be  feared.  Greatly  distended  drumheads  can  thus  be  brought  back 
to  normal  condition  with  perhaps  greater  safety  and  promptness  than  by  more 
radical  intervention. 

The  habit  of  treating  "earache  "  by  instilling  sedatives  is  not  to  be  com- 
mended. Any  fluid  introduced  should  be  warm,  and  is  efficient  in  proportion 
to  its  heat  rather  than  to  its  ingredients.  A  tincture,  such  as  laudanum,  is  apt 
to  be  irritating  ;  oils  and  glycerin  are  more  apt  to  harm  than  help  ;  and  cocaine, 
except  in  strong  solution,  has  less  value  than  atropine  or  morphine.  More 
than  would  be  a  full  dose  by  the  mouth  had  better  not  be  instilled,  lest  it  find 
penetration  and  cause  poisoning.  Poultices  are  apt  to  macerate,  and  are  gen- 
erally inferior,  in  convenience  and  directness  of  application,  to  hot  douching  or 
fomentations.  They  should  be  used  very  hot,  if  at  all,  and  removed  before 
they  have  cooled  to  the  body  temperature.  They  are  so  liable  to  improper  use 
that  their  employment  is  not  to  be  commended.  Leeching  is  advisable  only 
during  the  rise  or  acme  of  the  inflammation,  and  is  rarely  well  borne  by  chil- 
dren. As  it  is  generally  impossible  to  determine  at  first  whether  the  acute 
tympanic  inflammation  will  prove  suppurative  and  serious,  the  prognosis  should 
be  guarded  and  the  treatment  include  rest  in  bed,  with  regulated  diet  and  anti- 
febrile medication — matters  easier  to  regulate  in  children  than  in  adults.  After 
improvement  has  begun,  protection  against  renewed  or  increased  cold-taking  is 
still  very  important,  and  covering  of  the  ear-region  is  advisable  in  inclement 
weather.  Tonics  and  alteratives  may  be  necessary  as  well  as  advisable — 
cod-liver  oil  probably  serving  better  than  almost  any  other.  Chloride  of 
ammonium  and  syrup  of  iodide  of  iron  are  each  very  useful  in  its  place. 
Quinine,  which  is  often  taken  to  "  break  up  a  cold,"  has  been  vigorously  con- 
demned by  some  aurists  becstuse  it  stimulates  the  circulation  in  the  ears  as  well 
as  elsewhere.  Yet  stasis  is  worse  than  active  congestion,  and  the  facts  by  no 
means  fully  support  the  contention  as  to  its  counter-indication. 

One  form  or  phase  of  acute  tympanic  inflammation  deserves  a  word  in  pass- 
ing. The  most  inflamed  and  distended  portion  of  the  drumhead  is  sometimes 
its  upper  flaccid  portion,  especially  the  part  above  the  short  process  of  the  mal- 
leus. This  indicates  collection  in  the  upper  tympanic  cavity,  or  attic,  and  the 
rather  isolated  pouches  of  this  region,  largely  independent  of  the  condition  else- 
where. Rupture  may  give  exit  to  a  single  drop  of  fluid  with  relief  and  prompt 
resolution  ;  but  the  perforation  may  remain  as  a  pinhole  opening — the  so-called 
"foramen  of  Rivinus" — claimed  to  be  a  congenital  defect  of  development, 
although  less  often  seen  in  children  than  in  adults. 

Acute  Suppurative  Inflammation  of  the  Middle  Ear  diff"6rs  little  from 
the  catarrhal  form  in  its  onset,  although  apt  to  be  more  severe  in  its  febrile  and 
painful  symptoms.  It  is  specially  characterized  by  the  rupture  of  the  drum- 
head and  more  persistent  flow  of  secretion,  which  generally  contains  pus  and 
the  pyogenic  bacteria.  The  perforation  is  less  often  the  mere  pushing  apart  of 
the  tissues,  although  frequently  assuming  a  pouting,  nipple-like  form,  for  there 
is  generally  some  loss  of  substance ;  and  in  the  cases  due  to  scarlatina  and 
diphtheria  the  destruction  of  the  membrane  may  rapidly  be  extensive  or  total. 
Ulceration  of  the  inner  surface  of  the  drumhead  is  only  one  indication  of  the 
destructive  influence  of  the  inflammation  or  its  products ;  and  as  the  attic  and 
antrum  are  generally  involved,  as  well  as  the  tympanum  proper,  the  dangers  to 
meninges,  blood-vessels,  and  mastoid  are  real  and  great.  Paracentesis  may  be 
promptly  called  for,  either  to  make  or  enlarge  an  opening,  if  the  symptoms 
point  to  retention  of  secretion ;  and  the  temperature  should  be  carefully 
watched  for  evidence  of  extension  or  exacerbation  of  inflammation.  Tender- 
ness of  the  mastoid  and  other  neighboring  parts  is  to  be  frequently  sought ; 

74 


1170  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


Fig.  5. 


-5.\ 


VvV^\\', 


Swelling  of  the  Mastoid  Region,  pushing  the 
auricle  out  and  forward. 


and  it,  with  or  Avithout  swelling,  redness,  or   oedema,  calls  for  redoubled  pre- 
cautions.    The  position  of  the  auricle  should  be  critically  compared  Avith  that 

of  the  other  side,  especially  by  study 
from  directly  behind  the  head  (Fig.  5), 
for  displacement  is  almost  invariably 
present  if  there  be  any  surface  involve- 
ment of  the  temporal.  The  size  and 
form  of  the  auditory  canal  should  be 
noted,  so  as  to  detect  any  bagging,  es- 
pecially of  the  upper  back  wall,  by  re- 
tained secretion.  The  position  of  the  per- 
foration is  probably  of  small  importance, 
unless  it  be  in  the  flaccid  membrane,  as 
an  indication  of  suppuration  partly  or 
wholly  isolated  in  the  cavities  of  the 
attic ;  and  its  form  depends  principally 
on  its  size.  The  opening  at  the  apex 
of  a  pouting,  nipple-like  protrusion  has 
importance,  however,  since  it  is  in  itself 
an  evidence  of  incomplete  relief  of  pres- 
sure, is  rather  prone  to  clogging,  and 
serves  as  a  valve  to  exclude  all  medicinal 
applications.  It  may  readily  be  mistaken 
for  a  polyp,  and  attacked  with  the  snare  ; 
and  while  this,  used  only  to  cut,  is  not 
very  bad  as  a  method  of  enlarging  the  pin-hole^  opening,  any  traction  may 
be  very  injurious. 

Incision  should  be  free,  and  maintained,  if  made  at  all ;  for  it  has  a  tendency 
to  heal  quickly,  and  even  close  what  little  exit  was  present.  Dilatation  with  a 
conical  pledget  is  generally  better,  if  practicable.  The  distinctly  unfavorable 
meaning  which  the  pouting  perforation  has  in  adults  does  not  obtain  in  children  ; 
although  the  muco-purulent  secretion,  which  is  its  usual  concomitant,  is  in  youth 
almost  as  dangerous  as  the  more  destructive  pus.  It  is  most  often  in  such  cases 
that  the  use  of  dry  boric  powder  has  been  charged  with  dangerous  sequences,  and 
caution  is  necessary,  although  its  contra-indication  is  not  proven.  A  standing 
rule  may  be  made  for  all  insufllations,  that  free  use  of  insoluble  powder  always 
brings  danger  of  clogging  the  outflow ;  and  boric  acid  is  but  slightly  soluble  in 
mucus.  Hot  douches  are  more  valuable  in  these  than  most  cases,  since  the 
heat  can  penetrate  to  the  inflamed  tissues  when  drugs  cannot,  and  the  efl"ect 
upon  actual  or  imminent  involvement  of  the  mastoid  cells  may  be  most  valuable 
and  grateful.  In  other  respects  the  treatment  is  much  the  same  as  that  in 
catarrhal  inflammation — the  naso-pharyngeal  spraying  and  mopping,  Politzer 
inflation  after  such  cleansing,  and  the  syringing  through  the  canal  for  the 
maintenance  of  the  utmost  possible  cleanliness  of  the  tympanum.  A  course 
of  several  weeks  is  usual,  and  early  cessation  of  the  discharge  is  to  be  looked 
upon  with  suspicion,  and  evidences  of  retention  carefully  sought.  The  hearing 
may  be  much  impaired,  to  improve  but  slowly;  and  the  termination  of  the 
discharge  may  leave  the  auditory  apparatus  unduly  dry  and  stiff",  with  a  tem- 
porary decline  of  the  hearing  in  consequence.  It  is  best  to  prognosticate  this, 
for  patients  often  retain  the  old  idea  that  it  is  dangerous  to  check  all  such 
flows,    and   may  be  alarmed  or  discouraged. 

Chronic  Suppuration  of  the  Middle  Ear. — This  condition  is  almost 
always  the  result  of  a  neglected  acute  attack,  although  debility  may  invalidate 


DISEASES    OF   THE  EAR.  11 71 

the  very  best  treatment  and  cause  the  maintenance  or  recurrence  of  the  condition. 
Its  symptoms  are  often  inconspicuous,  and  neglect  is  quite  frequent,  especially 
under  the  impression  that  "it  -will  get  well  of  itself."  Histories  in  such  matters  are 
apt  to  be  wholly  untrustworthy,  and  perforations,  cicatrices,  losses  of  the  bony 
parts,  massive  chalk  deposits,  or  collections  of  exfoliated  epithelium  or 
inspissated  discharge  may  be  present  in  one  or  both  ears  which  are  declared 
to  have  been  always  sound.  A  tuberculous  affection  is  occasionally  insidious 
and  painless  in  its  onset,  and  may  be  characterized  by  multiple  perforations, 
which  probably  represent  broken-dowji  tubercles  of  the  drum-membrane. 
The  exanthemata  are  responsible  for  a  large  number  of  cases,  sometimes 
following  doubtful  or  unrecognized  attacks  :  while  more  often  the  illness  of 
the  patient  masks  the  ear  disease  or  overshadows  it  in  apparent  importance. 
The  spontaneous  cure  for  which  many  physicians  look,  as  well  as  the  laity, 
is  often  obtained,  but  may  prove  temporary  and  incomplete :  and  treatment  is 
called  for  in  all  cases  as  lessening  the  danger  to  hearincr  and  life,  mitia:atino' 
the  annoyance  to  patient  and  companions  due  to  the  discharge,  and  tending  to 
hasten  and  complete  the  cure. 

The  character  of  the  discharge  deserves  attention.  If  fetid,  it  tells  of 
retention  and  neglect ;  if  bloody,  polypoid  growths  are  probably  present ;  if 
ichorous,  search  should  be  scrupulously  made  for  dead  bone:  if  stringy  from 
mucous  admixture,  subacute  involvement  of  the  antrum  and  mastoid  cells  is 
probable,  and  a  slow,  obstinate  case  may  be  anticipated.  As  cleanliness  is  the 
prime  factor  in  restraining  evil  tendencies  and  securing  resolution,  the  character 
and  source  are  noteworthy  as  bearing  on  the  means  required  to  remove  secre- 
tion. The  syringe  remains  the  best  cleanser  here,  and  the  heat  which  its  fluid 
can  so  well  convey  can  have  efficacy  little  short  of  that  in  the  acute  conditions. 
Frequently,  isolated  cavities,  into  which  ordinary  syringing  hardly  penetrates, 
need  cleansing,  and  intratympanic  injections  are  needed.  A  steady  hand  can 
make  these  in  a  quiet  patient  with  almost  any  long,  fine  canula  introduced, 
under  good  light,  to  the  precise  point  requiring  it:  but  where  these  requisites 
are  lacking,  the  auditory  canal  should  be  filled  with  fluid — best  the  peroxide  of 
hydrogen — and  pressure  exercised  by  finger-tip  or  Politzer  bag  to  force  it  into 
every  opening;  and  it  can  often  be  thus  carried  down  into  the  pharynx.  In 
some  obstinate  cases  syringing  through  the  Eustachian  catheter  proves  very 
efficient,  thotigh  this  cannot  so  often  be  used  in  children.  Drying  should  follow 
cleansing,  and  all  epidermal  flakes  or  similar  material  removed  as  perfectly  as 
possible,  even  to  the  verge  of  meddling.  It  is  never  safe  to  form  a  diagnosis 
of  the  precise  condition  until  the  whole  accessible  tract  has  been  studied  by  the 
eye,  and  perhaps  with  the  probe.  Polyp  masses  or  other  protrusions  often  show 
most  characteristically  when  standing  out  as  reddish  islands,  surrounded  by 
whitish  pus;  so  study  before  cleansing  is  important:  and  many  conditions  need 
probing  for  their  comprehension,  for  Avhich  the  cotton-carrier,  guarded  with  a 
tip  of  cotton  of  appropriate  size,  is  best  adapted.  In  seeking  for  bare  bone  and 
roughnesses,  the  fibres  catch  upon  these,  and  may  not  only  reveal  but  remove 
them.  The  mopping  is  an  excellent  means  of  cleansing,  independent  of  syring- 
ing, and  should  alwavs  follow  it  to  remove  the  remaining  fluid.  It  also  affords 
valuable  instruction  and  practice  in  aural,  and  especially  intratympanic,  manip- 
ulation, preparing  the  physician  for  the  more  delicate  measures,  such  as  para- 
centesis. Often  a  flake  of  certimen-like  material  clings  closely  to  some  part  of 
the  wall  or  fundus,  and  its  removal  is  requisite  in  order  to  learn  whether  or  not 
a  sinus  or  other  lesion  lurks  beneath.  These  leathery  crusts  are  common  near 
the  short  process,  and  frequently  indicate  an  attic  inflammation,  with  a  per- 
foration in  the  flaccid  membrane,  and  all  too  often  caries  of  ossicles  or  adja- 


1172  A3IEBICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

cent  walls.  BaclcAvard,  too,  there  may  be  an  opening  into  the  antrum  or 
its  communicating  cells  sometimes  with  polypoid  granulations  surrounding  it. 

"  Polyp  of  the  ear"  is  no  sufficient  diagnosis.  Although  usually  a  symptom 
of  chronic  suppuration  of  the  tympanum,  its  real  cause  should  be  determined 
as  soon  and  accurately  as  possible,  and  its  removal  regarded  as  essential  to  a 
fair  beginning  of  treatment.  In  rare  cases  polyps  arise  in  furuncles,  generally 
after  poulticing  ;  but  most  of  them  come  from  the  tympanum.  When  seated 
upon  the  canal-wall  they  generally  indicate  a  carious  condition,  and  call  for 
scrupulous  study  and  care.  Their  removal  is  rarely  worth  considering  an  ope- 
ration, since  it  can  often  be  done  without  the  knowledge  of  the  patient  and  the 
probable  consequent  increase  of  difficulty.  Mere  rotation  with  the  probe  will 
often  "  wring  the  neck  "  of  a  polyp,  or  it  can  be  bitten  off  with  forceps  or 
snare.  The  new  tissue  is  generally  insensitive,  and  it  is  the  traction  on  its 
base  or  adjacent  parts  which  is  felt  more  or  less  painfully.  Complete  removal 
is  desirable,  and  chromic-acid  or  other  cauterization  of  the  stump ;  but  the 
mere  drying  eflFect  of  boric  or  alum  powder  often  suffices  for  those  not  arising 
from  inflamed  bone.  General  anfesthesia  may  be  required  for  proper  explora- 
tion and  removal,  and  the  arrangements  should  be  made  beforehand  to  carry 
through  at  once  any  requisite  operation  on  the  bone.  Caries  of  small  extent 
can  often  be  sufficiently  treated  by  rubbing  vigorously  with  the  cotton-carrier, 
or  may  be  curetted  with  the  small  sharp  spoon.  The  ossicles  can  be  excised 
if  considerably  involved,  since  their  usefulness  is  generally  gone,  and  they 
remain  as  obstacle  to  treatment  and  often  to  hearing.  Yet  such  intervention 
is  far  from  sure  to  give  either  prompt  or  lasting  relief  if  confined  to  cases  really 
demanding  it;  for  it  may  fairly  be  claimed  in  the  majority  of  cases  of  limited 
caries  of  the  ossicles  that  healing  can  be  secured  as  quickly  and  surely  without 
excision,  and  that  with  it  prompt  cure  can  be  expected  in  only  some  60  per 
cent,  of  the  apparently  appropriate  cases.  The  operation  of  Stacke,  in  which 
the  tympanic  attic,  and  often  the  antrum,  is  at  the  same  time  laid  freely  open 
by  removal  of  all  wall  intervening  between  it  and  the  canal,  is  called  for  in 
many  of  these  cases ;  and  the  turning  forward  of  the  auricle  and  cartilaginous 
canal,  by  incision  behind  it,  greatly  favors  thoroughness  and  safety,  while  not 
increasing  the  risk  of  operation. 

Chronic  suppurations  commonly  resist  any  treatment  which  parents  or 
nurses  can  give,  and  the  physician  who  treats  them  with  no  more  insight  rarely 
succeeds  better.  Yet  a  single  thorough  cleansing,  with  insufflation  of  boric 
powder,  will  often  cut  short  a  case  that  has  been  trifled  with  for  years.  Such 
prompt  drying  had  better  be  distrusted,  for  recurrence  is  probable.  Foci  of 
trouble  often  are  unreached,  and  the  exciting  causes  in  nares  and  tubes 
generally  remain.  Hearing  may  be  temporarily  lessened  by  reason  of  the  stiff- 
ness of  t'he  parts,  no  longer  even  duly  moist ;  and  perforations  in  the  drum- 
membrane  may  be  retained  by  repression  of  the  reparatory  inflammation.  Yet 
these  charges  against  the  dry  treatment  are  rarely  justly  condemnatory,  and 
proper  maintenance  of  naso-pharyngeal  treatment,  with  inflation  of  the  tym- 
panum, will  generally  secure  all  that  any  other  measures  can  do,  and  Avith  real 
gain  in  time  and  safety.  Serious  secondary  conditions,  like  mastoid  empyema  or 
caries  may  thus  be  averted  ;  but  there  is  no  evidence  that  they  are  not  rather 
lessened,  and  they  are  not  so  apt  to  be  masked  by  the  tympanic  condition. 

Aside  from  the  dangers  to  hearing,  a  number  of  perils  surround  both  the 
acute  and  chronic  forms  of  tympanic  suppuration.  The  bony  walls  are  every- 
where more  or  less  dependent  for  their  nutrition  upon  the  mucous  membrane, 
and  caries  of  ossicles  and  other  parts  can  readily  take  place,  with  occasionally 
extensive  necrosis.     Yet  without  this,  extension  of  inflammation,  even  when 


DISEASES    OF    THE  EAR. 


1173 


Fig.  7. 


not  septic,  may  involve  the  meninges,  the  great  blood-vessels  or  the  labyrinth  ; 
and  from  any  of  these  serious 
or  fatal  cerebral  lesions  may 
arise.  Brain-abscess  depends,  in 
most  cases,  upon  aural  suppura- 
tion, and  subdural  abscess  and 
septic  thrombosis  are  still  more 
frequent  in  children  (Fig.  7). 
Suppuration  in  the  labyrinth  gains 
ready  access  to  the  intracranial 
cavity  through  the  internal  audi- 
tory canal,  and  the  basilar  men- 
ingitis resulting  is  usually  fatal. 
This  is  noteworthy,  for  the  lep- 
tomeningitis due  to  caries  or  ne- 
crosis of  the  temporal  bone  is 
often  salutary,  and  builds  a  de- 
fence against  serious  invasion  for 
the  more  important  structures. 
(See  Figs.  8  and  9). 

Necrosis  may  lead  to  exfolia- 
tion of  large  portions  of  the  tem- 
poral bone,  including  the  laby- 
rinth and  facial  canal ;  yet  the 
cranial  contents  may  escape  un- 
harmed, in  spite  of  loss  of  much 
of  the  meningeal  surface  of  the 
bone,  and  the  facial  nerve  may  reorganize.  Facial  paralysis  is  not  rarely  met, 
for  the  facial  canal  is  frequently  incompletely  bony,  and  is  always  vulnerable 
as  it  passes  above  the  oval  window.  Bell's  palsy  in  children  is  usually  a  part 
Fig.  8.  Fig.  9. 


Portion  of  Base  of  Skull  of  Child  of  Three  Years,  showing 
carious  defect  in  the  roof  of  left  tympanum  and  the 
overlying  dura.  Death  resulted  from  a  large  brain- 
abscess  communicating  with  the  suppurating  tym- 
panum. 


Inner  Aspect  of  the  Temporal  Bone  of  a  Boy 
of  2}4  years,  showing  caries  of  roof  of 
attic  and  antrum.  Dural  thickening  effect- 
ually protected  the  brain  at  this  point,  but 
pus  "penetrated  with  fatal  result  through 
the  internal  auditory  meatus. 


Outer  Aspect  of  the  same  Bone,  showing 
destruction  of  mastoid  cortex  and  meatus- 
wall,  throwing  into  one  'open  cavity  the 
canal  and  tympanic  chambers.  The  oval 
window  is  seen,  as  in  life,  to  be  empty; 
the  facial  canal  above  it  is  open  and  va- 
cant, and  a  third  opening  is  into  the  hori- 
zontal semicircular  canal. 


1174  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 


of  an  otitis  media,  although  the  aural  symptoms  may  be  slight  and  fleeting. 
When  the  nerve  is  actually  destroyed,  restoration  is  not  likely,  and  the  canal 
may  prove  a  path  for  infection.  (See  Fig.  10). 

"  Burrowing  of  pus  ma}"  so  easily  take  place  out  along  the  bone,  instead  of 
through  it,  that  its  presence  upon  the  surface  should  never  be  accepted  as 
proof  of  a  bone-lesion,  but  the  region  must  be  carefully  searched  for  sagging 

of  the  wall?  of  the  canal,  es- 
FiG.  10.  pecially  above,  or  other  indi- 

cations of  subperiosteal  bur- 
rowing. Up  and  back,  near 
the  drumhead,  where  but  a 
thin  lamella  separates  the 
antrum  from  the  meatus,  a 
rounded  protrusion,  more  gen- 
erally of  reddish  color,  may 
be  found  as  the  result  of  pur- 
ulent collection,  which  has 
come  around  or  through  the 
bony  plate  ;  and  the  relations 
of  the  Shrapnell  membrane 
are  such  that  suppuration  in 
the  attic  may  pass  out  along 
the  wall,  instead  of  perforat- 
incr  the  membrane.  Bone- 
lesion  may,  therefore,  be  ab- 
sent ;  but  as  the  periosteum 
is  generally  detached,  super- 
ficial caries  is  almost  certain 
to  follow  unless  prompt  relief 
of  the  condition  is  obtained.  Incision  freely  down  upon  the  bone  is  called 
for,  in  order  to  lay  open  the  tract  throughout  as  soon  as  it  is  detected,  and 
stimulating  measures,  especially  the  hot  syringing,  should  be  vigorously 
employed.  Weak  acid  solutions,  best  in  75  per  cent,  glycerin,  have  been 
warmly  advocated  as  capable  of  decalcifying  and  aiding  to  remove  any  dead 
portions  of  bone,  while  energetically  stimulating  the  growth  of  healthy 
granulations. 

Chroxic  Catarrhal  Ixflammatiox  of  the  Middle  Ear  may  remain  as 
the  result  of  one  or  more  acute  attacks,  but  more  frequently  is  an  insidious  and 
progressive  disease  due  to  continuous  nasal  trouble,  directly  or  indirectly  acting 
through  the  Eustachian  tube.  These  slit-like  canals  are  normally  closed,  yet 
open  readily  in  yawning,  swallowing,  or  forced  respiration,  and  serve  to  venti- 
late the  tympanum  and  maintain  equality  of  pressure  upon  the  inner  and  outer 
surfaces  of  the  drumhead.  Nasal  catarrh  may  lead  to  violent  nose-blowing, 
with  undue  distention  of  the  tympanum ;  but  much  oftener  the  swelling  of  the 
mouth  or  lumen  of  the  Eustachian  tube  both  guards  the  ear  against  this  and 
also  precludes  the  normal  transmission  of  air.  The  unrenewed  air  in  the  drum- 
cavity  is  absorbed,  the  tympanic  membrane  pressed  in  by  the  preponderating 
external  pressure,  and  swelling  or  hypersecretion  of  the  lining  mucous  mem- 
brane, or  transudation  through  it,  results  from  the  partial  vacuum.  In  still 
other  cases  the  tube  is  duly  patulous,  and  nasal  obstruction  gives  rise  to  suction 
at  every  act  of  swallowing,  just  as  in  the  "  Toynbee  experiment  "  with  the  nose 
held  closed.  Whether  thus  medially,  or  through  direct  extension  of  inflamma- 
tion by  continuity,  the  tympanum  becomes  involved  in  a  low  grade  of  inflam- 


Large  Sequestrum.  >li.. wing  much  of  the  outer  surface  of  mastoid. 
It  comprises  also  much  of  the  facial  and  semicircular  canals, 
the  antrum,  and  its  removal  uncovered  extensively  the  dura 
and  lateral  sinus,  but  was  followed  by  recovery,  with  deafness 
aud  facial  palsy  of  this  side.  The  whole  temporal  bone  is 
sketched  in  to  show  the  relations  of  the  exfoliated  portions. 


DISEASES    OF    THE  EAR.  1375 

mation  tending  toward  sclerosis.  So  marked  is  this  tendency  that  some  cases 
may  well,  from  their  start,  be  designated  as  sclerotic ;  yet  such  are  rarely  recog- 
nizable in  early  childhood,  and  the  hypertrophic  form  is  here  the  most  import- 
ant. Slight  congestion  of  the  whole  tract  is  usually  present,  as  indicated  by 
the  distended  vessels  visible  along  the  malleus  handle ;  infiltrations  take  place 
in  limited  or  diffused  areas  of  the  drumhead  or  other  parts  of  the  tracts,  lead- 
ing to  fibrous  or  chalky  deposits;  and,  more  important  still,  the  ligaments  of 
the  ossicles  and  the  less  constant  reduplications  of  mucous  membrane  about 
them  undergo  stiffening  and  contraction.  The  pull  of  the  tensor  tympani  upon 
the  malleus  handle  may  thus  be  exaggerated  through  the  affection  of  its  tendon 
sheath,  increasing  the  depressed  or  retracted  condition  of  the  drumhead ;  and 
the  stapes,  which  is  often  surrounded  by  bands  of  tissue,  becomes  anchored 
firmly  in  its  niche  or  undergoes  true  ankylosis  of  its  foot-plate  in  the  oval 
window.  The  effect  of  this  in  hindering  the  due  transmission  of  aerial  sound- 
waves is  evident,  for  the  drum-membrane  is  stretched  too  tightly  to  respond 
properly  to  the  lower  tones,  the  conduction  through  the  chain  of  ossicles  is  hin- 
dered, and  the  cardinal  factor — the  slight  piston-like  movement  of  the  stapes — 
is  reduced  or  prevented.  Pain  of  a  neuralgic  character  is  sometimes  present, 
possibly  through  the  sharp  pressing  inward  of  the  drumheads,  and  subjective 
noise  or  vertigo  is  apt  to  be  added  to  the  deafness. 

Even  in  childhood  chronic  tympanic  catarrh  may  be  very  obstinate  and 
require  long  and  persistent  treatment.  The  naso-pharynx  is  to  be  put  in  the 
best  practicable  condition,  with  reduction  of  turbinal  hypertrophies,  shrinkage 
or  destruction  of  "adenoid  vegetations"  of  the  vault  of  the  pharynx,  and 
reduction  of  the  tonsils  by  astringents,  cauterization,  or  excision.  My  routine 
nasal  treatment  is  to  spray  clean  the  nares  with  a  detergent  alkaline  solution, 
such  as  Dobell's,  mop  the  pharynx-vault  with  glycerole  of  iodine  on  the  bent 
cotton-carrier,  give  a  protective  spray  with  a  10  per  cent,  menthol-camphor 
solution  in  alboline,  and  dust  lightly  with  calomel.  Inflation  of  the  tympanum 
can  usually  be  satisfactorily  done  with  the  Politzer  method,  the  patient  aiding 
by  pufiing  out  the  cheeks  or  saying  "  Huck  "  at  command.  If  water  is  given 
to  aid  the  swallowing  effort,  the  sip  should  be  small,  the  inflation  made  as  the 
larynx  is  seen  to  rise,  and  the  physician  will  be  wise  to  stand  out  of  range  of 
the  probable  spluttering.  If  the  collapse  of  the  drum-membrane  be  consider- 
able, its  distention  may  be  painful,  even  by  gentle  inflation ;  and  it  is  well  to 
have  the  fingers  thrust  into  the  ears  to  compress  the  air  in  the  canals  and  miti- 
gate the  pressure.  The  air  bloAvn  in  may  be  advantageously  medicated  by 
filling  the  bag  from  a  bottle  containing  a  little  iodine  or  other  stimulant.  The 
pneumatic  speculum  is  of  decided  value,  not  only  in  studying  the  condition  of 
the  drumhead,  but  also  as  an  excellent  means  of  using  massage.  Any  fulness, 
pain,  or  discomfort  caused  by  inflation  may  be  thus  promptly  relieved,  tinnitus 
and  deafness  much  lessened,  and  a  rational  method  of  relieving;  the  worst  fea- 
tures  of  the  trouble  readily  inaugurated.  Its  effect  can  be  continued  and 
increased  by  "tragus-pressure,"  or  pneumatic  massage,  done  with  the  finger- 
tip moving  in  and  out  while  hermetically  closing  the  canal.  Valsalva  infla- 
tion had  better  not  be  taught,  as  it  is  very  liable  to  be  abused,  but  this  other 
measure  is  generally  as  useful  and  probably  wholly  harmless. 

Affections  op  the  Internal  Ear, 

Lesions  of  the  internal  ear  are  fortunately  rather  rare  in  children.  Con- 
genital defects  are  hard  to  prove  during  life,  but  may  be  assumed  when  other 
malformations  are  present,  with  no  evidence  of  disease  and  where  no  hearing 


1176  AMEBICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

has  ever  been  detected.  When  deafness  is  total,  labyrinthine  lesion  is  almost 
certain,  since  disease  of  the  conducting  apparatus  can  hardly  abolish  the  func- 
tion of  the  organ. 

Acquired  Labyrinthixe  Deafness  is  usually  syphilitic,  except  in  the 
cases  of  necrotic  destruction  or  exfoliation  as  the  result  of  tympanic  suppuration ; 
and  evidence  of  the  inherited  taint  should  be  sought  in  the  eyes  and  teeth.  Even 
when  no  sign  of  interstitial  keratitis  or  other  ocular  syphilis  is  found,  and  the 
teeth  are  ■«'ell  formed  and  spaced,  the  facies  may  have  a  pinched  expression, 
with  precocious  marking  of  the  naso-labial  lines,  which  is  quite  characteristic. 
The  loss  of  hearing  is  generally  sudden,  and.  although  considerable  tympanic 
trouble  may  be  present  to  confuse  the  diagnosis,  the  routine  treatment  of  the 
middle-ear  lesion  will  prove  it  to  be  too  slight  to  be  a  probable  cause  of  the 
profound  deafness,  and  alteratives  will  have  distinct  influence  in  improving  the 
hearing.  Tuning-fork  tests  are  not  very  reliable  with  young  patients,  even 
when  intelligent  enough  to  understand  what  we  wish  to  learn,  and  the  objec- 
tive methods  are  of  uncertain  value.  It  is  claimed  that  through  long  stetho- 
scopic  tubes  connecting  the  ears  of  patient  and  observer  the  tuning-fork  on  the 
vertex  can  be  better  heard  from  the  less-aff"ected  or  normal  ear  if  the  lesion  is 
labyrinthine,  but  on  the  more  afi'ected  side  if  tympanic.  The  contrary  is 
sometimes,  if  not  generally,  true.  The  Galton  whistle  is  of  value  in  testing 
if  any  hearing  be  present,  as  it  can  be  concealed  in  the  hand  and  sounded  at 
various  pitches  in  proximity  to  the  ear  without  attracting  any  notice  unless  its 
sound  be  heard.  Yet  the  question  of  total  deafness  may  remain  undecided, 
and  the  history  throw  little  light  upon  diagnosis,  especially  in  children  who  do 
not  talk.  Sounds  accompanied  by  concussion,  even  of  the  air,  are  apt  to  be 
noticed,  and  calls  and  phrases  may  be  comprehended  in  spite  of  abolition 
of  hearing;  but  any  words  spoken  beyond  accidental  semblances  of  "ma-ma," 
etc.  may  be  taken  as  proof  that  some  hearing  is  or  has  been  present.  Cases 
of  labyrinthine  deafness  due  to  extravasation  or  sudden  exudation,  and 
accompanied  by  the  Meniere  symptoms  of  vertigo,  etc.,  are  very  rare  in  chil- 
dren, and  usually  unilateral.  It  is  still  a  question  how  far  acute  bilateral 
otitis  interna  is  mistaken  for  cerebro-spinal  meningitis,  the  intracranial  symp- 
toms of  which  are  merely  reflex,  and  recovery  takes  place  Avith  surprising 
promptness  except  for  the  persistence  of  total  deafness.  Such  cases  do  occur, 
but  more  often  the  lesion  is  doubtless  in  the  floor  of  the  fourth  ventricle,  with 
destruction  of  the  auditory  tracts  ;  and  any  labyrinth  lesions  later  found  are  due 
to  atrophic  degeneration. 

Whether  syphilitic  or  not,  the  treatment  of  these  disorders  is  about  the 
same.  A  full  mercurial  impression  should  be  obtained  with  all  possible  prompt- 
ness, and  the  alterative  effect  of  this  di'ug  and  iodine  well  maintained.  Mer- 
curial inunction  is  generally  safest  and  most  convenient  in  children,  the  oint- 
ment being  given  in  drachm  or  half-drachm  pellets,  of  Avhich  one  is  to  be 
rubbed  once  or  twice  daily  upon  the  belly  and  covered  with  a  flannel  band,  a 
new  surfice  being  taken  each  time  till  the  waist  is  encircled.  Pilocarpine  has 
some  curative  value,  but  is  probably  much  less  safe  or  certain  than  mercury. 

When  hearing  is  lost  in  early  life,  from  Avhatever  cause,  speech  is  either  not 
learned  or  is  very  apt  to  be  lost,  and  the  child  becomes  a  deaf-mute.  Yet 
some  trace  of  hearing  is  present  in  the  majority  of  those  in  the  mute  institu- 
tions, since  the  deafness  is  usually  tympanic ;  and  acquired,  as  it  often  is,  after 
some  language  has  been  learned,  this  only  needs  preservation  and  cultivation. 
A  considerable  proportion  can  be  taught  to  speak  intelligibly  and  read  the 
lips  of  others  with  facility.  The  process  is  slow  and  difficult:  so  it  should  be 
begun  early  and  with  rigorous  exclusion  of  the  easier  but  far  less  useful  sign- 


DISEASES    OF   THE   EAR.  1177 

language.  Any  remnant  of  hearing  may  be  of  immense  aid,  and  it  should  be 
made  as  good  as  possible  by  treatment ;  and  the  vocal  apparatus  should  in  like 
manner  be  put  in  the  best  practicable  condition,  that  it  may  add  no  needless 
impediment  to  the  acquisition  of  useful  speech. 

Mechanical  aids  to  the  hearing  may  be  of  value  to  the  mute  as  well  as  to  other 
deaf  persons,  both  for  hearing  the  sounds  of  the  words  spoken  to  them  and  their 
own  voices  in  speaking.  The  apj^liances  are  of  two  principal  forms — either  a 
trumpet  to  receive  in  the  expanded  mouth  a  larger  number  of  sound-waves 
than  the  ear  itself  could  catch,  and  transmit  them  by  air-conduction  to  the 
auditory  apparatus,  or  else  of  the  "dentaphone"  type — an  elastic  surface  to 
respond  to  the  vibrations  and  convey  them  by  bone-conduction.  Each  has  its 
limited  value  and  its  applicability  to  individual  cases ;  and  it  is  claimed  that 
they  sometimes  greatly  facilitate  that  exercise  of  the  auditory  apparatus  which 
can  occasionally  work  a  slow  but  immense  improvement  in  apparently  hopeless 
cases.  A  similar  therapeutic  idea  has  led  to  use  of  the  phonograph  as  a  means 
of  exercise  or  massage,  especially  by  the  believers  in  infinitesimals — perhaps 
"proved"  by  the  fact  that  the  attenuated  sounds  of  telephone  and  phonograph 
can  work  harm  to  diseased  ears.  Numerous  improved  forms  have  been  devised, 
all  promising  wonders  as  soon  as,  like  perpetual-motion  machines,  a  missing 
cog  shall  be  adjusted. 


PART    XIV. 


DISEASES  OF  THE  EYE, 

By  G.  E.  de  SCHWEINITZ,  A.  M.,  M.  D. 

Philadelphia. 


In  the  following  pages  only  those  diseases  of  the  eye  are  recorded  which 
the  general  practitioner  of  medicine  and  surgery  is  likely  to  encounter,  and 
which  do  not  demand  the  use  of  instruments  of  precision  for  their  detection 
and  study. 

Diseases  of  the  Lids. 

Abscess  and  Furuncle  of  the  Lid. — An  abscess  of  the  lid,  sometimes 
called  phlegmon,  appears  as  a  localized  red  elevation,  which  may  arise  in  debil- 
itated children  without  ascertainable  cause,  and  also  results  from  exposure, 
injury,  or  diseases  of  the  orbit.  The  affection  may  terminate  in  the  formation 
of  a  slough  or  "core,"  and  then  receives  the  name  ^'■furuncle,"  and  in  sub- 
jects of  poor  nutrition  may  be  complicated  with  gangrene  of  the  surrounding 
integument. 

Treatment. — Pointing  should  be  favored  by  the  application  of  moist 
heat  with  compresses  of  lint  steeped  in  hot,  slightly  carbolized  solutions. 
As  soon  as  fluctuation  is  detected,  or  even  earlier,  the  abscess  should  be  incised 
with  a  knife  thrust  through  it  parallel  to  the  muscle-fibres,  and  the  cavity  kept 
clean  with  a  solution  of  bichloride  of  mercury  or  with  peroxide  of  hydrogen. 
Nourishing  food  and  tonics,  as  quinine  and  iron,  are  indicated. 

Hordeolum,  or  Stye,  is  a  small  furuncle  on  the  margin  of  the  lid  caused 
by  a  circumscribed  inflammation  of  the  connective  tissue,  or  of  one  of  the  glands 
of  this  region. 

Ordinarily,  the  afl"ection,  though  annoying,  is  trifling  in  character:  the 
swelling  becomes  invested  with  a  yellow  cap,  indicating  suppuration,  and  the 
purulent  contents  are  evacuated  by  spontaneous  rupture  or  by  incision.  Some- 
times, however,  the  appearances  are  similar  to  those  of  purulent  conjuncti- 
vitis, from  which  it  may  be  diff"erentiated  by  observing  the  indurated  portion  of 
the  lid,  the  point  of  suppuration,  and  the  absence  of  profuse  purulent  discharge. 

Styes  tend  to  recur  or  to  come  in  "  crops."  They  are  excited  by  exposure  to 
dust  and  cold  and  the  strain  of  uncorrected  ametropia,  especially  hypermetropic 
astigmatism.  The  repeated  occurrence  of  styes  always  indicates  some  general 
derangement — dyspepsia,  constipation,  and,  in  girls  at  the  age  of  puberty, 
menstrual  disorders. 

Treatment. — An  attempt  to  abort  a  stye  may  be  made  by  the  repeated 
application  of  compresses  steeped  in  hot  boric-acid  solution,  by  rubbing  the 

1178 


DISEASES    OF   THE   EYE.  1179 

inflamed  area  with  a  1  per  cent,  ointment  of  yellow  or  red  oxide  of  mercury, 
or  by  painting  the  surface  with  collodion.  When  suppuration  occurs  the 
swelling  should  be  incised  by  cutting  through  its  base  parallel  to  the  lid. 
Constipation,  dyspepsia,  and  menstrual  disorders  should  be  corrected,  and 
in  children  of  suitable  age  refractive  anomalies  should  be  neutralized  with 
appropriate  glasses.  Sulphide  of  calcium  has  some  influence  in  preventing 
the  recurrence  of  styes, 

ExANTHEMATOUS  ERUPTIONS  are  found  upon  the  eyelids  during  the  various 
eruptive  fevers,  and  in  small-pox  a  pustule  may  form,  by  preference  at  the  com- 
missure, leaving  a  disfiguring  scar,  or  it  may  terminate  in  an  ulcer  of  stubborn 
character  which  is  denominated  post-variolous  ulcer.  Vaccine  vesicles  on  the 
free  border  of  the  lids  have  been  reported  by  Hirschberg,  Berry,  and  others,  after 
contact  with  vaccine.     The  aff"ection  receives  the  name  vaccine  blepharitis. 

Blepharitis, — This  term  describes  the  various  subacute  and  chronic  inflam- 
mations of  the  border  of  the  lids,  and  the  affection  usually  appears  in  a  non- 
ulcerated  and  an  ulcerated  form. 

The  non-ulcerated  varieties  manifest  themselves  as  a  simple  hypersemia  of 
the  lid  margins,  the  "red  eyes"  of  common  parlance,  characterized  by  swell- 
ing, redness,  and  passive  congestion  of  the  superficial  blood-vessels ;  or  in  an 
abnormal  secretion  of  the  sebaceous  glands,  characterized  by  the  formation  of 
crusts  and  scales  of  hardened  sebum  (a  similar  process  often  aff'ecting  the  eye- 
brows at  the  same  time)  at  the  roots  of  the  cilia,  and  lying  upon  a  slightly 
inflamed  and  occasionally  abraded  surface.  Distinct  ulcers  usually  are  not 
present.  This  form  is  always  bilateral,  and  is  known  as  sehorrhoea  of  the  lid 
border,  blepharitis  ciliaris,  or  squamous  blepharitis. 

The  ulcerated  varieties  manifest  themselves  as  a  marginal  eczema,  which 
resembles  an  aggravated  form  of  the  simple  hypersemia ;  or  as  a  blepharo-adenitis, 
characterized  by  the  matting  of  a  tuft  of  cilia  in  a  crust  which  covers  a  dis- 
tinct ulcer,  and  which  often  aff"ects  a  single  lid ;  or  as  a  pustular  inflamma- 
tion, characterized  by  the  development  of  thick  yellow  crusts  covering  deep 
ulcers  that  destroy  the  nutrition  of  the  eyelashes,  which  are  misshapen  and 
readily  fall  from  their  follicles.  This  type,  called  blepharitis  ulcerosa,^  often 
affects  all  of  the  lid  margins,  and  may  lead  to  deformities,  owing  to  the  loss  of 
the  cilia  and  the  change  in  the  shape  of  the  ciliary  border,  which  becomes 
thickened,   everted,  and  rounded  C-^lippitudo,"  or  blear-eye). 

Etiology. — Blepharitis  in  many  of  its  forms  is  distinctly  a  disease  of  child- 
hood, and  is  apt  to  attack  children  of  blonde  complexion  and  strumous  habit. 
It  frequently  follows  in  the  wake  of  the  exanthemata,  but  may  arise  in  other 
subjects  in  seemingly  perfect  condition.  Not  infrequently,  affections  of  the 
nares  and  naso-pharynx  are  present  (various  types  of  rhinitis,  catarrh,  and 
adenoid  vegetation),  which  probably  act  as  causative  factors.  Eczema  around 
the  nares  and  auricle  is  often  present.  Ametropia,  especially  hypermetropia 
and  astigmatism,  as  originally  pointed  out  by  Roosa,  probably  causes  many 
cases,  and  is  responsible  for  the  continuance  of  others.  Abnormal  shortness 
of  the  palpebral  fissure  may  originate  blepharitis  (Fuchs). 

Treatment. — This  depends  upon  the  type  of  the  disease.  In  children 
of  suitable  age  refractive  anomalies  should  always  be  corrected.  The  forms 
described  as  hypersemias  will  often  disappear  by  this  means  alone ;  if  not,  the 
lids  may  be  washed  frequently  Avith  warm  water  and  castile  soap,  and  an  eye- 

^  Eczema  of  the  border  of  the  lids,  according  to  its  raanifestations,  was  formerly  described 
under  several  names — blepharitis  ciliaris,  blepharitis  ulcerosa,  psorophthalmia,  lippitudo  ulce- 
rosa, tinea  tarsi,  sycosis  tarsi,  ophthalmia  tarsi,  etc. 


nso  AifumcAJv  text-book  of  diseases  of  children. 

douche  may  be  employed,  the  water  of  which,  at  a  temperature  of  about  60°  F., 
is  conducted  from  a  can  held  above  the  head  through  a  tube  to  the  end  of  which 
a  small  rose  is  fitted,  which  distributes  the  fluid  in  fine,  shower-like  jets  upon 
the  closed  lids.      Stimulating  salves  are  not  indicated  in  this  variety. 

In  the  seborrhoeas  the  crusts  should  be  removed  with  an  alkaline  solution, 
bicarbonate  of  sodium  (gr.  viij-fsj),  or  biborate  of  sodium  (gr.  iv-fsj),  and  then 
an  ointment  of  milk  of  sulphur  or  of  resorcin  (2  or  3  per  cent.)  applied  to  the 
lid  margins.  In  the  eczemas,  after  removal  of  all  crusts,  the  yellow  oxide  of 
mercury  (gr.  j-f^j)  is  the  most  useful  application.  In  any  type  associated  with 
much  ulceration  all  loose  cilia  should  be  removed  with  epilating  forceps  and  the 
ulcers  touched  with  a  solution  of  nitrate  of  silver.  In  place  of  the  salves  which 
have  been  mentioned,  boracic-acid  ointment  (10  per  cent.),  zinc  ointment,  or 
aristol  ointment  (2  per  cent.)  may  be  used.  The  puncta  and  lachrymo-nasal 
duct  should  be  patulous,  and  any  diseased  condition  of  the  nares  and  naso- 
pharynx should  be  corrected.  As  constitutional  remedies,  cod-liver  oil,  lacto- 
phosphate  of  lime,  iodide  of  iron,  and  syrup  of  hydriodic  acid  will  usually  find 
indications. 

Phtheiriasis  .of  the  Lids. — The  pediculus  pubis  (crab  louse)  occasion- 
ally infests  the  eyebrows  and  eyelashes.  The  parasites  cause  much  irritation, 
and  the  aifection  may  be  mistaken  for  ordinary  blepharitis. 

Treatment. — The  margins  of  the  lids  should  be  rubbed  with  balsam  of 
Peru,  mercurial  ointment,  or  a  solution  of  corrosive  sublimate. 

Syphilis  of  the  Eyelids. — A  hard  chancre  may  develop  on  any  portion 
of  an  area  included  by  the  lid  borders  and  inner  can  thus,  the  tarsal  conjunctiva 
and  the  cul-de-sacs  (De  Beck),  the  inoculation  usually  taking  place  by  con- 
tact with  the  secretion  from  a  syphilitic  mouth.  The  affection  begins  as  a 
pimple  which  develops  into  a  characteristic  ulcer  with  indurated  base. 

A  small  papular  syphilide  has  been  noted  upon  the  eyelids  of  infants  the 
subjects  of  hereditary  syphilis  a  few  weeks  after  birth,  and  madarosis  (fall- 
ing of  the  lashes),  as  well  as  a  form  of  ulcerated  blepharitis,  has  been  ascribed 
to  the  same  cause. ^ 

Tumors  and  Hypertrophies. — Clear,  small  cysts,  warts,  and  little  masses 
of  granulations  may  occur  on  the  margin  of  the  eyelid,  the  last  arising  from  the 
mouth  of  a  Meibomian  duct.  In  addition  to  these  attention  is  directed  to  the 
following  growths : 

Ncevi  (angiomas). — These  are  congenital  growths,  either  small  red  spots 
or  cavernous  structures  analogous  to  those  which  occur  elsewhere  in  the 
body.  They  should  be  removed  as  soon  as  practicable.  If  small,  excision 
may  be  practised  ;  if  large,  they  may  be  destroyed  by  galvano-cautery  puncture. 

Chalazion. — This  is  a  small  tumor  arising  in  the  tarsus,  due  to  inflammation 
of  a  Meibomian  gland  and  its  surrounding  tissue;  hence  it  is  an  adenitis  or  a 
periadenitis,  and  not  a  true  cyst.  It  occurs  in  children,  but  is  much  more  com- 
mon in  adolescence.  The  exact  cause  is  not  known,  although  it  is  connected 
with  stoppage  of  the  duct  of  a  Meibomian  gland,  which  in  its  turn  may  be  caused 
by  inflammatory  affections  of  the  lid  border.  Chalazia  are  apt  to  occur  in  the 
lids  of  those  suffering  with  hypermetropia  and  astigmatism. 

Treatment. — The  lid  should  be  everted  and  the  discolored  spot  on  the 
tarsal  conjunctiva,  which  marks  the  position  of  the  chalazion,  exposed.     This 

'  Those  interested  in  this  subject  should  consult  De  Beck,  Hard  Chancre  of  the  Eyelids  and 
Conjunctiva,  Cincinnati,  1886;  and  Alexander,  Syphilis  und  Auge,  Wiesbaden,  1889. 


DISEASES    OF   THE  EYE.  1181 

should  be  incised  and  the  contents  scraped  out  with  a  small  curette.  Large 
chalazia  should  be  removed  by  cutaneous  incision,  the  area  of  operation 
being  enclosed  in  a  suitable  clamp  forceps  (Snellen  or  Knapp).  Resolvent 
ointments  (yellow  oxide  of  mercury  gr.  j-.5j)  have  some  reputation,  but 
usually  their  employment  is  a  waste  of  time. 

Sarcoma  of  any  of  the  types  occurs  in  the  eyelids  of  children,  both  upper 
and  lower,  as  a  primary  growth.  At  first  the  growth  is  movable  under  the  skin 
and  slightly  elastic  to  the  touch,  but  rapidly  develops,  and  may  be  complicated 
with  ulceration  of  the  overlying  tissue.  Thorough  removal  should  be  prac- 
tised as  soon  as  the  diagnosis  is  established,  but  return  and  metastasis  are  likely 
to  take  place. 

Tarsitis. — This,  is  a  chronic  (very  rarely  acute)  inflammation  of  the  tarsus, 
often  syphilitic  in  origin,  and  then  consisting  of  a  gummatous  infiltration.  An 
idiopathic  tarsitis  also  exists  which  resembles  a  chronic  blepharitis,  from  which 
it  must  be  differentiated  by  observing  the  induration  of  the  tarsal  portion  of 
the  lid.  If  it  be  syphilitic,  the  usual  constitutional  remedies  are  indicated  ;  if 
idiopathic,  the  treatment  of  chronic  blepharitis  is  suitable. 

Blepharospasm. — This  term  comprises  several  varieties  of  involuntary 
contraction  of  the  whole  of  the  orbicularis  palpebrarum  or  of  a  few  of  the  fibres. 
It  is  either  clonic  or  tonic  in  character. 

Clonic  Blepharospasm. — The  most  trifling  type  of  the  clonic  variety  con- 
sists in  the  twitching  of  a  few  fibres  of  the  muscle,  sometimes  spoken  of  as 
"life  in  the  eyelid,"  being  significant  of  eye-strain  or  some  loss  of  tone  in  the 
nervous  system,  and  correctible  by  removing  the  evident  cause.  Occasionally, 
however,  it  becomes  stubborn,  and  requires,  in  addition  to  suitable  glasses,  the 
administration  of  antispasmodic  remedies — gelsemium  or  conium. 

That  form  of  nervous  disorder  which  Weir  Mitchell  has  called  '■'habit 
chorea"  manifests  itself  in  undue  winking  of  the  eyelids  and  j erky  movements 
of  the  facial  muscles,  partaking  of  the  nature  of  a  grimace.  It  is  very  com- 
mon in  nervous  school-children,  and  almost  always  refractive  error,  usually 
hypermetropic  astigmatism,  follicular  conjunctivitis,  and  blepharitis  will  be 
found.  Suitable  glasses  and  the  exhibition  of  iron  and  arsenic  usually  suffice 
to  cure  the  disease. 

Tonic  Blepharospasm  appears  as  a  more  or  less  persistent  cramp  of  the 
orbicularis,  and  may  be  caused  by  foreign  bodies  in  the  conjunctival  cul-de-sac 
or  in  the  cornea,  by  conjunctivitis,  and  by  various  types  of  keratitis. 

In  rare  instances  a  persistent  cramp  of  the  lid  occurs  in  children,  generally 
in  those  of  poor  nutrition,  which  continues  for  weeks  and  even  months,  and  for 
which  there  is  no  obvious  cause.  When  the  lids  are  finally  opened,  there  may 
be  blindness,  temporary  in  character  and  without  changes  in  the  fundus  oculi, 
or  associated  with  definite  lesions  in  the  choroid  and  retina.  In  the  one 
instance  the  blindness  is  probably  due  to  the  long-continued  exclusion  of  the 
rays  of  light,  and  in  the  other  to  alteration  in  the  coats  of  the  eye  from 
pressure. 

Treatment. — As  the  affection  in  the  large  majority  of  cases  partakes  of 
the  nature  of  a  reflex  originating  from  an  irritation  of  the  peripheral  trigem- 
inal fibres,  the  source  of  irritation — foreign  body,  phlyctenule,  or  fissure  at 
the  commissure — must  be  removed.  If  the  cramp  continues,  morphine,  conium, 
or  gelsemium  may  be  tried.  In  bad  cases  section  of  the  supraorbital  nerve 
has  been  performed. 


1182  ami:bicax  text-book  of  diseases  of  children. 

Ptosis. — In  this  aflfection  the  upper  lid  droops  over  the  eyeball,  and  more 
or  less  perfectly  covers  it.  It  may  be  congenital  or  acquired,  unilateral  or 
bilateral,  and  is  usually  divided  into  that  form  of  ptosis  which  is  caused  by  an 
hypertrophy  of  the  connective  tissue  or  an  excessive  accumulation  of  fat.  and 
that  variety  which  depends  upon  imperfect  development  of  the  levator  palpe- 
branim  or  paralysis  of  this  muscle.  Ptosis  may  also  be  the  I'esult  of  paralysis 
of  the  oculo-motor  nerve,  and  can  be  caused  by  injury  to  the  levator  of  the 
upper  lid. 

Cases  of  constitutional  origin — for  example,  from  syphilis  or  rheumatism — 
require  the  usual  remedies.  The  treatment  of  congenital  ptosis,  either  of  the 
hypertrophic  variety  or  that  due  to  imperfect  muscular  development,  requires 
an  operation. 

Lagophthalmos,  or  an  inability  to  close  the  eyelids,  may  result  from 
paralysis  of  the  facial  nerve,  and  also  when  the  globe  is  pushed  forward  by  a 
tumor  of  the  orbit,  or  is  prominent  as  the  result  of  exophthalmic  goitre,  or  pro- 
tuberant on  account  of  a  staphyloma.  The  affection  is  referred  to  because, 
under  certain  circumstances,  the  exposure  which  the  cornea  suffers  may  lead 
to  ulceration,  especially  if  with  the  facial  palsy  there  exists  an  involvement  of 
the  trigeminal  "fibres.  Under  these  circumstances  the  operation  of  tarsorrhaphy, 
which  consists  in  uniting  the  margins  of  the  upper  and  lower  lids  in  the  neigh- 
borhood of  the  external  commissure,  is  indicated. 

Symblepharon  is  really  an  affection  of  the  conjunctiva,  and  consists  of  a 
cohesion  between  the  eyelids  and  the  ball  which  may  be  partial  or  complete. 
It  generally  follows  an  injury,  particularly  a  burn  of  the  conjunctiva  with  acid 
or  lime,  and  may  also  result  from  violent  inflammations  of  the  conjunctiva.  It 
occasionally  occurs  as  a  congenital  defect. 

Treatment. — If  adhesions  form,  they  should  be  broken  down  with  a  probe, 
and  their  reattachment  prevented  by  introducing  between  the  lid  and  the  ball 
a  piece  of  gold-beaters  skin  or  by  keeping  the  cul-de-sac  packed  with  a  pledget 
of  lint  smeared  with  boric-acid  ointment.  If  these  simple  measures  fail,  then 
one  of  the  many  operations  for  the  relief  of  symblepharon  must  be  performed. 

Trichiasis;  Distichiasis. — Trichiasis  is  that  affection  in  which  the  cilia 
are  turned  inward  and  rub  against  the  ball.  It  is  most  commonly  caused  by 
chronic  inflammation  of  the  border  of  the  lid — for  example,  blepharitis — and 
by  granular  conjunctivitis.  The  cilia  produce  much  irritation,  and  may  cause 
an  ulceration  of  the  cornea. 

When  incurved  rows  of  supplementary  eyelashes  are  developed  from  the 
intermarginal  part  of  the  lid.  the  affection  receives  the  name  distichiasis. 
Sometimes  this  is  congenital,  but  it  also  arises  under  the  same  circumstances 
which  produce  trichiasis. 

Treatment. — If  the  misplaced  lashes  are  not  too  numerous,  they  may  be 
removed  with  cilium  forceps,  and  the  procedure  repeated  when  they  grow  again  ; 
but  if  the  affection  is  extensive,  some  operation  which  consists  in  strangulating 
or  destroying  the  I'oots  of  the  incurved  lashes,  or  in  which  a  single  or  double 
transplantation  of  the  entire  margin  of  the  lid  is  effected,  must  be  performed. 

ExTROPiOX. — With  or  without  trichiasis  there  may  be  an  inversion  of  the 
lid.  The  organic  variety  follows  long-continued  granular  conjunctivitis,  atrophy 
of  the  conjunctiva,  and  diphtheritic  ophthalmia.  A  spasmodic  entropion  is  com- 
mon as  the  result  of  inflammation  of  the  cornea  or  conjunctiva,  or  from  the 


DISEASES   OF   THE  EYE.  1183 

presence  of  foreign  bodies,  and  is  sometimes  a  marked  symptom  shortly  after 
birth,  owing  to  an  undue  activity  of  the  orbicularis  muscle. 

Treatment. — Spasmodic  varieties  usually  subside  by  removing  the  cause. 
In  the  event  of  failure  the  inverted  lid  may  be  drawn  outward  and  held  in 
place  by  a  piece  of  adhesive  plaster  attached  near  the  margin  of  the  lid  and 
passing  downward  on  the  cheek,  or  by  a  piece  of  gauze  fastened  with  collodion. 
When  there  is  organic  entropion  a  formal  operation  must  be  undertaken  for 
its  cure.^ 

Ectropion. — This  consists  in  an  eversion  of  the  lid,  partially  or  completely 
exposing  the  conjunctival  surface.  It  may  occur  as  an  acute  affection,  espe- 
cially in  children  with  inflammatory  affections  of  the  conjunctiva  and  cornea. 
In  its  organic  form,  however,  the  eversion  is  generally  caused  by  an  injury — 
for  example,  the  laceration  of  the  lid  with  a  sharp  instrument — by  cicatricial 
contraction  as  the  result  of  burns,  by  chronic  disease  of  the  margin  of  the  lid, 
and  by  caries  of  the  orbital  border  or  malar  bone.  A  slight  eversion  of  the  lid 
is  practically  always  present  in  children  with  facial  palsy. 

Treatment  depends  entirely  upon  the  type  of  the  affection.  The  spas- 
modic varieties  get  well  with  removal  of  the  cause,  associated  with  replace- 
ment of  the  everted  lids ;  mild  types  are  sometimes  curable  by  dilating  the 
punctum  lachrymale,  but  in  the  organic  forms  there  is  no  remedy  except  a 
formal  operation. 

Milium. — Milia  are  common  on  the  eyelids  about  the  age  of  puberty,  and 
consist  of  small,  yellowish  elevations  which  are  due  to  a  distention  of  the 
sebaceous  glands.  They  result  from  improper  care  of  the  skin,  but  often  indi- 
cate disturbances  in  the  alimentary  canal,  parti cularl}?^  dyspepsia  and  constipa- 
tion. They  may  be  removed  by  pricking  each  elevation  with  a  needle  and 
evacuating  the  contents. 

MoLLUSCUM  CoNTAGiosuM,  a  disease  of  the  sebaceous  glands,  perhaps  of 
the  rete  mucosum,  and  probably  of  parasitic  origin,  may  develop  upon  the  eye- 
lids. It  is  generally  seen  in  ill-nourished  children,  and  in  asylums  sometimes 
constitutes  an  epidemic.  Each  molluscum  is  a  rounded  papule  about  the  size 
of  a  pea,  of  a  somewhat  waxy  color,  and  with  a  slight  depression  near  its 
centre. 

The  treatment  consists  in  incising  it  and  forcing  out  the  contents. 

Sebaceous  Cysts,  as  well  as  Dermoid  Cysts,  may  occur  in  the  eyelids, 
but  are  more  commonly  seen  in  the  upper  portion  of  the  eyebrows.  Some- 
times in  the  latter  situation  they  adhere  to  the  periosteum  and  may  pass 
deeply  into  the  orbit.     They  should  be  removed  by  an  ordinary  dissection. 

Injuries  of  the  Eyelids. — The  eyelids  may  receive  an  incised,  lacerated, 
or  contused  wound,  depending  upon  the  character  of  the  implement  which  has 
caused  the  injury.  The  treatment  does  not  differ  from  that  of  similar  injuries 
elsewhere  located,  but  it  is  of  the  utmost  importance  that  scrupulous  asepsis 
should  be  followed,  and  accurate  adjustment  of  the  lips  of  the  wound  effected 
with  fine  silk  sutures. 

Blows  upon  the  lid  may  cause  a  simple  oedema  on  account  of  the  distention 
of  the  cellular  tissue  with  serum. 

^  For  the  description  of  operations  the  reader  is  referred  to  systematic  works  on  ophthalmic 
surgery. 


US4  AMEBICAJV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

(Edema  does  not  alone  result  from  an  injury,  but  independently  of  its  com- 
mon association  with  severe  inflammations  of  the  cornea  and  conjunctiva, 
appears  in  renal  and  cardiac  diseases ;  and  one  variety,  which  has  received  the 
name  fugitive  oedema,  may  occur  in  connection  with  migraine,  and  sometimes 
arises  in  association  with  the  establishment  of  the  menstrual  function,  and, 
again,  spontaneously  and  apparently  without  cause.  In  one  case  which  the 
author  has  seen  with  Dr.  Louis  Starr,  in  a  very  young  child,  it  depended  upon 
the  circulatory  disturbances  associated  with  slight  goitre. 

In  the  non-constitutional  varieties  evaporating  lotions — for  example,  lead- 
water  and  laudanum — and  removal  of  the  cause,  if  possible,  are  the  proper 
remedies. 

A  burn  of  the  eyelid,  either  by  hot  water,  acid,  or  caustic,  should  be  treated 
upon  general  principles,  care  being  taken  to  prevent  adhesions  between  the 
eyeball  and  lid.  One  of  the  very  best  preparations  for  soothing  the  pain  of 
burns  is  a  lotion  of  carbonate  of  sodium. 

Poivder-hurns. — The  bluish-black  specks  caused  by  the  implantation  of 
the  grains  of  powder  in  the  skin  should  be  picked  out  with  a  fine  needle  as 
soon  as  possible  after  the  injury,  and  recently  Dr.  Jackson,  of  this  city,  has 
suggested  that  each  grain  may  be  removed  by  touching  it  with  a  finely-pointed 
galvano-cautery  needle.  Afterward  the  ordinary  applications  for  burns  may 
be  applied. 

Emphysema  of  the  Lids  generally  indicates  a  fracture  of  the  orbit,  per- 
mitting the  escape  of  air  into  the  cellular  tissue  through  a  communication  with 
the  ethmoidal  or  frontal  sinus. 

If  blood  collects  in  the  same  situation,  ecchymosis  of  the  lid  results.  This 
condition,  commonly  called  "  black  eye,"  most  frequently  follows  a  blow.  It 
may  also  occur  with  fracture  of  the  base  of  the  skull,  and  occasionally  appears 
in  an  alarming  fashion  by  the  rupture  of  a  small  blood-vessel  after  a  violent 
paroxysm  of  whooping-cough. 

Treatment. — Frequent  applications  of  very  hot  water,  tincture  of  arnica, 
lead-water  and  laudanum,  or  diluted  fluid  extract  of  hamamelis,  have  some 
efi"ect  in  producing  absorption  of  the  eff"used  blood.  It  is  useless  to  attempt  to 
cause  absorption  of  the  blood  by  the  application  of  leeches. 

Affections  of  the  Conjunctiva. 

Inflammatory  diseases  of  the  conjunctiva  are  exceedingly  common  in  chil- 
dren, constituting  about  40  per  cent,  of  the  eye  cases  in  hospital  practice.  The 
most  important  group  is  that  described  under  the  general  term  conjunctivitis, 
which  for  purposes  of  description  may  be  conveniently  divided  into  several 
varieties : 

I.  Simple  Conjunctivitis,  generally  called  catarrhal  or  nmeo-purulcnt 
conjunctivitis,  is  characterized  by  hyperoemia  of  the  conjunctiva,  loss  of  its 
transparency,  some  dread  of  light,  with  a  feeling  of  grittiness  under  the  eye- 
lids and  a  muco-purulent  discharge,  which  may  be  slight  or  profuse. 

Etiology. — The  aff'ection  is  common  in  changeable  Aveather,  and  is  often 
seen  in  the  spring  and  fall.  In  severe  types  micro-organisms  (staphylococci, 
streptococci,  pneumococci)  are  present,  and  explain  the  contagious  nature 
of  some  forms  of  the  disease.  It  may  attack  perfectly  healthy  children, 
but  is  more  common  in  scrofulous  subjects,  and  is  more  likely  to  be  implanted 
on  a  conjunctiva  already  hypersemic  or  studded  with  swollen  follicles.  It 
may  be  associated  with  eczema,  erysipelas,  impetigo  contagiosa,  naso- 
pharyngeal affections,  bronchitis,  and  rheumatism,  and  commcnly  follows  or 


DISEASES    OF    THE   EYE.  1185 

attends  the  exanthemata.  It  may  further  arise  from  exposure  to  dust  or 
irritating  substances,  and  is  sometimes  the  result  of  eye-strain. 

Symptoms. — These  are — swelling  of  the  lids  and  slight  oedema  of  their 
margins;  mucous  or  muco-purulent  discharge,  which  may  excoriate  the  sur- 
rounding skin  ;  hyperemia  of  the  conjunctiva  and  congestion  of  the  posterior 
conjunctival  vessels,  in  bad  cases  associated  with  oedema  of  this  membrane; 
and  some  photophobia,  especially  if  small  corneal  ulcers  are  present.  The 
character  of  the  discharge  and  appearance  of  the  conjunctiva,  the  free 
mobility  of  the  iris  and  lack  of  change  in  its  color,  distinguish  it  from  iritis. 

Prog-nosis  is  good,  cure  usually  resulting  in  one  or  two  weeks,  but  when 
neglected  or  when  occurring  in  homes  or  asylums  conjunctivitis  of  this  charac- 
ter may  spread  with  great  rapidity  and  become  a  stubborn  epidemic. 

^  Treatment. — This  should  be  as  follows :  Eemoval  of  the  cause  in  so  far  as 
this  is  practicable ;  protection  of  the  inflamed  eyes  with  a  pair  of  dark  glasses 
or  a  shade,  but  U7ider  no  circumstances  the  application  of  a  bandage  or  of  a 
poultice  in  the  form  of  flaxseed,  tea-leaves,  bread  and  milk,  or  scraped  potatoes  ; 
prevention  of  contamination  with  the  discharge  through  any  medium  (in  homes, 
etc.  the  affected  inmates  should  be  isolated) ;  scrupulous  removal  of  the  secre- 
tion, which  may  be  effected  by  washing  the  eyes  frequently  with  tepid  water 
and  castile  soap  and  irrigating  the  conjunctival  cul-de-sac  with  the  following 
colly  rium : 

^.  Boric  acid gr.  xv. 

Table  salt  . gi'-ij- 

Distilled  water fgj. — M. 

When  the  discharge  becomes  profuse,  the  lids  should  be  everted  and  carefully 
painted  with'  a  small  cotton  mop  or  camel's-hair  brush  dipped  in  a  solution  of 
nitrate  of  silver  (gr.  v-f  5j).  In  place  of  nitrate  of  silver  a  5  or  10  per 
cent,   solution  of  protargol  may  be  employed. 

The  following  coUyria  have  also  found  favor  with  many  surgeons : 

Bichloride  of  mercury  (1  :  10,000) ;  alum  (gr.  iv-f§j);  sulphate  of  zinc 
(gr.  ij-f5J);  peroxide  of  hydrogen  (diluted  one-half  or  three-quarters);  and 
creolin  (1  per  cent.).  Atropine  is  generally  unnecessary.  A  saline  laxative 
and  tonic  doses  of  quinine  are  suitable  remedial  agents  in  cases  which  do 
not  present  special  therapeutic  indications. 

Acute  contagious  conjunctivitis,  often  called  epidemic  conjunctival 
catarrh,  "pink  eye,"  or  Koch-Weeks  bacillus  conjunctivitis,  was  formerly 
classified  as  a  form  of  simple  conjunctivitis.  It  may,  however,  be  considered 
as  a  distinct  affection. 

Etiology. — Many  cases  appear  to  be  due  to  a  small  bacillus  discovered 
independently  by  Koch  and  John  E.  Weeks  ;  other  cases  are  doubtless  caused 
by  the  pneumococcus  of  Frankel  (pneumococcus  conjunctivitis).  The  affec- 
tion is  highly  contagious,  and  is  commonest  in  the  spring  and  the  fall. 

Symptoms. — After  an  incubation  period  of  about  thirty-six  hours  a  mod- 
erate conjunctivitis  appears,  which  rapidly  develops  into  a  severe  type  with 
marked  congestion  of  the  bulbar  and  tarsal  conjunctiva,  subconjunctival 
hemorrhages,  oedema  of  the  lids,  thickening  of  the  retrotarsal  folds,  and  the 
secretion  of  thick  muco-pus.     Nearly  always  both  eyes  are  affected. 

Diagnosis  and  Prognosis. — The  diagnosis  depends  upon  the  presence 
of  the  symptoms  detailed  and  upon  bacteriological  examination.  The  prog- 
nosis is  good,  the  duration  of  the  disease  being  from  two  to  three  wrecks. 

Treatment. — This  is  exactly  the  same  as  has  been  advised  for  catarrhal 
'  conjunctivitis.      The  author  has  had  the  best  results  from  cold  compresses, 


1186  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  nitrate  of  silver  applied  to  the  everted  lids.  A  solution  of  sulphate  of 
zinc  is  said  to  be  a  valuable  collyrium. 

II.  Purulent  Coxjuxctivitis. — This  aflFection,  in  so  far  as  infants  are 
concerned,  is  generally  described  under  the  name  "  Ophthalmia  Neonatorum." 

Etiology. — The  infecting  material  enters  the  eye  from  some  portion  of  the 
genito-urinary  tract  during  the  passage  of  the  head  of  the  infant  through  the 
birth-canal,  or  inoculation  may  be  effected  shortly  after  birth  ;  in  rare  instances 
it  takes  place  in  utero  when  there  has  been  a  rupture  of  the  membranes. 

The  gonococci  of  Neisser  are  demonstrable  in  most  of  the  cases  and  in  all 
severe  forms,  and  bear  the  same  relation  to  this  disease  that  they  do  to  gonor- 
rhoea. There  is.  however,  one  non-specific  variety  in  which  this  micro-organ- 
ism is  not  present.  Therefore  a  virulent  vaginal  discharge  (gonorrhoeal)  is  not 
a  sine  qua  non  of  this  affection,  but  it  may  arise  from  the  introduction  of  any 
muco-purulent  discharge  during  birth,  while  careless  bathing  and  the  use  of 
soiled  towels  or  sponges  after  birth  are  evident  sources  of  infection. 

It  is  probable  that  injudicious  intravaginal  antisepsis  with  strong  solutions 
of  bichloride  of  mercury  may  originate  a  vaginitis  itself  capable  of  inducing 
one  form  of  ophthalmia  neonatorum,  and  the  best  obstetricians  confine  the 
application  of  germicidal  solutions  in  uncomplicated  labors  to  the  external 
genitalia.  The  author  is  confirmed  in  this  belief  bv  a  consultation  with  Prof. 
B.  C.  Hirst. 

Boys  are  more  apt  to  be  affected  than  girls,  and  inoculation  is  more  likely 
to  occur  during  retarded  labors  and  with  face  presentations. 

Symptoms. — Ophthalmia  neonatorum  usually  begins  on  the  third  day  after 
birth,  but  may  set  in  sooner,  and  when  it  results  from  secondary  infection — for 
example,  from  soiled  clothes — it  begins  at  a  later  date.  Almost  invariably  both 
eyes  are  affected. 

At  first  there  is  a  slight  discharge,  which  gathers  at  the  corners  of  the  eve, 
rapidly  succeeded  by  intense  injection  and  chemosis  of  the  conjunctiva,  great 
swelling  of  the  lids,  and  the  free  secretion  of  contagious  pus.  The  swollen 
lids  are  at  first  tense,  and  the  serous  infiltration  of  the  bulbar  conjunctiva 
almost  hides  the  cornea,  sometimes  forming  a  hard  rim  around  it ;  the  discharge 
increases  and  flows  out  underneath  the  lids,  often  being  mixed  with  blood 
and  serum.  During  the  earlier  stages  the  conjunctiva  is  red  and  velvety 
and  often  covered  with  flakes  of  lymph  ;  later  it  becomes  dark  red,  rough,  and 
easily  bleeds.  In  from  six  to  eight  weeks,  if  unattended,  the  disease  gradually 
declines  and  the  relaxed  conjunctiva  is  thick  and  granular-looking,  and  slowly 
regains  its  normal  appearance. 

The  intense  chemosis  of  the  conjunctiva  strangulates  the  vessels  which  sup- 
ply nutrition  to  the  cornea ;  hence  the  vitality  of  this  membrane  is  threatened, 
constituting  the  chief  danger  of  the  disease.  Ulcers  are  likely  to  form,  either 
at  the  margin  or  centre,  and  their  tendency  is  to  spread  and  perforate;  or  the 
entire  corneal  tissue  becomes  haz\^. 

The  results  of  perforation  are  the  formation  of  a  partial  or  complete 
staphyloma  and  adherent  leucoma,  or  a  pyramidal  cataract.  Even  without 
perforation  the  ulcers  leave  scai'S  which,  according  to  their  density,  are  nebu- 
lous or  leucomatous.  In  extensive  perforation  there  may  be  an  inflammatory 
involvement  of  all  the  coats  of  the  eye.  constituting  panophthalmitis,  which  is 
followed  by  shrinking  and  atrophy  of  the  globe. 

Some  non-specific  cases  of  ophthalmia  neonatorum  do  not  have  so  violent  a 
course,  and  present  the  appearance  of  an  ordinary  muco-purulent  conjunctivi- 
tis. Again,  others  are  analogous  to  diphtheritic  conjunctivitis,  and  the  danger 
of  corneal  destruction  is  even  greater  than  is  ordinarilv  the  case. 


DISEASES   OF    THE  EYE.  1187 

Prognosis. — This  is  always  grave,  but  under  the  guidance  of  competent 
medical  advice,  if  the  eye  is  seen  u'Jiile  the  cornea  is  still  clear,  except  in 
diphtheritic  types,  in  those  T\-ith  inherent  malignancy,  or  where  depreciation 
of  nutrition  diminishes  the  resisting  power  of  the  child,  most  of  the  cases 
should  he  brought  to  a  successful  termination.  The  chief  fault  lies  in  the 
indifference  of  attendants  to  what  seems  to  them  at  first  a  trivial  inflammation. 

Treatment. — The  treatment  should  meet  four  indications: 

(a)  During  the  earlier  stages,  when  the  inflammatory  swelling  of  the  lids  is 
great,  in  addition  to  proper  cleanliness  the  local  application  of  cold  is  the  most 
useful  agent.  This  should  be  applied  as  follows :  Upon  a  block  of  ice,  square 
compresses  of  patent  lint  are  laid,  which,  in  turn,  are  placed  upon  the  swollen 
lids,  and  are  as  frequently  changed  as  may  be  needful  to  keep  up  a  uniform 
cold  impression.  The  length  of  time  occupied  with  these  cold  applications 
must  vary  according  to  the  severity  of  the  case.  Sometimes  they  mav  be 
almost  continuously  used,  and  sometimes  frequently  for  periods  of  half  an 
hour. 

(h)  The  discharge  should  be  constantly  removed,  and,  if  possible,  by  a 
trained  hand.  In  order  to  accomplish  this,  proceed  as  follows :  Gently  separate 
the  lids,  Avipe  away  the  tenacious  secretion  with  bits  of  moistened  lint  or  absorb- 
ent cotton,  and  irrigate  the  conjunctival  sac  freely  with  an  antiseptic  solution, 
care  being  taken  that  the  point  of  the  pipette  does  not  come  in  contact  with 
the  cornea.  For  this  purpose  a  saturated  solution  of  boric  acid — which, 
while  it  is  not  germicidal,  is  still  feebly  antiseptic  and  slightly  astringent — is 
the  most  useful.  Bichloride  of  mercury,  one  grain  to  the  pint,  may  also  be 
employed. 

(c)  As  soon  as  the  discharge  becomes  free  and  creamy,  which  is  very  early 
in  the  disease,  nitrate  of  silver  should  be  employed;  and  this  drug  is  facile 
princejjs  of  the  local  remedial  agents.  It  must  be  applied  as  follows:  Care- 
fully evert  the  lids  and  secure  complete  exposure  of  the  inflamed  tarsal  con- 
junctiva ;  remove  all  discharge  and  flakes  of  lymph  by  irrigating  the  surfaces 
with  the  cleansing  lotion,  wiping  away  the  adherent  particles  with  moistened 
cotton;  carefully  touch  the  area  thus  prepared  with  a  cotton  mop  or  camel's- 
hair  brush  which  has  been  dipped  in  "a  solution  of  nitrate  of  silver,  ten,  or  at 
most  twenty  grains,  to  the  ounce;  neutralize  the  excess  with  a  solution  of  com- 
mon salt — a  pinch  of  salt  in  a  cup  of  water  will  suffice — and  keep  applying 
the  saline  solution  until  a  clean,  red  surface  is  secured;  finally,  return  the  lids 
to  their  proper  position  and  carefully  inspect  the  cornea  before  leaving  the  case, 
and  see  that  this  inspection  is  made  at  each  dressing  of  the  eye;  finally,  grease 
the  margins  of  the  lids  with  pure  vaseline,  some  of  which  should  be  introduced 
within  the  conjunctival  cul-de-sac. 

(d)  Should  the  cornea  become  hazy,  or  should  a  small  ulcer  form, 
atropine  two  to  four  grains  to  the  ounce,  one  drop  three  times  a  day,  should 
be  employed,  due  caution  being  exercised  to  avoid  the  constitutional  dis- 
turbance which  might  be  produced  by  absorption  of  the  medicament.  At 
one  time  it  was  advised  to  employ  eserine  in  a  strength  varying  from  one-sixth 
to  one-half  grain  to  the  ounce  in  corneal  ulcers  of  peripheral  situation — a 
practice  which  the  author  has  also  advocated  in  earlier  publications.  His 
maturer  experience,  however,  teaches  him  that  the  value  of  eserine  under 
these  circumstances  is  problematical.  If  there  is  corneal  haze,  indicating 
low  vitality  of  the  membrane,  the  cold  compresses  may  be  replaced  by  hot 
applications,  which  should  consist  of  squares  of  lint  wrung  out  in  a  slightly 
carbolized  solution  of  a  temperature  of  120°  F. 

The  author  has  thus  described  the  treatment  which  he  has  employed  many 


1188  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

times  with  success.  Among  the  other  solutions  which  have  found  favor  with 
surgeons  are  the  following :  Alum  (eight  grains  to  the  fluid  ounce) ; '  carbolic 
acid  {^  to  5  per  cent,  solution) ;  weak  solutions  of  nitrate  of  silver ;  protargol 
(2  to  5  per  cent.) ;  argentamin  (1  :  5000) ;  alcohol  and  bichloride-of-mercury 
solutions ;  creolin  in  1  per  cent,  solution ;  peroxide-of-hydrogen  solution ; 
permanganate  of  potassium  (1 :  2000),  employed  in  copious  irrigations ; 
cyanurct  of  mercury  (1  :  1500),  and  aqua  chlorinata.  Many  others  might 
be  mentioned,  but  the  evidence  is  not  sufficient  to  warr;jnt  their  recommen- 
dation or  even  their  trial. 

While  the  author  does  not  wish  to  condemn  the  use  of  a  proper  strength 
(1 :  8000)  of  bichloride  of  mercury  in  the  treatment  of  this  disease,  because  it 
has  often  served  him  to  good  purpose,  he  is  convinced  that  in  many  instances 
a  sense  of  false  security  has  arisen  simply  because  the  drug  has  been  employed 
and  because  of  its  vaunted  germicidal  properties.  Strong  solutions  of  sub- 
limate may  occasion  cloudiness  and  even  ulceration  of  the  cornea.  The  success 
of  treatment  depends  largely  upon  seeing  the  case  earh  while  the  cornea 
is  still  bright,  upon  the  faithfulness  of  the  attendants,  and  upon  assiduous 
attention  to  the  details  of  the  treatment. 

Prophylaxis. — Inasmuch  as  ophthalmia  neonatorum  is  one  of  the  most 
fruitful  causes  of  blindness,  prophylactic  measures  are  of  the  utmost  import- 
ance. All  things  considered,  Crede's  method  of  treating  the  eyes  of  the  new- 
born child  is  the  one  which  is  followed  by  the  best  results.  This  consists  in 
the  instillation  of  two  drops  of  a  2  per  cent,  solution  of  nitrate  of  silver  into 
the  conjunctival  sacs  of  the  newborn  child,  the  surfaces  of  the  eyelids  hav- 
ing first  been  carefully  \viped  clean.  This  instillation,  when  there  is  reason 
to  suspect  gonorrhoeal  contagion,  should  be  repeated  on  the  second  day. 
In  the  mean  time,  small  compresses  soaked  in  a  solution  of  salicylic  acid 
are  laid  upon  the  closed  lids.  Sometimes  the  instillation  of  the  silver 
solution  causes  hyperjemia,  which  disappears  in  a  few  days.  In  a  few 
instances  smart  conjunctival  hiTemorrhage  has  followed  this  treatment.  The 
enormous  value,  however,  of  this  prophylaxis  far  outweighs  the  few  accidents 
which  have  occurred  after  its  use. 

Numerous  other  methods  have  been' employed  in  the  prophylaxis  of  oph- 
thalmia neonatorum,  and  most  of  the  antiseptic  fluids  have  had  their  advocates, 
particularly  carbolic  acid,  1  per  cent.,  bichloride  of  mercury,  1 :  5000,  A"an 
Swieten's  solution  (corrosive  sublimate  1  part,  alcohol  100  parts,  water  900 
parts),  and  aqua  chlorinata,  the  last  drug  being  especially  recommended  by 
Schmidt-Rimpler.  Many  obstetricians  are  content  with  painstaking  cleanli- 
ness during  birth  and  also  during  childbed,  believing  that  this  will  reduce 
the  possibility  of  the  disease  to  a  minimum.  Certainly  whenever  infection 
or  the  suspicion  of  infection  can  be  excluded  by  suitable  examination, 
Crede's  method  is  not  necessary,  milder  measures  of  prophylaxis  being  suf- 
ficient ;  but  Crede's  method  should  be  employed  ahvays  to  protect  the  eyes  of 
those  children  who  have  passed  through  a  birth-canal  known  to  be  infected, 
or  from  which  the  suspicion  of  infection  could  not  possibly  be  eliminated 
prior  to  birth,  provided  that  the  method  is  properly  employed  and  not  so 
recklessly  or  imperfectly  that  of  itself  it  may  be  the  cause  of  an  irritative 
conjunctivitis. 

There  is  reason  to  hope  that  stringent  legislative  regulations  will  be 
formulated  to  lessen  this  appalling  cause  of  blindness,  but  in  their  absence 
it  is  the  evident  duty  of  physicians,  nurses,  and  directors  of  public  char- 

1  This  has  recently  received  fresh  endorsement  from  Mr.  Brudenell  Carter  (London  Lancet, 
December  10,  1892). 


DISEASES    OF    THE  EYE.  1189 

ities  to  disseminate  among  the  poorer  classes  a  knowledge  of  the  dangers 
of  this  disease  and  the  necessity  for  prompt  treatment.  When  the  disease 
has  developed  and  is  monolateral,  the  unaiFected  eye  may  be  protected  with 
a  bandage.     Attendants  should  be  warned  of  the  danger  of  contamination. 

III.  Diphtheritic  Coistjunctivitis. — This  is  an  exceedingly  contagious 
conjunctivitis,  which  may  arise  from  a  similar  case  or  during  the  course  of  a 
purulent  ophthalmia.  It  may  appear  in  connection  w4th  eczema  of  the  face  or 
accompany  an  acute  illness,  as  scarlet  fever  or  measles.  The  disease  is  also 
seen  during  epidemics  of  diphtheria,  when  it  is  occasioned  by  direct  inocu- 
lation. A  comparatively  rare  aifection  in  America  and  England,  it  is  common 
in  certain  parts  of  France  and  in  the  north  of  Germany.  It  is  most  frequent 
in  children  between  the  ages  of  two  and  eight. 

Symptoms. — The  chief  symptoms  are  swelling  of  the  lids,  which  become 
exceedingly  hard  and  board-like ;  a  dull,  grayish,  false  membrane,  either  dis- 
crete or  confluent,  covers  the  conjunctival  surface.  The  membrane  is  often 
deeply  incorporated  with  the  subjacent  tissue.  The  cornea  rarely  escapes,  and 
destruction  of  this  membrane  may  take  place  in  twenty-four  hours.  Even 
in  the  mild  cases  severe  ulceration  is  common.  In  addition  to  Klebs-LbfBer 
bacilli,  which  cause  the  disease,  staphylococci,  streptococci,  and  xerosis  bacilli 
are  found  in  the  discharge. 

Treatment. — During  the  earlier  stages  cold  compresses  are  proper,  to  be 
substituted  by  hot  affusions  later  on,  especially  if  there  is  corneal  ulceration. 
The  eyes  should  be  frequently  cleansed  with  boric  acid  or  w^eak  solutions 
of  bichloride  of  mercury,  and  atropine  drops  should  be  instilled.  French 
physicians  warmly  recommended  the  application  of  lemon-juice  and  citric- 
acid  ointment,  and,  on  the  advice  of  Tweedy,  solutions  of  quinine  have 
been  much  employed.  The  internal  treatment  is  that  suited  to  a  case 
of  diphtheria,  and  recent  experiences  indicate  that  the  greatest  reliance 
should  be  placed  upon  diphtheria  antitoxine,  which  should  be  administered 
exactly  as  it  is  in  ordinary  faucial  diphtheria. 

IV.  Croupous  Conjunctivitis. — A  true  croupous  conjunctivitis  occa- 
sionally attacks  children  between  the  first  half  year  of  life  and  the  seventh 
year.  The  disease  is  not  contagious,  and  the  cornea  usually  escapes.  Non- 
virulent  Lofller  bacilli,  staphylococci,  and  diplococci  have  been  found  in  the 
secretion.  The  chief  symptom  is  the  formation  of  a  false  membrane,  which 
has  a  rather  translucent  and  porcelain-like  appearance,  upon  the  inner  sur- 
face of  the  lids.  Healing  may  take  place  in  two  or  three  weeks,  or  the 
membrane  may  be  formed  again  and  again,  and  the  disease  continue  for 
months  and  even  years. 

There  is  a  second  variety  of  membranous  conjunctivitis  due  to  strepto- 
cocci which  occurs  in  children  in  connection  with  measles,  scarlet  fever, 
influenza,  impetigo,  and  sometimes  independently  of  febrile  complications. 
Unlike  the  preceding  form,  it  presents  a  most  unfavorable  prognosis,  not 
only  to  eyesight  but  also  to  life.  The  disease  is  often  mistaken  for  diphthe- 
ritic conjunctivitis.  Indeed,  it  is  called  streptococcus  diphtheria  of  the 
conjunctiva.  Bacteriological  examination  alone  would  make  the  differential 
diagnosis. 

Treatment. — This  should  include  the  application  of  iced  compresses,  fre- 
quent removal  of  the  discharge  with  a  solution  of  chloride  of  sodium  or 
chlorate  of  potassium,  and  such  constitutional  remedies  as  are  indicated  by 
the  child's  general  condition. 

V.  Spring  Conjunctivitis  {Fruehjahr  s  Catarrh). — This  curious  form 
of  conjunctival  disease  is  generally  seen  in  children  between  the  ages  of  five 


1190  AJIEBICAJV  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

and  fourteen  years.  Its  exact  cause  is  unknown.  Owe  of  the  characteristics 
of  the  disease  is  its  return  about  April,  and  its  subsidence  in-  the  fall  and 
winter,  although  sporadic  cases  are  seen  in  almost  every  month  of  the  year. 
Sometimes  it  accompanies  the  disease  known  as  hay  fever. 

Symptoms. — The  chief  symptoms  are  photophobia,  mucous  secretion, 
hypertrophy  of  the  tissues  surrounding  the  limbus  of  the  cornea  in  the  form 
of  grayish  nodules,  and  a  pale,  dull  color  of  the  palpebral  conjunctiva,  which 
has  been  compared  to  the  appearance  of  a  thin  layer  of  milk,  together  with 
the  formation  of  large  flattened  granulations  covering  the  tarsal  folds  and 
causing  the  eyes  to  droop  and  give  the  patient  a  peculiar,  sleepy  expression. 
It  must  not  be  confounded  with  granular  lids,  from  which  it  is  distinguishable 
by  the  flat  appearance  of  the  granulations  and  the  absence  of  corneal  compli- 
cations. So  far  as  vision  is  concerned,  the  prognosis  is  good,  but  the  prom- 
inent tendency  of  the  disease  to  return  with  the  early  spring  and  warm  weather 
makes  it  a  difficult  disorder  to  manage. 

Treatment. — The  eyes  should  be  protected  Avith  dark  glasses,  the  con- 
junctival cul-de-sac  freed  from  the  accumulated  secretion,  which  is  sometimes 
quite  free,  wdth  a  lotion  of  boric  acid  and  salt.  When  the  granulations 
are  prominent  the  lids  may  be  everted  and  their  surfaces  touched  with  a  20 
per  cent,  solution  of  boroglyceride  or  with  a  strong  solution  of  bichloride  of 
mercury  (1:500),  this  application  to  be  made  once  a  day.  In  bad  cases  the 
actual  cautery  may  be  employed  to  destroy  the  granulations,  or  these  may  be 
crushed  with  roller  forceps,  as  in  the  treatment  of  granular  lids.  Internally, 
some  form  of  arsenic  is  advisable,  preferably  Fowler's  solution. 

VI.  Follicular  Conjunctivitis. — This,  as  its  name  implies,  is  an  inflam- 
mation in  which  numerous  pinkish,  round  elevations  appear  in  the  conjunctiva, 
chiefly  in  the  retrotarsal  folds,  sometimes  associated  with  the  symptoms  of  an 
ordinary"  catarrhal  conjunctivitis  of  mild  degree.  These  bodies  are  tumefied 
lymphatic  follicles,  and  disappear  under  treatment  without  leaving  cicatricial 
changes  in  the  conjunctiva,  and  the  cornea  is  not  involved — points  which  dis- 
tinguish the  affection  from  true  granular  lids.  Some  authors  regard  it  as  an 
early  stage  of  granular  conjunctivitis.  The  evidence  is  in  favor  of  a  separate 
classification. 

It  occurs  usually  in  children  and  young  people,  and  in  its  aggravated  forms 
arises  under  the  influence  of  bad  hygienic  surroundings  in  overcrowded  schools 
and  asylums.  A  mild  form  is  common  in  school-children  under  good  con- 
ditions.    When  neglected,  it  may  become  a  serious  and  epidemic  disorder. 

Treatment. — This  consists  of  improvement  of  the  surroundings,  building 
up  of  the  general  health  if  this  is  below  par,  and,  locally,  boric-acid  solution 
or  sublimate  collyrium,  a  salve  of  sulphate  of  copper  (|  gr.  to  3j),  or  dusting 
upon  the  retrotarsal  folds  iodoform,  aristol,  or  equal  parts  of  subnitrate  of 
bismuth  and  calomel.  Refractive  errors  should  be  corrected.  If  the  disease 
is  at  all  stubborn,  the  swollen  follicles  should  be  destroyed,  preferably  with 
Knapp's  roller  forceps. 

VII.  Granular  Conjunctivitis  (Trachoma). — This  is  a  serious  form  of 
inflammation  in  which  rounded  granulations^  (trachoma-bodies)  form  in  the 
conjunctiva,  resulting  in  cicatricial  changes  in  the  lids  and  vascularization  and 
ulceration  of  the  cornea.  The  disease  may  be  acute  or  chronic.  It  is  dis- 
tinctly contagious. 

Although  not  nearly  so  common  in  childhood  as  in  adult  life,  many  cases 
occur  among  children,  especially  of  the  poorer  classes.  It  is  most  frequent 
among  the  Jews,  Irish,  Italians,  Indians,  and  inhabitants  of  the  East,  but, 
except  in  rare  instances,  is  unknown  among  the  pure  negroes.     Inhabitants  of 


DISEASES   OF    THE   EYE.  1191 

low  and  damp  regions  are  more  liable  than  those  who  live  on  high  ground,  an 
altitude  of  one  thousand  feet  conferring  comparative  immunity.  This  pre- 
disposition to  granular  lids  is  also  encouraged  by  residence  in  badly-ventilated 
homes  and  asylums,  where  the  disease  may  become  epidemic,  and  by  imperfect 
nutrition,  but  there  is  no  known  constitutional  disorder  at  the  bottom  of  the 
disease.  The  essential  characteristics  of  the  affection  are  the  "granulations" 
(trachoma-bodies),  sometimes  called  "follicles,"  which  differ  from  those  seen  in 
follicular  conjunctivitis  because  they  may  be  regarded  as  pathological  new 
formations.  It  is  probable  that  the  active  agent  in  the  production  of  trachoma 
and  its  dissemination  is  a  special  micro-organism,  the  trachoma-coccus,  but  its 
identity  is  not  clearly  established. 

Symptoms. — In  acute  granular  conjunctivitis,  in  addition  to  the  phe- 
nomena of  a  violent  conjunctivitis,  associated  with  great  dread  of  light,  free 
lachrymation,  and  later  a  muco-purulent  discharge,  the  conjunctival  papillae 
become  hypertrophied  and  there  is  a  liberal  growth  of  roundish  granulations 
in  this  membrane.  This  acute  type  must  be  distinguished  from  the  exacerba- 
tions which  are  common  in  the  chronic  variety  of  the  disease. 

In  chroyiic  granular  conjunctivitis  there  may  be  a  stage  of  acute  inflamma- 
tion, such  as  has  just  been  described,  but  most  frequently  it  appears  without 
such  preceding  condition.  The  grayish-white,  semi-transparent  granulations, 
often  in  rows  and  sometimes  resembling  the  spawn  of  frogs,  develop  chiefly  in 
the  retrotarsal  folds.  The  most  important  types  are  (a)  papillary  trachoma, 
(6)  follicular  trachoma,  and  (e)  mixed  or  diffuse  trachoma.  In  the  papillary 
and  mixed  varieties,  in  addition  to  the  granulations,  there  is  much  hypertrophy 
of  the  conjunctival  papillae.  At  first  there  is  little  discharge,  but  as  the  develop- 
ment of  the  follicles  increases  a  softening  process  takes  place  and  the  secretion 
becomes  abundant  and  is  extremely  contagious.  Gradually  the  stage  of  cica- 
trization is  reached,  which  results  in  the  formation  of  scar-tissue,  the  cicatrices 
often  lying  in  characteristic  parallel  lines,  while  the  lids  become  indurated  and 
their  borders  inverted,  resulting  in  conditions  which  have  already  been  described. 
In  bad  cases  there  is  a  practical  drying  up,  or  xerosis,  of  the  conjunctiva, 
with  obliteration  of  the  sulcus. 

Sequelae. — The  most  important  sequels  of  granular  lids  have  been  referred 
to,  with  the  exception  of  the  vascularization  of  the  cornea,  or  panniis,  which 
is  really  a  form  of  vascular  keratitis.  It  always  begins  under  the  upper  lid  by 
the  development  of  blood-vessels  in  the  superficial  layers  of  the  cornea,  often 
associated  with  ulceration  and  opacification  of  that  membrane.  This  pannus  is 
partly  due  to  the  mechanical  effect  of  the  granulations,  and  partly  to  a  special 
implantation  of  the  disease  in  the  cornea. 

Treatment. — Acute  granular  conjunctivitis  must  be  managed  on  the 
principles  already  laid  down  in  connection  with  an  acute  inflammation  of 
the  conjunctiva. 

In  chronic  granulations  the  object  is  to  promote  absorption  of  these  with 
the  least  cicatricial  change,  and  consequently  the  application  should  never  be 
so  caustic  as  to  create  scars,  which  would  be  worse  than  those  resulting  from 
the  natural  subsidence  of  the  disease.  It  would  be  impossible  in  this  brief 
description  even  to  refer  to  the  numerous  applications  which  have  been  made, 
and  the  author  will  hence  recommend  those  which  in  his  own  practice  he  has 
found  most  efficacious — namely,  (a)  nitrate  of  silver,  10  grains  to  the  ounce, 
during  any  stage  of  granular  lids  when  there  is  much  discharge,  to  be  apjjlied 
in  the  manner  already  described ;  (5)  strong  solutions  of  bichloride  of  mer- 
cury (1  :  500),  applied  to  the  everted  lids  with  a  cotton  mop,  associated  with 
^  These  should  not  be  confounded  with  the  granulations  of  wounds. 


1192  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

frequent  irrigation  of  the  conjunctival  cul-de-sac  with  a  tepid  solution  of  the 
same  drug,  1  grain  to  the  pint ;  suitable  in  practically  any  stage  of  granular 
lids,  but  especially  -when  there  is  decided  development  of  the  follicles  ;  (c)  sul- 
phate of  copper  in  the  form  of  a  smooth  crystal,  which  is  rubbed  over  the 
everted  lids  and  well  across  the  retrotarsal  folds,  useful  in  any  stage  except 
that  in  which  there  is  much  discharge,  and  particularly  valuable  in  the  later 
periods  of  the  disease ;  {d)  boro-glyceride,  20  or  50  per  cent.,  applied  in  the 
usual  manner  to  the  affected  conjunctiva,  most  valuable  after  cicatrization  has 
begun.  In  mild  cases  an  excellent  remedy  is  a  solution  of  tannin  and  glycerin, 
20  or  30  grains  of  tannic  acid  to  the  ounce  of  glycerin. 

Generally,  pannus  will  disappear  with  the  subsidence  of  the  granulations. 
If  it  does  not  or  if  exacerbations  are  present,  it  must  be  treated  after  the  man- 
ner suited  to  keratitis.     (See  page  1197.) 

Operative  interference,  except  in  the  acute  cases,  yields  the  most  satisfac- 
tory results  in  the  treatment  of  granular  lids.  The  best  method  is  expression 
of  the  granulations  by  means  of  forceps,  and  of  those  thus  far  devised,  the  one 
advocated  by  Knapp,  which  works  on  the  principle  of  a  roller,  is  the  most  val- 
uable. After  the  lids  have  been  thoroughly  rolled  the  local  treatment  must  be 
continued,  and  generally  the  sulphate-of-copper  crystal  will  then  be  found  use- 
ful. The  roller  forceps,  however,  are  not  sufficient  in  cases  of  diffuse  trachoma. 
Then  the  operation  called  '•'•  grattaye''  is  much  practised.  This  consists  essen- 
tially in  deep  scarifications  and  rubbing  out  the  trachoma-bodies  with  a  stiff 
brush  which  has  been  dipped  in  a  solution  of  bichloride  of  mercury.  This  last- 
named  method  is  a  vigorous  means  which  should  be  utilized  in  selected  cases, 
and  for  a  description  of  which,  and  of  the  many  other  methods,  the  reader  is 
referred  to  systematic  treatises  on  diseases  of  the  eye. 

EccHYMOSis  OF  THE  CONJUNCTIVA,  which  consists  of  an  escape  of  blood 
into  the  meshes  of  the  connective  tissue,  is  particularly  interesting  in  children 
as  the  common  result  of  a  violent  paroxysm  of  whooping  cough,  although  it 
may  arise  under  any  straining  effort.  It  is  also  seen  with  girls  at  the  begin- 
ning of  the  menstrual  epoch.  The  entire  conjunctiva  may  become  blood-red. 
The  blood  disappears  without  treatment,  although  hot  compresses  seem  to  hasten 
its  subsidence. 

Chemosis  of  the  Conjunctiva  is  common  in  various  types  of  conjunc- 
tivitis, bu^  it  is  also  a  symptom  of  deeper  diseases  of  the  eye ;  for  example, 
inflammatory  affections  of  the  uveal  tract.  Sometimes  it  occurs  without  appa- 
rent cause.  The  oedema  may  be  very  great,  and  the  conjunctiva  appear  like  a 
huge  bleb  and  protrude  between  the  lids.  Usually  the  oedema  subsides  under 
the  influence  of  hot  compresses  and  an  astringent  lotion  ;  for  example,  a  weak 
solution  of  alum.     If  it  be  very  severe,  the  swollen  tissues  may  be  incised. 

Tumors  and  Cysts  of  the  Conjunctiva. — Several  varieties  of  benign 
tumors  and  cysts  (dermoids)  have  been  described,  and  among  the  malignant 
tumors  in  children  should  be  mentioned  sarcoma,  which  develops  usually  at  the 
limbus,  and  is  generally  pigmented.  The  benign  growths  and  cysts  can  easily 
be  removed.  If  a  sarcoma  appears,  it  may  be  necessary  to  extirpate  the  entire 
eyeball. 

Tubercle  of  the  Conjunctiva,  under  rare  circumstances,  occurs  as  a 
primary  affection  in  the  form  of  uneven  ulcers  beset  with  grayish-red  nodules, 
in  which  a  decisive  diagnosis  could  be  made  by  bacteriological  examination. 


DISEASES    OF    THE   EYE.  1193 

Pemphigus  may  attack  this  membrane.  There  is  a  curious  form  of  atrophy 
of  the  conjunctiva  in  which  the  membrane  dries  up  entirely  and  the  borders  of 
the  lid  become  fixed  to  the  ball.  This  is  probably  a  form  of  pemphigus,  but  it 
has  also  been  described  as  essential  shrinking  of  the  conjunctiva.  Ordinary 
atrophy  of  the  conjunctiva  following  granular  lids  and  diphtheritic  conjuncti- 
vitis has  been  referred  to. 

Injuries  of  the  Con'JUNCTIVA. — Burns,  especially  with  lime  and  acid, 
are  to  be  feared  mostly  on  account  of  the  symblepharon  which  they  are  likely 
to  produce.  After  a  lime-burn  it  is  best  to  speedily  flood  the  eye  with  a 
rapid  stream  of  water — for  example,  from  a  spigot — and  pick  off  any  pieces 
which  the  water  fails  to  wash  away.  Iced  compresses  may  then  be  applied. 
Atropine  drops  should  be  instilled  if  there  is  corneal  involvement,  and  the 
conjunctival  cul-de-sac  should  be  frequently  cleansed  with  a  solution  con- 
taining boric  acid  and  common  salt.  An  acid  burn  is  treated  on  the  same 
principles,  an  alkaline  wash  composed  of  carbonate  of  sodium  being  at  first 
employed.  It  is  usually  recommended  to  drop  olive  oil  on  the  conjunctiva  after 
a  burn,  and  certainly  it  can  do  no  harm.  A  good  plan  is  to  incorporate  with 
liquid  vaseline  some  atropine  (gr.  iv— sj)  and  freely  introduce  this  substance. 

Phlyctenular  Kerato-con.junctivitis  {Phlyctenular  Ophthalmia,  Stru- 
mous, Pustular,  and  Vesicular  Keratitis  and  Conjunctivitis). — It  is  customary 
to  describe  phlyctenular  conjunctivitis  and  phlyctenular  keratitis  as  two  dis- 
tinct afiections,  but  as  both  cornea  and  conjunctiva  are  associated  in  the  inflam- 
mation, and  as  the  lesion  is  the  same  in  both  cases,  it  is  better  to  include  them 
under  one  name. 

The  disease  is  characterized  by  the  formation  on  the  bulbar  conjunctiva,  at 
the  corneal  margin,  or  on  the  cornea,  of  small,  grayish-white  elevations,  often 
called  vesicles  or  pimples,  and  usually  classified  under  the  generic  term  phlycte- 
nules, associated  wi^h  injection,  lachrymation,  and  dread  of  light. 

Etiology. — It  usually  occurs  in  children  before  their  tenth  year,  and  most 
frequently  in  those  of  strumous  constitution.  Eczema  of  the  face  is  frequently 
present.  The  use  of  unwholesome  food  (sweetmeats,  pastry,  tea,  and  coffee), 
and  consequent  derangements  of  the  alimentary  canal,  are  predisposing  causes  : 
the  conjunctival  form  follows  in  the  wake  of  scarlet  fever  and  measles.  AH 
varieties  are  more  common  and  more  aggravated  in  warm  and  moist  weather. 
There  is  a  direct  relation  between  this  disease  and  various  lesions  in  the  nasal 
fossae  and  naso-pharynx  (rhinitis,  congested  turbinals,  and  adenoid  vegeta- 
tions). It  is  probable  that  astigmatic  eyes  are  more  liable  than  those  with 
refractive  conditions  approaching  emmetropia.  Several  varieties  of  micro- 
cocci have  been  described,  but  no  definite  causal  relation  has  been  established. 

Symptoras. — In  the  conjunctival  variety  the  phlyctenules  form  on  the 
bulbar  conjunctiva  and  especially  aff"ect  the  margin  of  the  cornea.  There  may 
be  only  one  or  two  of  them  [single  form),  or  they  maybe  numerous  and  scattered 
everywhere  over  the  membrane  [multiple  form).  At  first  translucent,  they 
soon  become  turbid  and  break  down.  The  conjunctival  vessels  are  freely 
injected. 

In  the  corneal  types  the  phlyctenules,  about  the  size  of  a  millet-seed, 
appear  near  the  corneo-scleral  junction  or  encircle  the  margin  {marginal  kera- 
titis), or  a  single  one  develops  near  the  border  and  creeps  across  the  face  of 
the  cornea,  followed  by  a  leash  of  blood-vessels  {fascicular  keratitis).  There 
are,  in  addition,  conjunctival  hypereemia,  free  lachrymation,  and  intense  pho- 
tophobia.    Soon  the  phlyctenules  grow  yellow,  break  down,  and  ulcers  {phlyc- 


1194  AJIUBICA^'  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

tenular  ulcers)  are  formed,  which  at  first  are  superficial  and  may  remain  so;  or, 
in  the  more  aggravated  varieties,  they  Avill  grow  deeper,  the  surrounding  cornea 
become  infiltrated,  and  perforation  may  ensue.  This  is  especially  apt  to  occur  if 
a  large  yellow  phlyctenule  {pustular form)  develops  just  at  the  margin  of  the 
cornea.  Relapses  are  frequent ;  new  phlyctenules  form,  fresh  ulcers  result,  and, 
unless  the  process  is  checked,  the  epithelium  of  the  cornea  becomes  roughened, 
opaque,  and  vascular,  and  pldyctenular  pannus  arises.  Almost  invariably 
there  is  an  irritating  rhinitis,  causing  an  acrid  secretion  to  flow  from  the  nose 
and  excoriate  the  lip,  Avhile  frequently  patches  of  eczema  appear  around  the 
nares,  on  the  face,  or  at  the  auricle. 

Ti'eatment. — The  extreme  photophobia  makes  it  difficult  to  properly  apply 
local  remedies.  For  this  reason  the  child's  head  should  be  taken  between  the 
surgeon's  knees,  while  an  assistant  holds  the  hands  and  body.  The  lids  are 
then  separated  and  the  cornea  can  be  gradually  coaxed  into  view.  A  lid-elevator 
may  be  employed,  and  in  very  bad  cases  it  is  sometimes  needful  to  use  ether  or 
chloroform  before  the  necessary  inspection  of  the  eye  is  possible.  Cocaine  will 
temporarily  relieve  the  photophobia,  but  it  should  never  be  employed  as  a  con- 
stant application  where  corneal  ulceration  exists.  If  the  child  is  of  sufficient 
age,  the  eyes  may  be  protected  with  goggles,  and  under  all  circumstances  the 
little  patient  should  be  encouraged  not  to  bury  its  head  in  the  bed-clothes  or 
hide  in  dark  corners  of  the  room.  Photophobia  may  be  allayed  by  douching 
the  eyes  with  cold  water,  and  search  should  always  be  made  for  a  fissure  at  the 
external  commissure,  which  is  apt  to  keep  up  the  dread  of  light ;  if  this  be 
present  it  may  be  touched  with  a  crystal  of  blue-stone  or  the  fibres  of  the 
orbicularis  divided  at  this  point  with  a  sharp  knife. 

The  best  possible  hygienic  surroundings,  with  strict  regulation  of  the  diet, 
out-door  exercise  in  good  Aveather.  and  frequent  sponge  baths  Avith  salt  Avater 
are  advisable.  Atropine  drops,  4  grains  to  the  ounce,  should  be  used  until 
complete  mydriasis  is  obtained,  and  this  dilatation  of  the  pupil  should  be  kept 
up  as  long  as  there  is  irritation.  If  there  is  much  discharge,  boric-acid  drops, 
with  or  Avithout  the  addition  of  common  salt,  may  be  used.  After  the  irri- 
tation has  subsided  yellow  oxide  of  mercury,  1  grain  to  the  drachm,  should 
be  employed  as  a  local  application,  or  in  its  place  finely-powdered  calomel 
may  be  dusted  into  the  eye,  provided  the  patient  is  not  taking  iodide  of 
potash  or  any  preparation  of  iodine,  under  AA'hich  circumstances  such  practice 
Avill  result  in  a  violent  inflammation  of  the  conjunctiva. 

Internally,  after  the  alimentary  canal  has  been  prepared  by  a  course  of 
calomel,  the  most  useful  drugs  are  cod-liver  oil,  iron,  quinine,  and  arsenic. 

It  is  essential  in  all  these  cases  to  treat  the  nasal  conditions  Avhich  have 
been  described,  an  excellent  routine  practice  being  to  spray  the  parts  Avith 
Dobells  solution  or  listerine,  and  insufflate  poAvdered  iodoform,  or  a  mixture 
composed  of  camphor,  boric  acid,  and  subnitrate  of  bismuth,  or  finely-pul- 
verized chlorate  of  potassium.  If,  hoAvever,  adenoid  vegetations  or  hyper- 
trophied  turbinated  bodies  are  present,  these  must  be  treated  on  the  principles 
knoAvn  to  nasal  surgery.  In  stubborn  cases  and  Avith  ulcers  tending  to  per- 
forate the  measures  to  be  described  for  treating  corneal  ulcers  Avill  be  required. 
After  the  subsidence  of  the  disease  suitable  glasses  should  be  ordered,  if  the 
corneal  astigmatism  is  of  such  character  that  it  can  be  corrected. 

Diseases  of  the  Cornea. 

Ulcers  of  the  Cornea. — When  the  stage  of  infiltration  which  accom- 
panies an  inflammation  of  the  cornea,  or  a  keratitis,  fails  to  end  in  absorption. 


i 


DISEASES  OF  THE  EYE.  1195 

and"  tlie  corneal  tissue  disintegrates,  an  open  lesion  or  an  ulcer  results.  In 
children  the  majority  of  corneal  ulcers  which  are  of  primary  origin  result  from 
the  disease  Avhich  has  just  been  described,  and  are  hence  known  as  phlyctenular 
ulcers.  Systematic  writers  have  described  a  number  of  other  types  of  ulcer, 
among  which  the  following  varieties  may  be  mentioned  : 

(a)  Simple  Ulcer. — This,  sometimes  called  "pimple  ulcer"  when  it  arises 
from  a  phlyctenule,  is  a  small  gray  infiltration,  and  may  develop  from  an  injury. 
Frequently  it  appears  right  in  the  centre  of  the  cornea,  and  as  a  slightly  cone- 
shaped,  gray-white  opacity,  without  much  irritation,  and  is  then  known  as  the 
small  central  ulcer  of  chilclliood.  It  heals,  leaving  a  small  scar  directly  in  the 
axis  of  vision.  It  is  seen  in  poorly-nourished  children  of  the  strumous  habit, 
and  probably  represents  one  of  the  results  of  imperfect  nutrition.  It  may 
heal  quickly  or  develop  into  a  deep  ulcer. 

{h)  Deep  or  Purulent  Ulcer. — This  is  practically  described  in  its  title, 
and  is  a  more  aggravated  form  of  the  type  just  described,  of  yellowish  appear- 
ance with  infiltrated  margins,  and  a  tendency  to  penetrate  the  layers  of  the 
cornea.  It  may  be  the  result  of  injury,  or  may  follow  certain  conjunctival 
inflammations,  or  arise  because  a  simple  ulceration  has  been  neglected.  It 
heals  with  a  dense  white  scar. 

(c)  Indolent  Ulcers. — Several  varieties  of  these  have  been  described. 
One  is  apt  to  occur  in  the  centre  of  the  cornea — a  small  shallow  lesion  with  a 
slightly  turbid  base  and  not  much  injection  of  the  surrounding  tissues  {shallow 
central  ulcer).  It  is  often  seen  accompanying  granular  lids.  Another  variety 
is  called  gougecl-out  ulcer,  almost  without  any  injection  accompanying  it,  its 
most  common  situation  beino;  near  the  corneal  margin.  These  ulcers  heal  with 
less  dense  scars,  sometimes  only  a  faint  opaque  facet  remaining  {facetted  ulcer). 
They  are  common  in  anaemic  and  scrofulous  patients,  and  evidently  depend 
upon  failure  in  the  nutrition  of  the  cornea. 

{d)  Sloughing  Ulcer. — A  sloughing  or  infecting  ulcer  is  the  representa- 
tive oi purulent  keratitis,  and  is  a  more  serious  grade  than  the  deep  or  purulent 
ulcer  already  noted.  This  is  not  so  common  in  children  as  in  elderly  people ; 
but  at  the  same  time  very  violent  and  serious  ulcers,  which  are  serpiginous  or 
creeping  in  type,  arise  in  children  as  the  result  of  injuiy,  because  the  abrasion 
thus  produced  has  been  infected  with  pathogenic  bacteria.  True  serpiginous 
ulcers  of  the  cornea,  according  to  Uhthoif  and  Axenfeld,  are  practically 
always  caused  b}"  the  Frank el-Weichselbaum  capsulated  diplococcus.  Other 
forms  of  ulcers  may  be  due  to  an  infection  with  staphylococci  or  streptococci 
or  to  a  mixed  infection.  The  aspergillus  fumigatus  is  an  occasional  cause  of 
sloughing  keratitis.  These  various  micro-organisms  come  from  the  conjunc- 
tiva, the  ciliary  borders,  the  nares,  and  the  lachrymal  passages.  In  slough- 
ing ulcer  not  only  is  there  extensive  purulent  infiltration  of  the  cornea,  but  also 
the  iris  is  involved  and  pus  forms  in  the  anterior  chamber,  and  hence  the  disease 
is  called  hypopyon  keratitis.  In  like  manner,  instead  of  an  open  ulcer  of  this 
character,  the  pus  may  be  confined  within  the  layers  of  the  cornea,  and  an 
abscess  results,  or  its  superficial  layers  may  burst  and  there  is  an  open  lesion. 
This  also  is  due  to  the  fact  that  the  area  has  been  inoculated  with  pathogenic 
micro-organisms.  Some  of  the  most  typical  examples  of  abscess  of  the  cornea 
and  hypopyon  keratitis  occur  not  only  from  injuries  and  neglected  ulcers,  but 
with  small-pox,  scarlet  fever,  measles,  typhus,  and  typhoid  fever. 

Treatment. — Everything  which  tends  to  improve  the  surroundings  of  the 
patient  and  to  build  up  his  nutrition  is  indicated.  Proper  protection  of  the 
eves  with  goggles  is  important ;  whenever  possible,  out-door  exercise  is  advis- 
able.    The  remedies  already  suggested  w'ith  phlyctenular  keratitis  are  usually 


1196  AJIEEICAy  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

needed,  care  being  taken  to  inquire  into  possible  etiological  conditions,  which 
should  be  met  with  suitable  measures. 

Search  should  always  be  made  for  the  presence  of  a  foreign  body  and  for 
irritating,  misplaced  cilia.  The  lachrymal  passages  should  be  explored  to  see 
if  they  are  patent,  and  the  teeth  should  be  examined,  and  if  they  are  carious 
the  services  of  a  dentist  should  be  secured.  The  nasal  passages  and  the  naso- 
pharynx should  be  carefully  examined  and  treated. 

In  mild  cases  of  simple  ulcer  atropine  drops  for  a  few  days,  to  be  followed 
later  by  a  salve  of  yellow  oxide  of  mercury  (gr.  j-5j),  usually  suffice.  In 
severe  cases  atropine  drops  should  be  employed,  and  the  conjunctival  cul-de- 
sac  should  be  frequently  irrigated  Avith  a  mild  antiseptic  lotion,  a  saturated 
solution  of  boric  acid,  a  Aveak  solution  of  bichloride  of  mercury  (1  :  10,000), 
formaldehyde  (1  :  6000)  or  a({ua  chloriuata.  These  drugs  are  particularly 
indicated  if  there  is  an  associated  conjunctivitis  Avith  muco-purulent  dis- 
charge, Avhich  should  then  be  treated  also  on  the  principles  already  laid  down. 

If  the  ulcer  is  sluggish,  it  may  be  stimulated  to  heal  by  the  introduction 
of  the  yellow-oxide  salve.  In  sloughing  ulcers,  in  addition  to  the  measures 
already  indicated  it  may  be  necessary  to  curette  the  surface,  touch  it  gently 
Avith  a  solution  of  nitrate  of  silver.  10  grains  to  the  fluidounce,  tincture  of 
iodine,  or  formaldehyde  (1 :  60).  Finely  powdered  iodoform  dusted  upon 
the  surface  of  the  ulcer  is  useful.  In  many  cases  the  most  eifectual  treat- 
ment is  the  cautery,  the  point  of  a  galvano-  or  a  thermo-cautery  being 
applied  gently  but  thoroughly  to  the  involved  area.  In  hypopyon  keratitis 
or  in  abscess  of  the  cornea,  paracentesis  of  the  cornea  or  the  section  of  Ssem- 
isch  is  sometimes  necessary.  In  any  case  in  Avhich  rupture  is  impending, 
and  there  is  no  contraindication — as,  for  example,  associated  catarrhal  con- 
junctivitis— much  good  may  be  done  by  a  carefully  applied  compressing 
bandage.  In  any  type  of  corneal  ulceration  hot  compresses  are  often  inval- 
uable, as  they  aid  in  healing  and  preserve  the  nutrition  of  the  cornea.  If 
a  local  anaesthetic  is  re^juired.  holocain  should  be  used,  which  itself  has  some 
curative  action  on  corneal  ulcers. 

The  Results  of  Corneal  Ulceration. — Every  ulcer  is  followed  by  a  scar, 
which  may  be  a  mere  haze,  or  nehida.  a  more  pronounced  spot,  or  macula,  or  a 
dense  white  scar,  or  leucoma.  If  the  cornea  has  ruptured,  the  anterior  cham- 
ber is  evacuated,  and  the  iris  falls  forward  and  is  entangled  in  the  opening. 
This,  then,  is  an  anterior  synechia,  and  the  scar  on  the  cornea  is  an  adherent 
leucoma.  Sometimes  an  eye  of  this  character  becomes  quiet ;  sometimes,  how- 
ever, it  cannot  resist  the  intraocular  tension  and  the  area  bulges  forward,  form- 
ing a  staphyloma.  If  there  has  been  an  extensive  rupture  of  the  cornea  and 
complete  matting  of  the  prolapsed  iris  Avith  the  inflamed  and  broken-down 
corneal  tissue,  the  Avhole  cornea  protrudes  as  an  opaque  elevation,  forming  a 
complete  staphyloma. 

Treatmext  of  Sequels. — Slight  corneal  scars  and  nebulas  may  be  influ- 
enced beneficially  by  massage  of  the  cornea,  aided  by  the  previous  introduction 
of  a  small  particle  of  Pagenstecher's  ointment  (yellow  oxide  of  mercury,  1  gr. 
to  the  drachm).  The  dense  white  leucomas,  hoAvever,  are  not  thus  influenced. 
If  they  are  central  and  clear  cornea  remains  at  the  side,  an  optical  iridectomy 
may  be  performed  and  the  scar  tattooed  with  India  ink  to  improve  its  appear- 
ance. After  the  perforation  of  an  ulcer  and  prolapse  of  the  iris  it  is  sometimes 
possible,  when  recent,  to  disentangle  this  Avith  the  aid  of  an  instrument  and  the 
vigorous  use  of  eserine  or  atropine,  according  to  the  situation  of  the  ulcer.  If 
this  fails,  staphyloma  should  be  prevented  by  the  vigorous  use  of  a  compressing 
bandage.     If,  in  spite  of  this,  staphyloma,  either  partial  or  complete,  forms, 


DISEASES    OF    THE  EYE.  1197 

various  surgical  measures  are  indicated,  according  to  the  extent  of  the  dam- 
age— namely,  iridectomy,  the  operation  for  partial  staphyloma,  abscission  or 
evisceration,  Mules's  operation  or  enucleation. 

Infantile  Ulceration  of  the  Cornea,  with  Xerosis  of  the  Con- 
junctiva [Kerato-malacia). — In  certain  anaemic  and  badly-nourished  children, 
sometimes  after  measles,  scarlet  fever,  violent  diarrhoea,  and  other  illnesses  with 
great  depression  of  nutrition,  the  cornea  undergoes  a  rapid  destructive  ulcer- 
ation, while  the  conjunctiva  becomes  greasy  and  dry,  little  flakes  of  cheesy 
appearance  forming  upon  its  surface.  Not  only  is  the  destruction  of  the  sight 
almost  inevitable,  but  most  of  the  infants — for  it  usually  occurs  during  the  first 
year  of  life — die,  generally  of  intercurrent  pneumonia. 

The  usual  treatment  of  corneal  ulceration  is  indicated,  with  an  attempt  to 
improve  the  general  condition. 

This  disease  should  not  be  confounded  with  a  type  of  conjunctival  disease 
known  as  xerophthahnos,  in  which  the  same  cheesy  flakes  form  and  the  mem- 
brane becomes  greasy  and  dry,  and  which  sometimes  occurs  as  an  epidemic  with 
the  curious  symptom  of  night-blindness,  especially  in  people  who  have  long  fasted. 

Interstitial  Keratitis  [Syphilitic,  Parenchymatous  Keratitis). — In  this 
disease,  which  is  an  inflammation  of  the  chronic  type,  a  diffuse  keratitis,  prac- 
tically always  without  ulceration,  arises,  and  the  cornea  gradually  becomes 
thick  with  haziness  until  it  resembles  ground  glass,  while  superficial  and  deep 
vascularization  accompanies  the  condition. 

It  is  most  often  seen  between  the  ages  of  five  and  fifteen,  and  is  more  fre- 
quent in  females  than  in  males.  A  veiy  large  percentage  of  cases  is  due  to 
inherited  syphilis,  but  it  has  also  been  attributed  to  rachitis,  scrofula,  malaria, 
rheumatism,  and  depressed  nutrition.  In  the  syphilitic  cases  generally  some 
other  mark  of  syphilis  is  present,  particularly  Hutchinson's  teeth,  or  evidence 
of  this  taint  can  be  acquired  from  the  family  history. 

Symptoms. — The  disease  begins  with  slight  ciliary  congestion,  a  few  spots 
of  infiltration  in  the  cornea,  which  speedily  develop  into  the  general  haze 
already  described,  the  infiltration  being  in  the  interstitial  tissue ;  blood-vessels 
become  thickly  set  in  the  layers  of  the  cornea,  which  in  its  upper  part  assumes 
a  dull  reddish  color.  In  some  types  this  is  so  pronounced  that  a  special  variety 
of  it  is  denominated  vascular  keratitis.  There  are  considerable  pain  and  pho- 
tophobia. Quite  commonly  iritis  develops,  and  in  many  instances  inflammation 
of  the  deeper  coats  of  the  eye  occurs.  It  requires  from  six  months  to  a  year 
and  a  half  before  the  disease  passes  through  its  various  stages.  Under  proper 
treatment  clearing  of  the  cornea  usually  takes  place,  but  years  afterward 
careful  examination  will  show  traces  of  the  disease,  especially  in  the  pres- 
ence of  minute  channels  through  the  corneal  tissue,  indicating  the  course  of 
the  former  vessels. 

Treatment. — Any  irritating  application  is  distinctly  contraindicated. 
Hence  it  is  proper  to  employ  atropine  to  maintain  dilatation  of  the  pupil  and 
prevent  iritis ;  this,  if  the  photophobia  be  severe,  may  be  combined  with 
cocaine.  Hot  compresses  are  agreeable  and  soothe  the  inflammation.  The 
eyes  should  be  protected  with  goggles,  and  the  child  encouraged  to  have  out- 
door exercise  in  proper  weather.  The  best  general  medication  is  mercury, 
and,  in  the  opinion  of  the  author,  inunction  is  the  preferable  method  of  admin- 
istration, pushed  to  the  point  of  tolerance,  but  never  to  that  of  salivation. 
After  the  mercurial  course  iodide  of  potassium  may  be  given.  Later, 
bichloride  of  mercury  combined  with  the  tincture  of  the   chloride  of  iron 


1198  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

is  suitable,  and,  if  the  indications  are  present,  the  administration  of  cod-liver 
oil,  arsenic,  and  quinine.  When  all  irritation  has  subsided  the  remaining 
opacity  may  be  treated  by  massage  with  the  yellow-oxide-of-mercury  oint- 
ment. Iridectomy  is  sometimes  necessary  to  check  the  disease  or  to  make 
a  ncAv  pupil  if  a  central  opacity  remains.  The  disease  is  stubborn,  subject 
to  relapses,  and  nearly  ahvays  bilateral,  although  both  eyes  are  not  attacked 
at  the  same  time,  and  a  long  period  may  elapse  between  the  two  attacks. 

Injuries  of  the  Cornea. — The  most  important  of  these  are  the  ordi- 
nary Avounds,  burns,  and  scalds;  and  practically  the  directions  which  have 
already  been  given  in  diseases  of  the  conjunctiva  are  applicable,  although, 
naturally,  a  wound  of  the  cornea  is  likely  to  result  in  much  more  serious  dis- 
aster than  one  confined  to  the  conjunctiva,  because  the  lens,  iris,  and  even 
deeper  structures,  are  liable  to  injury. 

After  a  wound  of  the  cornea  the  most  thorougu  antisepsis  is  required.  If 
the  iris  is  prolapsed,  it  may  be  seized  and  cut  off  and  an  antiseptic  compress- 
ing bandage  applied.  Traumatic  iritis  is  best  combated  by  the  frequent  use 
of  iced  compresses.  In  severe  cases  the  question  of  enucleation  to  prevent 
sympathetic  irritation  must  be  considered. 

Foreign  Bodies  Imbedded  in  the  Cornea  must  be  removed  with  a 
spud  after  the  eye  has  been  rendered  insensitive  with  cocaine.  Avoidance  of 
much  digging  at  the  corneal  tissue  is  desirable.  It  is  necessary  to  locate  small 
bodies  by  means  of  oblique  illumination,  and  much  aid  is  often  given  by  drop- 
ping a  fluorescine  solution  into  the  eye,  which  colors  green  the  abraded  cornea 
and  brings  out  in  contrast  the  foreign  body  as  a  black  spot.  After  the  removal 
of  the  foreign  body  it  is  desirable  to  thoroughly  cleanse  the  conjunctival  cul- 
de-sac,  lest  the  abrasion  be  infected  and  a  serious  corneal  ulcer  result.  It  is 
equally  necessary  that  the  instruments  used  should  be  clean  in  the  surgical 
sense  of  the  word. 


Disease  of  the  Iris  and  Ciliary  Body  ;  Sympathetic  Inflamma- 
tion OF  THE  Eye. 

Diseases  of  the  iris  and,  indeed,  of  the  entire  uveal  tract,  are  comparatively 
rare  in  childhood. 

Iritis. — This  may  arise  in  utero^  and  is  then  called  conge7iital  iritis.  The 
child  is  born  with  occlusion  of  the  pupil,  and  actual  shrinking  of  the  eyeball 
may  ensue. 

It  also  develops,  but  infrequently,  during  the  first  few  months  of  life 
(from  two  to  nine  months),  and  in  practically  all  instances  is  due  to  inherited 
syphilis.  The  ordinary  symptoms  of  iritis  are  present,  but  not  usually  in  so 
severe  a  type  as  in  adults  :  fine  pericorneal  injection,  discoloration  of  the  iris, 
sluggish  or  immobile  pupil,  abnormal  reaction  of  the  iris  to  a  mydriatic,  and 
the  formation  of  attachments  between  the  pupillary  margin  of  the  iris  and  the 
capsule  of  the  lens,  or  jjostei-ior  si/nechice, — symptoms  whidi  are  absent  in  con- 
junctivitis, and  hence  should  alwavs  serve  as  distino-uishino;  features. 

Iritis  associated  with  inflammation  of  the  ciliary  body,  opacity  in  the 
vitreous  and  changes  in  the  choroid,  and  the  deposition  of  a  triangular  patch  of 
punctate  exudations  upon  the  posterior  layer  of  the  cornea  (keratitis  2nmctata, 
serous  iritis,  serous  irido-cyclitis)  is  also  seen  in  3'oung  subjects,  and,  like  the 
preceding  affection,  may  he  due  to  inherited  syphilis.      Sometimes  the  iritis 


DISEASES   OF    THE   EYE.  1199 

whicli  frequently  accompanies  interstitial  keratitis  is  the  most  prominent 
feature  of  the  disease. 

G-umma  of  the  Iris  and  so-called  gummatous  iritis  have  occasionally  been 
seen  in  children  of  syphilitic  parents  (Alexander,  \Yatson,  Mules). 

As  the  age  of  puberty  is  approached  diseases  of  the  uveal  tract  become 
more  frequent,  and  iritis,  both  plastic  and  serous,  may  be  seen,  the  latter 
especially  in  girls  with  disturbances  attending  the  development  of  the  men- 
striial  functions.  In  one  form  of  iritis  lardaceous  deposits  or  nodules  appear 
in  the  iris,  some^vhat  resembling  the  small  yellowish  bodies  seen  in  so-called 
gummatous  (really  papular)  iritis,  constituting  the  disease  called  scrofulous 
iritis^  which  is  seen  in  strumous  and  anaemic  subjects.  An  insidious  form  of 
iritis,  associated  with  vitreous  opacities,  occurs  in  the  children  of  gouty  parents. 
The  author  has  seen  several  examples,  and  this  taint  should  be  suspected  in 
the  iritis  of  boys  near  the  age  of  puberty. 

Tubercles  may  also  appear  in  the  iris  {tubercular  iritis)  and  constitute  a 
primary  tuberculosis. 

Finally,  an  iritis  may  arise  from  injury  {traumatic  iritis),  and  under  the 
influence  of  infection  become  purulent  {purulent  iritis) — a  type  of  the  disease 
which  has  also  been  described  in  connection  with  several  infectious  diseases 
(recurrent  fever,  pneumonia,  typhus  and  typhoid  fever,  and  pyaemia). 

Treatment. — This  consists  in  ascertaining  the  cause  and  exhibiting  suit- 
able remedies,  the  most  important  of  which  are  mercury  and  iodide  of  potassium. 
Locally,  atropine  drops,  sufficient  to  maintain  mydriasis,  are  indicated  in  prac- 
tically all  cases.^  In  children  of  a  proper  age,  if  there  be  much  pain  and 
inflammatory  reaction,  leeches  may  be  applied  to  the  temple.  Hot  compresses 
are  soothing.  In  traumatic  iritis  it  is  proper  to  employ  iced  applications,  but 
not  in  the  other  varieties  of  the  disease.  The  ordinary  astringent  applications 
are  never  needed  unless  there  should  be  associated  conjunctivitis.  The  speedy 
detection  of  iritis  and  prompt  use  of  atropine  are  important,  lest  the  posterior 
synechise  become  too  strong  to  be  influenced  by  the  drug. 

INJURIES  TO  THE  Iris  axd  Ciliart  Regiox  :  Sympathetic  Irrita- 
tion AXD  Sympathetic  Ixflammatiox. — Surrounding  the  cornea  there  is  a 
zone  about  one-quarter  of  an  inch  wide,  which  Mr.  Xettleship  has  very  properly 
called  ''the  dangerous  area,"  and  which  indicates  the  ciliary  region.  Wounds 
of  this  portion  of  the  eye,  when  followed  by  plastic  or  purulent  inflammation 
of  the  ciliary  body  {cyclitis),  are  liable  to  cause  fiinctional  disturbance  of  the 
other  eye  {sympathetic  irritation),  or  serious  organic  change,  which  manifests 
itself  as  an  iritis,  irido-cyclitis.  or  choroido-retinitis.  to  which  the  general  term 
sympathetic  inflammation  or  sympatlietic  ophthalmitis  is  applicable.  The  eye 
primarily  injured  or  diseased  is  usually  spoken  of  as  the  excitor,  and  the  one 
which  becomes  involved  in  the  manner  just  described  as  the  sympathizer. 
Sympathetic  inflammation  may  also  be  produced  by  a  foreign  body  which  is 
retained  within  the  eye,  and  less  commonly  by  corneal  ulcers  which  have  rup- 
tured and  in  which  the  iris  has  become  entangled,  and  by  shrunken  eyeballs — 
for  example,  after  a  panophthalmitis. 

It  is  important  to  distinguish  between  sympathetic  irritation  and  sympa- 
thetic inflammation,  because,  while  the  first  may  be  the  prodromal  stage  of 
the  second,  ordinarily  they  represent  two  essentially  different  conditions. 

Sympathetic  irritation  is  probably  a  neurosis,  and  manifests  itself  in  the 
form  of  blurred  vision,  photophobia,  tenderness  in  the  ciliary  region,  and 
conjunctival  hypertemia,  and  is  promptly  cured  by  the  removal  of  the  cause. 

^  There  are  a  few  exceptions  to  the  rule  in  serous  iritis  if  the  intraocular  tension  rises. 


1200  A2IEEICAX  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

whether  this  be  an  eye  injured  or  diseased  as  before  described,  or  whether  it  \s> 
sorae  temporary  condition,  as,  for  example,  a  foreign  body  in  the  exciting  eye. 

Sympathetic  inflammation  on  the  other  hand,  as  its  name  indicates,  is  an 
organic  disease  manifesting  itself  in  one  of  the  forms  of  inflammation  already 
indicated,  or,  in  general  terms,  as  a  sympathetic  uveitis,  because  it  is  the 
uveal  tract  Avhich  is  involved.  It  has  a  definite  period  of  incubation,  vary- 
ing in  the  majority  of  cases  from  three  to  six  weeks.  Exceptionally,  the 
disease  begins  earlier,  or  its  appearance  may  be  delayed  to  a  much  later 
period.  We  are  not  certain  of  the  exact  nature  of  this  grave  malady.  In 
all  likelihood,  some  form  of  infection  passes  from  the  ciliary  region  of  the 
exciting  eye  to  a  similar  region  in  the  sympathizing  eye.  It  is  particularly 
important  to  remember  that  sympathetic  inflammation  is  more  apt  to  occur 
in  children  and  young  people  than  in   adults. 

Treatment. — If  an  eye  has  been  so  injured  in  the  dangerous  region  that 
it  is  sightless,  and  especially  if  a  foreign  body  has  entered  which  cannot  be 
removed,  enucleation  or  one  of  its  substitutes  should  be  performed  in  order 
to  prevent  sympathetic  inflammation.  An  eye  with  a  wound  in  the  danger- 
ous region  already  complicated  by  severe  inflammation  of  the  iris  or  ciliary 
body,  especially  if  infection  in  the  form  of  a  purulent  inflammation  is  pres- 
ent, should  be  enucleated,  even  if  some  sight  still  remains  in  the  eye.  If 
sympathetic  inflammation  has  already  begun,  then  the  exciting  eye  should 
be  enucleated,  provided  it  is  sightless,  because  this  would  remove  a  source 
of  irritation  ;  but  the  exciting  eye  should  not  be  removed  if  there  is  any 
vision  in  it,  because  in  the  end  it  may  prove  to  be  the  more  useful  organ. 

The  general  treatment  of  sympathetic  ophthalmitis  is  that  already 
described  in  connection  with  iritis :  atropine,  hot  compresses,  mercury  in 
robust  cases,  while  in  others  quinine,  iron,  and  tonics  should  be  exhibited. 
When  all  signs  of  inflammation  have  passed  from  the  svmpathetically 
inflamed  eye,  it  is  sometimes  possible  to  restore  vision  by  iridectomy  or  by 
modified  forms  of  extraction  of  the  opaque  lens. 

Diseases  of  the  Lachrymal  Apparatus  and  Orbit. 

Inflammation  of  the  Lachrymal  Gland  {Dacryoadenitis)  is  an  un- 
common aifection,  and  may  be  either  acute  or  chronic,  a  lobulated  swelling 
appearing  at  the  upper  and  outer  part  of  the  eyelid,  associated  Avith  che- 
mosisof  the  conjunctiva.  Sometimes  suppuration  occurs,  and  an  abscess  points 
upon  the  skin  or  in  the  conjunctiva.  The  chronic  form  has  been  seen  among 
scrofulous  children,  and  may  follow  an  injury  or  diseases  of  the  conjunctiva. 
In  acute  cases  warm  applications  should  be  applied  to  encourage  suppuration, 
and  the  pus  evacuated  by  an  incision  through  the  conjunctiva.  In  chronic 
cases  appropriate  internal  remedies  are  the  various  preparations  of  iodine,  and 
locally  iodide-of-cadmium  ointment  may  be  applied  over  the  swollen  gland. 

Disease.?  of  the  Lachrymal  Sac  and  Nasal  Duct. — The  universal 
symptom  of  almost  every  form  of  disease  of  this  region  is  an  excessive  secre- 
tion of  tears,  or  epiphora.  Acute  inflammation  of  the  sac,  which  is  not  uncom- 
mon in  children,  is  known  as  dacryocystitis.  The  sac  becomes  distended  with 
secretion,  which  may  be  catarrhal  or  purulent,  forming  a  little  swelling  in  the 
region  of  the  lachrymal  sac.  pressure  upon  which  causes  the  contained  fluid  to 
exude  from  the  puncta  lachrymalia.  Occasionally  this  inflammation  is  very 
acute  and  assumes  a  phlegmonous  type,  the  surrounding  connective  tissue 
becoming  infiltrated  with  purulent  matei'ial,  while  a  brawny  swelling  spi'eads 


DISEASES    OF    THE  EYE.  1201 

over  the  face.  Usually  the  lachrymal  abscess  under  these  circumstances  points 
below  the  tendo  oculi,  where  it  -may  rupture  and  the  opening  become  sur- 
rounded by  pouting  granulations.  Stricture  of  the  nasal  duct  generally  pre- 
cedes these  inflammations  of  the  sac,  but  in  many  instances  there  is  no  true 
stricture,  but  simply  a  swelling  of  the  lining  membrane. 

A  fistula  of  the  lachrymal  sac  may  be  congenital  or  may  result  from  the 
failure  of  a  rupture  of  the  lachrymal  sac  to  heal.  The  little  opening  which 
generally  leads  into  the  sac  appears  about  half  an  inch  below  the  punctum  or 
further  outward  along  the  lower  orbital  border,  and  can  generally  be  detected 
by  the  presence  of  a  drop  of  fluid  at  its  mouth. 

The  causes  of  diseases  of  the  lachrymal  sac  and  duct  are  various.  Dacryo- 
cystitis has  been  noted  a  great  many  times  in  infants,  sometimes  shortly  after 
birth  and  apparently  without  cause.  A  great  many  cases  are  due  to  an  inflam- 
mation which  starts  in  the  nose  or  naso-pharynx,  and  hence  it  is  not  uncom- 
monly seen  after  measles,  scarlet  fever,  and  small-pox.  Other  cases  are  due 
to  inherited  syphilis  and  disease  of  the  bones  (periostitis  and  caries)  and  to 
traumatism. 

Treatment. — A  lachrymal  abscess,  if  it  is  pointing  in  the  manner  already 
described,  should  be  opened  with  a  sharp  scalpel,  and  the  sac  and  abscess- 
cavity  frequently  syringed  with  bichloride  of  mercury,  peroxide  of  hydrogen, 
protargol  (5  per  cent.).  The  cavity  may  be  packed  with  iodoform  gauze 
and  allowed  to  heal  by  granulation.  Sometimes  it  is  possible  to  effect  a  cure 
by  dilating  the  punctum  and  irrigating  the  sac  through  the  natural  passages. 
If  there  is  a  stricture,  positive  and  cicatricial,  the  canaliculus  should  be  split, 
the  stricture  divided,  and  probes  passed  ;  but  it  is  extremely  desirable  to 
avoid  mutilating  the  punctum  and  the  canaliculus  if  it  is  possible  to  effect  a 
cure  without  it.  Naturally,  all  cases  require  intranasal  treatment  on  account 
of  the  common  association  of  disease  in  this  region,  particularly  rhinitis, 
hypertrophied  turbinals,  and  deflections  of  the  septum.  A  fistulous  communi- 
cation into  the  sac  may  be  cured  by  freshening  the  edges  and  closing  it  or  by 
the  use  of  the  galvano-cautery.  Generally,  however,  capillary  fistulas  may  be 
allowed  to  remain  undisturbed.  A  judiciously  applied  pressure  bandage  will 
sometimes  permanently  close  up  one  of  these  openings.  Internally,  iron,  cod- 
liver  oil,  and  mercury  are  indicated,  according  to  the  general  conditions  which 
may  be  present. 

Diseases  op  the  Orbit. 

Periostitis. — Either  acute  or  chronic  periostitis,  which  may  be  due  to 
syphilis,  scrofula,  tuberculosis,  or  injuries,  sometimes  attacks  the  margin  of 
the  orbit,  causing  localized  pain,  injection  and  chemosis  of  the  conjunctiva, 
swelling  of  the  lids,  and  protrusion  of  the  eyeball.  Caries  of  the  orbit  occurs 
quite  frequently  in  children,  and  is  situated  nearly  always  at  the  margin  of 
the  orbit.  It  may  be  due  to  syphilis,  scrofula,  tuberculosis,  or  to  an  injury, 
and  presents  practically  the  same  symptoms  as  those  which  occur  with  peri- 
ostitis. A  probe  will  detect  the  carious  condition  of  the  bone.  Great  deformity 
of  the  lid  (ectropion)  is  not  uncommon  as  the  result  of  this  disease. 

Treatment. — The  treatment  consists  in  the  use  of  the  proper  constitutional 
remedies  and  the  surgical  measures  which  are  suited  to  the  treatment  of  peri- 
ostitis and  caries. 

Cellulitis  op  the  Orbit  [Phlegmon  of  the  Orbit). — Phlegmonous  inflam- 
mation of  the  cellular  tissue  of  the  orbit,  producing  in  its  acute  variety 
exophthalmos,  limitation  of  the  movements  of  the  eye,  swelling  and  oedema 

76 


1202  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

of  the  lids,  and  considerable  hyperaemia  and  chemosis  of  the  conjunctiva, 
together  with  decided  constitutional  disturbances — chills  and  fever — may  occur 
in  children  from  a  variety  of  causes.  The  most  common  are  caries  of  the 
orbit,  septic  phlebitis,  injuries,  and  inflammations  of  the  eye  which  result  in 
panophthalmitis.  Sometimes  the  disease  occurs  in  infants  a  very  short  time 
after  birth. 

Treatment. — In  addition  to  proper  supporting  measures  and  frequently 
changed  hot  compresses,  an  incision  should  be  made,  preferably  from  the 
conjunctiva,  which  secures  the  evacuation  of  the  pus  at  as  early  a  moment  as 
possible.  Proper  drainage  must  afterward  be  secured,  and  the  case  treated 
upon  the  general  principles  which  govern  the  management  of  purulent  inflam- 
mations. 

3Iorhid  groivths  are  not  uncommon  in  the  orbit,  either  because  an  intra- 
ocular tumor  (sarcoma  or  glioma)  has  ruptured  and  invaded  the  orbit,  or  as 
primary  growths — namely,  the  various  forms  of  sarcoma. 

Simple  and  compound  cysts  are  also  seen,  and,  under  rare  circumstances,  a 
pulsating  exophthalmos  due  to  arterio- venous  aneurism. 

Bleeding  in  the  orbit  has  sometimes  been  observed  in  new-born  children, 
and  also  occurs  in  haemophilia,  scurvy,  and  occasionally  in  violent  attacks  of 
whooping-cough. 

Congenital  Cataract. 

A  certain  number  of  infants  are  born  with  complete  cataract,  which  is 
usually  white  or  bluish-white  in  color,  and  may  readily  be  detected  even  with- 
out instruments  of  precision.  The  eye  may  be  otherwise  healthy,  or  there  may 
be  associated  with  it  other  congenital  anomalies  and  diseases  of  the  choroid, 
retina,  or  optic  nerve. 

Treatment. —  The  treatment  of  complete  congenital  cataract  consists  in 
discission,  and  the  patient  is  ready  for  operation  after  the  completion  of  the 
first  dentition  ;  indeed,  it  is  advisable  to  operate  as  early  as  possible,  so  that 
the  retina  may  receive  the  stimulus  afforded  by  the  rays  of  light,  and  that  the 
sense  of  sight  may  thus  be  educated. 

In  addition  to  the  complete  congenital  cataracts,  there  are  numerous  varie- 
ties of  partial  cataract  which  occur  in  infants  and  children,  of  which  the  most 
important  are:  {a)  Zonular  or  Lamellar  Cataract ;  (b)  Central  Cataract ;  and 
{c)  Pgramidal  or  Polar  Cataract.  The  acquired  anterior  polar  cataracts  Avhich 
develop  in  infancy  are  due,  as  has  already  been  explained,  to  perforating  corneal 
ulcers,  especially  during  ophthalmia  neonatorum. 

Treatment. — In  some  of  these  cases  the  treatment  is  practically  without 
avail ;  in  others,  particularly  in  zonular  cataract,  either  iridectomy,  discission, 
or  sometimes  extraction,  may  be  practised.^ 

The  Refraction  of  the  Eye  in  Childhood. 

The  most  important  study  of  the  refraction  of  the  human  eye,  made  from 
a  careful  study  of  the  recorded  examinations  of  the  eyes  of  school-children, 
was  published  by  Dr.  B.  Alexander  Randall  in  the  American  Journal  of  the 
Medical  Sciences,  in  1884.  From  this  author's  investigations  we  know  that 
myopia  scarcely  ever  occurs  in  infancy  and  is  very  infrequent  before  the 
beginning  of  school-life ;  that  hypermetropia,  or  far-sightedness,  is  the  prepon- 

'  Those  interested  in  congenital  cataract  and  its  numerous  varieties  should  consult  Professor 
Michel's  article  in  Gerhardt's  Handbuch  der  Kwdertrankheiten,  Fiinfter  Band,  Zweite  Abtheilung. 
Tubingen,  1889;  and  Picque,  Anomalies  de  Developpement  et  Maladies  conqenitales  du  Globe  de 
l'(EiL  Paris,  1886. 


I 


DISEASES  OF  THE  EYE.  1203 

derating  condition  of  refraction  in  infancy  and  early  childhood,  and  that  there 
is  but  little  reduction  in  this  proportion  even  during  the  first  years  of  school- 
life;  that  astigmatism  is  common,  and  that  a  measurable  degree  of  it  is  found 
in  the  majority  of  ametropic  eyes;  and  that  the  approximately  emmetropic  or 
normal  eye  is  infrequent  at  all  ages,  and  probably  at  no  time  exceeds  more 
than  10  per  cent. 

The  great  frequency  of  hypermetropia  and  hypermetropic  astigmatism  in 
children  is  i-esponsible  for  a  number  of  the  inflammatory  conditions  -which  have 
already  been  described,  particularly  blepharitis,  and  slight  conjunctivitis,  as  well 
as  hyperaemia  of  the  external  and  internal  coats  of  the  eye.  Moreover,  it  is 
well  established  that  fully  50  per  cent.,  if  not  more,  of  the  headaches  of  func- 
tional origin  which  occur  in  school-children  are  due  to  eye-strain,  which  in  its 
tarn  is  the  result  of  the  refractive  anomalies  which  have  been  mentioned.  iS^ot 
only  is  headache  commonly  caused  by  hypermetropia  and  astigmatism,  but  they 
also  contribute  to  the  existence  of  a  variety  of  so-called  reflex  neuroses — habit 
chorea,  chorea  itself,  night-terrors,  dyspepsia,  irritability  of  disposition,  and 
general  nervousness.  While  the  influence  of  eye-strain  in  these  respects  has  some- 
times been  crrossly  exacca;erated.  in  the  sensitive  orc^anism  of  a  growing  child  it 
is  very  frequently  one  of  many  factors  which  foster  and  aggravate  these  affec- 
tions, and  the  evident  indication  in  the  investigation  of  all  functional  head- 
aches and  nervous  diseases  is  the  proper  examination  of  the  eyes,  and  in  chil- 
dren of  suitable  age  the  prescription  of  glasses  to  neutralize  the  refractive 
anomalies. 

It  is  not  always  necessary  to  condemn  a  child  to  glasses  for  the  remainder 
of  his  life  because  he  happens  to  be  somewhat  hypermetropic,  and  very  often 
a  temporary  use  of  spectacles  Avill  bridge  him  over  until  he  has  gained  sufiicient 
strength  to  control  the  symptoms  induced  by  slight  accommodative  strain. 
Glasses  should  not  be  ordered  unless  proper  examination  has  demonstrated 
their  real  necessity.  Judicious  hygiene,  quitting  school,  and  perhaps  the  use 
of  tonics,  will  often  relieve  symptoms  which  are  inaccurately  ascribed  to  eye- 
strain simply  because  emmetropia  is  not  present. 

Strabismus,  or  Squint. 

In  general  terms,  strabismus  includes  those  conditions  in  which  the  visual 
axis  of  one  eye  is  directed  away  from  the  point  of  fixation. 

Squint  may  be  convergent  —  that  is,  the  visual  line  of  one  eye  deviates 
inward  and  crosses  that  of  the  sound  eye  at  some  point  nearer  than  the  object 
fixed;  or  divergent — that  is,  the  visual  line  of  one  eye  fixes  the  object,  while 
the  visual  line  of  the  other  eye  fails  to  intersect  that  of  its  fellow  at  the  point 
of  fixation.  More  rarely  there  is  an  upivard  or  a  doiomvard  squint.  So  far 
as  children  are  concerned  and  for  the  purpose  of  the  present  paragraph,  con- 
vergent strabismus  is  the  most  important.  This  may  be  either  concomitant — 
that  is,  the  squinting  eye  is  able  to  follow  the  movements  of  the  other  eye  in 
all  directions,  or  paralytic — that  is,  there  is  limitation  of  movement  in  the 
direction  of  the  action  of  the  aff"ected  muscle. 

Concomitant  Convergent  Squint. — This  is  the  ordinary  "crossed  eye"  of 
children,  and  usually  begins  between  the  third  and  fourth  years  of  life. 
It  may  be  either  permanent  or  periodic,  and  the  last-named  variety  may 
afiect  one  eye  alone  or  each  eye  in  turn ;  that  is,  it  is  either  monolateral  or 
alternating. 

There  are  numerous  causes  of  concomitant  squint,  to  which  oniy  a  brief 
reference  can  be  made.  The  most  important  of  these  is  a  disturbance  of  the 
relation  which  exists  between  the  power  of  accommodation  of  the  eyes  and 


1204  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN. 

their  power  of  convergence,  which  is  caused  by  errors  of  refraction — in  con- 
vergent squint,  usually  by  hypermetropia,  in  divergent  squint,  generally  by 
myopia.  Squint  may  also  be  caused  by  a  disparity  in  the  length  or  thickness 
of  opposing  muscles ;  for  example,  the  internal  rectus  muscle  may  be  strong 
and  well  developed,  while  the  external  rectus  is  flat  and  poorly  developed. 
Quite  commonly  the  squinting  eye  is  very  amblyopic,  and  this  has  been  regarded 
as  a  cause  of  convergent  squint.  This  amblyopia,  according  to  one  theory,  is 
due  to  lack  of  use  on  the  part  of  the  squinting  eye,  and,  according  to  the  other, 
depends  upon  imperfect  development  of  the  visual  centres;  that  is  to  say,  the 
amblyopia  in  the  squinting  eye  is  congenital.  There  is  a  widespread  popular 
belief  that  convergent  squint  may  be  brought  about  by  fright  or  by  imitation  or 
by  looking  at  some  object  hung  in  an  oblique  direction.  These  causes,  of  course, 
never  obtain.  Squint,  however,  is  quite  commonly  first  noticed  in  children 
after  an  acute  illness — for  example,  scarlet  fever,  measles,  diphtheria  (which 
may  cause  one  form  of  paralytic  squint),  or  very  depressing  illnesses — cholera 
infantum  and  similar  conditions.  These,  by  weakening  the  system,  determine 
a  strabismus,  the  conditions  for  the  production  of  which  are  already  present  in 
the  eyes  of  the  child. 

Concomitant  strabismus  must  be  distinguished  from  a  paralytic  strabismus, 
which  may  be  caused  by  syphilis,  rheumatism,  diphtheria,  poisons,  and,  especi- 
ally in  children,  by  diseases  of  the  base  of  the  brain — for  example,  tuber- 
cular meningitis — by  observing  that  in  concomitant  strabismus  the  squinting 
eye  follows  the  movements  of  the  other  eye  in  all  directions ;  that  the  second- 
ary and  primary  deviations  of  the  eye  are  equal ;  that  double  vision  is 
extremely  uncommon ;  and  that  there  are  usually  considerable  degrees  of 
refractive  error.  In  paralysis  of  an  ocular  muscle  there  is  limitation  of  move- 
ment of  the  affected  eye  in  the  direction  of  the  paralyzed  muscle  ;  the  second- 
ary deviation  {i.  e.  the  deviation  of  the  sound  eye,  while  the  aff'ected  eye 
"fixes"  an  object  held  about  one  foot  from  it)  is  greater  than  the  primary 
deviation;  double  vision  is  the  rule;  and  there  is  no  special  relation  to  refrac- 
tive errors.  Many  of  the  differential  points  are  difficult  to  determine  in  young 
children,  although  usually  it  is  possible  to  elicit  that  which  compares  the  move- 
ments of  the  eyes. 

Treatment  of  Concomitant  Convergent  Strabismus. — This  may  be 
divided  into  the  mydriatic  treatment,  the  spectacle  treatment,  and  the  opera- 
tive treatment.  In  very  young  children  who  begin  to  squint  good  results  will 
sometimes  follow  the  use  of  a  weak  solution  of  atropine — for  example,  a  half 
or  one  grain  to  the  fluidounce — continued  for  long  periods  of  time,  just  suffi- 
cient being  introduced  into  the  conjunctival  sac  to  maintain  mydriasis  and 
keep  the  ciliary  muscle  paralyzed.  As  soon  as  the  child  is  of  sufficient  age 
the  refractive  error  should  be  carefully  neutralized  by  means  of  spectacles. 
In  many  instances  of  periodic  squint  properl}^  adjusted  spectacles  will  produce 
a  cure,  and  the  effect  of  the  treatment  is  in  direct  ratio  to  the  youth  of  the 
patient.  In  the  event  of  failure  the  eyes  may  be  straightened,  either  by 
tenotomy  of  one  or  both  internal  recti,  or  tenotomy  combined  Avith  advance- 
ment of  the  external  rectus.  It  is  not  advisable  to  operate  upon  a  case  of 
convergent  strabismus  before  the  sixth  year:  in  fact,  many  of  the  cases  do 
better  if  the  time  of  operation  is  postponed  to  a  later  period  than  the  one 
just  mentioned.  It  is  also  never  proper  to  operate  upon  children,  even  if 
there  is  very  considerable  amblyopia  of  one  eye,  until  the  spectacle  treatment 
has  been  given  a  faithful  trial.  For  the  method  of  performing  tenotomy  and 
the  rules  which  govern  the  expediency  and  character  of  the  operation  the 
reader  is  referred  to  systematic  treatises  on  diseases  of  the  eye. 


INDEX. 


Abdomen,  condition  of,  in  ty- 
phoid fever,  197 
distention  of,  14 
causes  of,  14 
diagnosis  of,  14 
in  ascites,  14 
in  peritonitis,  14 
examination  of,  13 
in  disease,  13 
inspection  of,  13 
palpation  of,  14 
percussion  of,  14 
in  health,  13 
protuberance  of,  in  rachitis, 

326 
scaphoid,  causes  of,  14 
tenderness  of,  diagnosis  of,  14 
Abdominal  pneumonia,  916 

tenderness  in  variola,  164 

Abscess  after  vaccination,  175 

in  hip-joint  disease,  1072 

treatment  of,  1076 
in  Pott's  disease,  1067 
treatment  of,  1071 
ischio- rectal,  588 
marginal,  587 
of  brain,  630 
diagnosis  of,  632 

from  meningitis,  632 
duration  of,  631 
etiology  of,  630 
in    etiology    of   headache, 

722 
pathology  of,  630 
prognosis  of,  632 
rupture  of,  632 
symptoms  of,  631 
treatment  of,  632 
of  cornea,  1195 
of  eyelid,  1178 
of  lachrymal  gland,  1200 
of  lachrymal  sac,  1201 
of  liver.     See  Hepatitis,  sup- 
purative. 
of  lobule  of  ear,  1160 
of  lung,  924 
after  croupous  pneumonia, 

917 
following    broncho  -  pneu- 
monia, 908 
prognosis  of,  923 
rupture  of,  into  bronchus, 

923 
surgical  treatment  of,  923 
temperature  in,  923 
treatment  of,  923 
perinephritic.     See  Perineph- 

ritic  abscess. 
perityphlitic,  509 
retro-pharyngeal.    See  Retro- 
pharyngeal abscess. 
tuberculous       periumbilical, 
290 


Abscesses,  cutaneous,  with  ec- 
zema, 1101 
Abscission  of  tonsils,  423 
Acarus  scabiei,  1154 
Accumulation,  fecal,  diagnosis 

of,  14 
Acetanilide.     See  Antifebrin. 

in  tuberculosis,  302 
Acetone  in  diabetic  urine,  1000 
Aching   of   limbs   in    chicken- 
pox,  156 
Achorion  Shoenleinii,  1149 
Acid-lemonade  in  cholera,  244 
Acne,  1093 

Aconite  in  acute  tubal  nephri- 
tis, 1015 
in  broncho-pneumonia,  912 
in  peritonsillar  abscess,  421 
in  scarlet  fever,  145 
in  variola,  168 
Acromegaly,  690 

diagnosis  of,  from  gigantism, 
692 
from  myxoedema,  692 
from  pulmonary  osteo-ar- 
thropathy,  692 
pathology  of,  692 
symptoms  of,  691 
treatment  of,  693 
Acute  ascending  paralysis.   See 
Paralysis,  Landry's. 
gastritis.   See  Gastric  catarrh, 

acute. 
nephritis     in     etiology     of 
chronic  tubal  nephritis, 
1018 
Adenitis,   cervical,   tubercular, 
283 
in  scarlet  fever,  140 
Adenoid  vegetations.  See  Naso- 
pharyngeal adenoid  hyper- 
trophy. 
Adenoma  of  umbilicus,  575 
Adenomo-sarcoma    of   kidney, 

1035 
Adenopathy     in    chicken-pox, 

159 
^stivo-autumnal  fevers,  312 
diagnosis  of,  315 

from  tuberculosis,  315 
parasites  of,  307 
Afanassiew's  bacillus,  184 
Age  in  etiology  of  acute  endo- 
carditis, 977 
of  chicken-pox,  156 
of  chlorosis,  362 
of  chorea,  756 
of     croupous     pneumonia, 

913 
of  diphtheria,  252 
of  erysipelas,  222 
of  intussusception,  518 
of  measles,  118 


Age  in  etiology  of  progressive 
pernicious  anaemia,  365 
of  rheumatism,  351 
of  tuberculous  meningitis, 

610 
of  tumors  of  kidney,  1006 
of  typhlitis,  510 
of  whooping-cough,  183 
in  prognosis  of  rheumatism, 
356 
of  tracheotomy,  294 
of  whooping-cough,  189 
of  occurrence  of  rachitis,  322 
of  onset  of  infantile  cerebral 
palsies,  650 
Agenesis  corticalis,  655 
Agoraphobia,  704 
Agraphia,  659 
Air-passages,  hypersemia  of,  in 

chicken-pox,  157 
Alse  of  nose,  dilatation  of,  in 
broncho-pneumonia,  906 
Albinism,  1135 
partial,  1135 
Albumin  in  acute  tubal  neph- 
ritis, 1011 
in  chrouic  interstitial  neph- 
ritis, 1026 
in  chronic  tubal    nephritis, 
1019 
Albuminoids  in  milk,  46 
Albuminuria  after  epilepsy,  751 
chronic,  in   etiology  of  amy- 
loid kidney,  1024 
in  diabetes  insipidus,  1005 
in  diabetes  mellitus,  1000 
in  diphtheria,  256 
in  erysipelas,  225 
in  etiology  of   incontinence 

of  urine,  998 
in  malaria,  314 
in  simple  atrophy,  506 
in  splenic  anaemia,  369 
in  stone  in  bladder,  1009 
Albuminuric   retinitis    in 
chronic  interstitial  neph- 
ritis, 1026 
Alcohol.     See  Stimulants. 
in  bronchitis,  933 
in  broncho-pneumonia,  911 
in  cholera,  246 

in  chronic  intestinal  indiges- 
tion, 471 
in  croupous  pneumonia,  918 
indications  for,  36 
in  diphtheria,  261 
in     epidemic     cerebro-spinal 

meningitis,  213 
in  influenza,  219 
in  mucous  disease,  459 
in  peritonitis,  567 
in  rheumatism,  357 
in  scarlet  fever,  146 

1205 


1206 


INDEX. 


Alcohol  in  variola,  169 
Alcoholism   in  etiology  of  cir- 
rhosis of  liver,  558 
of  hysteria,  729 
Alexia,  (i59 

Algid  stage  of  cholera,  240 
state  in  acute  milk  infection, 
476 
Alkalies    in   diabetes  mellitus, 
1004 
in  mucous  disease,  461 
in  rlieumatism,  357 
Allingham's     method    in    pro- 
lapse of  rectum,  591 
Alloxuric  bodies  as  a  cause  of 
lithaimia,  94 
excretion  of,  95 
Almond-flour  in  diabet«s,  1002 
Alopecia  areata,  1136 
diagnosis  of,  1136 

from  ringwojm,  1136 
etiology  of,  1136 
prognosis  of,  1136 
syphilitic,  112 
treatment  of,   1137 
Alternate  heart-beat,  988 
Altitude  in  etiology  of  granular 
conjunctivitis,  1190 
in  tuberculosis,  300 
Alum  in   ophthalmia  neonato- 
rum, 1188 
Alveolar    sarcoma    of   kidney, 

1035 
Amaurosis    in    hydrocephalus, 

604 
Amblyopia  in  erysipelas,  227 

in  hysteria,  734 
American  gout,  94 
Ametropia  in  etiology  of  bleph- 
aritis, 1179 
Amimia,  659 
Ammonia   in  functional  aflPec- 

tionsof  heart,  989 
Ammoniaco  -  magnesian  -  phos- 
phate calculus,  1038 
Ammonium  carbonate  in  bron- 
cho-pneumonia, 911 
in  diphtheria,  261 
in  malignant  measles,  128 
chloride  in  bronchitis,  931 
in  cirrhosis  of  liver,  560 
in     congestion     of     liver, 

551 
in  jaundice,  548 
in  measles,  128 
salicylate  in  rheumatism,  356 
urate  calculus,  1038 
Amoeba  coli,  490 
dyseuteriffi,  490 
dysenterica  in  pus  from  liver, 
542 
Amussat's  operation,  580 
Amygdalitis,     follicular.       See 

Follicular  amygdalitis. 
Amyl    nitrite    as    a    cause  of 
hsematuria,  992 
in  asthma,  961 
in  epilepsy,  753 
Amyloid     changes     in    Pott's 
disease,  1067 
disease  of  kidney,  1024 
etiology  of,  1024 
morbid  anatomy  of,  1024 
prognosis  of,  1024 
treatment  of,  1025 
Anadenia  of  stomach,  447 
Anaemia.  360 


Anaemia  as  a  cause  of  inconti- 
nence of  urine,  1027 
definition  of,  360 
following     acute     nephritis, 
1017 
rheumatism,  354 
in  acute  endocarditis,  978 
in    chronic   tubal    nephritis, 

1019 
in  functional  heart  affections, 

treatment  of,  989 
in    heart-disease,   treatment 

of,  984 
in  hereditary  syphilis,  110 
lymphatic,  370 
diagnosis  of,  372 

from     pseudo-leukaemia, 

372 
from  tubercular  adenitis, 
372 
etiology  of,  370 
morbid  anatomy  of,  371 
prognosis  of,  372 
symptoms  of,  370 
treatment  of,  372 
progressive  pernicious,  364 
diagnosis  of,  367 
etiology  of,  365 
morbid  anatomy  of,  366 
prognosis  of,  367 
symptoms  of,  365 
treatment  of,  367 
secondary,  360 
diagnosis  of,  361 
from  chlorosis,  361 
from  pernicious  anaemia, 

361 
from  splenic  anaemia,  361 
etiology  of,  360 
prognosis  of,  361 
symptoms  of,  361 
treatment  of,  361 
splenic,  368 

diagnosis  of,  369 

from  amyloid  infiltration 

of  spleen,  369 
from     enlarged    kidnev, 

370 
from  leukaemia,  369 
etiology  of,  368 
morbid  anatomy  of,  368 
prognosis  of,  370 
spleen  in,  369 
symptoms  of,  369 
treatment  of,  370 
Anaemias,  primary,  362 
Anaemic  headache,  723 

murmurs    in    chronic    tubal 
nephritis,  1019 
Anaesthesia  dolorosa,  802 
in  acromegaly,  602 
in  acute  spinal   leptomenin- 
gitis, 780 
in  cerebrospinal  meningitis, 

211 
in  hereditary  ataxia,  818 
in  hysteria,  733 
in  Raynaud's  disease,  821 
in    tumors    of    spinal    cord, 
802 
Anaesthetics    in     tracheotomy, 

877 
Analgesia  in  tumors  of  spinal 

cord,  802 
Anastomosis,    lateral,    in    con- 
genital      malformations 
of  intestines,  577 


Anastomosis,  lateral,  in  intus- 
susception, 523 
Anatomy  of  urinary  organs  in 

children,  1045 
Anderson's     dusting    powder, 

1095 
Angina  in  rubella,  154 

in  scarlet  fever,  136,  139 
Angioma  of  rectum,  593 

pigmentosum  et  atrophicum. 
See  Kaposi's  disease. 
Animal     broths     in     sul)acute 

milk  infection,  483 
Animals,     experimental     pro- 
duction of  rachitis,  in  324 
Ankle,  tuberculous  disease  of, 

1079 
Ankle-clonus     in     hereditary 

ataxia,  817 
Ankle-joint  disease,  1079 
diagnosis  of,  1079 
operative  treatment  of,  1080 
prognosis  of,  1079 
symptoms  of,  1079 
treatment  of,  1079 
Ankylosis  following  tuberculo- 
sis  of  joints,    treatment 
of,  1081 
Anomalies      of      auriculo-ven- 
tricular  orifices,  970 
of  valve-segments,  972 
Anorexia,  hysterical,  735 
in  chicken-pox,  156 
in  measles,  120 
in  typhoid  fever,  197 
in  vaccinia,  174 
Anterior    fontanelle,    ossifica- 
tion of,  13 
region  of  neck,  anatomy  of, 
872 
Antifebrin  in   diabetes  insipi- 
dus, 1006 
in  diabetes  mellitus,  1004 
in  tuberculosis,  302 
Antihygienic  conditions  in  eti- 
ology of  rachitis,  323 
Antipyretics,  dangers  of,  36 
in  erysipelas,  229 
in  measles,  129 
in  tuberculosis,  302 
in  typhoid  fever,  206 
in  variola,  169 
Antipyrine,  caution  in  the  use 
of,  36 
in  acute  follicular  tonsillitis, 

422 
in  diabetes  insipidus,  1006 
in  diabetes  mellitus,  1004 
in  epilepsy,  753 
in  migraine,  720 
in  pyrexia  of  broncho-pneu- 
monia, 912 
in  tuberculosis,  302 
in  whooping-cough,  192 
Antisepsis     in     treatment     of 

new-born,  75 
Antiseptic    alkaline    solution, 

416 
Antiseptics  in  dysentery,  494 
in  subacute   milk   infection, 

483 
intestinal,  in  pernicious  an- 
aemia, 368 
Autitoxines  of  diphtheria,  266 
Anuria,  995 

intermittent,     in     hydrone- 
phrosis, 1030 


INDEX. 


1207 


Anus,  diphtheria  of,  587 
diseases  of,  584 
fissure  of,  586 
occlusion  of,  complete,  578 
stricture  of,  587 
syphilitic  affections  of,  584 
vegetations  or  warts  of,  585 
Aorta,  stenosis  of,  972 
Aortic  obstructive  murmur,  982 
regurgitant  murmur,  983 
regurgitation,  983 
prognosis  of,  984 
stenosis,  982 
prognosis  of,  984 
Apex -beat,  altered  position  of, 
in  disease,  15 
position  of,  in  infant,  15 
Apex  pneumonia,  914 
Aphasia,  659 

during  acute  gastric  catarrh, 

444 
etiology  of,  660 
from  hereditary  syphilis,  661 
in  infantile  cerebral  palsies, 

651 
in  typhoid  fever,  200 
Aphonia  due  to  ascarides,  527 

in  hysteria,  735 
Aphtha,  309 
Aphthae,  Bednar's  400 

in  simple  atrophy,  505 
Aphthous  ulcer,  400 
Apnoea,  physiological,  76 
Apomorphine  in  broncho-pneu- 
monia, 910 
Apoplexy  neonatorum,  74 

pulmonary,  in  new-born,  75 
Apparatus  for  hot-air  bath,  1014 
Appendicitis,  509 
operation    for,    after    conva- 
lescence, 516 
operations  for,  514 
Appendix,     diseases     of.      See 
Csecimi  and  Appendix. 
in  congenital  hernia,  516 
Appetite  in  chronic  gastric  ca- 
tarrh, 449 
in  chronic  intestinal  indiges- 
tion, 468 
in  chronic  peritonitis,  568 
in  simple  atrophy,  505 
in    tuberculous    meningitis, 

611 
in  typhoid  fever,  206 
Arrhythmia,  988 
Arrow-root,  value  of,  22 
Arsenic    bromide    in    diabetes 
mellitus,  1004 
in  childhood,  36 
in  chorea,  763 

in  chronic  intestinal  indiges- 
tion. 471 
in  chronic  malaria,  318 
in  convalescence  from  vari- 
ola, 170 
in  diabetes  mellitus,  976 
in  eczema,  1105    • 
in  leukaemia,  376 
in  lymphatic  anaemia,  372 
in  pernicious  anaemia,  367 
in  psoriasis,  1113 
in    pulmonary    emphysema, 

954 
in    purpura     haemorrhagica, 

383 
in  secondary  anaemia,  362 
in  splenic  anaemia,  370 


Arsenic  in  tuberculosis,  301 
Arterial   tension,  increased,  in 
chronic  interstitial  neph- 
ritis, 1026 
trunks,  transposition  of,  972 
Artery,  external    carotid,  liga- 
tion of,  427 
Arthritis  in  scarlet  fever,  140 
Arthropathies    in    syringomy- 
elia, 813 
Arthrospores  of  Hiippe,  233 
Artificial  feeding,  21 

in  etiology  of  chronic   in- 
testinal      indigestion, 
468 
of  gastric  catarrh,  441 
foods,  chemistry  of,  47 
Asafoetida  in  constipation,  500 
in  croupous  pneumonia,  918 
in  whooping-cough,  191 
Ascaris  lumbricoides,  524 
diagnosis  of,  528 
habitat  of,  525 
in  cystic  and  common  bile- 
ducts,  527 
methods  of  infection  by,  526 
ova  of,  525 
symptoms  of,  526 
treatment  of,  528 
Ascites,  571 

diagnosis  of,  572 
etiology  of,  571 
in   cirrhosis  of   liver,   treat- 
ment of,  561 
pathology  of,  572 
physical  examination  in,  572 
prognosis  of,  573 
symptoms  of,  572 
treatment  of,  573 
Asphyxia  from  delayed  labor,  76 
local,   821.       See,    also,   Ray- 

naud^s  disease. 
of  the  new-born,  75 
causes  of,  76 
complications       of      labor 

causing,  76 
electricity  in,  80 
oxygen  in, 80 
prognosis  in,  77 
prophylaxis  of,  77 
recovery  after,  77 
symptoms  of,  76 
tracheotomy  for,  80 
treatment  of,  77 
partial,  causes  of,  82 
Aspiration    in    hydronephrosis, 
1031 
in  pleural  effusion,  946 
Astasia-abasia,  734 
Asthenia  in  tuberculous  menin- 
gitis, 611 
Asthma,  bronchial,  956 
diagnosis  of,  959 

from       bronchitis       and 

pneumonia,  959 
from  cardiac  asthma,  960 
from  emphysema,  969 
from    obstructive     dysp- 
noea, 959 
from    pleuritic    effusion, 

960 
from  pulmonary  cedema, 

960 
from      spasm      of      dia- 
phragm, 960 
from    uraemic    dyspnoea, 
960 


Asthma,  broncliial,  etiology  ot, 
956 
pathology  of,  957 
physical  signs  in,  959 
prognosis  of,  959 
symptoms  of,  958 
theories   regarding  nature 

of,  957 
treatment  of,  960 
Milarii, 
rachiticum, 

thymicum  Koppii.     See  Lar- 
yngismus stridulus. 
uraemic,  treatment  of,  1023 
Astigmatism,  1203 

in   etiology   of   phlyctenular 
k  e  r  a  t  o-conjunctivitis, 
1193 
Astringents  in  subacute  milk 

infection,  483 
Astrophobia,  704 
Ataxia,  hereditary,  815 
diagnosis  of,  819 
etiology  of,  815 
morbid  anatomy  of,  817 
symptoms  of,  817 
treatment  of,  819 
with  tumors  of  spinal  cord, 
803 
Atelectasis   during  bronchitis, 
926 
in  whooping-cough,  187 
post-natal,  899 
diagnosis  of,  901 
from  acute   miliary   tu- 
berculosis, 902 
from    pleuritic    effusion, 

902 
from  pneumonia,  901 
etiology  of,  899 
pathology      and       morbid 

anatomy  of,  899 
physical  signs  of,  901 
prognosis  of,  902 
symptoms  of,  900 
treatment  of,  902 
Athetoid    affections    in    idiots 

and  imbeciles,  694 
Athetosis,  694 
diagnosis  of,  696 
from  post-hemiplegic  cho- 
rea, 696 
etiology  of,  695 
in  infantile  cerebral  palsies, 

654 
pathology  of,  695 
prognosis  of,  696 
symptoms  of,  694 
treatment  of,  695 
Atresia  ani  urethralis,  583 
vaginalis,  582 
vesicalis,  582 
congenital,  of  auditory  me- 
atus, 1165 
of     pulmonary    orifice     and 
artery,  971 
Atrophies  of  skin,  1135 
Atrophy  in  acute  spinal  lepto- 
meningitis, 780 
in  knee-joint  disease,  1077 
muscular,       in       hereditary 

ataxia,  818 
of  conjunctiva,  1193 
simple,  503 

bathing  in,  507 
diagnosis  of,  506 
from,  syphilis,  506 


1208 


INDEX. 


Atrophy,  simple,  diagnosis   of, 
from  tubercular  meniu- 
gitis,  506 
from  tuberculosis,  506 
etiology  of,  503 
morbid  au atomy  of,  504 
prognosis  of,  506 
symptoms  of,  505 
treatment  of,  507 
Atropine  in  atelectasis,  903 
in  interstitial  keratitis,  1197 
in  night-sweats,  302 
in  ophthalmia    neonatorum, 

1187 
in   phlyctenular   kerato-con- 

junctivitis,  1194 
in  sim(>le  corneal  ulcer,  1196 
Attenuants,  dextrinized,  50 

in  artificial  feeding,  25 
Attenuation,   barley-water    in, 
50 
gelatin  in,  50 
oatmeal  water  in,  50 
of  milk,  50 
Attic,  tympanic   inflammation 

of,  1169 
Attitude       in       pseudo-hyper- 
trophic  paralysis,  769 
Auditory  canal,  caries  of  wall 
of,  1165 
direction    of,    in    infancy, 
1167 
Aura  in  epilepsy,  749 

in  hj'steria,  730 
Auricle,  congenital   malforma- 
tions of,  1160 
lesions  of,  from  ear-piercing, 

1160 
minuteness  of,  1160 
position   of,    in   diagnosis   of 
mastoid        inyolyement, 
1170 
supernumerary,  1160 
Auriculo-yentricular      orifices, 

anomalies  of,  970 
Auscultation  of  chest,  15 
in  emphysema,  15 
in  pleurisy,  15 
in  pneumonia,  15 
of  heart,  16 
Auvard's  incubator,  80 

Bacilli  in  meconium,  472 

of  pseudo-diphtheria,  253 
Bacillus  in  bronchitis,  926 

in  measles,  118 

of    cholera.       See    Spirilluni, 
cholerse  Asiaticse. 

of  Eberth,  195 

of  foot-and-mouth  disease  of 
cattle,  399 

of  Friedliinder    in    croupous 
pneumonia,  914 
in  broncho-pneumonia,  904 

of    influenza     in      croupous 
pneumonia,  914 

of  Klebs-Lofiier,  252 

of  Letzerich,  373 

of  Lustgarten  in  syphilis,  103 

of  tuberculosis  in  tuberculous 
meningitis,  610 

of  typhoid  feyer,  195 

parotidis,  178 

scarlatinse,  134 

tuberculosis,  271 

anatomical     changes     pro- 
duced by,  277 


Bacillus    tuberculosis,    biology 
of,  272 
distribution  of,  272 
in  broncho-pneumonia,  904 
in  fibroid  phthisis,  964 
in  lupus  yulgaris,  1139 
in  pleural  eflusion,  940 
in  urine,  281 
method  of  staining,  271 
tussis  conyulsivae,  184 
Backache  in  variola,  164 
Backward  children,  668 
Bacteria,  absence  of,  in  milk, 
39 
in    acute  milk  infection,  475 
in  diarrha-a,  varieties  of,  454 
in  stomatitis  gangrsenosa,  405 
in  stool  of  healthy  infant,  454 
multiplication  of,  in  milk,  39 
presence  of,  in  milk,  39 
toxicogenic,   in   milk    infec- 
tion, 472 
Bacterium  coli  commune,  454 
in  normal  stools,  472 
foetidum  in  bromidrosis,  1093 
in  parotitis,  178 
lactis  aerogenes,  454 

in  normal  stools,  472 
Ball's  incision,  580 
Bandage,    abdominal,    for    in- 
fants, 34 
Barley-water,    preparation    of, 

23 
"  Barrel-shaped  "  chest,  472 
Basham's  mixture   in    ascites, 

573 
Bath,    i)ermanent,    Winckel's, 
80 
temperature  of,  in  childhood, 
33 
in  infancy,  33 
the  cold,  33 
the  cooled,  33 
the  hot,  33 
Bathing,  18 

frequency  of,  32 

hour  for,  33 

in    chronic    gastric   catarrh, 

450 
in  hot  weather,  33 
in  rachitis,  343 
in  simple  atrophy,  507 
Baths  in    broncho-pneumonia, 
912 
in  croupous  pneumonia,  918 
in  eclampsia,  745 
in  insanity,  708 
in  laryngismus  stridulus,  863 
in  measles,  129 
in  Raynaud's  disease,  824 
in  variola,  169 
Bath-tub,  Winckel's,  80 
Battledore-hands    in   acromeg- 
aly, 691 
Bednar's  aphthae,  400 
Bed-sores  in  acute  myelitis,  785 
in  typhoid  fever,  207 
with  tumors  of  spinal  cord, 
803 
Bed-wetting.     See  Urine,  incon- 
tinence of. 
in  gravel,  1008 
Beef-peptonoids  in    Pott's   dis- 
ease, 1008 
Beef-tea,  formula  for,  25 
Belladonna,  administration  of, 
in  childhood,  36 


Belladonna  in  functional  heart 
afiections,  990 
in  incontinence  of  urine,  997 
in  intussusception,  521 
in  peritonitis,  567 
in  pertussis,  191 
in  typhlitis,  513 
Bell's  palsy,  774 
Benzoate   of    lithium    in    lith- 

semia,  101 
Benzoic  acid  in  alkaline  lith- 

iasis,  1010 
Bichloride    of    mercury.      See 
Mercuric  chloride. 
for  vaginal  douche,  88 
in  chicken-jjox,  161 
Bigeminal  pulsation,  988 
Bilharzia  haematobia  a  cause  of 

hsematuria,  993 
Biliary  cirrhosis,  558 
Bismuth  salicylate  in  cholera, 
244 
in  typhoid  fever,  206 
subnitrate  in   chronic   intes- 
tinal indigestion,  471 
in  dysentery,  493 
Bladder,    distention    of,    diag- 
nosis of,  14 
paralysis    of,    in   hydrocei)h- 
alus,  626 
with  tumors  of  spinal  cord, 
804 
peculiarities  of,  in  children, 
1045 
Bland's  pill,  364 
Bleeding  in  cerebral  meningi- 
tis, 603 
Blepharitis,  1179 
ciliaris.     See  Blepharitis. 
etiology  of,  1179 
treatment  of,  1179 
ulcerosa,  1179 
Blepharo-adenitis,  1179 
Blepharospasm,  1181 
tonic,  1181 

treatment  of,  1181 
Blisters  in  cerebral  meningitis, 
604 
in  cerehro-spiual  meningitis, 

608 
in  diabetes  insipidus,  1006 
Blood  after  paroxysm  of  tertian 
fever,  304 
characteristics    of,    in    new- 
born, 359 
examination  of,  in  leukaemia. 
374 
in  lymphatic  ansmia,  371 
in  malarial  fever,  316 
in  pernicious  anaemia,  366 
in  splenic  anaemia,  369 
in  subacute  purpura  haem- 
orrhagica,  381 
in  cholera,  2.38 
in  diphtlieria,  2.54,  256 
infections  of,  in  new-born,  92 
in  hysteria,  7.37 
Blood-cells,     colorless,     in    in- 
fancy, 3.59 
nucleated  red,  359 
Boils  after  vaccination,  175 
with  subacute  milk  infection, 
481 
Bone,  analysis  of,  327 
cancellous  tissue  of,  328 
compact  tissue  of.  328 
growth  of,  in  rachitis,  330 


INDEX. 


1209 


Bone,  minute  anatomy  of,  328    , 
Bones  in  child  and  adult  life, 

327 
Borax  in  diphtheria,  264 
Boric  acid  in  alkaline  lithiasis, 
1010 
in  gonorrhoea  of  mouth,  89 
in  vulvo-vaginitis,  1056 
Bothriocephalus  latus,  533 
Bowels  in  typhoid  fever,  199 
primary  tuberculosis  of,  287 
secondary  tuberculosis  of,  287 
Bow-legs,  braces  for,  1089 

treatment  of,  1087 
Braces  for  bow-legs,  1089 
for  knock-knee,  1089 
for  Pott's  disease,  1070 
Brachial  plexus,   obstetric  in- 
jury to,  83 
Brachycardia,  988 
Brachycephalic  idiocy,  671 
Bradycardia,  988 
Brain,  abscess  of.     See  Abscess 
of  brain. 
following  chronic  suppura- 
tion of  middle  ear,  1173 
chronic  diffuse  tuberculosis 
of,  282 
dropsy  of,  624 
in  diphtheria,  255 
in  pernicious  malaria,  308 
in  rachitis,  327 
lesion  of,  in    typhoid   fever, 

197 
symptoms  in  typhoid  fever, 
200 
Bran  bread  in  diabetes,  1002 
Brand     method     in     typhoid 

fever,  206 
Brandy  in  typhoid  fever,  206 
Breast-milk,  characters  of,  21 
constituents  of,  21 
quantity  of,  21 
substitutes  for,  21 
farinaceous,  22 

deleterious  eflFects  of,  22 
Breath,  amraoniacal,  in  uraemia, 
8 
catarrhal,  7 
"feverish,"  7 
foetid,  7 

gangrenous,  in  noma,  8 
in  acute  gastric  catarrh,  443 
m   chronic    gastric    catarrh, 

447 
in  gangrene  of  lung,  922 
of  the  child  in  disease,  7 

in  health,  7 
sour,  7 
Breathing,   accelerated,  causes 
of,  10 
embarrassed,  vrith  tumors  of 

spinal  cord,  804 
in  Landry's  paralysis,  799 
labored,  distinction  of,  from 
laryngeal       obstruction, 
870 
Breath-sounds      in       croupous 

pneumonia,  917 
Bright's    disease,    acute.      See 
Nephritis,  acute  tubal. 
chronic,  1018 
Bromides   in    cerebral    menin- 
gitis, 604 
in  diabetes  mellitus,  1004 
in  epilepsy,  752 
in  rheumatism,  357 


Bromidrosis,  1093 
Bromoform  in  pertussis,  192 
Bronchial  catarrh  in  measles, 
123 
glands,  chronic  diffuse  tuber- 
culosis of,  282 
Bronchiectasis,  927 
Bronchitis,  924 
acute,  anatomical  changes  in, 

926 
capillary,     924.       See,     also, 

Broncho-pneumonia. 
chronic,  anatomical  changes 

in,  927 
classification  of,  924 
diagnosis  of,  930 

from  pleural  effusion,  931 
from  pneumonia,  931 
etiology  of,  924 
in  malaria,  314 
in  typhoid  fever,  197,  193 
in  variola,  167 
in  -whooping-cough,  187 
mechanical  causes  of,  925 
mode  of  drinking  in,  6 
morbid  anatomy  of,  926 
prognosis  of,  929 
sea-air  in,  63 
subacute,   in    chronic    heart 

disease,  981 
symptoms  of,  927 
treatment  of,  931 
Broncho-adenitis,  diagnosis  of, 
from  tuberculosis,  929 
in  etiology  of  asthma,  955 

of  bronchitis,  926 
treatment  of,  931 
Bronchophony  in  pleural  effu- 
sion, 942 
Broncho-pneumonia,  904 
acute  tuberculous,  292 

morbid  anatomy  of,  293 
pneumococci  in,  293 
staphylococci  in,  293 
streptococci  in,  293 
symptoms  of,  294 
diagnosis  of,  909 

from  croupous  pneumonia, 

909 
from   pleurisy    with    effu- 
sion, 909 
duration  of,  909 
etiology  of,  904 
in  etiology  of  fibroid  phthisis, 
963 
of  secondary  pleurisy,  937 
in  scarlatinal  nephritis,  142 
in  typhoid  fever,  198 
in  variola,  167 
in  w^hooping-cough,  187 
morbid  anatomy  of,  905 
physical  signs  of,  908 
prognosis  of,  909 
symptoms  of,  906 
treatment  of,  910 
I  Bronchus,   compression  of,   by 
I  cheesy  glands,  276 

Bruit  of  fontauelle,  339 
Buelau  operation.     See  Siphon- 

age. 
Buhl's  disease,  92 
Bullous  syphiloderm,  1144 
Burn  of  eyelid,  1184 
Burns  of  conjunctiva,  1193 
Burrow  of  itch-mite,  1154 
Bush's   extension   in  hip-joint 
disease,  1074 


Butyric   acid,    presence    of,    in 
acute  gasrric  catarrh,  443 

Cachexia  of  malaria,  313 

strumipriva,  684 
Csecitis,  509 

Caecum  and  appendix,  inflam- 
matory affections  of, 
509 
diagnosis  of,  511 
from  enteritis,  511 
from  hip  disease,  512 
from  iliac  abscess,  511 
from  internal  strang- 
ulation, 511 
from        intussuscep- 
tion, 511 
from   psoas    abscess, 
511 
etiology  of,  510 
exciting  causes  of,  510 
morbid  anatomy  of,  509 
prognosis  of,  512 

after  perforation,  512 
symptoms  of,  510 
treatment  of,  513 
Caffeine  in  migraine,  720 
Calamine-and-zinc  lotion,  1095 
in  eczema  of  ears,  1109 
of  face,  1109 
Calcification  of  fangs  of  teeth, 
410 
of  tubercle,  278 
Calcium  -  carbonate      calculus, 

1038 
Calcium  -  phosphate      calculus, 

1038 
Calcium  sulphide  in  furuncu- 

lus,  1124 
Calculi,  impacted,   in  ureters, 
1007 
mode  of  formation  of,  1007 
Calculus,  vesical,  1038 
classification  of,  1038 
diagnosis  of,  1043 
etiology  of,  1039 
examination  for,  in  females, 

1044 
in    children,  varieties    of, 

1038 
operative  treatment  of,  1046 
in  females,  1052 
relative  frequency  of,  1040 
solvent  treatment  of,  1044 
symptoms  i^f,  1042 
treatment  of,  1044 
Callus,  spurious,  85 
Calomel  and  soda  in  lithsemia, 
101 
in  acute  gastric  catarrh,  445 
in  acute  milk  infection,  478 
in  constipation,  500 
in  pleurisy,  946 
in  typhlitis,  513 
in  typhoid  fever,  206 
sublimed,  in  diphtheria,  265 
vapor  in  diphtheria.  260 
Camphor  in  diphtheria,  261 
Canaliculi  of  bone,  328 
Cancer  of  omentum,  570 
Cancrum   oris.      See   Stomatitis 

gangrxnosa. 
Cane-sugar,  46 

Cannabis  indica  in  pertussis,  191 
Cantharides     as     a     cause     of 

hsematuria.  992 
i  Caput  Medusae,  572 


1210 


INDEX. 


Caput  succedaueum,  68 
abscess  in,  69 
inechauisiu  of,  (58 
pathology  of,  69 
treatment  of,  69 
Carbohydrates   iu   breast-milk, 
21 
iu   subacute   milk   infection, 
483 
Carbolic    acid    as    a    cause   of 
haematuria,  992 
in  diphtheria,  265 
in  eczema,  1106 
in  ophthalmia  neonatorum, 

1187 
in  whooping-cough,  192 
Carbolic-acid       injections      in 
treating  erysipelas,  229 
Carcinoma,  eucephaloid,  of  kid- 
ney, 1035 
of  peritoneum,  570 
Carcinomata  of  brain,  636 
Cardiac  impulse,  extended,  sig- 
nificance of,  15 
neuroses,  983 
Caries  of  orbit,  1201 
of   wall    of   auditory  canal, 
1165 
Carpopedal  spasms  in  laryngis- 
mus stridulus,  861 
Caseation  in  tubercle,  278 
Casein  in  breast-milk,  21,  46 
in  cow's  milk,  21,  46 
iu  human  milk,  21,  46 
Casselberry's  forceps,  433 
staphylorraphy-needle,  436 
tonsillotome,  424 
Castor  oil   in   acute  intestinal 
indigestion,  466 
in  constipation,  499 
Casts  in  acute  tubal  nephritis, 
1012 
in  chronic  interstitial  neph- 
ritis, 1026 
in  first  stage  of  chronic  tubal 

nephritis,  1019 
in  second    stage  of   chronic 

tubal  nephritis,  1019 
in  third  stage  of  chronic  tubal 
nephritis,  1019 
Catalepsy,  732 
Cataract,  cougenital,  1202 
complete,  1202 

treatment  of,  1202 
partial,  treatment  of,  1202 
Catarrh,    acute     gastric.      See 
Gastric  catarrh,  acute. 
bronchial,  in  measles,  123 
gastrointestinal,  in  cirrhosis 

of  liver,  558 
intestinal,  in  measles,  123 
nasal,  sea-air  in,  63 
objections  to  use  of  the  term, 

442 
pharyngeal,  sea-air  in,  63 
Catarrhal  lieadache,  722 

nephritis,  acute.      See  Neph- 
ritis, acute  tubal. 
chi-onic.      See      Nephritis, 
chronic  tubal. 
pneumonia.       See      Broncho- 
pneumonia. 
in    stomatitis  gangrsenosa, 
406 
symptoms  of  measles,  120 
of  rubella,  154 
Catarrhs  in  rachitis,  325,  341 


Catarrhs  of  larynx  and  bronchi 
in   etiology  of  laryngis- 
mus stridulus,  859 
Cathartics    in    acute    myelitis, 
786 
in    chi'onic  tubal    nephritis, 
1023 
Cautery    in    haemorrhage  after 

tonsillotomy,  426 
Cautions  iu  syringing  in  audi- 
tory canal,  1164 
Cavernous     tumors     of    skin, 

1137 
Cellulitis  of    neck   in    scarlet 
fever,  140 
suppuration     or     gan- 
grene in,  140 
of  orbit,  1201 
Central  cataract.    See  Cataract, 

congenital. 
Cephalalgia.     See  Headache. 

in  typhoid  fever,  200 
Cephalhaematoma,  69 
bony  ring  in,  70 
diagnosis  of,  70 
from  aneurism,  72 
from  encephalocele,  72 
from  hernia  cerebri,  72 
from    tumors  due  to  vio- 
lence, 72 
etiology  of,  71 
false,  69 

intracranial,  70 
in  utero,  71 
multiple,  71 
pathology  of,  70 
treatment  of,  72 
true,  69 
Cephalic  index,  671 
Cerebral  complications  in  per- 
tussis, 188 
lesions  following  scarlatinal 

nephritis,  143 
pneumonia,  916 

and  typhoid   fever,  differ- 
ential diagnosis  of,  204 
symptoms  in  pleurisy,  941 
iu  rheumatism,  352 
Cerebro-spinal  meningitis,  epi- 
demic, 208 
bacteriology  of,  208 
complications  of,  211 
definition  of,  208 
diagnosis  of,  212 
from  scarlatina,  212 
from    tubercular   men- 
ingitis, 212 
from  typhoid  fever,  212 
etiology  of,  208 
historv  of,  208 
pathology  of,  209 
prognosis  of,  212 
prophylaxis  of,  212 
relation  of,  to  influenza, 

209 
sequelse  of,  211 
symptoms  of,  209 
synonyms  of,  208  . 
treatment  of,  212 
simple.       See      Meningitis, 
simple  cerebro-spinal. 
Certified  milk,  39 
Cerumen  impaction,  1162 

treatment  of,  1162 
Cervical     glands,    ejilargement 

of,  in  rubella,  154 
Chalazion,  llbO 


Chalazion,  treatment  of,  1180 
Chalybeate    tonics  after  acute 
tubal  nephritis,  1017 
in       chronic       interstitial 

nephritis,  1026 
in  chronic  tubal  nephritis, 
1022 
Champagne  in  peritonitis,  566 
Chancre  of  eyelids,  1180 
('hemistry  of  artificial  foods,  47 
Chemosis  of  conjunctiva,  1192 
Chenopodium  against  ascarides, 
529 
against  seat-worms,  531 
Chest,   auscultation    of,    in    in- 
fants and  children,  15 
characteristics     of,     in     em- 
physema, 15 
in  infants,  15 
in  pleural  eflTusion,  15 
in  rickets,  15 
contraction     of,     in     fibroid 

phthisis,  964 
examination  of,  14 
in  disease,  15 
posture  for,  14 
inspection  of,  15 
palpation  of,  16 
percussion  of,  16 
retraction  of,  15 
Chest-wall,  retraction  of,  after 

pleurisy,  945 
Cheyne-Stokes  respiration,  10 
in     cerebro-spinal    menin- 
gitis, 210 
Chicken-pox,  156 

change  of  air  in,  161 
complicating  other  diseases, 

159 
complications  of,  158 
course  of,  1.58 
diagnosis  of,  160 
from  vaccinia,  160 
from  variola,  181 
from  variola  and  varioloid, 
eruption  of,  156 
erysipelas  in,  1.59 
formation  of  pits,  158 
history  of,  156 
hoarseness  in,  157 
hyperemia  of  air-passages  in, 

157 
incubation  of,  1.56 
laryngeal  irritation  in,  157 
nephritis  in,  159 
"  pockmarks  "  in,  1.57 
profuseness    of    eruption   in, 

159 
prognosis  of,  161 
quarantine  of,  182 
recurrence  of,  158 
scarlatiniform   erythema  in, 

159 
secondary  infections  in,  159 
sequelfe  of,  158 
sore  throat  in,  157 
spasm  of  the  glottis  in,  159 
suffocative  laryngitis  in,  159 
symptoms  of,  156 
treatment  of,  161 
vesicles  of,  1.57 
Chilblain,  1096 
Child,  anatomical  peculiarities 

in,  492 
Child-crowing,  744 
Childhood,  diet  in,  32 
diet-tables  for,  32 


INDEX. 


1211 


Childhood,  duration  of,  1 
Children,  general  management 

of,  18 
Chill.     See  Chilliness  and  Chills. 
in  acute  spinal  leptomenin- 
gitis, 779 
in  acute  tubal  nephritis,  1011 
in  croupous  pneumonia,  914 
in    epidemic    cerebro-spinal 

meningitis,  208 
in  erysipelas,  225 
in  pleurisy,  940 
in  typhlitis,  510 
Chilliness  in  measles,  119 
in  scarlet  fever,  136 
in  small-pox,  164 
Chills  in  cerebro-spinal  menin- 
gitis, 209 
in  influenza,  216 
in  peritonitis,  565 
in  pyonephrosis,  1032 
in    simple    cerebral    menin- 
gitis, 598 
in  typhoid  fever,  197 
in  variola,  164 
Chloral  in  asthma,  960 

in  broncho-pneumonia,  912 
in  chorea,  763 
in  eclampsia,  745 
in  pertussis,  191 
iu  rheumatism,  357 
in  scarlet  fever,  145 
in  variola,  168 
Chloride  of  iron  in  acute  fol- 
licular tonsillitis,  420 
in  diphtheria,  262 
in  erysipelas,  228 
in  scarlet  fever,  145 
in  variola,  169 
Chlorodyne  in  cholera,  244 
Chloroform  in  cerebral  menin 
gitis,  604 
in  eclampsia,  745 
in  paroxysm  of  asthma,  960 
in  tracheotomy,  878 
in  uraimic  convulsions,  1016 
Chlorosis,  362 
diagnosis  of,  363 
from    pernicious    ansemia, 
364 
etiology  of,  362 
morbid  anatomy  of,  363 
prognosis  of,  364 
symptoms  of,  362 
treatment  of,  364 
Choked  disk  in  brain  abscess, 
632 
in  cerebral  meningitis,  601 
Cholera  Asiatica,  231 

conditions  of  infection  in, 

235 
definition  of,  231 
diagnosis  of,  242 
etiology  of,  231 
foudroyant  attacks  of,  241 
modes  of  infection  in,  234 
non-contagious  attacks  of, 

236 
personal    hygiene    during 

epidemics  of,  249 
prognosis  of,  243 
prophylaxis  of,  248 
secondary  septic   fever  in, 

241 
special  complications  of,  242 
special  phases  of,  241 
symptoms  of,  236 


Cholera  Asiatica,  symptoms  of, 
in  algid  stage,  240 
in     period    of    reaction, 

240 
in  period  of  serous  evac- 
uations, 237 
in  prodromal  period,  237 
treatment  of,  243 
in  algid  stage,  248 
in    period    of    reaction, 

248 
in  prodromal  period,  244 
in  stage  of  serous  diar- 
rhcea,  245 
infantum.   See  Milk  infection, 

acute. 
infectiosa     epidemica.       See 

Cholera  Asiatica. 
sicca,  242 
Choleriform  diarrhoea,  475 

See  Milk  infection,  acute. 
Chorea,  754 

after  influenza,  217 
description  of,  754 
diagnosis  of,  760 
from  habit-spasm,  761 
from  maladie  des  tics  con- 

vulsifs,  760 
from  paramyoclonus   mul- 
tiplex, 761 
from         p  o  s  t-hemiplegic 
hemichorea,  761 
due  to  ascarides,  527 
duration  of,  755 
etiology  of,  756 
in  etiology   of  incontinence 

of  urine,  997 
in  hereditary  syphilis,  647 
major,  732 
minor,  754 
pathology  of,  759 
prognosis  of,  762 
relation   of,  to  endocarditis, 
758 
to  rheumatism,  756 
treatment  of,  762 
with  rheumatism,  353 
Choreic  idiocy,  673 

insanity,  treatment  of,  709 
Choreiform  movements  in  in- 
fantile cerebral    palsies, 
652 
Chronic    catarrh     after    diph- 
theria, treatment  of,  266 
joint-disease,  1071 
Chrysarobin  in  favus,  1150 
in  psoriasis,  1113 
in  tinea  tonsurans,  1153 
Chyluria,  995 

in  elephantiasis,  995 
Circumcision,  1059 

tuberculosis  after,  98 
Cirrhosis  of  liver,  558 
hypertrophic,  558 
in  diabetes  mellitus,  999 
in  the  etiology  of  ascites, 
571 
of  lung.     See  Phthisis,  fibroid. 
Claustrophobia,  704 
Clavicle,  changes  in,  in  rachi- 
tis, 335 
fracture  of,  at  birth,  85 
Clavus,  730 
Cleft  palate,  433 

etiology  and  pathology  of, 

434 
operative  treatment  of,  435 


Cleft   palate,    palliative    treat- 
ment of,  435 
prophylaxis  of,  435 
symptoms  of,  434 
Clemens's  solution,  1004 
Climate,  change  of,  in  asthma, 
962 
in  whooping-cough,  190 
in  etiology  of  vesical  calcu- 
lus, 1040 
Clinical    investigation   of   dis- 
ease, 1 
inspecting  the  child  in,  3 
physical  examination  iu, 

9 
questioning  the    attend- 
ants in,  2 
Clothing,  34 

in  chronic  heart  disease,  984 
Clubbing  of  fingers  and  toes  in 

fibroid  phthisis,  965 
Club-foot,  1083 
etiology  of,  1083 
fasciotomy  in,  1084 
from  paralysis,  1086 
pathological  anatomy  of,  108S 
plaster-of-Paris    bandage  in, 

1084 
prognosis  of,  1083 
shoe  for,  1085 
symptoms  and  diagnosis  of 

1083 
tenotomy  in,  1084 
treatment  of,  1083 
varieties  of,  1083 
Coagulable  lymph  in   periton- 
itis, 564 
Coal-oil  in  pediculosis,  1156 
Cocaine  in  pertussis,  192 
Coccus  of  vaccinia,  173 
Cocoanut  against  taenia,  537 
Codeine  in  acute  tubal  nephri 
tis,  1015 
in  diabetes  mellitus,  1004 
in  phthisis,  302 
Cod-liver  oil  in  broncho-aden- 
itis, 934 
in  convalescence  from  var- 
iola, 170 
in    convalescence    of   mu- 
cous disease,  462 
in  lupus  vulgaris,  1140 
in  pulmonary  emphysema. 

954 
in  rachitis,  347 
in  simple  atrophy,  507 
in  splenic  ausemia,  370 
in  syphilis,  116 
in  tuberculosis,  301 
in  typhoid  fever,  161 
Cceliotomy  in   chronic  periton- 
itis, 570 
in    tumors     of     peritoneum, 
571 
Cohen's  tracheotomy-tube,  876 
Cold  abscess  in  Pott's  disease, 
1007 
applications     in    peritonitis, 

567 
douches  in   incontinence  of 

urine,  997 
in   acute  spinal  leptomenin- 
gitis, 781 
in  cerebi-al  meningitis,  604 
iu     epidemic     cerebro-spinal 

mcninsritis,  213 
in  erysipelas,  229 


1212 


INDEX. 


Cold  abscess  inetiology  of  acute 
peritonitis,  563 
of  chronic  tubal  nephritis, 

1018 
of  croupous  pneumonia,  913 
of  pleurisy,  938 
in    ophthalmia   neonatorum, 

1187 
in  peritonsillar  abscess,  421 
in  Raynaud's  disease,  825 
in  variola,  169 
sore.     See  Herpes  simplex. 
Colic  intussusception,  517 
Collapse     of     lung     following 
broncho-pneumonia,  908 
Colles's  law,  104 
Collyria  in  simple  conjunctivi- 
tis, 1185 
Color-fields,   narrowing    of,   in 

hysteria,  734 
Colosti'um,  18 

Coma  in  cerebro-spinal  menin- 
gitis; 209 
in  malignant  measles,  123 
in  pernicious  malaria,  314 
in  scarlet  fever,  137 
in    tuberculous     meningitis, 

611,  617 
uraemic,  1011 
Comedo,  1092 

treatment  of,  1092 
Comma  bacillus,  231.     See  8pi- 

rillum  cholerte  Asiatics. 
Compensation,     failure    of,    in 
chronic  heart  disease,  981 
in  heart-disease,  981 
Compensatory  emphysema.  See 
Emphysema,  compensatory. 
Concealed  gout,  94 
Concepts,  703 
Condensed  milk,  49 
analysis  of,  49 
disadvantages  of,  22 
food  value  of,  49 
for  temporary  use,  22 
in    etiology    of  scorbutus, 
389 
Condiments    in    diabetic  diet, 

1003 
Condylomata,     treatment     of, 

1147 
Congenital  affections  of  heart, 
968 
dislocation  of  hip,  1082 
iritis,  1198 
malformations,  84 
Congestion  of  lungs  in  typhoid 

fever,  198 
Conjunctiva,  atrophy  of,  1193 
diseases  of,  1184 
ecchymosis  of,  1192 
in  jaundice,  543 
injuries  of,  1193 
pemphigus  of,  1193 
tubercle  of,  1192 
tumors  and  cysts  of,  1192 
xerosis  of,  1197 
Conjunctival  congestion  in  ru- 
bella, 155 
Conjunctivitis,       See     Conjunc- 
tivitis, simple. 
acute  contagious,  1185 
chronic    granular,    types  of, 

1191 
croupous,  1189 
diphtheritic,  1189 
symptoms  of,  1189 


Conjunctivitis,        diphtheritic, 
treatment  of,  1189 
follicular,  1190 

treatment  of,  1190 
granular,  1190 
sequelae  of,  1191 
symptoms  of,  ]  191 
treatment  of,  1191 
in  measles,  120 
in  variola,  167 

muco-purulent.       See      Con- 
junctivitis, simple. 
purulent,    1186.       See,    also, 
Ophthalmia  neonatorum. 
etiology  of,  1186 
non-specific      variety      of, 
1186 
simple,  1184 

etiology  of,  1184 
prognosis  of,  1185 
symptoms  of,  1185 
treatment  of,  1185 
spring,  1189 

symptoms  of,  1190 
treatment  of,  1190 
Constipation,  chronic,  496 
diagnosis  of,  498 
etiology  of,  196 
extrinsic  causes  of,  497 
intrinsic  causes  of,  496 
pathology  of,  497 
prognosis  of,  499 
symptoms  of,  498 
treatment  of,  499 
habitual,  in  etiology  of  typh- 
litis, 510 
in    chronic    gastric  catarrh, 

448 
in  diabetes  mellitus,  1000 
in  diseases  of  nervous  sys- 
tem, 497 
in  infants,  497 
in  intussusception,  519 
in  invasion  of  variola,  164 
in  measles,  120 
in    tuberculous    meningitis, 

611,  613 
in  typhlitis,  511 
in  typhoid  fever,  197 
Contracted    kidney.      See  A^e- 
phritis,  chronic  interstitial. 
Contractures    in    acute   spinal 
leptomeningitis,  780 
in  hysteria,  734 
with  tumors  of  spinal  cord, 
803 
Conus    arteriosus,   stenosis  of, 

971 
Convalescence    from    chicken- 
pox,  182 
from  scarlet  fever,  143 
from  variola,  170 
in  typhoid  fever,  198 
Convallaria   in    chronic    heart 

disease,  985 
Convulsions.     See  Eclampsia. 
due  to  ascarides,  527 
in  acute  gastric  catarrh,  444 
in  acute  myelitis,  784 
in  acute  spinal  leptomenin- 
gitis, 779 
in  brain  abscess,  632 
in  brain  tumors,  637 
in  cerebro-spinal  meningitis, 

209 
in  chicken-pox.  179 
in  croupous  pneumonia.  914 


Convulsions  in  erysipelas,  225 
in  hereditary  syphilis,  645 
in  hydrocephalus,  626 
in  infantile  cerebral  palsies, 

651 
in  invasion  of  variola,  164 
in  jaundice  due  to  oblitera- 
tion of  bile-ducts,  546 
in  lithsemia,  97,  98 
in  malignant  measles,  123 
in  measles,  124 
in  onset  of  pleurisy,  940 
in  pernicious  malaria,  314 
in  scarlet  fever,  137 
in  simple    cerebral     menin- 
gitis, 598 
in  teething,  412 
in  tuberculous  mengitis,  611, 

613 
in  whooping-cough,  188 
replacing    chill    in    malarial 
fever,  311 
Cooled  bath  in  diphtheria,  262 
Copper  sulphate  in   trat;homa, 

1192 
Coprolalia,  661 
Cord,  spinal,  in  rachitis,  327 
umbilical,  prolapse  of,  77 
treatment  of,  77 
after  birth,  86 
Cornea,  affections  of,  in  simple 
cerebro-spinal    meningi- 
tis, 606 
danger    to,    in     ophthalmia 

neonatorum,  1186 
diseases  of,  1194 
foreign  bodies  in,  1198 
injuries  of,  1198 
ulcer  of.     See  Ulcer  of  cornea. 
ulceration  of,  in  variola,  167 
Corneal   ulceration,  results  of, 
1196 
ulcers  in  ophthalmia  neona- 
torum, 1186 
Corrosive  sublimate.     See  Mer- 
curic chloride. 
for  nsevus  vascularis,  1139 
Coryza  in  hereditary  syphilis, 
1        '     109 

I      replacing  sweating  in  mala- 
I  ria,  314 

Cosme's  paste   in  lupus  vulga- 
ris, 1141 
Coster's   paint  in  tinea  tonsu- 
rans, 1153 
Cotton  jacket  in  bronchitis,  932 
in  broncho-pneumonia,  910 
j  in  croupous  pneumonia,  918 

!  Cough,  character  of,  in  bron- 
I  chitis,  6 

in  laryngeal  catarrh,  6 
I  in    pneumonia    and    pleu- 

I  risy,  7 

'  in  spasmodic  croup,  6 

in  true  croup,  6 
in  bronchitis,  928 
in  broncho-pneumonia,  907 
in  croupous  pneumonia,  915 
in  disease,  6 
in  measles,  120,  122 
in  pleurisy,  940 
in   severe    spasmodic    laryn- 
gitis, 852 
in  simple  catarrhal  laryngi- 
tis. 846 
in  spasmodic  laryngitis,  843 
in  typhoid  fever,  198 


INDEX. 


1213 


Cough  iu  whooping-cough,  186 
region     iu    whooping-cough, 

184 
with  broncho-adenitis,  9'29 
Counter-irritation  in  acute  my- 
elitis, 786 
in  bronchitis,  932 
in  cirrhosis  of  liver,  559 
Cowling's  rule,  35 
Cow-pox.     See  Vaccinia. 

spontaneous,  171 
Cow's  milk,  21 

characters  of,  21 
constituents  of,  21 
definition  of,  38 
effect  of  dilution  of,  23 
Cracked-pot    sound   in   hydro- 
cephalus, 626 
in  pulmonary  tuberculosis, 
296 
Cramps  in  cholera,  238 
Craniectomy  in  hydrocephalus, 
629 
in  idiocy,  679 
Craniotabes  in  rachitis,  332 
relation    of,   to   laryngismus 

stridulus,  340 
symptoms  of,  339 
syphilitic,  108 
Cream  and  whole  milk  mixt- 
ures, 56,  58 
importance  of,  in  diet,  345 
strength  of,  56 

tables  of  dilutions  with  sugar 
solution,  57 
Creasote    in    broncho-adenitis, 
934 
in  diabetes  mellitus,  1005 
in  gangrene  of  lung,  923 
in  jaundice,  549 
intrapulmonarv  injection  of, 

301 
in  tuberculosis,  301 
Crede's  method,  1188 
Creolin  for  vaginal  douche,  88 
in  erysipelas,  229 
in  haemorrhages  from  mucous 

surfaces,  82 
in  mucous  disease,  460 
Crescentic    bodies    in    sestivo- 

autumnal  fever,  308 
Cretinism,  680 
diagnosis  of,  683 
endemic,  684,  685 
etiology  of,  682 
pathology  of,  683 
prognosis  of.  685 
sporadic,  684,  685 
symptoms  of,  680 
synonyms  of,  680 
treatment  of,  680 
Cretinoid  idiocy,  635 
Crisis  in  croupous  pneumonia, 

916 
Critical  period  in  chronic  heart 

disease,  933 
Cross-legged  progression  in  in- 
fantile  cerebral    palsies, 
652 
Croton  oil  in  tinea  tonsurans, 

1154 
Croup,    catarrhal.     See    Laryn- 
gitis, spasmodic,  severe. 
spasmodic.      See     Laryngitis, 
catarrhal. 
Croupous  nephritis,  acute.    See 
Nephritis,  acute  tahal. 


Croupous     nephritis,     chronic. 

See  Nephritis,chroHic  tubal. 

pneumonia.     See   Pneumonia, 

croupous. 

in    etiology    of    secondary 

pleurisy,  937 

Crust-formation     in     atrophic 

rhinitis,  834 
Cry,  causes  of  the,  6 

character    of,    in    spasmodic 

croup,  6 
hydrencephalic,     description 

of,  6 
in  acute  pleuritis,  6 
in  disease,  6 
in  epilepsy,  749 
in  intestinal  pain,  6 
in  membranous  croup,  6 
in    simple    catarrhal    laryn- 
gitis, 846 
nasal  tone  of,  iu  swelling  of 
nasal       mucous      mem- 
brane, 6 
Crying   during   cough,    indica- 
tion of,  6 
Curative   eifects  of   erysipelas, 

230 
Curetting    in    lupus    vulgaris, 

1142 
Curschmann's   spirals  in  asth- 
ma, 957 
Curvature     of    spine,     lateral, 

1063.     See  Scoliosis. 
Curv^atures   of    spinal   column, 

rachitic,  333 
Cyanosis  in  acute  endocarditis, 
978 
in  broncho-pneumonia,  907 
in  chronic  heart  disease.  981 
iu    pulmonary    tuberculosis, 

296 
of  face  in  lymphatic  anaemia, 
371 
Cvclitis,  1199 
Cyst  of  brain,  636 
of  omentum,  570 
of  orbit,  1202 
paranephric,  1028 
renal,  1027 
Cysticerci  in  children,  535 
Cysticercus  cysts,  534 
Cystic-oxide  calculus,  1038 

Daceyoadenitis.  1200 
Dacryocystitis,  1200 
Dactylitis   in    late    hereditary 
syphilis,  114 
syphilitic,  107 

diagnosis   of,    from    tuber- 
cular, 113 
symptoms  of.  111 
Dairies,  care  of  milk  in,  39 
hygienic  couditions  of,  33 
inspection  of,  38 
Dance's  sign  in  intussusception, 

520 
Davies-CoUey   method   of    sta- 

phylorraphy,  437 
"  Dead  finger,"  821 
Deaf-mutes,  education   of.  1176 
Deaf-mutism,  662 
Deafness,      acquired      labyrin- 
thine, 1176 
after  parotitis,  180 
in  hysteria,  733 
Death       after        tracheotomy, 
causes  of,  884 


Death-rate  at  the  sea-coast,  61 
Deaver's  retractor,  869 
Debility  in  chronic  tubal  neph- 
ritis, 1019 
Decubitus  iu  disease,  4 
in  diseases  of  liver,  540 
in  pericarditis,  974 
in  peritonitis,  565 
in      simple      cerebro  -  spinal 

meningitis,  606 
in  suppurative  hepatitis,  554 
in  typhlitis,  510 
Defect   of  ventricular   septum. 

969 
Deficiency    of    phosphates    in 
etiology  of  cleft  palate, 
434 
Deformities     in     mouth     and 
pharynx,  664 
of  trunk  and  limbs  in  idiocy, 

675 
old,  from  joint-disease,   1081 
paralytic.  1066 
rachitic,  1037 
Deformity  in  hip-joint  disease, 
1072,  1073 
in  Potts'  disease,  1068 
Degeneration,  acute  fatty,   of 

new-born,  92 
Delay  in  walking,  causes  of,  13 
Delirium  cordis,  988 

in  cerebro-spinal  meningitis, 

209 
in  chicken-pox,  156 
in  invasion  of  variola,  164 
in  rheumatism,  352 
in  scarlet  fever,  136 
in  simple  cerebral  meniugiris, 

639 
in       simple       cerebro-spinal 

meningitis,  607 
in     tuberculous     meningitis 

611-616 
in  typhoid  fever,  200 
period  of,  iu  hysteria,  731 
Delusions  in  typhoid  fever,  200 
Dental  sac,  410 
Dentine-germ,  410 
Dentition,      409.       See,      also. 
Teething. 
delayed,  phosphorus  iu,  411 

relation  of,  to  rachitis,  321 
effect  of  rachitis  upon,  338 
in  etiology  of  eclampsia,  743 
of    laryngismus    stridulus, 
859  ' 
primary,   fr^iuency  of  bron- 
cho-pneumonia    during, 
904 
retarded. by  chronic  diarrhoea, 
411 
by  rickets  and  syphilis.  411 
Depletion  in  cirrhosis  of  liver, 

559 
Depurative  disease.      See  Amy- 
loid disease  of  Icidney. 
Dermatitis    exfoliativa    neona- 
torum, 1119 
gangrjenosa     infantum,    160, 
^1120 
treatment  of,  1121 
in  rachitis,  341 
Dermoid  cyst  of  eyelid,  1183 

cysts  behind  auricle,  1160 
Desquamation  in  measles,  121 
iu  rubella,  153 
in  scarlet  fever,  138 


1214 


INDEX. 


Desquamative  nephritis,  acute. 
See  Xephritis,  acute  tubal. 
Development,  general,  12 
in  health,   12 
of  new-born  child,  12 
of  articulation,  665 
of  senses,  665 
Dextrin,  45,  50 
Dextrinized  atteuuants,  50 

analysis  of,  50 
Dextrose,  45 
Diabetes  insipidus,  1005 
diagnosis  of,  1005 
etiology  of.  1005 
morbid  anatomy  of,  1005 
prognosis  of,  1005 
symptoms  of,  1005 
treatment  of,  ]006 
mellitus,  999 
diagnosis  of,  1000 
etiology  of,  999 
hygienic  treatment  of,  1003 
in  etiology  of  chronic  tubal 
nephritis,  1019 
of  incontinence  of  urine, 
998 
morbid  anatomy  of,  999 
prognosis  of,  1001 
symptoms  of,  999 
treatment  of,  1002 
Diacetic  acid  in  diabetic  urine, 

1000 
Diaphoresis     in     acute     tubal 
nephritis,  in03 
in    chronic   tubal    nephritis, 

1023 
in  scarlatinal  nephritis,  147 
Diarrhoea,  catarrhal,  481 
chronic.        See      Indigestion, 

chronic  intestinal. 
croupous,  481 
during  teething,  412 
treatment  of,"  413 
dysenteric,  4'5l 
in  broncho-pneumonia,  907 
in  chronic  peritonitis,  5G8 
in  invasion  of  variola,  164 
in  leukfemia,  374 
in  malarial  fever,  314 
in  measles,  120.  122 
in  prodromal  period  of  chol- 
era, 237 
in    pnlmonarv    tuberculosis, 

296 
in  scarlet  fever.  136,  140 
in  simple  atrophy,  505 
in  tuberculosis,  2S6 
in  typhoid  fever.  197,  198 
simple.    See  Indigestion,  acute 

intestinal. 
with  constipation,  498 
Diarrhoeal  diseases,  463 
classification  of,  463 
Diathesis,  scrofulous,  276 
tuberculous.  276 

characteristics  of.  15 
Diet  in  acute  gastric  catarrh, 
446 
in  acute  tubal  nephritis,  1017 
in  asthma.  961 
in  broncho-pneumonia,  910 
in  chicken-pox,  161 
in    chronic    gastric    catarrh, 

450 
in  chronic  intestinal  indiges- 
tion, 470 
in  chronic  peritonitis,  569 


.1 


Diet  in  chronic  tubal  nephritis, 
1022 
in  cirrhosis  of  liver,  559 
in  croupous  pneumonia,  918 
in  diabetes  mellitus,  1002         i 
in  diplitheria,  261  | 

in  dysentery,  492  | 

in  eczema,  1104  j 

in  erysipelas,  229 
in     etiology     of     secondary 
anaemia,  360 
of  vesical  calculus,  1040        ' 
in    functional    affections  of  j 
heart.  9-9  ; 

in  gonorrhoea.  10.54  i 

in  influenza,  219  ' 

in  jaundice.  .547 
in  laryngismus  stridulus,  864 
in  lithamia.  99 
in  lithiasis,  1010  : 

in  measles,  127  1 

in  peritonitis,  566  j 

in  prophylaxis  of  stone,  1044 
in    pulmouarv    emphvsema, 

9.54  ■ 

in  rachitis.  344 
in  rheumatism.  356 
in  scarlet  fever,  145 
in  simple  atrophy,  507 
in  typhlitis,  513* 
in  whooping-cough,  190 
of  infant  in  health,  29 
tables  of.  29,  30 
water  in.  .30 
Diffu.ve  nephritis,  chronic.    See 
Xephritis,  chronic  tubal. 
trachoma,  1191. 
Digestion  of  cow's  milk,  46 
Digitalis  in  acute  endocarditis,  j 
980 
in  acute  tubal  nephritis,  1017 
in  croupous  pneumonia,  918 
in    chronic     heart     disease, 

984 
in   chronic   tubal    nephritis, 

1023 
in  diphtheria,  261 
in  functional  heart  affections, 

989  I 

in  malignant  mea.sles,  128        i 
in  pericarditis,  976  ' 

in  peritonitis,  567  ; 

in  pleurisy.  946 
in  scarlatinal  nephritis,  148 
in  typhoid  fever.  207 
Dilatation  in  treatment  of  ad- 
herent prepuce.  1058 
of  heart  in  scarlatinal   neph- 
ritis. 143 
Diphtheria.  250 

antitoxines  of.  266.  269 
ascending,     of    trachea    and  ' 

larynx,  258 
bacteriology  of,  2.52 
complicated  by  parotitis,  178  ' 
complicating  other  disea-ses, 

259 
definition  of.  2.50  • 
diagnosis   of.   from  catarrhal 
and  spa.smodic  larvngitis, 
257 
from     other    pseudo-mem- 
branes. 255 
from       simple       follicular 
amygdalitis,  2o6 
disinfection  in.  260 
etiology-  of.  250 


Diphtheria,  general  disease  the- 
ory of.  2.51 

incubation  of,  253 

in   etiology  of  chronic  tubal 
nephritis,  1019 

in  typhoid  fever.  199 

intubation  in,  267 

Klebs-Loffler  bacilli  in,  266 

laryngeal.  266 

local  pathological  changes  in, 
254 

local  treatment  of,  263 

mode  of  infection  and  prop- 
agation of.  253 

mortality  of.  2(30 

nasal,  in  scarlet  fever.  144 

naso-pharyngeal,  266 

of  anus,  588 

of  bronchi.  259 

of  conjunctiva,  258 

of  larynx,  257 

of  nares,  257 

of  pharynx  and  mouth,  257 

of  tonsils,  256 

prognosis  of,  259 

prophylaxis  of,  260 

sequelae  of,  2.59 

streptococci  in.  266 

symptoms  and  diagnosis  of. 
2.55 

synopsis  of  treatment  of,  268 

treatment  of,  261 

of  albuminuria  of,  266 
of  anaemia  following,  266 

unfavorable  prognostic  signs 
in,  260 

with  pertussis,  188 
Diphtheritic  sore  throat.  418 
Diplococcus  in  normal  urethra, 
1054 

pneumoniae.-    See  Pneinnococ- 
cus. 
in  pleurisy.  938 

scarlatinae  sanguinis,  134 
Diplopia,    monocular,    in   hys- 
teria, 734 
Dipsomania,  703 
Discharge  in  chronic   suppura- 
tion of  middle  ear.  1171 

in    ophthalmia    neonatorum. 
1186 
Disease,  appearance  of  the  .skin 
in,  5 

Buhls.  92 

clinical  investigation  of,  1 

cough  in, 6 

cry  in.  6 

decubitus  in.  4 

expression  of  the  face  in,  3 

faecal  evacuations  in,  8 

features  of.  3 

mode  of  drinking  in,  6 

temperature  in,  12 

tirine  in.  8 

Winckels,  92 
Disinfection      after      purpura 
hfemorrhagica,  384 

against  seat-worms,  .532 

during  pertussis.  190 

in  acute  milk  infection,  479 

in  cholera.  24S 

in  influenza.  219 

in  malignant  measles,  130 

in  -rcarlet  fever,  149 

in  variola.  170 

of  intubation-tubes.  897 

of  skin  in  variola.  169 


INDEX. 


1215 


Disiufection  of  typhoid   dejec- 
tions, 207 
Dislocation  of  hip,  congenital, 
1082 
diagnosis  of,  1082 
etiology  of,  1082 
prognosis  of,  1083 
symptoms  of,  1082 
treatment  of,  1083 
at  birth,  treatment  of,  85 
in  utero,  causes  of,  84 
Displacement     of    viscera     in 

pleurisy,  942 
Disseminated   sclerosis    in   he- 
reditary syphilis,  647 
Dissociation  symptom  of  syrin- 
gomyelia, 812 
Distichiasis,  treatment  of,  1182 
Diuretic  pill,  compound,  985 
Diuretics     in     chronic     tubal 

nephritis,  1023 
Diuretin  in  scarlatinal  nephri- 
tis, 148 
Dolichocephalic  idiocy,  671 
Douche  in  atrophic  rhinitis,  836 
Dover's  powder  in  phthisis,  302 

in  pleurisy,  946 
Drainage,    permanent,  in  asci- 
tes, 574 
Dried-blood     test   for    typhoid 

fever,  205 
Drinking,  mode  of,  in  disease,  6 
in  disease  of  throat,  6 
in  pneumonia,  6 
in  severe  bronchitis,  6 
in  soi-eness  of  mouth,  6 
Drinking-water  in  etiology  of 
amcebic  dysentery,  490 
of  dysentery,  486 
Drinks  in  diabetic  diet,  1003 
Drop-foot  in  acute  poliomyeli- 
tis, 793 
Dropsy.     See  Qidema. 

in  acute  tubal  nephritis,  1012 
in   chronic  tubal    nephritis, 

1019 
of  the  brain,  624.  See  Hydro- 
cephalus. 
Drowsiness  in  jaundice,  543 

in  measles,  120 
Drugs     in     etiology    of    acute 

tubal  nephritis,  1011 
Drum-head.      See    Drum-mem- 

brnne. 
Drum-membrane,  distention  of, 
1167 
in    childhood,   misapprehen- 
sions concerning,  1167 
incision  of,  1168 
retraction  of,  in  chronic  tym- 
panic catarrh,  1175 
Dry  cases  of  tracheotomy,  882 
catarrh,  833 

cups    in     epidemic    cerebro- 
spinal meningitis,  213 
pleurisy,  935 
Dryness  of  tissues  in  diabetes 

mellitus,  1000 
Ductus    arteriosus,    persistence 
of,  971 
diagnosis  of,  972 
Duke's    method     of    artificial 

respiration,  79 
Dulness,  area  of,  in  pericardial 
eflFusion,  975 
movable,  in  pleural  eflFusion, 
value  of,  in  children,  943 


Dulness  of  liver,  superior  border 

of,  16 
Duodenum,  condition  of,  in  ty- 
phoid fever,  196 
Dvssesthesia  in  Landry's  paral- 
ysis, 799 
Dysentery,  485 
amoebic,  490 

diagnosis  of.  491 
lesions  of  liver  in,  490 
morbid  anatomy  of,  490 
prognosis  of,  491 
symptoms  of,  491 
catarrhal,  485 
absence  of  specific  germ  in, 

486 
diagnosis  of,  489 
etiology  of,  485 
improper   feeding   in,    eti- 
ology of,  486 
microscopic  appearances  in, 

487 
prognosis  of,  489 
symptoms  of,  488 
diphtheritic,  491 
microscopical    appearances 
in,  491 
disinfection  in,  492 
hygiene  of,  492 
in  scarlet  fever,  140 
morbid  anatomy  of,  486 
prophylaxis  of,  492 
treatment  of,  492 
varieties  of,  485 
Dyslexia,  659 
Dyspepsia,  acute.     See   Gastric 

catarrh,  acute. 
Dysphagia  in  Landry's  paraly- 
sis, 799 
Dysphrasia,  659 
Dyspncea,  expiratory,  10 
causes  of,  10 
n  aortic  stenosis,  982 
n  asthma,  958 
in  bronchitis,  929 
n  broncho-pneumonia,  906 
n  chronic  heart-disease,  981 
n  fibroid  phthisis,  965 
n  leukaemia,  374 
n  lymphatic  ansemia,  371 
in  marked  laryngeal  stenosis, 

10 
in  mitral  stenosis,  982 
n  pericarditis,  975 
in  pleurisy,  941 
n      progressive      pernicious 

anaemia,  365 
n    pulmonary    tuberculosis, 

296 
n  secondary  ansemia,  361 
n  spasmodic  laryngitis,  840 
nspiratory,  causes  of,  10 
in    substantive    emphysema, 
953 
Dystochia  from   hydronephro- 
sis,  1029 

Ear,  anatomy  of,  1167 
diseases  of,  1158 

importance  of,  1158 
embryology  of,  1158 
externa],  affections  of,  1159 
internal,  affections  of,  1175 
middle,  acute  simple  inflam- 
mation of,  1166 
affections  of,  1166 
chronic  catarrh  of,  1174 


Ear,  middle,  chronic  suppura- 
tion of,  1170 
treatment     of     eczema     of, 

1109 
treatment  of,  method  of  hold- 
ing child  in,  1159 
Earache,  a  symptom,  1166 
Eberth's  bacillus,  195 
Ecchymosis  in  cholera,  239 
of  conjunctiva,  1191 
of  eyelids,  1184 
treatment  of,  1184 
Echinococcus    cyst    of    brain, 

636 
Echolalia,  661 
Eclampsia,  741 
diagnosis  of,  745 
etiology  of,  742 
in  chronic  constipation,  498 
in  Jithsemia,  98 
in    prognosis    of    scarlatina, 

144 
in  rachitis,  341 
pathology  of,  743 
prognosis  of,  744 
seat  of  origin  of,  741 
symptoms  of,  744 
treatment  of,  745 
Ectopia  cordis,  973 
Ectropion,  1183 
Eczema,  1100 

after  vaccination,  175 
associated  with  asthma,  957 
diagnosis  of,  1103 

from  papular  urticaria,  1103 
from  pediculosis   capillitii, 

1104 
from  scabies,  1103 
from  syphilodermata,  1103 
etiology  of,  1102 
in  lithsemia,  99 
intertrigo,  1102 

treatment  of,  1110 
marginal,  of  lids,  1179 
of  ears,  treatment  of,  1109 
of  face,  treatment  of,  1109 
of  lids,  treatment  of,  1110 
of  scalp,  treatment  of,  1109 
prognosis  of,  1109 
resemblance    of,    to    mucous 

catarrhs,  1101 
rubrum  or  madidans,  1101 
seborrhceal,  1091 
squamosum,  1101 
treatment  of,  1104 

of  regional  forms  of,  1109 
Eczematous    inflammations   of 

auricle,  1160 
Education  in  moral  imbecility, 

679 
Educational        treatment       of 

idiocy,  678 
Effusion,  pleural,  diagnosis  of, 
943 
diagnostic     use     of    hypo- 
dermic needle  in,  943 
Eggs  in  diabetic  diet.  1003 

in  lithfemic  diet,  99 
Ehrlich's  reaction  in  acute  tu- 
berculosis, 281 
test,  in  children,  200 
Eichoff's  thymol  soap,  1103 
Elbow-joint  disease,  1080 
diagnosis  of,  1080 
prognosis  of,  1080 
symptoms  of,  1080 
treatment  of,  1081 


1216 


INDEX. 


Elaterium     in     chronic     tubal 

nephritis,  1023 
Electric   cataphoresis   in    tinea 

tonsurans,  1154 
Electrical    excitability   in  tet- 
any, 765 
Electricity  in   acute   poliomy- 
elitis, 794 
in    incontinence     of    urine, 

997 
in  iufaotile  cerebral  palsies, 

657 
in  naevus  vascularis,  1138 
Electrization     of    stomach    in 

mucous  disease,  461 
Electro-cautery     in     hypertro- 
phic rhinitis,  833 
Electrolysis    in    treatment    of 
lupus  vulgaris,  1142 
of   moUuseum    epitheliale, 

1130 
of  naevus  pigmentosus,  1132 
of  verruca,  1131 
Elongation  of  uvula,  471 
Emaciation   in   hydrocephalus, 
627 
in    tuberculous    meningitis, 

611,  618 
in  typhoid  fever,  198 
rapid,   in   diabetes    mellitus, 
1000 
Embolism    in    acute    endocar- 
ditis, 978 
in  infantile  cerebral  palsies, 

656 
of  brain  in  rheumatism,  353 
Embryocardia,  988 
Embryonine,  1002 
Emetics    in    broncho-pneumo- 
nia. 911 
in  eclampsia,  745 
Emotions   in   etiology  of  hys- 
teria. 729 
Emphysema,  compensatory,  950 
etiology  of,  950 
pathology  of,  951 
symptoms  of,  951 
treatment  of.  953 
in  pertussis,  188 
interstitial,  950 
of  eyelids,  1184 
pulmonary,  950 
subpleural,  complicating 

broncho-pneumonia,  918 
substantive,  951 
etiology  of,  951 
pathology  of,  951 
physical  signs  of,  953 
prognosis  of,  953 
symptoms  of,  953 
treatmeut  of,  953 
surgical,   after   tracheotomy, 

886 
vesicular  or  alveolar,  950 
Emprostliotonos      in     cerebro- 
spinal meningitis,  210 
Empyema.  935 

in    etiologv    of    pericarditis, 

975 
in  pertussis,  187 
in  scarlatinal  nephritis,  142 
necessitatis,  946 
of    antrum    in    etiology    of 

nasal  mysomata,  841 
perforation  of.  945 
Enamel-germ.  410 
Endemic  cretinism,  684 


Endocardial  murmurs  in  rheu- 
matism, 352 
Endocarditis,  acute,  977 
etiology  of,  977 
physical  signs  of,  978 
prognosis  of,  979 
symptoms  of,  978 
treatment  of,  980 
with  old  valvular  lesions, 
979 
during  scleroderma,  1133 
in  diphtheria.  256 
in  rheumatism,  352 
in  scarlatinal  nephritis,  143 
in  typhoid  fever,  201 
in  variola,  167 
relation  of,  to  chorea,  978 
ulcerative,  353 
Enemata    against    seat-worms, 
532 
in    chronic    intestinal    indi- 
gestion, 471 
in  constipation.  499 
in  prolapse  of  rectum,  591 
nutritive,  in  peritonitis,  263 
Enlargement  of  liver,  diagnosis 

of,  540 
Enterectomy    in     intussuscep- 
tion, 523 
Enteric     fever.     See     Typhoid 

fever. 
Enteroclysis  in  cholera.  289 
Entero-colitis.     See,  also,  Milk 
infection  subacute. 
anatomical  changes  of,  480 
chronic,  467.     See  Indigestion, 

chronic  intestinal. 
in  measles.  124 
in  variola,  167 
sea-air  in  treatment  of,  62 
Enterorraphy,  circular,  in  con- 
genital malformations  of 
intestines,  576 
in  intussusception,  523 
Enterotomy  in  intussusception, 

522 
Entropion.  1182 

treatment  of.  1183 
Enucleation      in     sympathetic 

irritation.  11^3 
Eosinophile      cells,    value     of, 

in  diagnosis.  376 
Epilation  in  tinea  favosa.  1150 

in  tinea  tonsurans,  1153 
Epilepsie  larvee,  750 
Epilepsy.  747 
as  a  cause  of  incontinence  of 

urine.  998 
diagnosis  of.  751 

from    gross  brain    disease, 

751 
from  hysteria,  751 
from  ursemia,  751 
etiology  of,  748 
in  hereditary  syphilis,  645 
in  hydrocephalus,  626 
in  infantile  cerebral  palsies, 

653 
morbid  anatomy  of,  748 
motor  symptoms  of,  749 
patliology  of.  748 
prognosis  of,  752 
symptoms  of,  749 
psychic,  750 
sensory.  749 
treatment  of.  752 
varieties  of,  751 


Epileptic  headache,  722 

insanity,  treatment  of,  710 
Epile])togenetic  centres,  742 
Epileptoid    period   of  hysteria, 

730 
Epiphora  in  diseases  of  lachrv- 

mal  sac,  1200 
Epiphyseal  swelling  in  syphilis, 
diagnosis  of,  from  rickets, 
107 
Epiphyseo-diaphyseal      separa- 
tion in  hereditary  sphy- 
ilis,  107 
Epistaxis  in  chronic  heart  dis- 
ease, 981 
in  haemophilia,  377 
in  measles,  124 
in  typhoid  fever,  197,  198 
Epithelioid  cells,  278 
Ejistein's  apparatus  for  bowel- 
washing.  460 
Ergot  in   cerebro-spinal    men- 
ingitis, 608 
in  diabetes  insipidus,  1006 
in  diabetes  mellitus,  1004 
in     epidemic     cerebro-spinal 

meningitis,  213 
in     incontinence    of    ui'ine, 

998 
in  Landry's  paralysis.  800 
Ergotine    in     gastro-intestinal 
hfemorrhage,  87 
in    haemorrhage   of    typhoid 

fever.  207 
in  scarlatinal  nephritis,  148 
Erotomania,  703 
Eruption  of  cerebro-spinal  men- 
ingitis, 211 
of  chicken-pox,  156 
of  erysipelas,  226 
of  rubella,  153 
of  scarlet  fever,  1.37 
of  typhoid  fever,  199 
of  variola,  165 
stage    of     desiccation    of, 

165 
stage    of    maturation     of, 

165 
upon   mucous   membranes, 
165 
Eruptions,   exanthematous,  on 
eyelids.  1179 
in  cholera,  242 
in  diphtheria.  2.59 
i?i  measles.  120 
in  rheumatism,  352 
in  rubella,  153 
Erysipelas,  221 
after  tracheotomy,  885 
after  vaccination,  175 
complications    and     sequelfe 

of,  226 
contagiousness  of,  223-228 
definition  of,  221 
diagnosis  of,  227 

from  acne  rosacea,  227 
from  angeio-neurotic  oede- 
ma, 227 
from  erythema,  227 
from     malignant     oedema, 

227 
from  urticaria.  227 
etiology  of.  221 
history  of,  221 
in  chicken-pox,  1.59 
of  auricle,  1160 
of  new-born,  90,  225 


INDEX. 


1217 


Erysipelas,   pathological    anat- 
omy of,  223 
prognosis  of,  227 
pulmonary  lesions  in,  224 
symptoms  of,  225 
therapeutic  use  of,  229 
treatment  of,  228 
with  peritonitis,  564 
Erythema  annulare,  1098 
buUosum,  1098 
caloricum,  1096 
gyratum,  1098 
idiopathic,  1095 
infantile,  1097 
diagnosis  of,  from  measles, 
1098 
from  rotheln,  1098 
from  scarlatina,  1098 
treatment  of,  1098 
in  rheumatism,  354 
intertrigo,  1096 
diagnosis  of,  1096 
treatment  of,  1096 
in  vaccination,  175 
iris,  1098 

marginatum,  1098 
miiltiforme,  1098 
diagnosis  of,  1099 
etiology  of,  1099 
prognosis  of,  1099 
treatment  of,  1099 
nodosum,  1099 
of  buttocks  in  subacute  milk 

infection,  481 
of    legs    in    typhoid    fever, 

199 
pernio,  1096 

treatment  of,  1097 
relapsing  scarlatiniform,  1100 
diagnosis  of,  1100 

from  scarlatina,  1100 
treatment  of,  1100 
simples,  1095 
symptomatic,  1097 
traumaticum,  1096 
tuberculatum,  1098 
venenatum,  1096 
vesiculosum,  1098 
Erythematous        syphiloderm, 

1143 
Eserine  in  ophthalmia  neona- 
torum, 1187 
Essential     shrinking    of    con- 
junctiva, 1193 
Estlander's    operation     distin- 
guished   from    resection 
of  rib,  948 
Etat  mamelonne,  447 
Ethmoiditis,  necrosing,  in  eti- 
ology of  nasal  myxomata, 
841  " 
Ethyl  iodide  in  asthma,  961 
Eucalyptol  in  tuberculosis,  302 
Eucalyptus  in  malaria,  318 
Eustachian  tube,  formation  of, 

1158 
Evacuation   of  bowels   during 
urination  in  vesical  cal- 
culus, 1042 
Exalgin  in  chorea,  762 
Examination  of  the  mouth  and 

fauces,  17 
Exanthemata    in    etiology    of 
acute     tubal     nephritis, 
1011 
of  bronchitis,  924 
of  chronic  peritonitis,  568 

77 


Exanthemata    in    etiology    of 
middle-ear  inflammation, 
1166 
Exanthematous    eruption     on 

eyelids,  1179 
Excision  in    treatment  of  ad- 
herent prepuce,  1058 
Exercise,  35 
hours  for,  357 
in  chronic    gastric    catarrh, 

451 
in    chronic     heart     disease, 

984 
in  convalescence  from  acute 

nephritis,  1018 
in   etiology    of    paroxysmal 

hsematuria,  994 
in    functional    aflfections  of 

heart,  990 
in  lithsemia,  100 
in  pseudo-hypertrophic  mus- 
cular paralysis,  773 
in     pulmonary    emphysema, 
953 
Expectoration  in  asthma,  958 
in  bronchitis,  928 
in  broncho-pneumonia,  907 
in  croupous  pneumonia,  915 
in  fibroid  phthisis,  965 
in  gangrene  of  lung,  922 
in  measles,  120 
Expiratory  dyspncea,  causes  of, 
10 
respiration,  character  of,  10 

significance  of,  10 
theory  of  compensatory  em- 
physema, 950 
of  substantive  emphysema, 
952 
Exploratory  incision  in  chronic 

peritonitis,  570 
Exploring  needle   in  appendi- 
citis, 514 
Exposure  in  etiology  of  acute 
gastric  catarrh,  442 
of  rheumatism,  351 
External     ear,     alfectious    of, 

1159 
Extra-cellular  pigmented  bod- 
ies in  malaria,  306 
Exudate  in  infectious  pseudo- 
membranous   tonsillitis, 
418 
Exudates,     pleural,     chemical 
composition  of,  937 
interchange   of    fluids    in, 

937 
without  microbic  elements, 
939 
Eye,  diseases  of,  1178 

refraction   of,    in   childhood, 
1202 
Eyelid,  furuncle  of,  treatment 

of,  1178 
Eyelids,  abscess  of,  1178 
diseases  of,  1178 
ecchymosis  of,  1184 
emphysema  of,  1184 
injuries  of,  1184 
syphilis  of,  1180 
tumors  and  hypertrophies  of, 
1180 
Eyes,  treatment  of,  in  measles, 

128 
Eye-strain  in  migraine,  721 
Eye-symptoms   of    hydroceph- 
alus. 626 


Face,  expression  of,  in  health 
and  disease,  3 
treatment  of  eczema  of,  1109 
Facial    hemiatrophy,    progres- 
sive, 775 
symptoms  of,  776 
treatment  of,  776 
nerve,  obstetric  paralysis  of, 

83 
paralysis  of,  774 
diagnosis  of,  775 
etiology  of,  774 
in  otitis  media,  1117 
in  tuberculous  meningitis, 

617 
symptoms  of,  774 
treatment  of,  775 
phenomenon  in  tetany,  766 
Facies  in  asthma,  958 
in  bronchitis,  929 
in  hereditary  ataxia,  818 
in  suppurative  hepatitis,  554 
in  typhoid  fever,  197 
Faecal  accumulation,  diagnosis 
of,  14 
evacuations  in  catarrhal  ul- 
ceration of  the  intestines, 
8 
in  diarrhoea  of  sucklings,  8 
in  disease,  8 
in  dysentery,  8 
in  entero-colitis,  8 
in  follicular  enteritis,  8 
in  health,  8 
in  helminthiasis,  8 
in  indigestion,  8 
in  intestinal  catarrh,  8 
in  tubercular  disease,  8 
in    tuberculous    ulceration 

of  the  intestines,  8 
in  typhoid  fever,  8 
Faeces  in  jaundice,  543 
incontinence  of,  in  tubercu- 
lous meningitis,  618 
Failure   of   heart,   sudden,    in 
diphtheria,  256 
sources   of,   in   sounding   for 
stone,  1044 
Fall  fever.     See  Typhoid  fever. 
Fallopian  tube,  tuberculosis  of, 

299 
Faradism  in  simple  jaundice  of 

infants,  545 
Farinaceous   food,    when    per- 
missible, 22 
Fascia,  cervical,  deep,  872 

superficial,  872 
Fascicular  keratitis,  1193 
Fasciotomy  in  club-foot,  1084 
Fat,   deficiency  of,  in  food  of 
rachitics,  323 
in  human  milk,  44 
in  milk,  46 

relative  size  of  globules^  of, 
46 
percentage    of,    in    modified 
milk,  55 
Fatty  calculus,  1038 
degeneration,  acute,  of  new- 
born, 92 
Fauces,      appearance      of,      in 
health,  17 
ascarides  in,  527 
examination  of,  17 
Favus,    1148.      See    Tinea    fa- 
vosa. 
Features  of  disease,  3 


1218 


INDEX. 


Febrile  and  post-febrile  insan- 
ity, 706 
Feeble-mindedness  in  infantile 

cerebral  palsies,  654 
Feeding,  18 

after  tracheotomy,  ^84 
artificial,  21 

asses'  milk  in,  25 
attenuants  in,  23 
bicarbonate  of  sodium  in, 

23 
goat's  milk  in  25 
lime-water  in,  25 
method  of  preparation  in, 

23 
mode  of  administration  of, 

30 
modified  milk  in,  55 
peptonization  in,  25 
position  of  child  iu,  31 
preservation  of  milk  for,  31 
quantity  of  food  for,  22 
rules  for,  21 
selection  of  food  for,  21 

of  milk  for,  31 
"strippiugs  ■'  in,  25 
substitutes  for  milk  in,  28 
sugar  of  milk  in,  23 
table  for,  24 
vomiting  in,  25 
by  wet-nurse.  20 
from  maternal  breast,  18 

duration  of.  18 
improper,  in  i-tiology  of  acute 
intestinal        indigestion, 
465 
in  acute  milk  infection,  478 
in  insanity,  708 
in  tuberculosis,  301 
mixed.  1!) 
Feet,  enlargement  of,  in  acro- 
megaly. 691 
Fehleisen,  streptococcus  of.  223 
Fehling's  solntiou,  composition 
of.  1000 
qualitative  test  by,  1000 
quantitative  test  by,  1001 
Femur,  changes  in,  in  rachitis, 
337 
fracture  of,  at  birth,  85 
Fenestrated  spring  forceps  for 

circumcision,  1059 
Fermentation,  butyric,  45 
reaction  of,  45 
intestinal,  in  lithsemia,  97 
lactic,  45 

bacteria  in,  44 
test  for  sugar,  1001 
Ferrum  dialvsatum  in  chronic 

tu))al  nephritis,  1023 
Fetor  in  ati-n]>hic  rhinitis,  834 
Fever.     See  Tempemture. 
in  rheumatism,  352 
in  scurvy,  392 
scarlet.     See  Scarlet  fever. 
typhoid.     See  Typhoid  fever. 
Fever-blister.      See  Herpes  sim- 

ple.r. 
"  Feverish  "  breath,  7 
Fibrinous  calculus,  1038 
exudates  in  scarlatina,  139 
diagnosis    of,    from    diph- 
theria. 139 
pleurisy,  936 
Fibroid  limitation  of  tubercle, 
278 
phthisis.   See  Phthisis,  fibroid. 


Fibrous     deposits     in    chronic 
tympanic  catarrh,  1175 
nodules  in  rheumatism,  354, 
978 
Fibula,  changes  in,  in  rachitis, 

337 
Fievre  dothienenterie,  194 
infectieuse    tuberculeuse  sur 
aigue,  280 
Filaria    sanguinis    hominis    a 
cause  of  chyluria,  995 
a  cause  of  ha^maturia,  993 
Fish  in  diabetic  diet,  1003 
Fissure  of  anus,  .586 
Fistula,  fiEcal,  576 

after  appendicitis,  515 
in  ano,  585 

treatment  of,  586 
of  lachrymal  sac,  1201 
Fistulfe,  perinea],  in  congenital 
malformation  of  rectum, 
581 
Flagellate    bodies    in    tertian 

malaria,  306 
"  Flat-chest,"  432 
"Flat-nose,"  842 
Flatulency  in   chronic  intesti- 
nal indigestion,  468 
Flesh,   loss  of,  in  tuberculous 

meningitis,  611 
Flour-ball,  51 

preparation  of,  24 
Fluid  in  hydronephrosis,  1030 
Fluoresciue  in  diagnosis  of  cor- 
neal abrasion,  1198 
Focal  epilepsy,  747 
svmptoms  in   brain   abscess, 
632 
Fcetal  head,  compression  of,  83 

rachitis,  322 
Foetus,  rachitic,  description  of, 

330 
Follicular    amygdalitis,    diph- 
theritic nature  of,  251 
trachoma.  1191 
ulceration  of  bowel,  481 
Fontanelle.    anterior,    ossifica- 
tion of,   13 
bruit  of,  in  rachitis,  339 
bulging  of,  13 
depressed,  in  chronic  gastric 

catarrh.  448 
in  simple  atrophy,  505 
late  closure  of,  in  rickets,  331 
puncture   of.    in    hydroceph- 
alus, 628 
Food,  average  quantitv  of,  for 
'  infants,  346 
dailv  average  of,  for  children, 

346 
daily  quantity  of,  22 
in  etiology  of  rachitis,  323 
insufficiency  of,  .503 
in  treatment  of  constipation, 
499 
Food  and  drink  admissible  in 

diabetes  mellitus,  1003 
Foods,  artificial,  chemistrv  of, 
47 
comparison  of,  52 
predigested,  29 
to  be  avoided  in  diabetic  diet, 
1003 
Foramen  ovale,  patency  of,  968 

cause  of,  9(59 
Forceps,      obstetric,       injuries 
from,  83 


Forceps,   obstetric,   limitations 
of,  83 
precautions  in  using,  83 
Foreign     bodies     in     auditorv 
canal,   1163 
treatment  of,  1164 
in  caecum  or  appendix,  509 
in  cornea,  1198 
in     larynx,     trachea,    and 
bronchi,  865 
diagnosis  of,  866 
from  acute  laryngitis, 

866 
from  lai-yngeal  obstruc- 
tion by  lymphatic  en- 
largement, 867 
from  oedema  of  glottis, 
867 
prognosis  of,  867 
symptoms  of,  865 
treatment  of,  867 
in  rectum,  .595 
body,  impaction   of,  in  tym- 
panum, 1165 
Forest's    method    of    artificial 

respiration.  79 
Fractures   at    birth,   prognosis 
and  treatment  of,  85 
in  utero,  85 
Frank  pneumonia  and  typhoid 
fever,    ditlerential    diag- 
nosis of,  204 
Freckles.     See  I.eiitifio. 
Fremitus,    hydatid,    in     renal 
cysts,  1028 
vocal,  in  broncho-pneumonia, 
908 
French  measles.     See  Rubella. 
Fresh  air  in  rachitis,  343 

in  tuberculosis,  300 
Friction  in  massage,  57 
Friction-sound  in  pleurisy,  942 

in  pericarditis,  975 
Friedreich's  disease,  815.     See, 

also,  Ataxia,  hereditary. 
Friedrichshall   water   in  jaun- 
dice, 547 
Fromentine  in  diabetes,  1002 
Fruehjahr's  catarrh,  1189 
Fruits  in  diabetic  diet.  1003 

in  litheemic  diet.  99,  100 
Fuchsin,  Ziehl's  solution  of,  271 
Fundus  oculi,  haemorrhages  in, 

iu  leuksemia,  374 
Fungus    of    favus,   microscopy 
of,  1149 
of  tinea  tricophytina,  1152 
Furuncle  of  auditory  canal,  1161  ■ 
treatment  of,'  1125-1161 
of  eyelids,  1178 
Furuncnlosis,  1124 
in  chicken-pox,  159 
in  typhoid  fever,  199 
post-eczematous.  1101 
Furunculus.  1123 
diagnosis  f)f.  1124 
from  carbuncle.  1124 
from  syjihiloderm,  1124 
etiology  of,  1124 
prognosis  of,  1124 
treatment  of,  1124 

Gait  in  hereditary  ataxia,  818 

in  idiocy,  674 

in  Pott's  disease,  1066 
Gallic   acid    in    diabetes   iusiji- 
idus.  1006 


INDEX. 


1219 


Gallic  acid  in  hsemorrhage  of 

typhoid  fever.  207 
Galton  whistle  in  diagnosis  of 

aural  disease,  1176 
Galvanism   in  alopecia   areata, 
1137 
in  constipation,  502 
in  diabetes  insipidus,  1006 
in  Raynand's  disease,  824 
Galvano-cautery  in  lupus,  1142 
in  stomatitis  mycosa,  407 
in  ulcer  of  cornea,  1196 
-puncture  in  enlarged  tonsils, 
423 
Gangrene,  diabetic,  rarity  of,  in 
children,  1000 
in  parotitis,  180 
in  vaccinia,  175 
of  lung,  919 
etiology  of,  919 
following      broncho -pneu- 
monia, 906-908 
in  tuberculosis,  920 
pathology,  921 
symptoms  of,  921 
treatment  of,  923 
with     chronic     bronchitis, 

920 
with  septic  processes  of  ear, 

920 
with  ulcerations  in  mouth, 
920 
symmetrical,  822.     See,  also, 
Raynaud's  disease. 
Grangrenous  varicella,  160 
Gastric  catarrh,  acute,  441 
diagnosis  of,  444 

from  meningitis,  444 
from  pneumonia,  444 
from  scarlet  fever,  444 
from  typhoid  fever,  444 
etiology  of,  441 
pathology  of,  442 
prognosis  of,  445 
symptoms  of,  443 
treatment  of,  445 
chronic,  446 
course  of,  449 
diagnosis  of,  449 

from  typhoid  fever,  450 
etiology  of,  446 
in  infancy,  448 
pathology  of,  446 
prognosis  of,  450 
simulating  pernicious  ante- 

mia,  449 
symptoms  of,  447 
treatment  of,  450 
fever.     See  Typhoid  fever. 
juice,  action  of,  on  milk,  21 
ulcer,  452 

etiology  of,  452 
prognosis  of,  453 
symptoms  of,  452 
treatment  of,  453 
Gastritis,  atrophic,  450 

chronic  glandular.     See  Gas- 
tric catarrh,  chronic. 
mucous,  450 
simple,  449 
Gastro-adenitis,  441     See,  also. 

Gastric  catarrh,  acute. 
Gastro-intestinal   catarrh.     See 
Milk  infection,  subacute. 
chronic.      See    Mucous  dis- 
ease. 
tuberculosis  following,  282 


Gastro-intestinal  disorder  in  eti- 
ology of  eclampsia,  542 
of  laryngismus,  859 
of  urticaria,  1120 
hfemorrhage,  86 
Gastro-malacia,  453 
Gavage  in  dysentery,  492 
Gelatin,  preparation  of,  23 
Gelsemium   in    chronic  bleph- 
arospasm, 1181 
General  development,  12 
in  health,  12 

of  the  new-born  child,  12 
management  of  children,  18 
Genital     organs,     involvement 

of,  in  parotitis,  180 
Genu    valgum,    treatment    of, 

1088 
Geratubuugen,  55 
German  measles.     See  Rubella. 
Germicidal  drugs  in  acute  milk 

infection,  479 
Giant-cells  in  tubercle,  278 
Giddiness  in  brain  abscess,  632 
in  cerebro-spinal  meningitis, 
209 
Girdle  sensation  in  acute  mye- 
litis, 784 
in   tumors  of  spinal  cord, 
802 
Glands,    anterior    mediastinal, 
tuberculosis  of,  284 
axillary,  swelling  of,  in  vac- 
cinia, 174 
bronchial,  enlargement  of,  in 
etiology     of     bronchitis, 
925 
enlargement  of,  in  measles, 

122 
tuberculosis  of,  284 
cardiac,  tuberculosis  of,  284 
disorders  of,  1091 
enlargement  of,  in  lymphatic 

ansemia,  371 
in  rubella,  154 

inguinal,  enlargement  of,  in 
milk  infection,  481 
swelling    of,    in    vaccinia, 
174 
in  measles,  120 
intercostal,    tuberculosis    of, 

284 
Ivmphatic,    enlargement    of, 
13 
in  leuksemia,  375 
mesenteric,    tuberculosis    of, 

286 
posterior  mediastinal,  tuber- 
culosis of,  284 
sternal,  tuberculosis  of,  284 
tracheal,  tuberculosis  of,  284 
tracheo-bronchial,      tubercu- 
losis of,  284 
Glandular   enlargements   after 
vaccination,  175 
in  diphtheria,  256 
with  eczema,  1101 
Glioma  of  orbit,  1202 
Gliomata  of  brain  and  menin- 
ges, 635 
Globus  hystericus,  730 
Gluten-flour  in  diabetes,  1002 
Glycerin   in  diuretic  formulse, 

1017 
Goat's  milk  in  artificial  feed- 

.  ing,  25 
Goitre  with  cretinism,  682 


Gold   and   sodium   chloride  in 
chronic  interstitial  neph- 
ritis, 1026 
Gonococcus,    diagnostic    value 
of,  1053 
of  Neisser,  1186 
value  of,  in  diagnosis  of  vul- 
vo-vaginitis,  1056 
Gonorrhoea,  ante-partum  treat- 
ment of,  88 
in  male  children,  1053 
treatment  of,  1054 
of  mouth,  in  new-born,  88 
\  treatment  of,  89 

i  Gonorrhceal  infection  of  new- 
j  born,  88 

ophthalmia,  88 
Gout,  American,  94 
concealed,  94 

in  etiology  of  psoriasis,  1112 

of  vesical  calculus,  1039 

Gouty  kidney.      See  Nepliritis, 

chronic  interstitial,  1025 
Grand  movements,  period  of,  in 

hysteria,  731 
Granulations   of    wound    after 

tracheotomy,  886 
Grattage  in  trachoma,  1192 
Gravel  in   bladder,    symptoms 
of,  1008 
in  diabetes  insipidus,  1006 
Green  stools  in  acute  intestinal 
indigestion,  466 
in  chronic  intestinal  indi- 
gestion, 468 
Grippe  and  typhoid  fever,   dif- 
ferential    diagnosis     of, 
204 
Grisolle  sign  in  variola,  167 
Growing  pains,  758 
Grunting  expiration    in   bron- 
chitis, 928 
prognostic   importance   of, 
930 
Gum-lancing,  danger  of,  413 
Gumma,  1144 
of  brain,  636 
of  iris,  1199 
Gummata  in  hereditary  syph- 
ilis, 646 
Gummatous  iritis,  1199 
Gums,  bleeding  of,  in  scorbutus, 
391 
condition     of,     in     tvphoid 
fever,  199 
Gymnastics  in  hysteria,  740 
in  scoliosis,  1064 

Habit  chorea,  1181 

due  to  eye-strain,  1203 
Habits  of  life  in  etiology  of 

chlorosis,  362 
Hsematemesis    in    tuberculosis 

of  the  bowels,  288 
Hsematogenous  jaundice,  543 

in  new-born,  92 
Hsematoma     of     stern  o-cleido- 

mastoid  muscle,  72 
Hsematomata  of  auricle,  1160 
Hematuria,  991 

diagnosis    of,    from    calculi. 
992 
from    cvstitis    or   pvelitis, 

992 
from  hvpersemia  of  kidney, 

992 
from  icteric  urine,  991 


1220 


INDEX. 


Haematuria,  diagnosis  of,  from 
passive  hypersemia,  992 
from  tuberculosis  of  blad- 
der, 992 
in    acute     tubal     nephritis, 

1011 
in  malarial  fever,  314 
in       scarlatinal       nephritis, 

treatment  of,  148 
in  scorbutus,  391 
in  tumors  of  kidney,  1036 
in  vesical  calculus,  1042 
paroxysmal,  994 
Haemic  murmur  in  secondary 

anaemia,  3(il 
Haemoglobin,  excess  of,  at  birth, 
76 
percentage   of,    in   chlorosis, 

363  ' 
proportion     of,    in    infancj% 
359 
Hsemoglobinuria,     acute,      of 
new-born,  92 
in  erysipelas,  227 
in  Raynaud's  disease,  822 
Haemophilia.  377 
etioln-y   of,  377 
hereditary    transmission    of, 

377 
morbid  anatomy  of,  377 
prognosis  of,  378 
in  females,  378 
treatment  of,  378 
Haemoptysis  in  chronic  pulmo- 
nary tuberculosis,  295 
in  fibroid  phthisis,  965 
in  gangrene  of  lung,  922 
in  tuberculosis,  277 
Haemorrhage    after     tonsillot- 
omy, 426 
cerebral,  following  asphyxia, 
74 
following  labor,  74 
forms  of,  74 
during  tracheotomy,  881 
fatal,  after  gum-lancing,  413 

after  tonsillotomy,  426 
from  kidney,  992 
from  mucous  surfaces,  blood- 
count  in,  82 
from  vagina,  82 
gastro-intestinal,  86 

pathology  of,  87 
in  abscission  of  the   tonsils, 

426 
in  infantile  cerebral   palsies, 

656 
in  new-born,  73 
causes  of,  74 
diagnosis  of,  74 
etiology  of,  73 
parenchymatous,  75 
prophylaxis  of,  75 
intestinal,  in  scorbutus,  391 

in  typhoid  fever,  199 
meningeal,  in  infantile  cere- 
bral palsies,  655 
multiple,  following  umbilical 

infection,  73 
secondary,  after  tracheotomy, 

885 
subperiosteal,   in    scorbutus, 

480 
umbilical,  85 
treatment  of,  86 
Haemorrhages  from  mucous  sur- 
faces, 82 


Haemorrhages   in   cirrhosis   of 
liver,  558 
treatment  of,  560 
in  jaundice,  544 

from   obliteration    of   bile- 
ducts,  546 
in  leukaemia,  374 
in  pertussis,  118 
in  whooping-cough,  116 
of  the  skin,  1125 
punctiform,      in      pernicious 
ana?niia,  366 
Haemorrliagic    infarcts    in    ty- 
plioid  fever,  196 
pleurisy  in  morbus  Werlhofii, 
936 
in  scurvy,  936 
Hfemorrhoids,  592 

in  cirrhosis  of  liver,  558 
Hair,  falling  out  of,  in  typhoid 

fever,  198 
Halitosis,  causes  of,  7 
Hall's  method  of  artificial  res- 
piration, 79 
Hands,      enlargement     of,    in 

acromegaly,  691 
Harrison's  groove,  326,  335 
Head,  foetal,  compression  of,  83 
retraction     of,    in     cerebral 
meningitis,  599 
Headache,  718 
diagnosis    and   prognosis  of, 

724 
etiological  varieties  of,  723 
in  acute  gastric  catarrh,  443 
in  acute  tubal  nephritis,  1011 
in  brain  abscess,  632 
in  brain  tumors,  636 
in  cerebral  meningitis,  599 
in  cercbro-spinal  meningitis, 

209 
in  chicken-pox,  151 
in    chronic    gastric    catarrh, 

447 
in  erysipelas,  225 
in  leukaemia,  374 
in  measles,  119 
in     tuberculous     meningitis, 

611,  612 
in  typhoid  fever,  197 
in  variola,  164 
mechanism  of,  718 
persistent,      in      hereditary 

syphilis,  645 
treatment  of,  725 
vertical,  in  chlorosis,  363 
with   tumors   of  spinal  cord, 
804 
Headaches  due  to  organic  dis- 
ease, 721 
from  eye-strain,  1203 
Head-banging,  713 
Head-louse,  1156 
Head-nodding   and    head-jerk- 
ing, 713 
Hearing,   mechanical    aids    to, 

1049 
Heart,  congenital  afl'ections  of, 
968 
symptoms  of,  973 
treatment  of,  973 
disease  in  etiology  of  chi-ouic 
gastric  catarrh,  991 
chronic,  981 

clinical  history  of,  981 
etiology  of,  981 
prognosis  of,  983 


Heart  disease,  chronic,   symp- 
toms of,  981 
treatment  of,  984 
functional  afl'ections  of,  986 
course  of,  989 
diagnosis  of,  989 
etiology  of,  986 
prognosis  of,  989 
symptoms  of,  987 
treatment  of,  989 
in  diphtheria,  254 
in  typhoid  fever,  200 
irregularity  of,  during  sleep, 

987 
lesions   of,  in  typhoid  fever, 

197 
obstructive     lesions     of,    in 
etiology    of     bronchitis, 
925 
organic  diseases  of,  974 
peculiarities  of,  in  childhood, 

974 
rapid,  988 

relative  weight  of,  974 
slow,  988 
syphilis  of,  106 
Heart-action,    irregularity    of, 

in  children,  987 
Heart-consciousness,  988 
Heat  in    interstitial   keratitis, 
1197 
in    ophthalmia    neonatorum, 
1187 
Hebetude    in  adenoid   vegeta- 
tions, 431 
Hebrew  race,   haemophilia    in, 

377 
Height,  increase  of,  in  typhoid 

fever,  198 
Hemianaesthesia     in    hysteria, 
733 
in    tumors   of  crura  cei-ebri, 
641 
Hemianopsia     in     acromegaly, 
691 
in  brain  tumors,  640 
in  hysteria,  733 
in  infantile  cerebral  palsies, 

651 
in  migraine,  719 
Hemicrauia.     See  Migraine. 
Hemiplegia       from       obstetric 
injury,  83 
in  hereditary  syphilis,   646 
in  typhoid  fever,  200 
Henoch's  disease,  384 
Hepatitis,  suppurative,  535 
diagnosis  of,  554 
prognosis  of,  555 
treatment  of,  555 
with  dysentery,  555 
Hepatogenous  jaundice,  543 
Hereditary   ataxic    paraplegia, 
815.       See,    also.    Ataxia, 
hereditary. 
syphilis.     See  Syphilis,  hered- 
itary. 
Heredity   in    etiology   of   cleft 
palate,  434 
of  diabetes  mellitus,  999 
of  eczema,  1102 
of  hysteria,  728 
of    laryngismus    stridulus, 

859  ' 
of  leukaemia,  373 
of  lithaemia,  94 
of  myotonia,  688 


INDEX. 


1221 


Heredity  in  etiology  of  pemphi- 
gus, 1115 
of         pseudo-hypertrophic 

paralysis,  771 
of  psoriasis,  1112 
of  rachitis,  323 
of  Raynaud's  disease,  823 
of  rheumatism,  351 
of      substantive      emphy- 
sema, 951 
of  tuberculous  meningitis, 

610 
of  vesical  calculus,  1039 
Hernia,  csecal,  536 

umbilical,  86 
Herpes    facialis.       See    Herpes 
simplex. 
febrilis.     See  Herpes  simplex. 
iris,  1099 

labialis     in    croupous    pneu- 
monia, 915 
of  auricle,  1160 
simplex,  1116 
zoster,  1116,  1117 
Herpetic  eruptions   in  typhoid 

fever,  199 
High    operation    in    tracheot- 
omy, 878 
High-arched  palate,  430 
Hip,  congenital  dislocation  of, 

1082 
Hip-joint  disease,  1072 

abscess     in    treatment    of, 

1076 
ankylosis  from,  1081 
atrophy  in,  1072 
Buck's  extension  in,  1074 
deformity  in,  1072,  1073 
diagnosis  of,  1072 
etiology  of,  1072 
opei-ative  treatment  of,  1076 
pain  in,  1072 
pathology  of,  1072 
premonitory     symutoms     of, 

13 
prognosis  of,  1074 
sea-air  in,  64 
symptoms  of,  1072 
Taylor's    hip-splint    in,  1074, 

1075 
treatment  of,  1074 
Hives.     See  Urticaria. 
Hoarseness  in  chicken-pox,  157 

in  laryngeal  disease,  6 
"  Holding-breath  "  spells,  340 
Holt's     rule     for     changes     in 
formula       of       modified 
milk,  55 
Home    modifications    of   cow's 

milk,  56 
Hordeolum,  treatment  of,  1178 
Horse-pox,     vaccination     with 

virus  of,  173 
Hot  bath  in  acute  tubal  neph- 
ritis, 1015 
douche   in  acute  middle-ear 
infiammation,  1168 
in      chronic      suppui-ating 

middle  ear,  1171 
in     furuncle    of    auditory 

canal,  1161 
in  suppurating  middle  ear, 
1170 
Hot-air  bath  in  acute  tubal  ne- 
phritis, 1014 
in      scarlatinal    nephritis, 
147 


Huguier's  operation,  580 
Humanized  milk,  26,  48 

analysis  of,  49 
Humerus,    changes    in,    in    ra- 
chitis, 336 
fracture  of,  at  birth,  85 
"Hunger  for  oxygen,"  76 
Hunyadi    water    in    jaundice, 

547 
Hutchinson's  teeth,  114 
Hydatid  cysts  of  kidney,  1028 
diagnosis  of,  1029 
pathology  and  symptoms 

of,  1028 
prognosis  of,  1029 
treatment  of,  1029 
fluid  from  liver,  542 
fremitus,  556 
of  liver,  555 
tumor  of  omentum,  570 
Hydrsemia      in     etiology     of 

ascites,  571 
Hydragogue        cathartics       in 
chronic   tubal   nephritis, 
1023 
Hydrencephalic    cry,    descrip- 
tion of,  6,  612 
Hydrocephalic  idiocy,  671 
Hydrocephalus,  624 
duration  of,  628 
etiology  of,  625 
externus,  624 
in  hereditary  syphilis,  646 
internus,  624 
morbid  anatomy  of,  628 
symptoms  of,  626 
treatment  of,  628 
varieties  of,  624 
with  spina  bifida,  627 
Hydrochloric    acid,    deficiency 
of,      in      acute      gastric 
catarrh,  443 
in  cholera,  244 
with    pepsin,    in    chronic 
gastric  catarrh,  451 
Hydrogen    peroxide    in    acute 
follicular  tonsillitis,  419 
in  angina  of  variola,  169 
in  atrophic  rhinitis,  836 
in      chronic      suppurating 

middle  ear,  1171 
in  diphtheria,  264 
in  eczema  of  auricle,  1161 
in  gonorrhoea  of  mouth,  89 
in  scarlet  fever,  146 
in  whooping-cough,  192 
Hydronephrosis,  1029 
diagnosis    of,    from    ascites, 
1030 
from  ovarian  cyst,  1030 
from  pyonephrosis  and  peri- 

nephi'ic  abscess,  1030 
from  renal  cysts.  1030 
etiology    and    pathology  of, 

1029 
prognosis  of,  1031 
symptoms  of,  1030 
treatment  of,  1031 
Hydrophobophobia,  704 
Hyoscine  in  chorea,  763 
in    epidemic    cerebrospinal 
meningitis,  213 
Hyperfesthesia,  in  acute  myel- 
itis, 784 
in  cerebro-spinal  meningitis, 

211 
in  hysteria,  732 


Hyperfesthesia    in    Raynaud's 
disease,  821 
in  simple  cerebro-spinal  men- 
ingitis, 606 
in  tumors  of  spinal  cord,  802 
in  typhoid  fever,  200 
Hyperalgesia  in  hysteria,  732 
Hyperidrosis,  1093 
etiology  of,  1093 
prognosis  of,  1094 
treatment  of,  1094 
Hypermetropia  in  infancy  and 

childhood,  1203 
Hyperpyrexia      in      croupous 
pneumonia,  917 
in  measles,  129 
in   rheumatism  of  children, 

352 
in  scarlet  fever,  137 
Hypertrophies  of  skin,  1128 
Hypertrophy  of  fingers,  602 
of    right     heart     in    fibroid 

phthisis,  966 
of  tonsils.    See  Tonsils,  hyper- 
trophy of. 
Hypodermic  administration  of 
mercury      in       syphilo- 
derma,  1146 
puncture     in    diagnosis    of 
pleural  effusion,  944 
safety  of,  in  pleurisy,  944 
Hypodermoclysis    in     cholera, 

246 
Hypophosphites    in  tuberculo- 
sis, 301 
Hypopyon  keratitis,  1195 
Hysteria,  727 
diagnosis  of,  739 
from  epilepsy,  739 
from  organic  paralysis,  740 
etiology  of,  728 
interparoxysmal      symptoms 

of,  732 
paroxysmal  symptoms  of,  729 
statistics  of,  in  children,  728 
symptoms  of,  729 
treatment  of,  740 
Hysterical  headache,  724 
Hystero-epilepsy,  730 

IcHTHYOL  in  chicken-pox,  161 
Ichthyosis,  1128 

diagnosis  of,  1129 

etiology  of,  1129 

hystrix,  1128 

prognosis  of,  1129 

simplex,  1128 

treatment  of,  1129 
Icterus  neonatorum,  87 

physiological,    of    new-born, 
87 
Idiocy,  648,  667 

accidental,  671 

classification  of,  670 
pathological,  676 

congenital,  670 

developmental,  670 

diagnosis  of,  676 

etiology  of,  673 

from  hydrocephalus,  626 

from  obstetric  injury,  83 

legal  definitions  of,  668 

pathology  of,  675 

prognosis  of.  677 

symptoms  of,  674 

treatment  of,  677 
Idiotic  myxoedermateuse,  684 


1222 


INDEX. 


Idiots  savants,  670 
Igni puncture  in  enlarged  ton- 
sils, 423 
Ileal  intussusception,  517 
Ileo-caecal  intussusception,  517 

valve  in  typhoid  fever,  196 
Ileo-colic  intussusception,  517 
Ileo-colitis.     See  Dysentery. 
Ileum,  changes  in,  in  typhoid 

fever,  196 
Ill-temper  in  tuberculous  men- 
ingitis, 611,  616 
Imbecility,  667,  668 
Immunity,  artificial,  in  cholera, 
2:54 
in  tuberculosis,  277 
personal,  from  cholera,  234 
Imperative  acts  or  movements, 
703 
movements,  etiology  of,  716 
diagnosis  of,  716 
in  defective  children,  712 
prognosis  of,  716 
treatment  of,  717 
Impetigo  contagiosa,  1117 
after  vaccination,  175 
diagnosis  of,  1119 
etiology  of,  1118 
prognosis  of,  1119 
relation     of,     to    vaccinia, 

1119 
treatment  of,  1119 
Improper  feeding  in  etiology  of 
acute     gastric      catarrh, 
441 
Incision  and  drainage  in  peri- 
tonitis, 567 
in  furuncle  of  auditory  canal, 

1161 
in  perinephritic  abscess,  1034 
in  pleural  effusion,  947 

disadvantage  of,  947 
in  treatment  of  hydatid    of 
liver,  557 
of     hydatids     of     kidney, 
1029 
of  drum-membrane,  1168 
in  suppurating  middle  ear, 
1170 
Incisions  in  operations  for  ap- 
pendicitis, 514 
Incontinence  of  urine,  996 
in  lithfemia,  96 
in  tuberculous  meningitis, 

618 
spontaneous     cure     of,     at 

puberty, 996 
treatment  of,  997 
Incubator,  Auvard's,  80 
Indigestion,    acute     intestinal, 
465 
etiology  of,  465 
prognosis  of,  466 
synonyms  of,  465 
treatment  of,  466 
chronic  intestinal,  467 
diagnosis  of,  469 
etiology  of,  467 
prognosis  of,  468 
synonyms  of,  467 
treatment  of,  470 
of  infants,  dietetic  treatment 
of,  29 
Indigo  calculus,  1038 
Indolent  corneal  ulcers,  1195 
Infancy,  duration  of,  1 
Infantile  cerebral  palsies,  649 


Infantile  osteomalacia  and  cre- 
tinism, 682 
paralysis,  sea-air  in,  65 
remittent  fever,  194 
Infants,    chronic    constipation 
in,  497 
nursing,  wasting  in,  504 
vaccination  of,  176 
Infants'  food,  value  of,  22 
Infarcts,   luemorrhagi(-,    in    ty- 
phoid fever,  196 
Infection  by  tubercle  bacilli  in 
milk,  286 
in  utero,  73 

by  tubercle  bacilli,  90 

by  ty])hoid  bacilli,  90 

modes  of,  in  cholera,  234 

in  measles,  117 
of  tracheotomy  wound,  885 
of    tvphoid   fever   by   water, 

i95 
septic,  of  new-born,  89 
through  umbilicus,  89 
prophylaxis  of,  89 
treatment  of,  89 
tubercular,  of  new-born,  90 

dog's  serum  in,  91 
typhoid,  of  new-born,  90 
Infections  attacking  the  new- 
born, 88 
of  blood  in  new-born,  92 
Infectious   diseases  in  etiology 
of  pleurisy,  938 
with  parotitis,  179 
Inflammation    in    intussuscep- 
tion, 521 
sympathetic,  of  eye,  1200 
Inflammations  of  skin,  1095 
Inflammatory  phenomena    in, 

vaccination,  175 
Influenza,  epidemic,  214 
bacteriology  of,  214 
circulatory  symptoms  in,  216 
clinical  history  of,  21() 
complications  and  sequelje  of, 

217 
convalescence  from,  219 
definition  of,  214 
diagnosis  of,  218 
from  bronchitis,  218 
from  meningitis,  218 
from  pneumonia,  218 
•from  simple  catarrh,  218 
from  typhoid  fever,  218 
disinfection  in,  218 
etiology  of,  214 
gastro-intestinal      symptoms 

in,  217 
incubation  of,  215 
in     etiology     of     bronchitis, 

924 
in  infants,  215 
lossof  weight  in,  216 
nervous  symptoms  in,  217 
pathology  of,  215 
prognosis  and   mortality   of, 

218 
respiratory     symptoms      in, 

216 
treatment  of,  219 
with  parotitis,  180 
Infusoria  in  gangrene  of  lung, 

921 
Injections  in  gonorrhcea,  1054 
in  intussusception,  521 
intravascular,      in      cholera, 
247 


Injuries,  obstetric,  medico-legal 
aspect  of,  83 
treatment  of,  84 
Innutrition  in  etiology  of  bron- 
chitis, 925 
Insanity,  697 
cataleptic;,  701 
choreic,  700 

circular  or  alternating,  700 
diagnosis  of,  707 
difierences   of,  in   child   and 

adult,  697 
epileptic,  701 
general  etiology  of,  707 
hysterical,  700 
in  children,  697 
in  infants,  697 
moral,  702 

treatment  of,  710 
primary  delusional,  702 
prognosis  of,  708 
treatment  of,  708 
varieties  of,  in  children,  698 
Insistent  idea,  703 
Inspection  of  chest,  15 
Inspiration  of  amniotic  li(juid, 

76 
Insi)iration-piieumonia,  76,  91 
Inspiratory  dj'spncca,  10 
causes  of,  10 
theory  of  compensatory  em- 
physema, 950 
of  substantive  emphysema, 
952 
Instillations       into      auditory 

canal,  1169 
Instinctive  perversions,  702 
Insufflation,    mouth-to-mouth, 

79 
Internal  ear,  affections  of,  1175 
raritj'  of,  in  children,  1175 
Interruption  of  stream  in  vesi- 
cal calculus,  1042 
Interstitial  emjihysema,  950 
keratitis.     See   Keratitis,   in- 
terstitial. 
pneumonia.       See     Phthisis, 
fibroid. 
Intertrigo   in   simple  atrophy, 

505 
Intestinal  antiseptics  in  dysen- 
tery, 492 
in  mucous  di.sease,  459 
in  typhoid  fever,  206 
catai-rh,    chronic.     See   Indi- 
gestion, chronic  intestinal. 
lavage  in   acute  milk   infec- 
tion, 477 
lesion  in  typhoid  fever,  196 
parasites.     See  Parasites,  in- 
testinal. 
Intestine,  large,  abscess  of,  583 
Intestines,  chronic  diffuse  tu- 
berculosis of,  282 
congenital  malformations  of, 

575 
tuberculosis  of,  286 
Intravascular      injections      in 

cholera,  247 
Intubation  of  larynx,  891 

accidents  during  and  after, 

895 
after-treatment  of,  896 
feeding  after,  896 
indications  for,  891 
in     spasmodic     laryngitis, 
856 


INDEX. 


1223 


Intubation  of  larynx  in  steno- 
sis of  larynx,  898 
instruments  for,  892 
position  of  patient  for,  894 
preparations  for,  893 
prognosis  in,  891 
technique  of,  894 
unfavorable  cases  for,  898 
Intubation-tubes,     disinfection 
of,  897 
removal  of,  897 
Intussusception,  517 
chronic,  520 
diagnosis  of,  520 

from  appendicitis,  520 
from  colic,  520 
from  dysentery,  520 
from  enteritis,  520 
from  fjecal  impaction,  520 
from     internal    strangula- 
tion, 520 
from  suppurative  peritoni- 
tis, 520 
etiology  of,  518 
irreducible,  518 
locality  of,  517 
morbid  anatomy  of,  518 
prognosis  of.  520 
symptoms  of,  519 
treatment  of,  521 
Intussusceptions,  double,  517 

triple,  517 
Intussusceptum,  517 
Intussuscipiens,  517 
Invagination    of   bowel.       See 

Intussusception. 
"Inward    spasms"    in    simple 

atrophy,  506 
Iodide    of    iron    in    bronchial 
catarrh  of  rachitis.  347 
of  potassium   in   hydroceph- 
alus, 628 
in  syphilis,  116 
in  tuberculous  meningitis, 
623 

Iodides     in     amvloid    kidney, 
1025 
in  rheumatic  pleurisy,  357 
Iodine  in  acquired  labyrinthine 
deafness,  1176 
in  chronic  peritonitis,  569 
in  lupus  vulgaris,  1140 
Iodine-test  in  amvloid  kidney, 

1024 
Iodoform  in  scrofuloderma,  1143 
in  tuberculosis.  301 
ointment  in  chicken-pox,  161 
Ipecacuanha  in  bronchitis.  932 
in  broncho-pneumonia,  910 
in  congestion  of  liver,  551 
in  constipation,  500 
in  jaundice.  543 
in  spasmodic  laryngitis,  851 
Iris  and  ciliary  body,  diseases 
uf.  1198  ' 
and    ciliary   region,   injuries 
of,  1199 
Iritis,  119- 

in  hereditary  syphilis,  112 
treatment  of,  llt^9 
Iron  in  antemia  after  malarial 
fever,  318 
in  chicken-pox,  161 
in  chlorosis,  364 
in  chronic  heart  disease,  957 
in  convalescence  of  mucous 
disease,  462 


Iron  in  convalescence  of  rheu-  | 
matism,  357 
in  lymphatic  ansemia,  372        ; 
in  phthisis.  302 
in     purpura     hfemorrhagica, 

383 
in  secondary  ansemia.  361 
in  splenic  ansemia,  370 
in  syphilis.  116  , 

in  variola,  170  _    i 

iodide,    syrup  of,  in    chronic  j 
peritonitis.  569 
in  lymphatism,  433 
Irregular  remittent  fevers,  312. 
See  Remittent  fevers,  irreg- 
ular. 
Irrigation  in  diphtheritic  dys- 
entery, 495 
in     naso  -  pharyngeal     diph- 
theria, 263 
intestinal,  in  dysentery,  493 
in  subacute  milk  infection, 

483 
method  of,  494 
of  bowel  in  mucous  disease, 

460 
of  pleural  cavity  after  resec- 
tion, 948 
of    stomach    in   mucous   dis- 
ease, 460 
j  Irritability  in  tuberculous men- 
ingitis,  611 
Irritation,  svmpatlietic,  of  eye, 
!  1199 

Ischio-rectal  abscess,  588 
Ischuria,  hysterical,  735 
•  Italians,  frequency  of  rachitis 
j  among,  320 

Itch.     See  Scabies. 
Itching  about  anus  with  seat- 
worms. 530 
j      in  eczema,  1101 
[      in  jaundice,  543 

treatment  of,  548 
It«h-mite,  1158 


Jabobaxdi     in     acute     tubal 
nephritis,  1014 

in  erysipelas,  228 
in  scarlatinal  nephritis,  147 
Jacksoniau  epilepsy.  747 
.Tacobi  on  origin  of  calculi,  95 
Jalap  in  scarlatinal  dropsy,  148 
Jambul   in    diabetes    mellitus, 

1005 
Japanese,     non-occurrence     of 

rachitis  among,  324 
Jaundice,  543 
diagnosis  of,  544 
from     Addisou"s      disease, 

544 
from  chlorosis,  544 
from  malaria,  544 
from    pernicious     ansemia, 
544 
due  to  congenital  obliteration 

of  bile-ducts,  545 
epidemic,  545 
etiology  of,  543 
following   acute    gastric    ca- 
tarrh, 444 
from  inflammation  of  umbil- 
ical vein,  545 
j      hsematogenic,    in    new-born, 
I  92 

:      in  childhood,  54 1 
i      in  cirrhosis  of  liver,  .558 


Jaundice  in  croupous  pneumo- 
nia, 9x7 
in  hydatid  of  liver,  556 
in  new-born,  544 
in  Eaynaud's  disease,  823 
in  Winckel's  disease,  546 
simple,  in  infants,  543,  544 
Jejunal  intussusception,  517 
Jellies  in  diabetic  diet,  1003 
Joint  affection  in  rheumatism, 
352 
disease,  chronic,  1071 

old,  deformities  from,  1081 
tuberculous,  1072 
swelling  in  hfemophilia,   377 
Juvenile  dementia  from  hered- 
itary syphilis,  706 
myxcfidema,  6S4 

Kaposi's  disease,  1137 

Katatonia,  701 

Keratitis,  interstitial,  1096 

in  late  hereditary  sj-philis, 

115 
symptoms  of,  1096 
treatment  of,  1097 
punctata,  1098 
purulent,  1094 
Kerato  -  conjunctivitis,    phlyc- 
tenular, 1193 
etiology  of,  1193 
symptoms  of,  1193 
treatment  of,  1194 
Kidney,    amyloid    disease    of. 
See    Amyloid    disease   of 
kidney. 
complications  of,  in  chicken- 
pox,  159 
congenital  cvstic    degenera- 
tion of,  1027 
hydatid  cysts  of,  1028 
in  diphtheria,  254 
in  malarial  fever,  309 
in  rachitis,  327 
in  scarlet  fever,  135 
in  tvphoid  fever,  197 
large  fatty,  1021 
large  white,   1021 
lesions  of,  in  cholera,  239 

in  diabetes  mellitus,  999 
tumors   of.      See    Tumors   oy 
kidney. 
Kidneys,  chronic  diffuse  tuber- 
culosis of.  282 
syphilis  of,  106 
tuberculosis  of,  298 
"Kink"     of    whooping-cough, 

186 
Klebs-Loffler  bacillus,  relations 
of,  to  diphtheria,  251,  266 
Kleptomania.  703 
Knapp's  roller-forceps,  1192 
Knee-jerk  in  hereditary  ataxia, 
817 
in  Pott's  disease,  1066 
Knee-joint  disease,  1076 
ankylosis  from.  1081 
di.'ignosis  of,  1077 
etiology  of,  1076 
operative     treatment      of, 

1079 
pathology  of,  1077 
prognosis  of.  1078 
symptoms  of.  1077 
Thomas's   splint   in,    1078, 

1079 
treatment  of,  1078 


1224 


INDEX. 


Knock -knee,  brace  for,  1089 
treatmeut  of,   1088 

Koplik's  eruption  in  measles, 
120 

Roster's  theory  of  congenital 
cystic  degeneration  of 
kidney,  1027 

Kousso  against  taeniae,  r>37 

Krull's  method  in  jaundice, 
548 

Kussmaul's  apparatus  for  irri- 
gating stomach,  560 

Kyphosis,  334 

in  syringomyelia,  813 

Labor,      precipitate,     injuries 

from,  84 
Labyrinth,  formation  of,  1158 
Labyrinthine    lesion    in    total 

deafness,  1176 
Lachrymal  abscess,  1201 
apparatus,  diseases  of.  1200 
gland,  abscess  of,  1200 

inflammation  of,  1200 
sac  and  duct,  diseases  of,  1200 
sac,  fistula  of.  1201 
Lactalbumin,  46 
Lactation,   commencement    of, 

18 
Lactic  acid,  decomposition  of, 
45 
in  cholera,  244 
in  etiology  of  rheumatism, 

351 
presence  of,  in   acute   gas- 
tric catarrh,  443 
Lactic-acid   theory  of  rachitis, 

324 
Lactophenin  in  tvphoid  fever, 

206 
Lactose,  digestion  of,  44 
in  human  milk,  44 
properties  of,  44 
Lacunse  of  bone,  328 
Lagophthalmos,  1182 
Lamellar  cataract.    See    Cata- 
ract, congenital. 
Landry's  paralysis,  798 
Laparotomy  for   perforation  in 
typhoid  fever,  207 
in  intussusception,  522 
Lardaceous  disease,  1024.     See, 
also.    Amyloid   disease  of 
lei  due  I/. 
Laryngeal  obstruction,  258 
symptoms  of,  268 
in  diphtheria,  258 
Laryngismus  stridulus.  S57 
complications  of,  '^62 
course  and  duration  of,  861 
diagnosis  of,  862 

from   bilateral   paral.vsis 
of  glottis-dilators.  862 
from     spasmodic    laryn- 
gitis, 862 
etiology  of,  858 
in   hereditary  syphilis,  645 
in  rachitis,  340 
paroxysm     of,     described, 

861 
pathology  of,  860 
I)rognosis  of,  862 
relation  of,  to  tetany,  857 
.synii)toms  of.  S60 
synonyms  of.  .■*.")7 
treatment  of,  862 
Laryngitis,  catarrhal,  844 


Laryngitis,  catarrhal,  etiology 
of,  845 
in  broncho-pneumonia,  845 
in  pulmonary  phthisis,  845 
in  t.vphoid  fever,  845 
pathology  of.  845 
catarrhal  is  simplex,  846 
complications  of,  847 
diagnosis  of,  847 
prognosis  of,  847 
treatment  of,  847 
diphtheritic,  tracheotomy  in, 

S73 
in  measles,  124 
spasmodic.  848 
diagnosis  of,  850 

from  laryngismus  strid- 
ulus, 8.50 
I  from  true  croup,  850 

severe,  852 
course  of,  853 
symptoms  of,  852 
treatment  of,  854 
I  prophylactic,  856 

I  symptoms  of,  848 

treatment  of,  850 
suffocative,   in    chicken-pox, 
159 
Laryngotomy  in    treatment  of 
foreign  bodies  in  larynx 
and  trachea,  868 
I  Laryngo-tracheotomy  in  treat- 
ment  of    foreign   bodies 
in   larj'nx    and  trachea, 
868 
Larynx,  ascarides  in,  527 
Lassars  paste,  1107 

modification  of,  1096 
Lateral  lithotomy,  1049 
Lausedat's  drops,  245 
Lavage  of  stomach  in  cholera, 
248 
in  chronic  gastric  catarrh, 
451 
Laxatives  in  lithsemia,  101 
in  pleurisy,  946 
in  subacute  milk   infection, 
483 
Lead,  acetate  of.  in  cholera,  246 
Leeches  in  peritonitis,  566 
in  typhlitis,  513 
in  ursemic  convulsions,  1016 
Lentigo,  etiology  of,  1128 

treatment  of,  1128 
Leptomeningitis,  acute  spinal, 
779 
diagnosis  of,  780 

from  hemorrhage,  780 
from  myelitis,  780 
from  tetanus,  780 
from  tetany,  780 
etiology  of,  779 
pathology  of,  779 
treatment  of,  781 
chronic  cerebral,  600 

spinal,  731 
simple.  See  Meningitis,  simple. 
subacute  cerebral,  600 
Letzerich's  bacillus,  382 
Leucocytosis      in      hereditary 

syphilis,  110 
Leucoderma,  1135 
diagnosis  of.  1135 
from  morphcea.  1132 
from  nerve-leprosy,  1136 
from  partial  albinism,  1135 
etiology  of,  1135 


Leucoderma,  prognosis  of,  1136 

treatment  of,  1136 
Leucoma,  1196 
Leukaemia,  373 
diagnosis  of,  375 
from  pseudo-leukfemia,  375 
from  scrofulosis,  375 
from  splenic  anamia,  375 
etiology  of,  373 
morbid  anatomy  of,  375 
prognosis  of,  376 
treatment  of,  376 
Levden's    crvstals   in   asthma, 

957 
Lichen  planus,  1110 
diagnosis  of,  1111 
prognosis  of,  1111 
treatment  of,  1111 
scrofulosorum,  1142 
tropicus,  1094.     See  Miliaria. 
urticatus,  relation  of,  to  ec- 
zema. 1120 
Lids,  eczema  of,  1110 

phtheiriasis  of,  1180 
Liebig's  foods,  analysis  of,  51 
preparation  of.  41 
with  milk,  analysis  of,  52 
Ligaments,      changes     in,     in 

rachitis,  326 
Lime,  saccharated  solution  of, 

formula  for,  23 
Linimentum  exsiccans,  1107 
Lipoma  of  peritoneum,  570 
Lippitudo,  1179 
Lips,  condition  of,    in  tvphoid 

fever,  197, 199 
Liquor    potassse   in    acid  lithi- 

asis,  1009 
Lithaemia,  94 
alloxuric  bodies  as  a  cause  of, 

94 
convulsions  in,  97,  98 
diet  in,  99 
eclampsia  in,  98 
eczema  in,  99 
etiology  of,  94 
exercise  in,  100 
gastric  pain  in,  96 
gastro-enteric  svmptoms  in, 
96 
in  functional  heart  affec- 
tions, 990 
inactivity  as  a  cause  of.  94 
incontinence  of  urine  in,  96 
influence  of  heredity  in,  94 
intestinal    fermentation    in, 

97 
mother's  milk  in,  99 
migraine  in,  98 
nausea  in.  96,  97 
nervous  symptoms  in,  97 
painful  urination  in,  95 
pelvic  disease  in,  100 
precocity  in,  97,  98 
reflex  factors  in,  100 
sick  headache  in,  98 
s.vmptoms  of,  95 
temperature  in.  97 
treatment  of.  99 
uric  acid  as  a  cause  of,  95 
j      urine  in.  96.  99 

vomiting  in,  96,  97 
I  of  blood  in,  97 

'  Lithfemic  eczema,  99 
'  Lithia  in  treatment  of  vesical 
calculus,  1045 
Lithia-water  in  lithaemia,  101 


INDEX. 


1225 


Lithiasis,  1006,  1007 
diagnosis  of,  1009 
etiology  of,  1008 
prognosis,  1009 
treatment  of,  1009 
Lithic  acid  in  the  blood,  94 
Lithium  benzoate  in  lithsemia, 
101,  102 
carbonate   in    diabetes    mel- 

litus,  1004 
citrate  in  lithsemia,  102 
Litholapaxy,  1046 
advantages  of,  1050 
conclusions  regarding,  1051 
in  females,  1052 
Lithotomy,  1046 
lateral,  1049 

emasculation  after,  1049 
median,  1049 
suprapubic,  1048 

in  females,  1052 
vaginal,  1052 
Lithuria,  94 
Littre's  operation,  580 
Liver,  amyloid  disease  of,  551 
diagnosis  of,  552 
symptoms  of,  552 
treatment  of,  552 
apparent  enlargement  of,  541 
chronic    diffuse    tuberculosis 

of,  282 
cirrhosis  of,  558 
diagnosis  of,  559 
etiology  of,  288 
treatment  of,  559 
congestion  of,  549 
diseases  of,  538 
compared  with  adults,  538 
diagnosis  of,  541 
general  etiology  of,  538 
general      symptomatology 

of,  539 
physical    examination    in, 
540 
enlarged,  diagnosis  of,  from 

tumor  of  kidney,  542 
fatty,  551 

treatment  of,  551 
hydatid  of,  555 
diagnosis  of,  557 

from  pleural  effusion,  557 
prognosis  of,  557 
treatment  of,  557 
in    infancy    and    childhood, 

540 
in  pernicious  anaemia,  367 

malaria,  309 
in  rachitis,  326 
in  typhoid  fever,  203 
lesions  of,  in  cholera,  239 
in  diphtheria,  254 
in  typhoid  fever,  196 
operative  exploration  of,  542 
palpation  of,  541 
passive  congestion  of,  540 
percussion  of,  541 
pus  from,  542 

syphilitic    inflammation    of, 
106,  552 
diagnosis  of,  553 
treatment  of,  553 
tuberculosis  of,  288 
Liver-dulness,  superior  border 

of,  16 
Local  applications  in  erysipe- 
las, 229 
asphyxia,  821 


Local  asphyxia  and  symmetri- 
cal gangrene.     See  Ray- 
naud's disease. 
syncope,  821 

treatment  of  pertussis,  192 
Localizing   symptoms  of  brain 

tumors,  637 
Locomotor  ataxia  in  hereditary 
syphilis,  647 
with  syringomyelia,  813 
Lordosis  in  double  congenital 
dislocation  of  hip,  1082 
in  Pott's  disease,  1066 
in  pseudo-hypertrophic  paral- 
ysis, 769 
in  syringomyelia,  813 
Lotions  in  eczema,  1106 
Low  operation  in  tracheotomy, 

876 
Lumbar  nephrotomy  for    pyo- 
nephrosis, 1032 
pain  in  acute  tubal  nephritis, 

1011 
puncture  for  hydrocephalus, 
628 
Lung,  abscess  of,  923 
fibroid    induration   of.      See 

Phthisis,  fibroid. 
gangrene  of,  919 
Lungs,  cirrhosis  of.     See  Phthi- 
sis, fibroid. 
congestion    of,     in     typhoid 

fever,  197 
hypostatic  congestion  of,  in 
subacute  milk  infection, 
481 
lesions  of,  in  diphtheria,  254 

in  pernicious  malaria,  309 
syphilis  of,  105 
tuberculosis  of,  292 
Lupus  hypertrophicus,  1140 
serpigiuosus,  1140 
verrucosus,  1140 
vulgaris,  1139 
diagnosis  of,  1140 
etiology  of,  1140 
prognosis  of,  1140 
treatment  of,  1140 
Luschka's  tonsil,  428 
Lustgarten,     bacillus     of,     in 

syphilis,  103 
Lymphadenitis,     retropharyn- 
geal.     See    Retropharyn- 
geal abscess. 
tracheotomy  for,  427 
Lymphadenoma     of     kidney, 

1035 
Lymphatic    anaemia.       See 
Ansemia,  lymphatic. 
glands,  enlargement  of,  13 
Lymphatism  in  chronic  follic- 
ular pharyngitis,  418 
in    hypertrophy    of    tonsils, 
418 
Lymphocytes,  278 
Lysis  in  typhoid  fever,  202 

Mackenzie's  astringent  mixt- 
ure, 426 

Macrocephalic  idiocy,  671 

Macula  of  cornea,  1196 

Magnesium  carbonate  in  consti- 
pation, 499 
citrate  in  constipation,  499 

Malaria  and  typhoid  fever,  dif- 
ferential diagnosis  of, 
204 


Malaria  in  etiology  of  ansemia, 
360 
of  leukaemia,  373 
of  urticaria,  1120 
Malarial  cachexia,  313 

morbid  anatomy  of,  309 
fever,  303 

sestivo-autumnal    type    of, 
312 
parasites  of,  307 
conditions     favorable     to, 

303 
course    and    prognosis    of, 

317 
diagnosis  of,  315 

from  tuberculosis,  315 
etiology  and  pathology  of, 

303 
examination   of   blood   in, 

366 
geographical     distribution 

of,  303 
morbid  anatomy  of,  306 
pernicious,  314 
prophylaxis  of,  317 
quartan,  parasite  of,  366 
quotidian  or  double  tertian, 

311 
relation    of    types    of,    to 

types  of  organism,  304 
specific  micro-organism  of, 

304 
symptoms  of,  309 
synonyms  of,  303 
tertian    intermittent   type 
of,  310 
parasite  of,  304 
peculiarities  of,  in  young 

children,  311 
temperature  in,  310 
time    of    paroxysm    of, 
312 
treatment  of,  317 
visceral     affections      asso- 
ciated with,  314 
with  typhoid,  315 
hsematuria,  992 
hsemoglobinuria,  theories  of, 

992 
infection  in   Raynaud's  dis- 
ease, 823 
Male  fern  against  tsenise,  537 
Malformations,  congenital,  84 
diagnosis  of,  85 
simulating  fracture,  84 
of  intestines,  congenital,  575 
causes  of,  576 
diagnosis  of,  576 
prognosis  of,  576 
treatment  of,  576 
of  rectum  and  anus,  congen- 
ital, 577 
pathology  of,  577 
Malignant  growths  in  caecum, 
516 
measles,  12S 
Maltose,  45 
Malt-sugar,  46 
Management  of  children,  18 
at  sea-shore,  67 
bathing  in,  32 
clothing  in,  34 
exercise  in,  35 
feeding  in,  18 
sleep  in,  34 
Mania,  699 
after  influenza,  218 


1226 


TNDEX. 


Mania,  homicidal,  703 

moral,  703 
Marasmus.     See   Atrophy,    sim- 
ple. 
Marginal  abscess,  587 

keratitis,  1193 
Marie's  disease,  600.     See  Acro- 
megaly. 
Markoe's  wry-neck  face,  10(>3 
Marrow  of  bone,  328 

of  long  bones  in  lymphatic 
anaemia,  372 
Massage  in  constipation,  518 
in  incontinence  of  urine,  969 
in  pseudo-hyjiertrophic  mus- 
cular paralysis,  773 
in  scoliosis,  1064 
in    simple    jaundice    of    in- 
fants, 561 
of  cornea,  1140 
Mastitis  in  new-born,  91 
Mastoid   tenderness   in   suppu- 
ration of  the  middle  ear, 
1169 
Masturbation  from  seat-worms, 

530 
Masturbational  insanity,  706 

treatment  of,  710 
Maternal    inlinence    in    iiered- 

itary  syphilis,   10 1 
MaxilliC,  changes  in,  in   rachi- 
tis, 334 
McBurney's  point  in  typhlitis, 

510 
Measles,  117-130 
black,  123 

complications  of,  123 
decline  of,  122 
definition  of,  117 
diagnosis  of,  124 

from  acute  catarrh,  124 
from  eczema,  125 
from  rubella.,  125 
from  scarlatina,  125 
from  sypliilitic  roseola,  125 
from  variola,  125 
eruption  of,  120 
etiology  of,  117 
experimental  inoculation  of, 

117 
hybrid.     See  Rubella. 
incubation  of,  118 
in  etiology  of  bronchitis,  924 
of  chronic  tul)al  nephritis, 
1019 
malignant,  123,  128 
modified  forms  of,  123 
morbid  anatomy  of,  118 
mortality  of,  12(5 
prognosis  of,  125,  126, 
quarantine  in,  130 
relapses  and  second  attacks 

of,  126 
sequel*  of,  124 
symptoms  of,  119 
treatment  of,  126 
with  pertussis,  208 
witii  whooping-cough,  124 
without  catarrh,  123 
without  interruption,  123 
Meats  in  diabetic  diet,  1003 

in  litha^mic  diet,  99 
Mechanism    of    jiaroxysms    of 
spasmodic  laryngitis,  849 
Meckel's  diverticulum,  575 
in  intussusception,  517 
Meconium,  vomiting  of,  576 


Median  lithotomy,  1049 
Melaena  in  tuberculosis  of  the 
bowels,  288 
neonatorum,  92 

ulcer  of  duodenum  in,  92 
Melancholia,  699 
agitated,  699 
in  typhoid  fever,  200 
treatment  of,  709 
Meniere  symptoms  in  internal 

ear  disease,  1176 
Meninges,   involvement  of,  in 
chronic    suppuration   of 
middle  ear,  1173 
Meningitis,  Ijasilar.     See    Men- 
hujith,  tHhervnJar. 
following  operation,  598 
cerebral,  simple,  596 
diagnosis  of,  601 

from     cerebral     pneu- 
monia, 601 
from    middle-ear    dis- 
ease, 601 
from  pysemia,  602 
from    tubercular  men- 
ingitis, 601 
from  typhoid  fever,  602 
etiology  of,  596 
morbid  anatomy  of,  597 
prognosis  of,  602 
symptoms  of,  598 
treatment  of,  602 
cerebro-spinal,  simple,  605 
diagnosis  of,  607 
from  tetanus,  608 
from  tubercular,  608 
from    typhoid     fever, 
608 
distinguished  from  cere- 
bro-spinal fever,  605 
etiology  of,  605 
prognosis  of,  608 
symptoms  of,  605 
treatment  of,  608 
of  Pott's  disease,  1065 
pneumonic  lesions  in,  598 
spinal,  777 
syphilitic,  diagnosis  of,  from 

tubercular,  646 
tuberculous,  610 
and  typhoid  fever  differen- 
tial diagnosis  of,  204 
diagnosis  of,  619 

from  pain  tumor,  619 
from        gastro-intestinal 

disorder,  619 
from  hysteria,  619 
from     infantile     convul- 
sions, 619 
from  pneumonia,  620 
from  typhoid  fever,  619 
duration  of,  619 
etiology  of,  610 
in  Pott's  disease,  1067 
morbid  anatomy  of,  620 
prognosis,  618 
symptoms,  611 
with  parotitis,  179 
Mental      changes       in      brain 
tumor,  677 
in  tuberculous  meningitis, 
615 
symptoms  of  hydrocephalus, 
626 
Menthol  in  tuberculosis,  302 
Mercurial    ointment    in    peri- 
tonitis, 566 


Mercurial     stomatitis,     resem- 
blance  of,    to   stomatitis 
ulcerosa,  402 
Mercurials  in  diphtheria',,  262 
Mercuric    chloride    in   chronic 
interstitial         nephritis, 
1026 
in      ophthalmia     neonato- 
rum, 1187,  1188 
Mercuric-chloride       baths       in 
syphiloderma,  1146 
solution     in     corneal     ulcer, 
1196 
Mercury     in     acquired      laby- 
rinthine deafness,  1176 
in  acute  myelitis.  787 
in   acute   spinal   leptomenin- 
gitis, 781 
in  cerebral  meningitis,  603 
in  cliroiiic  peritonitis,  569 
in  hereditary  syphilis,  115 
in  liydrocephalus,  628 
in  interstitial  keratitis,  1201 
in  syphiloderma.  1146 
Mesenteric  glands,  chronic  dif- 
fuse tuberculosis  of.  282 
lesions  of,  in  typhoid  fever, 

196 
swelling     of,     in     typhoid 

fever,  196 
tuberculosis  of,  286 
Mesenteron,  577 
Methylene     blue,      Gabbet- 
Ernst's  solution  of,  271 
in  malaria,  318 
Microcephalic  idiocy,  673 
Micrococci  in  meconium,  472 
Micrococcus  of  Fehlei.sen,  90 
Micro-organisms     in      etiology 
of  eczema,  1103 
in  measles,  118 
in  siiinal  fiuid  in  acute  lepto- 
meningitis, 779 
in  whooping-cough,  184 
Micturition,    frequent,    in    dia- 
betes mellitus,  999 
in  gravel,  1008 
in  hydronephrosis,  1030 
in  vesical  calculus,  1170 
painful,  causes  of,  9 
Middle   ear,   acute    simple    in- 
flammation of.  11()6 
diagnosis  of,  1168 
acute    suppurative    inflam- 
mation of,  1169 
symptoms  of,  1169 
afi"ectioiis  of,  IKJfJ 
chronic  catarrh  of.  1174 
chronic      suppuration      of, 

1170 
stages  of  inflammation  of, 
1168 
Migraine,  719 
diagnosis  of,  720 
etiology  of,  720 
in  lithremia,  98 
pathology  of,  720 
treatment  of,  720 
Miliaria,  1094 
crystallina,  1094 
diagnosis  of,  1095 

from     eczema    jiapulosum, 

1095 
from  varicella,  1095 
from      vesicular      eczema, 
1094 
etiology  of,  1095 


IXDEX. 


1227 


Miliaria  iu  rachitis,  339 

papulosa,  1094 

treatment  of,  1095 

vesiculosa,  1094 
Miliarv  tuberculosis,  acute,  279 
Milium,  1093,  1183 

etiology  of.  1093 

prognosis  of,  1093 

ti'eatment  of,  1093 
Milk,  albuminoids  in,  46 

and   cream  modifications   of. 
for  infant  feeding,  53 

as  a  culture  medium,  472 

as  a  source  of  typhoid  infec- 
tion, 195 

breast-,  19 

casein  in,  46 

chemistry  of,  37 

commercial  bottled,  38 

compared   with   other  foods, 

composition  of,  37 
condensed,  49 
dilution  of.  for  food,  47 

with  lime-water,  47 
fat  in,  46 

home  modification  of,  56 
human,    albuminoids   in.  41, 
44 
color  of.  41 

comparison  with  cow's,  41 
coustaucr    of   composition 

of,  41  ' 
reaction  of,  41 
specific  gravity  of,  41 
table  of  analyses  of,  42,  43, 
taste  of,  41 
humanized,  43 

in  acute  tubal  nephritis,  1018 
in  Pott's  disease,  1063 
in  typhoid  fever,  205 
infection,  471 
acute,  475-479 
diagnosis  of,  477 
from  cholera,  477 
from  sunstroke,  477 
etiology  of,  475 
from     condensed     milk. 

475  __ 

prognosis  of,  Au 
season  of,  475 
synonyms  of,  475 
treatment  of,  477 
advantages    of   the    term. 

465 
subacute.  479 

complications  of,  431 
diagnosis  of,  482 
from  chronic  intestinal 

indigestion,  482 
fi-om    intussusception, 
432 
dietetic     treatment     of, 

482 
etiology  of,  479 
prognosis  of.  432 
prophylaxis  of,  482 
synonyms  of,  479 
treatment  of,  482 
inorganic  matter  in,  46 

analysis  of,  47 
legal  standard  of,  in  various 

States,  40 
modified.     See  Modified  milk. 
peptonized,  characters  of,   25 
prohibited  in  acute  milk  in- 
fection, 477 


Milk,   prohibited   in    subacute 
milk  infection,  432 
prophylactic   precautions    in 

marketing,  473 
sound  dairy,  analysis  of,  40 

characteristics  of,  40 
sterilization  of,  26,  39,  47 
transportation  of.  31 
Milkers,  accidental  inoculation 

of,  with  vaccinia,  172 
Milk-laboratories.  53 

Walker-Gordon,  .55 
Milk-mixtures,  percentage,  53 
Milk-secretion,         diminished. 

Treatment  of,  20 
Milk-sugar,  46 
percentage    of,    in    modified 
milk,  55 
Milk-teeth,  appearance  of,  17 
Mineral    waters    in    lithsemia, 

102 
Mitral     obstructive     murmur, 
982 
regurgitant  murmur,  981 
regurgitation,  931 
prognosis  of,  933 
stenosis,  932 
prognosis  of.  984 
Mixed  feeding,  19 

or  fusible  phosphate  calculus, 

1033 
treatment  in  syphilis,  116 
Modified  milk.  53 
feeding  with,  55 
home  preparation  of,  .56 
percentage  of  constituents 
for  feeding   healthy  in- 
fant, 55 
preparation  of.  .54 
theoretical  basis  for  feeding 
with,  55 
Molluscum  contagiosum  of  eye- 
lids, 1133 
epitheliale.   1129 
diagnosis  of,  11.30 
etiology  of,  1129 
treatment  of,  1130 
Monas  scarlatinosum.  132 
Mongolian  idiots,  671 
Monomania,  suicidal,  703 
Monophobia.  704 
Monsel's    solution     in     hsemo- 

philia.  373 
Morbid  fears.  704 
impulses,  702 

movements  in  infantile  cere- 
bral palsies.  652 
propensities,  703 
Morbus  cseruleus,  5 

maeulosus.         See      Purpura, 
hxmorrhagica. 
Morphine  in  asthma,  960 
in  diphtheria.  262 
in  phthisis,  302 
Morphoea,  11.34 

diagnosis    of,    from     keloid, 
11.34 
from  leprosy,  1134 
from  leucoderma,  1134 
etiology  of,  11.34 
prognosis  of,  1135 
treatment  of,  1135 
Mortality  of  first  year,  63 
Motor    symptoms    of   syringo- 
myelia, 812 
Mouth,  changes  in,  in   disease, 
17 


Mouth,  cleansing  of,  at  birth, 
78 
diseases  of,  396 

general  etiology  of,  396 
examination  of,  17 
exanthematous  eruptions  in, 

IS 
inflammation  of,  changes  in, 

18 
mucous     membrane     of,     in 

health,  17 
of  the  infant,  396 
^-rimarv  svphilitic  lesions  of, 

408 
secondarv   svphilitic    lesions 
of.  403 
Mouth-breathing    in     adenoid 
vegetations,  429 
in  hypertrophic  rhinitis,  831 
with  enlarged  tonsils,  423 
Mouth-suction  of  tracheotomy 

wound, 830 
Muco-pus   in   urine  iu   vesical 

calculus,  1043 
Mucous  disease,  454 
cppetite  in,  456 
breath  in,  456 
diagnosis  of,  457 
from    ascaris  lumbricoi- 

des,  457 
from  dysentery,  437 
from   pulmouary    tuber- 
culosis, 457 
diet  in,  453 
etiology  of,  4.54 
microscopy    of   stools    in, 

457 
morbid  anatomy  of,  457 
mucus  in  stools  of,  456 
nervous  symptoms  of,  456 
nervous  theory  of,  455 
pain  in,  456 
prognosis  of.  458 
skin  in,  456 
symptoms  of,  455 
synonyms  of.  454 
temperature  in,  4.56 
tongue  in,  455 
treatment  of,  478 
urine  in,  456 
membranes,   changes    in,    in 
rachitis.  326 
lesions  of     erysipelas    in, 
224 
patches,  treatment  of,  1147 
surfaces,    hemorrhages  from, 
82 
Mucus,    hypersecretion   of,    in 
chronic    gastric   catarrh, 
446 
Mulberry    calculus.     See    Oxa- 

late-of-lime  calculus. 
Mulls,     plaster   and    salve,    of 

Unna,  in  eczema,  1108 
Mumps.     See  Parotitis. 
Murmur  in  acute  endocarditis, 
979 
in  aortic  regurgitation,  983 
i7i  aortic  stenosis,  982 
iu  mitral  regurgitation,  981 
in  mitral  stenosis,  982 
in     stenosis     of    pulmonary 

artery,  971 
in    tricuspid     regurgitation, 
933 
Murmurs,  ha;mic,  in  chlorosis, 
363 


1228 


INDEX. 


Murmurs,  hiemic,  in  Icnkfemia, 
374 
in  pernicious  auiemia,  366 
in     anomalies    of    auriculo- 

ventricular  orifices,  970 
transient,  in  rapid  or  irregu- 
lar hearts,  987 
Muscles,  lesions  of,  in  typhoid 

fever,  197 
Muscular  atrophy  in  hereditary 
ataxia,  H18 
with  tumors  of  spinal  cord, 
803 
power  in   hereditary  ataxia, 

818 
rheumatism.      See    Bheuma- 
tifim,  mnscnlar. 
Musk  in  diphtheria,  261 
Mussey's        modification        of 

Whitehead  gag,  436 
Mustard-bath     in      malignant 

measles,  129 
Mydriatics     in    treatment    of 
concomitant   convergent 
stral)ismus,  1204 
Myelitis,  782 
acute,  782 

diagnosis  of,  786 
etiology  of,  782 
pathology  of,  783 
treatment  of,  785 
chronic,  787 

with    simple     cerebro-spinal 
meningitis,  606 
Myocarditis  in   tvphoid  fever, 

200 
Myopathic    atrophy,  infantile 
type  of,  771 
juvenile  type  of,  771 
Myopia,     infrequency     of,    in 

childhood,  1202 
Myo-sarcoma  of  kidney,   1035 
Myositis,  syphilitic,  111 
Myotatic  excitability  in  hered- 
itary ataxia,  817 
Myotonia,  687 
diagnosis  of,  689 
etiology  of,  688 
pathology  of,  688 
treatment  of,  689 
Myotonic  reaction,  688 
Myotonus  with  tumors  of  spi- 
nal cord,  803 
Mysophobia,  704 
Myxfcdenia,  juvenile,  684 
Myxcp.deniatous  idiocy,  684 
Myxomata,  nasal,  837 
etiology  of,  838 
morbid  anatomy  of,  841 
treatment  of,  841 
Myx(j^-sarcoma  of  kidney,  1035 

N^vi  of  eyelids,  1180 
Nsevus  pigmentosus,  1131 
etiology  of,  1131 
prognosis  of,  1131 
treatment  of,  1131 
pilosus,  1131 
spilus,  1131 
vascularis.  1137 
diagnosis  of,  1138 
etiology  of,  1138 
prognosis  of,  1138 
treatment  of,  1138 
verrucosus,  1131 
Nails,  condition  of,  in  typhoid 
fever,  199 


Naphthaline  in  cholera,  244 
in  jaundice,  549 
in  mucous  disease,  460 
Naphthol  in  ichthyosis,  1129 
Narrowing  of  rectum,  congen- 
ital, 578 
Nasal   catarrh,    chronic,     after 
scarlatina,  142 
in   etiology  of  chronic  ca- 
tarrh of  middle  ear,  1174 
douche  in  etiology  of  middle- 
ear  inflammation,  1166 
myxomata,  837 
stenosis,  830 
Naso-pharyngeal    adenoid  hy- 
pertrophy, 428 
etiology  of,  429 
histology  of,  428 
treatment  of,  432 
Naso-pharyngitis,  415 
Naso-pharynx,  local  treatment 

of,  in  variola,  169 
Nausea,  9 
and      vomiting     in      brain- 
tumors,  637 
in    chronic    gastric  catarrh, 

447 
in  lithffimia,  96,  97 
in  rubella,  154 
in  typhoid  fever,  197,  198 
in  vaccinia,  174 
Nebula  of  cornea,  1196 
Neck,  anterior  region  of,  anat- 
omy of,  872 
arteries     of,     concerned     in 
tracheotomy,  872 
Necrosis  of  temporal   bone  in 
chronic  inflammation  of 
middle  ear,  1173 
osseous    in    tvphoid    fever, 
197 
Negroes,  frequency  of  rachitis 
among,  320 
rarity  of  trachoma  among, 
1190 
Nelaton's  operation,  522 
Neoplasms  as  a  cause  of  haema- 

turia,  992 
Nephrectomy  for  hydi-onephro- 
sis,  1031 
for  pyonephrosis,  1032 
in  children,  1037 
in  tumors  of  kidney,  1036 
Nephritic  colic,  1170 
Nephritis,  acute  tubal,  1011 
diagnosis  of,  1012 

from  chronic  nephritis, 

1012 
from  cyanotic  indura- 
tion,  1012 
etiology  of,  1011 
morbid  anatomy  of,  1012 
prognosis  of,  1013 
synonyms  of,  1011 
treatment  of,  1013 
chronic  interstitial,  1025 
etiology  of,  1025 
morbid  anatomy  of,  1026 
prognosis  of,  102G 
rarity  of,    in    childhood, 

1025 
synonyms  of,  1025 
treatment  of,  1026 
chronic  tubal,  1018 
diagnosis  of,  1020 

from   amvloid  kidney, 
1020 


Nephritis,  chronic  tubal,  diag- 
nosis   from    chronic 
interstitial     nephri- 
tis, 1020 
from  cyanotic  indura- 
tion,* 1020 
etiology  of,  1018 
morbid  anatomy  of,  1020 
in  first  stage,  1020 
in  second  stage,  1021 
in  third  stage,  1021 
prognosis  of,  1021 
in  first  stage,  1021 
in  second  stage,  1022 
in  third  stage,  1022 
synonj-ms  of,  lOlG 
treatment  of,  1022 

of  convalescence  from 
1022 
complicating  croupous  pneu- 
monia, 917 
in  chicken-pox,  159 
in  cirrhosis  of  liver,  559 
in   late  hereditary  syphilis, 

115 
in  parotitis,  180 
in  subacute   milk    infection, 

481 
in  suppurative  hepatitis,  554 
scarlatinal.      See    Scarlatinal 

nephritis. 
with  parotitis,  179 
Nephrotomy     for     hydroneph- 
rosis," 1031 
Nerve,  superior  laryngeal,  irri- 
tation of,  in  pertussis,  185 
Nerves,    peripheral,    affections 
of,    in    hereditary   syph- 
ilis, 647 
disorders  of,  in  tetany,  765 
Nervous  diseases  in  causation 
of  chronic   constipation, 
497 
symptoms  in  bronchitis,  929 
in  litlipeniia,  97 
in  typhoid  fever,  200 
system,  influence  of,  in  child- 
hood, 1 
obstetric  injuries  to,  82 
Nervousness  m  litbsemia,  97 
Nettle-rash.     See  Urticaria. 
Neuritic  headache,  724 
Neuritis   mviltiple,  after   paro- 
titis, 180 
complicating  epidemic  cer- 
ebro-spinal    meningitis, 
211 
peripheral,      after       diph- 
theria, 259 
New  growths  of  skin,  1137 
New-born,  hsemorrhage  in,  73 
Night-dress  for  summer,  34 

for  winter,  34 
Night-terrors  due  to  eye-strain, 

1203 
Nipples,  India-rubber,  30 
Nitre   in    hydatids  of  kidney, 

1029 
Nitre-i)aper  in  asthma,  961 
Nitro-glycerin  in  asthma,  961 
in  atelectasis,  903 
in  diphtheria,  262 
in  scarlet  fever,  148 
Nitro-niuriatic    acid     in     lith- 
semia,  102 
in  oxalate-of-lime  lithiasis- 
1010 


INDEX. 


1229 


Nocturnal  epilepsy,  751 
Noma,  405.     See,  also,  Stomatitis 

gangrsenoaa. 
Nomenclature  of  affections  of 

middle  ear,  1166 
Nose,  diseases  of,  826 
Nose-picking  with  tsenise,  535 
Nursing,   importance   of  regu- 
larity in,  18 
intervals  between,  18 
proper  position  in,  18 
woman,  diet  of,  44 
Nursing-bottle,  care  of,  30 
graduated,  30 
improper  form  of,  503 
Nutrolactis,  344 
Nuts  in  diabetic  diet,  1003 
Nux  vomica  in  chronic  gastric 
catarrh,  451 
in  chronic  intestinal  indi- 
gestion, 451 
in   functional  heart  affec- 
tions, 989 
in   incontinence   of  urine, 

997 
in  night-sweats,  302 
in  simple  atrophy,  507 
Nymphomania,  703 
Nystagmus,  715 
in  albinos,  1135 
in  hereditary  ataxia,  818 
in  infantile  cerebral  palsies, 
652 

Obstetric    foeceps,    injuries 
from,  83 
prognosis  of,  84 
limitations  of,  83 
precautions  in  using,  83 
injuries,  medico-legal  aspect 
of,  83 
treatment  of,  84 
paralysis,  82 
Obstruction,    laryngeal    symp- 
toms of,  870 
Obturator  for  cleft  palate,  435 
Occlusion    of    anus,    complete, 

578 
Oculo-niotor       symptoms       in 

syringomyelia,  813 
Odor  in  favus,  1149 

in  stomatitis  gangrsenosa,  406 
of    breath    in    gangrene    of 
lung,  922 
CEdema,  13 

cardiac  variety  of,  13 

fugitive,  1184 

hepatic  variety  of,  363 

in  chicken-pox,  159 

in  chlorosis,  363 

in  chronic  heart  disease,  981 

in     progressive       pernicious 

ansemia,  365 
in  scarlatinal  nephritis,  141 
in  secondary  ansemia,  361 
in  tumors  of  kidney,  1036 
localized,  in  scarlatinal  neph- 
ritis, 142 
in    suppurative    hepatitis, 
553 
of  eyelids,  1183 
in  renal  and  cardiac  dis- 
ease, 1184 
of  face  in  rubella,  154 
of  glottis  in  pertussis,  188 
of  lungs  in  acute  tubal  neph- 
ritis, 1012 


CEdema  of  lungs  in  chronic  tu- 
bal nephritis,  1020 
of   neck    after  tracheotomy, 

885 
renal  variety  of,  13 
CEsophagismus,  735 
CEsophagus,  perforation   of,  285 
Offensive  breath,  causes  of,  7 
O'idium  albicans,  400 
Ointments,  application  of,  1107 

in  eczema,  1106 
Old  deformities  of  joints,  1081 
Oleum    phosphoratum    in     ra- 
chitis, 349 
Omentum,     tumors     of.      See 

Peritoneum ,  tumors  of. 
Onychia,  syphilitic,  112 
Oogonia  of  Ferran,  233 
Operative    treatment    of    con- 
comitant        convergent 
strabismus,  1204 
Ophthalmia  in  measles,  124 
neonatorum,  88,  1186 
prognosis  of,  1187 
prophylaxis  of,  88,  1188 
results  of,  1186 
symptoms  of,  1186 
treatment  of,  1187 
phlyctenular.       See    Kerato- 
conj  uncti  vitis,  pJi  lycten  ular. 
Opisthotonos,  cervical,  in  cere- 
bral meningitis,  600 
in  cerebro-spinal  meningitis, 

210 
in  tuberculous  meningitis,617 
with   tumors  of  spinal  cord, 
803 
i  Opium   in  acute    endocarditis, 
1  980 

in   acute  intestinal  indiges- 
tion, 467 
in  bronchitis,  931 
in  cerebral  meningitis,  604 
in  cerebro-spinal  meningitis, 

608 
in  cholera,  246 

in  chronic  heart  disease,  985 
in  croupous  pneumonia,  918 
in  diabetes  insipidus,   1006 
in  diabetes  mellitus,  1004 
in     epidemic     cerebro-spinal 

meningiti,  213 
in  intussusception,  .521 
in  pericarditis,  976 
in  peritonitis,  .567 
in  pertussis,  191 
in     purpura     hsemorrhagica, 

383 
in  rheumatism,  357 
in  therapeutics  of  childhood, 

35 
in  tuberculous  meningitis, 622 
in  typhlitis,  513 
Optic    atrophy    in    hereditary 
ataxia,  818 
in  hydrocephalus,  626 
disk,     appearance     of,    with 

tumors  of  cord,  804 
neuritis  after  erysipelas,  227 
in  brain  abscess,  632 
in  brain  tumors,  637 
in  cerebral  meningitis,  .599 
in     simple     cerebro-spinal 

meningitis,  606 
in  tuberculous  meningitis, 
611,  618 
Orange-juice  in  scorbutus,  395 


Orbit,  bleeding  in,  1202 
caries  of,  1201 
cellulitis  of,  1201 
cysts  of,  1202 
diseases  of,  1201 
morbid  growths  of,  1202 
periostitis  of,  1201 
Orthopeedics,  1062 
Osseous  system,  alterations  of, 
in  rachitis,  328 
in  health,  327 
Ossicles  of  ear,  caries  of,  1172 
stiffening   of    the    ligaments 
of,  1175 
Osteitis  in  chicken-pox,  159 
Osteo  -  chondritis,       syphilitic, 

106 
Osteoplasty,  435 
Otic  vesicle,  1158 
Otitis  in  influenza,  217 
in  measles,  124 
in  scarlatinal  nephritis,  143 
in  typhoid  fever,  199 
in  variola,  167 
media  in  chicken-pox,  159 
in  typhoid  fever,  199 
Ova  of  pediculus  capitis,  1156 
Ovaries,  tuberculosis  of,  299 
Over-feeding    in    etiology    of 
acute  intestinal  indiges- 
tion, 465 
of  eczema,  1102 
Ovoid  bodies  in  sestivo-autum- 

nal  fever,  308 
Oxalate-of-lime  calculus,  1038 

sediments  in  urine,  1006 
Ox-gall  in  constipation,  500 
Oxyuris  vermicularis,  529 
diagnosis  of,  531 
habitat  of,  .529 
method    of    infection    by, 

529 
ova  of,  529 
treatment  of,  531 
Ozsena,  833 
Ozone  in  sea-air,  60 

Pachymexixgitis        externa, 
777 
interna,  778 
Pagenstecher's  ointment,  1196 
Pain  in  acute  myelitis,  7S4 
in  acute  poliomyelitis,  791 
in    chronic    gastric    catarrh, 

449 
in  chronic  heart  disease,  981 
in  chronic  peritonitis,  568 
in  croupous  pneumonia,  915 
in  diseases  of  liver.  532 

diagnosis  of,   from  pleu- 
risy, 540 
from  pleurodynia.  540 
in  hip-joint  disease,  1072 
in  intussusception,  519 
in  knee-joint  disease,  1077 
in  mitral  stenosis,  982 
in  pericarditis,  975 
in  peritonitis,  565 
in  Pott's  disease,  1066,  1067 
in  Eaynaud's  disease,  821 
in  simple  cerebro-spinal  men- 
ingitis, 606 
in  suppurative  hepatitis,  553 
in  tumors  of  kidney,  1035 

of  spinal  cord,  802 
in  typhlitis,  510 
in  vesical  calculus,  1042 


1230 


INDEX. 


Painful  micturition,  9 

in  lithffimia,  95 
Paints  in  eczema,  1109 
Palate,  soft,  appearance  of,  17 
Pallor  in   chronic  tubal   neph- 
ritis, 1020 
Palpation  of  chest,  16 
Palpitation  in  chlorosis,  363 
in  chronic  heart  disease,  981 
in  luitral  stenosis,  982 
in  pericarditis,  975 
of  heart,  9h9 
Palsies,  cerebral,  acquired,  651 
infantile  cerebral,  649 

diagnosis  of,  diBerential, 

656 
etiology  of,  650 
morbid  anatomy  of,  654 
prognosis  of,  656 
statistics  of,  650 
symptoms  of,  651 
treatment  of,  656 
occurring  during  parturition, 

651 
of  pre-natal  origin,  620 
Palsy  in  tuberculous  meningi- 
tis. 611,  617 
of  brachial  plexus  in  heredi- 
tary sj'i)hilis.  647 
Pancreas,  sypliilis  of,  106 
Pancreatic  disease,  relation  of, 
to  diabetes  mellitus,  971 
juice  in  new-born,  463 
Pancrcatin  in  jaundice,  548 

in  simple  atrophy,  507 
Pannus,  1191 

phlyctenular.  1194 
Panophthalmitis  from  ophthal- 
mia neonatorum,  1186 
Pantophobia,  704 
Papilla  of  tooth,  410 
Papillary  trachoma,  1191 
Papular  syphiloderm,  1144 
Papules  in  stomatitis  syphilit- 
ica, 409 
Paracentesis       abdominis       in 
ascites,  574 
in  ascites  of  cirrhosis  of  liver, 

561 
in  chronic  peritonitis,  569 
of  coi-nea.  1196 
of  drum-membrane,  1169 
pericardii,  977 
Paradoxical  pulse.  988 
Parsestbesia  in  J^andrv's  paral- 
ysis, 799 
in  Raynaud's  disease,  821 
in  tumors  of  spinal  cord,  802 
Paralexia,  6.59 
Paralysis.  dii)hthcritic,  259 
treatment  of,  266 
facial.  774 
hysterical,  7-'54 
in  acute  gastric  catarrh,  444 
in   acute   spinal  leptomenin- 
gitis, 780 
in  cerebral  meningitis,  599 
in  cerebro-spinal  meningitis, 

210 
infantile,  789 
in  hydrocephalus,  626 
in  measles,  124 
in  Pott's  disease,  1066 
recognition  of.  1068 
treatment  of,  1071 
in    tuberculous     meningitis, 
617 


Paralysis,  Landry's,  798 
diagnosis  of,  799 

from  myelitis,  799 
etiology  of,  798 
pathology  of,  798 
prognosis  of,  799 
symptoms  of,  798 
treatment  of,  799 
local,  in  simple  cerebro-spinal 

meningitis,  607 
obstetric,  82 
rachitic,  342 

with  tumors  of  spinal  cord, 
803 
Paralytic  deformities,  1086 
Paramimia,  6.59 
Paranephric  cyst,  1028 
Paranoia,  702 
Paraphimosis,  1060 
Paraplegia  in  acute  spinal  lep- 
tomeningitis, 7h0 
in  hereditary  syphilis,  647 
Parasites,  intestinal.  524 
Parasitic    atiections    of    skin, 

1148 
Parenchymatous  keratitis.   See 
Keratitis,  interstitial. 
nephritis,  acute.     See  Neph- 
ritis, acute  tubal. 
chronic.        See     Nephritis, 
chronic  tnhal. 
Paresis  with  tumors  of  spinal 

cord,  803 
Paretic  dementia.  705 
Parker's  soda  solution,  882 
Parotid  gland,  enlargement  and 
suppuration    of.    in    ty- 
phoid fever,   199 
Parotitis,  177 
bacillus  of,  178 
bacterium  in,  178 
complications  of,  180 
conditions    of    infection    in, 

189 
definition  of.  187 
epidemics  of.  187 
etiology  of,  l.*8 
incubation  of,  1S9 
infectious,  etiology  of,  188 
in  influenza.  217 
in  typhoid  fever,  199 
involvement  of  other  glands 

in,  180 
micrococci  in,  188 
pathological  anatomy  of,  187 
period  of  greatest  contagious- 
ness of,  181 
quarantine  in.  181 
traumatic,  187 

etiology  of,  188 
treatment  of,  ISO 
Paroxysmal  hfematuria,  994 
Parrot's  disease,  (548 

nodes,  108 
Passionate  movements,  period 

of,  in  hysteria,  731 
Pastes  in  eczema,  1107 
Pasteurization.  28,  48 
Patency  of  foramen  ovale,  968 
Patent    foods    in    etiology    of 

scorbutus.  .'589 
Paternal    influence    in    hered- 
itary sv])liilis,  103 
Pathophobia,' 704 
Pavor     nocturiius     with     pin- 
worms,  530 
I  Pediculosis,  1156 


Pediculosis,  etiology  of,  1157 

treatment  of,  1157 
Pediculus  capitis,  11.56 

pubis  on  eyebrows,  1180 
Pelletierine  against  ta-nia?,  536 
Pelvic    bones,   changes    in,   in 
rachitis,  336 
disease  in  lithjemia,  100 
Pelvimetry,  74 
Pemphigus,  1114 
diagnosis  of,  1115 
etiology  of,  1115 
foliaceus,  1115 
of  conjunctiva,  1193 
prognosis  of.  1115 
treatment  of,  1115 
vulgaris,  1114 
Pepsin  in  diphtheria,  264 
Pe])sol  in  tyj)hoid  fever,  206 
Peptogenic  milk-powder,  26,  48 

method  of  using,  48 
Peptones,  formation  of,  45 
Peptonization  in  artificial  feed- 
ing, 25 
partial,  advantages  of,  26 
Peptonized  milk,  characters  of, 

25 
Percentage  milk-mixtures.  53 
Percussion  of  chest.  1(» 
method  of,  in  child,  16 
resonance  in  health,  16 
Perforation    of    bowel    in    ca- 
tarrhal dysentery.  4H6 
in  typhoid  fever,  196,  199 
of  caecum  or  appendix,  diag- 
nosis of.  512 
Pericarditis,  974 

complicating  croupous  pneu- 
monia, 917 
during  scleroderma,  1133 
etiology  of.  975 
in  rheumatism,  3.53 
in  scarlatinal  nephritis,  142 
in  typhoid  fever,  201 
in  variola.  167 
physical  signs  in,  975 
prognosis  of,  976 
treatment  of,  977 
tuberculous,  298 
without  liquid  effusion,  353 
Perinej)hritic  abscess.  1032 
diagnosis  of.  1033 
etiology  and  pathology  of, 

1032 ' 
prognosis  of,  1033  • 

symptoms  of,  1033 
treatment  of,  1034 
Periostitis    in    late    hereditary 
syphilis.  114 
in  typhoid  fever.  197 
nodular,  in  rheinnatism,  3.52 
of  orbit.  1201 
syphilitic.  l')7 
Periproctitis.  .588 
Peritoneum,  tumors  of,  570 
prognosis  of.  571 
treatment  of.  .571 
Peritonitis,  acute.  .5()3 
diagnosis  of,  566 
etiology  of,  563 
morbid  anatomy  of,  564 
prognosis  of,  566 
treatment  of.  566 
ulceration    of,    pus    from, 
.56.5 
chronic.  .568 

diagnosis  of,  569 


IXDEX. 


1231 


Peritonitis,   clirooic,    diagnosis 
of,    from   tubercular   pe- 
ritonitis, 569 
etiology  of,  568 
prognosis  of,  569 
treatment  of,  569 
chronic  adhesive  tuberculous, 
290 
diagnosis  of,  291 
prognosis  of,  291 
treatment  of,  291 
in  intussusception,  518 
in  new-born,  90,  563 
in  typhoid  fever,  196,  199 
in  utero,  563 
tuberculous,  283 
ascitic  form  of,  289 
morbid  anatomy  of,  288 
ulcerative  form  of,  290 
Peritonsillar  abscess,  421 
diagnosis  of,  421 
etiology  of,  421 
evacuation  of,  422 
prognosis  of,  421 
treatment  of,  421 
Perityphlitis,  509 
Permanent  teeth,  17 

order  of  appearance  of,  411 
Pernicious  malarial  fever,  314 
Peroxide  of  hydrogen  in  chick- 
en-pox, 161 
Persistence  of  ductus  arteriosus, 

971 
Perspiration    in    rachitis,    325, 
33s 
profuse,  in  etiology  of  consti- 
yjation,  497 
Pertussis,  190.     See   Whooping- 
cough. 
in  etiology  of  bronchitis,  924 
of  mucous  disease,  454 
Petechiae  in  cholera.  242 
in  invasion  of  variola,  164 
significance  of,  164 
Petechial    fever.     See    Cerebro- 
spinal meningitis,  epidemic. 
Petit  mal,  751 
Peyer's  patches  in  cholera,  236 

in  typhoid  fever,  196 
Pharyngitis,  acute,  415 
diagnosis  of,  415 
etiology  of,  415 
pathology    and    symptoms 

of,  415' 
prognosis  of,  416 
treatment  of,  416 
chronic,  417 

treatment  of,  417 
foUiculous,  acute,  415 
chronic,  418 

treatment  of,  418 
in  scarlet  fever,  137 
lateralis,  418  ' 

Pharvnx,     appearance     of,    in 

health,  17 
Phenacetin,  caution  in  the  use 
of.  36 
in  acute  foUiculous  tonsillitis, 

420 
in  bronchitis,  932 
in  diabetes  mellitus,  1004 
in  eczema,  1105 
in  endocarditis.  1108 
in    epidemic     cerebro-spinal 

meningitis,  213 
in  measles,  130 
in  migraine,  720 


Phenacetin  in  parotitis,  180 
in  pleurisy,  946 
in  pyrexia  of  broncho-pneu- 
monia, 912 
in  scarlet  fever,  145 
in  ■niiooping-cough,  192 
Phimosis,  1057 

as  a  cause  of  enuresis,  998 
secondary,  1059 
Phlebitis,  umbilical,  89 
Phlegmon  of  orbit,  1201 
Phlegmonous  ulceration  in  vac- 
cinia, 175 
Phlvctenular     kerato-conjunc- 
tivitis,  1193 
pannus,  1194 
ulcers,  1193 
Phlvctenule,  1193 
Phobias,  704 
Phosphate  of  sodium    in   lith- 

semia,  101 
Phosphatic  sediments  in  urine, 

1006 
Phosphorus     in      laryngismus 
stridulus,  864 
in  rachitis,  347 
Photophobia   in  cerebral  men- 
ingitis, 599 
in  cerebro-spinal  meningitis, 

210 
in      simple      conjunctivitis, 

1185 
in  spring  catarrh,  1190 
Photopsia  in  migraine,  719 
Phtheiriasis  of  lids.  1180 

treatment  of,  1180 
Phthisis,  fibroid,  963 
diagnosis  of,  966 
from    chronic    pleurisy, 

966 
from  pulmonarv  tubercu- 
losis, 966 
etiology  of,  963 
morbid  anatomy  of,  964 
prognosis  of,  966 
svmptoms    and   course  of, 
■^965 

treatment  of,  966 
pulmonalis.   See  Tuberculosis, 
pulmonary. 
in     etiologv     of     amyloid 
kidney,  1024 
Physical     examination,     order 

of  examination  in,  9 
Physiognomy  of  adenoid  vege- 
tations, 430 
Pick's    linimentum    exsiccans, 
1108 
paste.  1096 
"  Pigeon  -  breast  "      deformitv, 

432 
Pilocarpine   in   acquired   laby- 
rinthine deafness,  1176 
in     acute     tubal     nephritis, 

1014 
in  asthma,  961 
in    chronic    tubal    nephritis. 

1022 
in  erysipelas,  223 
in  jaundice,  548 
in  scarlatinal  nephritis,  147 
in  spasmodic  laryngitis,  851 
Pin-worm.       See    Orynris    ver- 

miculnris. 
Piperadzin  in  lithiasis,  1010 
Pityriasis  rosea,  1122 
diagnosis  of,  1122 


Pityriasis   rosea,    diagnosis   of, 
from    circinate    syphi- 
lide,  1122 
from  ringworm,  1122  * 
from  seborrhcea,  1122 
etiology  of,  1122 
prognosis  of,  1122 
treatment  of,  1122 
Placenta,  syphilis  of,  105 

tuberculosis  of,  273 
Plagiocephalic  idiocy,  671 
Plasmodium  malarite,  .304 
Plaster-of-Paris      bandage      in 
club-foot,  1084 
jacket  in  Pott's  disease,  1069 
splint   for  hip-joint  disease, 
1075 
for  knee-joint  disease,  1078 
Plasters  in  eczema,  1107 
Plethora,  definition  of,  .3.59 
Pleura,      thickening      of,      in 
fibroid  phthisis,  964 
tuberculosis  of,  298 
Pleurisy,  935 
complicating  croupous  pneu- 
monia, 917 
complications  of,  945 
diagnosis  of,  943 
etiology  of,  937 
following     broncho-pneumo- 
nia, 903 
frequency  of,  935 
gangrenous,  921 
in  erysipelas,  224,  227 
in  rheumatism,  353 
in  variola,  167 
pathology  of,  935 
physical  signs  of,  941 
prognosis  of,  945 
symptoms  of,  940 
treatment  of,  946 
tubercular,  pathology  of,  936 
with  effusions,  935 
Pleuritis  necessitatis,  9.36 
Pleurosthotonos      in     cerebro- 
spinal meningitis,  210 
Plox  scindens,  133 
Pneumatic  speculum  in  chronic 

tympanic  catarrh,  1175 
Pneumococcus    in   exudate    of 
simple  meningitis,  .597 
of  Frankel  in  broncho-pneu- 
monia, 904 
in     croupous     pneumonia, 
913 
Pneumonia,     catarrhal.         See 
Brouvho-pnenmonia. 
in  measles,  123 
chronic.     See  Phthisis,  fibroid. 
following       broncho-pneu- 
monia, 907 
complicated  by  parotitis.  178 
with    pleurisy,    incomplete 
crisis  in,  944 
croupous.  913 

complications   and   sequels 

of,  917 
diagnosis  of,  917 

from       broncho-pneumo- 
nia, 917 
from  pleurisy  with  effu- 
sion. 917 
etiology  of,  913 
in  pertussis,  188 
morbid  anatomy  of.  914 
physical  signs  of.  916 
prognosis  of,  918 


1232 


INDEX. 


Pneumonia,     croupous,    symp- 
toms of,  914 
treatment  of,  918  , 

•  varieties  of,  916  ! 

embolic,  in  rheumatism,  353 
fibrinous.        See     Pneumonia, 

croupous. 
following  asphyxia,  80 
in  diabetics,  1000 
in  etiology  of  fibroid  phthi- 
sis, 963 
of  pericarditis,  975 
infective  intei-stitial,  in  ery- 
sipelas, 224 
in  rheumatism,  353 
in  septic  infection,  89 
inspiration,  76,  91 
lobar.     See  Pneumonia  croup- 
ous. 
lobular.      See    Broncho-pneu- 
monia. 
migrans,  916 
mode  of  drinking  in,  6 
septic,  in  scarlet  fever,  142 
■Staphylococci  in,  74 
with  parotitis,  179 
Pneumothorax       complicating 
broncho-pneumonia,  908 
Pockmarks  in  chicken-pox,  157 
Pointing    of    perinephritic  ab- 
scess, 1033 
Poliomyelitis,    acute    anterior, 
789 
diagnosis  of,  793 
from     cerebral     palsy, 

793 
from  diphtheritic  pal- 
sv,  793 
etiology  of,  789 
morbid  anatomy  of,  789 
pathology  of,  790 
prognosis  of,  793 
symptoms  of,  790 
treatment  of,  794 
subacute  and  chronic  ante- 
rior, 795 
diagnosis  of,  796 

from  neuritis,  796 
treatment  of,  797 
Politzer  bag  in  middle-ear  in- 
flammation, 1168 
inflation  in  chronic  tympanic 
catarrh,  1175 
in  suppurating  middle  ear, 
1169 
Poluboskos  in  diabetes,  1002 
Polyadenitis,  diagnosis  of,  from 
Hodgkin's  disease,  283 
from  syphilis,  283 
tuberculous,  283 
after  infectious  disease,  283 
Polymyoclonus,     post-hemiple- 

gic,  652 
Polyp   masses   in    chronic  sup- 
])urating  middle  ear,  1171 
umbilical,  86 
Polypus  of  rectum,  592 
Polyuria  in  diabetes  insipidus, 
1005 
in    etiology  of    constipation, 
497 
Pomegranate     against     tajuije, 

536 
Porencephalv.  649 
Post-natal  atelectasis.  899.     See 

Atelectasis,  post-natal. 
Posture  in  infancy,  12 


Posture    in    perinephritic    ab- 

sce.ss,  1033 
Postures  in  rising  in     pseudo- 
hvpertrophic     paralvsis, 
770 
Potassium    acetate   in    ascites, 
573 
in  rheumatism,  357 
bromide  in  chorea,  763 

in  diabetes  insipidus,  1006 

in  eclampsia,  746 

in  epidemic  cerebro-spinal 

meningitis,  213 
in  erysipelas,  229 
in  infancy,  36 
in  pertussis,  191 
in  scarlet  fever,  146 
in  variola,  169 
carbonate    in    treatment   of 

stone,  1045 
chlorate  as  a  cause  of  hema- 
turia, 992 
in  acute  pharyngitis,  416 
in  diphtheria,  262 
in  diseases  of  the  mouth, 

397 
in  mercurial  stomatitis,  409 
in  stomatitis  ulcerosa,  404 
citrate  in  measles,  128 
iodide  in  acute  myelitis,  787 
in  asthma,  961 
in  brain  tumors,  644 
in  broncho-adenitis,  931 
in  cerebral  meningitis,  603 
in    cerebro-spinal    menin- 
gitis, 213 
in  chronic    interstitial  ne- 
phritis, 1026 
in  cirrhosis  of  liver,  559 
in  epilepsy,  752 
in  fibroid  phthisis,  967 
in     interstitial     keratitis, 

1197 
in  pulmonary  emphysema, 

954 
in  syphiloderma,  1146 
salts  in  acute  tubal  nephritis, 
1017 
Pott's  disease,  1064 
abscess  in.  1067 

treatment  of,  1071 
ambulatory   treatment    of, 

1068 
amyloid  changes  in,  1067 
cervical,  1066 
complications  of,  1066 
deformity  in,  1066,  1068 
diagnosis  of,  1067 
dorsal,  1066 
etiology  of,  1064 
gait  in,  1066 
lumbar,  1066 
pain  in,  1066,  1067 
paralysis  in,  1066 

treatment  of.  1071 
pathology  of,  1065 
prognosis  of,  1068 
psoas  spasm  in,  1067 
pulmonary  tuberculosis  in, 

1067 
symptoms  of,  1065 
treatment  of,  1068 
tuberculous  meningitis  in, 
1067 
Poultices  forbidden  in  conjunc- 
tivitis, 1185 
in  bronchitis,  933 


Poultices  in  pericarditis,  976 
in  peritonitis,  566 
in  peritonsillar  abscess,  422 
Pouting   perforation    of  drum- 
membrane,     significance 
of,  in   suppurating  mid- 
dle ear,  1170 
Powder-burns  of  eyelid,  1184 
Powders  in  eczema,  1106 
Prjecordial  distress,  988 

pain,  988 
Predigested  food    in  acute   in- 
testinal indigestion,  465 
in  mucous  diseases.  458 
Predigestion,  chemistry  of,  47 
Predisposition   in   etiology    of 

diphtheria,  252 
Prepuce,  adherent,  1057 
treatment  of,  10,58 
traction     upon,      in     gravel, 
1(X)8 
Preputial  adhesions,  spontane- 
ous separation  of,  1057 
Presystolic      mitral     murmur, 
comparative      frequency 
of,  982 
murmur  in   mitral  stenosis, 
982 
Priapism  in  acute  myelitis,  784 

in  adherent  prepuce,  10.57 
Prickly   heat,   1094.     See  Mili- 
aria 
Primary   pleurisy,    etiology  of, 

937,  940 
Prince's   s  tap  h  vlorraph  v- 

needle,  436 
Proctitis,  587 

acute  catarrhal,  588 
chronic  catarfhal,  588 
Proctodjeum,  .577 
Procursive  e])ilepsy,  751 
Profound  sleep  in   etiology  of 
incontinence     of    urine, 
996 
Prolapsus  ani  in  chronic  intes- 
tinal indigestion,  469 
of  rectum,  590 
in  pertussis,  188 
Proliferation,    zone   of,    in    ra- 
chitic bone,  329 
Prophylaxis  of  septic  infection, 

89 
Prostate     gland     in    children, 

1045 
Prostration  in  cholera,  237 

in  variola,  164 
Proteid    food,   excess    of,  as   a 
cause  of  lithjemia,  94 
poisons      from       toxicogenic 
germs,  474 
Proteids,      percentage     of,     in 

modified  milk,  ,55 
Prurigo,  1123 
Pruritus  ani,  584 
genital,  in  diabetes  mellitus, 

1000 
in  vaccinia,  174 
Pseudo-croup,  848 
P.seudo-diphtheria,     418.      See 
Tonsillitis,  infectious 

pseudo-membranous. 
in  variola,  167 
Pseudo-hypertrophic   muscular 
paralysis,  768 
diagnosis  of,  773 

from   congenital    spas- 
tic paraplegia,  773 


INDEX. 


1233 


Pseudo-hypertrophic   muscular 
paralysis,  diagnosis  of, 
from       progressive 
chrouic  neuritis,  773 
etiology  of,  771 
morbid  auatomy  of,  772 
treatment  of,  773 
Pseudo-membrane   of  diphthe- 
ria, 254 
of  pharynx  in  variola,  165 
Pseudo-membranes,        strepto- 
cocci in,  251 
varieties  of,  260 
Psoas  abscess  in  Pott's  disease, 
1067 
spasm  in  Pott's  disease,  1067 
Psoriasis,  1111 
circiuata,  1112 
diagnosis  of,  1112 

from     scaliug     svphilides, 

1113 
from  scaly  eczema,  1112 
from  seborrhcea,  1112 
diffusa,  1112 
etiology  of,  1112 
guttata,  1112 
gyrata,  1112 
nummularis,  1112 
prognosis  of,  1113 
punctata,  1112 
treatment  of,  1113 
varieties  of,  1112 
"Psychical      equivalent"      of 

hysteria,  736 
Ptomaines  in  scarlatinal  neph- 
ritis, 140 
in  septic  infection,  89 
Ptosis,  1182 
Ptyalin,  scarcitv  of,  in  infants, 

45 
Pubic    louse    in    eyebrows    or 

lashes,  1156 
Puerile  respiration,  16 
Pulmonary  arterv,  steLosis  of, 
970 ' 
emphysema,  950 
orifice  and  arterv,  atresia  of, 

971 
resonance,  alterations  of,  17 
at  bases,  17 

in  infrascapular  regions,  17 
in  interscapular  space,  17 
in  scapular  region,  17 
tuberculosis.       See    Tuhercu- 
losia,  pulmonary. 
in  Pott's  disease,  1067 
Pulsating  pleurisy,  945 
Pulse,  10 

diminished  frequency  of,  11 
in  jaundice,  11 
in  nephritis,  11 
importance  of,  in   diagnosis, 

11 
in  acute  milk  infection,  476 
in  acute   spinal    leptomenin- 
gitis, 780 
in  acute  tubal  nephritis,  1011 
in  asthma,  958 
in  bronchitis,  928 
in  broncho-pneumonia,  906 
in  catarrhal  dysentery,  488 
in  cerebral  meningitis,  599 
in  cerebro-spiual  meningitis, 

211 
in  childhood,  character  of,  11 
in  chlorosis,  363 
in  cholera,  238 

78 


Pulse  in  chronic  tubal  nephri- 
tis, 1019 
increased  frequency  of,  11 
in  croupous  pneumonia,  915 
in  diphtheria,  256 
in  er3'sipelas,  225 
in  gangrene  of  lung,  922 
in  influenza,  216 
in  invasion  of  variola,  164 
in  jaundice,  543 
in  leukffimia,  374 
in  measles,  120,  121 
in  pericarditis,  947 
in  peritonitis,  565 
in  pernicious  antemia,  366 
in  pleurisy,  940,  941 
in  post-natal  atelectasis,  900 
in  rachitis,  339 
in  rubella,  154 
in  scarlet  fever,  136 
in      simple      cerebro-spiual 

meningitis,  607 
in  stomatitis  gangraeuosa,  406 
in  subacute  purpura  hsemor- 

rhagica,  381 
in     tuberculous    meningitis, 

611,612 
in  typhoid  fever,  193,  200 
palpation  of,  in  infants,  11 
relation  of,  to  fever,  11 
Pulsus  paradoxus,  987 
Pumpkin-seed  against    tsenige, 

537 
Puncture,  lumbar,    for   hydro- 
cephalus, 628 
Pupil,  alterations  of,  with  tu- 
moi-s  of  spinal  cord,  804 
in  cerebro-spinal  meningitis, 

210 
in  simple  cerebro-spinal  men- 
ingitis, 606 
in  uraemia,  1011 
Pupillary  symptoms  in  heredi- 
tary ataxia,  818 
in  syringomyelia,  813 
Pupils  in  cerebral  meningitis, 
599 
in  coma  of  pernicious  malaria, 

314 
in     tuberculous    meningitis, 
617 
Purgatives  in  cerebral  meningi- 
tis, 603 
in  cerebro-spinal  meningitis, 

608 
in  tvphlitis  and  appendicitis, 
'513 
Purpura,  1125 
after  influenza,  218 
diagnosis  of,  1127 
from  flea-bite,  1127 
from  scurvy,  1127 
etiology  of,  1127 
hsemorrhagica,  379,  1126 
acute,  384 

cases  complicating  preg-  ! 

nancy,  386  : 

cases  with  marked  sepsis,  ' 

285 
cases  with  visceral  hem- 
orrhages, 386 
essential,  379 
ordinary  cases  of,  380 
secondary,  387  i 

after  fright,  etc.,  388  j 

in  non-syphilitic  infants. 
388 


Purpura     hsemorrhagica,     sec- 
ondary,in  syphilitic  in- 
fants, 388 
with  anaemia,  etc.,  388 
with  cases  of  severe  jaun- 
dice, 388 
with  infectious  diseases, 

388 
with  malignant  endocar- 
ditis, 3y8 
with  multiple  sarcomata, 
388 
subacute,  380 
constitutional  svmptoms 

of,  380 
haemorrhagic    symptoms 

of,  380 
pathology  of,  381 
prognosis  of,  382 
treatment  of,  382 
neonatorum,  1126 
prognosis  of,  1127 
rheumatica,  387,  1126 
simplex,  387 
treatment  of,  1127 
Purulent  corneal  ulcer,  1195 
iritis,  1199 
pleurisy,  935 
Pustular  syphiloderm,  1144 
Pustule  of  haemorrhagic  variola, 
163 
of  variola.  163 
Putty  stools,  468 
Pyonephrosis,  1031 
diagnosis  of,  1032 
etiology    and    pathology    of, 

1031 
prognosis  of,  10.32 
treatment  of,  1032 
tubercular,  298 
Pyopneumothorax,  945 
Pyrexia,  types  of,  12 
Pyrogallic  acid  in  lupus  vulga- 
ris, 1141 
Pyromania,  703 
Pyrophobia,  704 
Pyuria,  995 
in  stone  in  bladder,  1009 

QuAEANTiXE  in  measles,  130 

in  rubella,  1.55 
Quartan  malarial  fever,  charac- 
teristics of,  312 
parasite  of,  306 

differences      of,     from 
tertian,  306 
Questioning     the     attendants, 

definite    order   in,  2 
Quincke's  lumbar  puncture  in 
diagnosis    of    tubercu- 
lous meningitis,  620 
in  hydrocephalus,  629 
Quinine  and  urea,  muriate  of, 
in  malaria,  317 
in  acute  endocarditis,  980 
n   acute   middle-ear  inflam- 
mation, 1169 
n  amcebic  dy.sentery,  495 
n  asthma,  962 
n  broncho-pneumonia,  911 
in  croupous  ])neumonia,  918 
in  eczema,  1105 
in  malarial  fever,  317 
in  malignant  measles,  128 
in  measles,  128 
n  pertussis,  191 
in  Raynaud's  disease,  825 


1234 


INDEX. 


Quinine  in  rheumatism,  357 
iu  scarlet  fever,  146 
iu  tuberculosis,  302 
in  variola,  169,  170 
locally  in  pertussis,  192 
Quinsj'.       See  Feritousillur    ab- 
scess. 
Quotidian   intermittent  fever, 
diagnosis  of,  315 
temperature  in,  311 

Race  in  etiology  of  vesical  cal- 
culus, 1040 
Rachitic  bone,  analyses  of,  330 
child,  characters  of,  331 
deformities,  10«7 

of  pelvis,  336 
foetus,  330 

bead,  description  of,  332 
paralysis,  342 
pseudo-cretinism,  682 
rosary,  diagnostic  value  of,322 
Rachitis,  319    See,  also.  Rickets. 
age  of  occurrence  of,  322 
among  the  well-to-do,  320 
anatomical      characters      in 
stage    of    deformity    of, 

330 
in  stage  of  proliferation 

of,  328 
in  stage  of  reconstruction 
of  338 
changes  in  osseous  system  in, 
327 
in  soft  tissue  in  325 
of  cranial  bones  in,  331 
definition  of,  319 
diagnosis  of,  320 
dietetic  causes  of,  325 
due  to  proprietary  foods,  323 
etiology  of,  323 
foetal,  322 
frequency  of,  319 
among    Italians     and    ne- 
groes, 320 
general  symptoms  of,  338 
hygienic  treatment  of,  342 
pathology  of,  325 
treatment  of,  342 
Radius,  changes  iu,  in  rachitis, 

336 
Rales  in  asthma,  959 
in  bronchitis,  930 
in  broncho-pneumonia,  908 
in  pleurisy,  942 
in  pneumonia,  916 
in    pulmonary    tuberculosis, 
296 
Rapid  heart,  988 

with  tumors  of  spinal  cord, 
804 
Rash.     See,  also.  Eruption. 

in  malignant  measles,  123 
Rashes.     See,  also.  Eruptions. 
in    chronic    gastric   catarrh, 

448 
initial,  in  variola,  164 
Raspberry  excrescence,  174 
Raynaud's  disease,  820 

course,  duration,  results  of, 

»24 
diagnosis  of,  824 
etiology  of,  822 
pathology  of,  823 
relation     of    intermittent 

hsemoglobinuria  to,  823 
treatment  of,  824 


Reaction    of   degeneration     in 

acute  poliomyelitis,  791 
Reactions,   electrical,   in  acute 
poliomyelitis,  791 
in       pseudo  -  hypertrophic 
paralysis,  771 
Rectum,  absence  of,  .583 

congenital  narrowing  of,  578 
diseases  of,  584 
foreign  bodies  in,  595 
imperforate,  578 

perineal  operation  for,  479 
malignant  diseases  of,  594 
nffivus  of,  593 
polypus  of,  592 

treatment  of,  593 
prolapsus  of,  590 
diagnosis  of,  591 
treatment  of,  591 
varieties  of,  590 
with  seat-worms,  530 
stricture  of,  589 
syphilis  of,  589 
ulceration  of,  589 
wounds  of,  594 
Recurrence  after  nephrectomy 
for    tumors    of    kidney, 
1037 
after    operations    for    stone, 

1047 
in  endocarditis,  978 
of  paroxysms  of    spasmodic 
laryngitis,  849 
Recurrent  attacks  in  purpura 
hsemorrhagica,  381 
headache,  721 
"  Red  softening,"  630 
Reduplication  of  second  sound 
at  apex  iu  endocarditis, 
979 
Reflex  headache,  723 
insanities,  706 

irritation  of  anus  in  chronic 
gastric  catarrh,  449 
of  nostrils  in  chromic  gas- 
tric catarrh,  449 
pains  in  veoical  calculus,  1043 
symptoms  from  cerumen  im- 
paction, 1162 
Reflexes  in  acute  myelitis,  784 
in  acute  poliomyelitis,  791 
in  athetosis,  695 
in  hereditary  ataxia,  817 
iu   infantile  cerebral  palsies, 

652 
with  tumors  of  spinal  cord, 
803 
Refraction  of  eye  in  childhood, 

1202 
Regurgitation,  aortic,  983 
mitral,  981 
tricuspid,  983 
Reinfection  in  rubella,  154 
Relapses  in  rubella,  1.54 

iu   subacute   milk  infection, 

482 
in  typhoid  fever,  198 
Remittent  fevers,  irregular,  312 
Renal  cirrhosis.     See  Nephritis, 
chronic  interstitial. 
cysts,  1027 

insufficiency  in  chronic  heart 

disease,  treatment  of,  985 

sclerosis.  See      Nephritis, 

chronic  interstitial. 

Resection  of  rib  in  empyema, 

947 


Resonance  of   chest,    difiierent 
degrees  of,  16 
percussion,  in  health,  16 
pulmonary,     alterations    of, 
17 
at  bases,  17 
in     infrascapular    regions, 

17 
in  interscapular  space,  17 
in  scapular  region,  17 
Resorcin  in  erysipelas,  229 
in  mucous  disease,  459 
in  pertussis,  192 
Respiration,  10 
accelerated,  causes  of,  10 
arrest     of,    during      trache- 
otomy, 881 
artificial,  Duke's  method,  79 
Forest's  method,  79 
Hall's  method,  79 
Reynolds's  method,  79 
Schultze's  method,  78 
Sylvester's  method,  79 
changes    in,    in    tuberculous 

meningitis,  618 
Cheyne-Stokes,  10 
diminished  frequency  of,  10 
expiratory,  10 
in  ascites,  15 
in  asthma,  958 
in  bronchitis,  928 
in  cerebral  meningitis,  599 
increase  in  rapidity  of,  10 
in  enteritis,  15 
in  infancy,  16 
in  malignant  measles,  123 
iu  measles,  122 
in  peritonitis,  15,  565 
in  pleurisy  and   pneumonia, 

15 
in  post-natal  atelectasis,  901 
in  rachitis,  15 

in   severe  spasmodic    laryn- 
gitis, 852 
in  tubercular  meningitis,  604 
in  variola,  164 
irregularity  of,  10 
iu  children,  987 
mode  of  estimating,  10 
puerile,  16 

rapid,  in  hy.steria,  735 
rates  of,  during  sleep,  10 

in  children,  10 
type  of,  in  children,  10 
Rest  in  chronic  tubal  nephritis, 
1022 
in  hip-joint  disease,  1074 
in  knee-joint  disease,  1078 
in  Pott's  disease,  10(i8 
Results  of   corneal    ulceration, 

treatment  of,  1196 
Retention    of    clots    iu    hfema- 

turia,  991 
Retraction     of    chest-wall     in 

atelectasis,  901 
Retractors      in      tracheotomy, 

caution  in  use  of,  878 
Retro-pharyngeal  abscess,  427 
treatment  of,  428 
lymphadenitis,  427 
tracheotomy  in,  440 
Reynolds's  method  of  artificial 

respiration,  79 
Rhabdis   genitalis  a    cause  of 

hsematuria,  993 
Rhabdo-sarcoma     of     kidney, 
1035 


INDEX. 


1235 


Ehagades  in  hereditary  syph- 
ilis, 160 
syphilitic,  characteristics  of. 
408 
Eheumatic  diathesis  in  etiology 
of  acute  gastric  catarrh, 
443 
Eheumatism,  351 
acute,  351    • 

course  and  duration  of,  355 
cutaneous  eruptions  in,  354 
definition  of,  351 
diagnosis  of,  354 
from  cerebro-spinal  fever, 

355 
from  pyfemia,  355 
from  rickets,  355 
from     scarlatinal    rheu- 
matism, 354 
from  scurvy,  355 
from  syphilis,  355 
etiology  of,  351 
prognosis  of,  355 
treatment  of.  356 
after  influenza,  217 
chronic,  358 

diagnosis    of,    from    rheu- 
matoid arthritis,  358 
treatment  of,  35S 
in  etiology  of  acute  endocar- 
ditis, 977 
of  pericarditis,  975 
of  psoriasis,  111-2 
of  vesical  calculus.  1039 
local  treatment  of.  357 
morbid  anatomy  of,  352 
muscular,  357 
diagnosis  of,  358 

from  neuralgia,  358 
prognosis  of,  358 
treatment  of,  358 
of  the  legs  in  scurvy,  391 
with  peritonitis,  564 
Rhinitis,  acute,  826  i 

treatment  of,  827 
atrophic,  833  I 

diagnosis  of,  835 

from  hereditarv  syphilis, 
835 
treatment  of,  836 
hypertrophic.  829 
diagnosis  of,  831 
pathology  of,  829 
treatment  of,  832 
purulent,  828 

treatment  of,  829 
simple  chronic,  828 
diagnosis  of,  828 
Eibs,   changes  in,  in   rachitis, 

334 
Eickets.     See  Rachitis. 
acute,  342 
in  the  etiology  of  eclampsia. 

742 
in   the  etiology  of  laryngis- 
mus stridulus,  858' 
of  splenic  anfemia,  368 
predisposing     to     scorbutus, 
339 
Eigidity   and    contractures    in 
infantile  cerebral  palsies, 
652 
in  acute   spinal   leptomenin- 
gitis, 779 
in  simple  cerebro-spinal  men- 
ingitis, 606 
Eigors.     See  CMlls. 


Eingworm.     See    Tinea    tncho- 

phyt'ina. 
Eomanowsky's  method  of  stain- 
ing in  malaria,  316 
Eosanilin      hydrochlorate      in 

tinea  tonsurans,  1153 
Eose  spots    in    typhoid   fever, 

199 
Eoseola,  epidemic.    See  Rubella. 

infantilis,  1097 
Eotch,  Thomas  M.,  method  of 

modified  milk,  53 
Eotheln.     See  Rubella. 
Eound-worm.    See  Ascaris  lum- 
1  bricoides. 

i  Eubella,  152 

complications  and  sequelae  of, 

154 
definition  of,  1.52 
diagnosis  of,  151 
from  measles,  154 
from  scarlet  fever,  155 
distinction  of,  from  measles, 

1.54 
incubation  of,  152 
in  etiology  of  bronchitis,  924 
morbilliforme,  153 
prognosis  of,  154 
quarantine  in,  155 
scarlatiniforme,  153 
symptoms  of,  153 
synonyms  of,  152 
treatment  of,  155 
Eubeola.     See  Measles. 

Sacchaeix   in    diabetic    diet, 

1003 
Saccharomyces  albicans,  401 

biology  of,  401 
Saemisch's  section,  1196 
Salads  in  lithsemic  diet,  100 
Salicin  in  rheumatism,  357 

in  scarlatinal  arthritis,  146 
Salicylate  of  bismuth  in  typhoid 
fever,  206 
of  sodium  in  lithgemia,  101 
Salicylates  in  lithsemia,  101 
in  rheumatic  tonsillitis,  357 
value  of.  in  rheumatism,  356 
in  treatment  of  warts,  1131 
in  tuberculosis,  302 
Salicylic-creasote    plaster-mull 

in  lupus,  1141 
Salines  in  dysentery,  493 

in  peritonitis.  567 
Salivation   in   stomatitis    ulce- 
rosa, 404 
Salol  in  cholera,  244 

in    chronic    gastric    catarrh, 

451 
in  gonorrhcea,  1054 
in  jaundice,  549 
in  lithfemia,  101 
in  mucous  disease,  459 
in  parotitis,  180 
in  vulvo-vaginitis,  10.56 
Salophen  in  chorea,  762 
Santonin  against  ascarides,  528 

against  seat-worms,  531 
Sarcoma  of  eyelids,  1181 
of  kidney, 'l 035 
of  orbit,  "l202 
of  peritoneum,  570 
Sarcomata  of  brain  and  menin- 
ges, 635 
Satyriasis,  703 
Scabies,  1154 


Scabies,  diagnosis  of,  from  ecze- 
ma, 1155 
etiology  of,  1155 
prognosis  of,  11.55 
treatment  of,  1155 
Scalp,  eczema  of,  treatment  of, 

1109 
Scaphocephalic  idiocy,  671 
Scarification    in   treating    ery- 
sipelas, 229 
Scarlatina.     See  Scarlet  fever. 
fulminans,  137 
intermittens,  139 
miliaria,  139 
jiupulosa,  1.38 

pemphigoides  sen  bullosa,  139 
petechialisseu  hsemorrhagica, 

139 
simplex,  137 
sine  angina,  137 
with  pertussis,  188 
Scarlatinal  nephriti.s,  140 

diagnosis   of,   from  septic, 

142 
heart-failure  in,  148 
prognosis  of,  144 
treatment  of,  146 
Scarlatiuiform    erythema    fol- 
lowing chicken-pox,  159 
Scarlet  fever,  146.      See,    also. 
Scarlatina. 
association   of,   with    vari- 
cella, 131 
bacteriology  of,  133 
complications  of,  139 
contagion  after  disinfection 
in,  133 
by  fomites.  1.33 
by  milk,  1.33 
contagiousness  of,  131 
contagium  of.  132 
danger  in  light  cases  of,  144 
day  of  minimum  tempera- 
ture in,  137 
definition  of,  1.30 
diagnosis  of,  143 
from  erythema  scarlatini- 
forme, 143 
from  measles,  144 
from  rubella,  144 
disinfection     of     bedding 
after,  151 
of  room  after,  151 
endocarriitis  with,  978 
etiology  of,  131 
examination    of    urine   in, 

147 
history  of,  131 
incubation  of,  136 
in  etiology  of  chronic  tu- 
bal nephritis,  1018 
of  pericarditis,  975 
microbic  origin  of,  132 
mode    of    transmission   of, 

133 
mortality  of,  145 
pathology  of,  i:35 
prognosis  of,  144 
prophylaxis  of,  149 

failure  of  drugs  in,  149 
quarantine  in,  149 
sequelae  of,  142 
symptoms  of.  136 
treatment  of,  1.36 
value  of  isolation  in,  149 
varieties  of,  139 
Schools,  physical  culture  in,  54 


1236 


INDEX. 


Schultze's  method  of  artificial 

respiration,  78 

Sclerema  neonatorum,  1132 

diagnosis  of,  1132 

from  (edema,  1132 
etiology  of,  1132 
prognosis  of,  1132 
treatment,  1132 
Scleroderma,  1133 
diagnosis  of,  1133 
from  Ka]iosi's  disease,  1134 
from      sclerema     neonato- 
rum, 1133 
etiology  of,  1133 
prognosis  of,  1134 
treatment  of,  1134 
Sclerosis,  lateral,  with  syringo- 
myelia, 813 
of    Ammon's    horn    in    epi- 
lepsy, 748 
of  tubercle.  278 
Scoliosis,  334,  1063 
causes  of,  54 
diagnosis  of,  1063 
due  to  Pott's  disease,  1064 
etiology  of,  1063 
in  syringomyelia,  813 
mechanical  support  in,  1064 
prognosis  of,  1064 
treatment  of,  54 
Scorbutus,  389 
diagnosis  of,  395 
etiology  of,  389 
pathology  of,  390 
prognosis  of,  395 
relation  to  rickets,  392 
symptoms  of,  391 
treatment  of,  395 
Scrofula,  relation  of,  to  tuber- 
culosis. 277 
Scrofuloderma,  1143 
diagnosis  of,  1143 
etiology  of,  1142 
treatment  of,  1143 
Scrofulous  diathesis,  276 

in  etiology  of  acute  gastric 
catarrh,  442 
iritis,  1199 
kidney,  298 
Scurvy,  389.     See  Scorbutus. 

as  a  cause  of  hfematuria,  994 
Scutulum  of  favus,  1148 
Sea-air,  60 
in  asthma,  63 
in  chorea,  64 
in  convalescence,  62 
from  measles,  128 
in  diseases  of  the  eye,  65 
in  entero-colitis,  62 
in  nasal  catarrh,  63 
in  pharyngeal  catarrh,  63 
in  phthisis,  63 
in  Pott's  disease,  64 
in  rheumatism,  64 
in  rickets,  04 
ill  whoopiug-cough,  65 
odor  of,  60 
ozone  in,  60 
sodium  chloride  in,  90 
Sea-hathiiig,  65 
eflects  of,  66 
frequency  of,  66 
hour  for,  66 
rules  for,  66 
season  for,  66 
value  of,  65 
Sea-coast,  clothing  at,  67 


Sea-coast,  death-rate  at,  61 
exercise  at,  07 
food  at,  (i7 
rainfall  at,  62 
temperature  at,  61 
wind  at,  02 
Season   in   etiology  of   chorea, 
756 
of  erysipelas,  221 
of  malaria,  304 
of  measles,  118 
of  variola,  163 
of  whooping-cough,  182 
Seat- worm.     See    Oxyuris    ver- 

niictdaris. 
Sea-water,  comjiosition  of,  65 
Sebaceous  cj'st  of  eyelid,  1183 
Seborrhcea,  1091 
diagnosis  of,  1091 
from  eczema,  1091 
from  psoriasis,  1091 
etiology  of,  1091 
of  lid-border.     See  Blephari- 
tis. 
prognosis  of,  1092 
treatment  of,  1092 
Second    attacks    of    whooping- 
cough,  1H2 
Sedentary  habits  in  etiology  of 
constipation,  497 
life  in  etiologv  of  constipa- 
tion, 497 
Sediment  in  urine  of  acute  tu- 
bal nephritis,  1012 
Segmentation   of   malarial   or- 
ganisms, 306 
relation  of,  to  paroxysm, 
306 
Sensory  symptoms  of  syringo- 
myelia, 812 
Septal     deflection    in    adenoid 

hypertrophy,  431 
Septic   di.seases  in  etiology  of 
acute     tubal     nephritis, 
1011 
infection  of  new-born,  89 
projihylaxis  of,  89 
treatment  of,  89 
Septicajmia  in  etiology  of  bron- 
chitis, 925 
in  scarlet  fever,  142 
Septico-pyremia    of    new-born, 

pleurisy  in,  938 
Serous  cystic  tumors  of  perito- 
neum, 570 
exudate  in  peritonitis,  565 
irido-cvclitis,  1198 
iritis,  il98 
Serpiginous  corneal  ulcer,  1195 
Serum-test  for  typhoid  fever, 

205 
Serum    treatment   of  croupous 

pneumonia,  918 
Sex    in    etiologv   of    chlorosis, 
362 
of  chorea,  7.56 
of  chronic  ])eritonitis,  ,568 
of    cirrhosis   of    tlie   liver, 

558 
of  diabetes  mellitus,  999 
of  intussusception,  518 
of    laryngismus    stridulus, 

858 
of  rheumatism,  351 
of  simple  meningitis,  596 
of  tuberculous  meningitis, 
610 


Sex  in  etiology  of  typhlitis,  510 
of  vesical  calculus,  1040 
of  whooping-cough,  183 
in  prognosis  of  pertussis,  189 
Sexual  organs  in  idiocy,  675 
power  in    hereditary  ataxia, 
817 
Shell-fish  in  diabetic  diet,  1003 
Shingles.     See  Herpes  ::oster. 
Shoe  for  club-foot,  1085 
Shoes  for  children,  34 
Shoulder-joint  disease,  1081 
prognosis  of,  1018 
symptoms  of,  1081 
treatment  of,  1081 
Signe  de  Dance,  519 
Silver   nitrate  in  jaundice,  .548 
in  ophthalmia  neonatorum, 

1187 
in  stomatitis  aphthosa,  400 
catarrhal  is,  39H 
syphilitica,  409 
Simple   atrophy.     See  Atrophy, 
sim2)le. 
corneal  ulcer,  1195 
Sinapisms    in    Landry's    paral- 
ysis, 799 
Sipbonage  in  empyema,  948 
of  chest,  details  of  operation, 
949 
Size,    average,     of     new-born 

child,  12 
Skeleton,     efl'ect     of     rachitis 

upon,  337 
Skin,    appearance    of,    in    dis- 
ease, 5 
in  health,  5 
atrophies  of,  1135 
condition  of',  in  health,  13 
in    intestinal    tuberculosis 

13 
in  marasmus,  13 
in  mucous  disease,  13 
in  ])rotracted  diarrhoea,  13 
diseases  of,  1090 
haemorrhages  of,  1125 
hypertrophies  of,  1128 
in  acute  poliomyelitis,  792 
in  post-natal  atelectasis,  900 
in  scarlet  fever,  136 
in  simple  atro])hy,  505 
in  typhoid  fever,  197 
new  growths  of,  1137 
parasitic  aflTections  of,  1199 
symptoms  in  tyjjhoid  fever, 
199 
Skoda's  resonance,  296 
Skull,  depressions  in,  83 
Sleep,  34 

amount  required,  34 

in    chronic    gastric   catarrh, 

449 
in  typhoid  fever,  198 
regularity  in,  34 
temperature  of  room  for,  35 
"  Sleeping  cool,"  4 
"  Sleeping  high,"  4 
Sloughing  corneal  ulcer,  1195 
Slow  fever.     See  Ti/jihoid  fever. 
heart,  988 

pulse  in  acute  gastric  catarrh, 
444 
in  diphtheria,  256 
Small-pox.     See  Variola. 
Soap  i)laster,  Hardaway's  modi- 
fication of  Pick's,  1108 
Pick's,  in  eczema,  1108 


INDEX. 


1237 


Soda  solution,  Parker's,  882 
Sodium  bicarbonate  in  chronic 
gastric  catarrh,  451 
in  rheumatism,  357 
in  stomatitis  mycosa,  402 
bromide    in     clironic    heart 
disease,  985 
in     ursemic     convulsions, 
1016 
ethylate    for    nsevus    vascu- 
laris, 1139 
hypophosphite  in  furunculus, 

1124 
phosphate  in  cirrhosis  of  liver, 
560 
in  congestion  of  liver,  551 
in  constipation,  499 
in  jaundice,  548 
in  lithEemia,  101 
salicylate  in  acute  folliculous 
tonsillitis,  420 
in  chorea,  762 
in  diabetes  mellitus,  1004 
in  lithsemia,  1101 
in  peritonsillar  abscess,  421 
in  rheumatism,  356 
Softening  of  tubercle,  278 
Solitary    follicles     in    typhoid 

fever,  196 
Solution,  Gabbet-Ernst's,  271 

of  fuchsin,  Ziehl's,  271 
Somatose  in  typhoid  fever  diet, 

206 
Somnambulism,  732 
Somnial  epilepsy,  751 
Sore  throat.     See  Awiina. 
in  chicken-pox,  157 
in  typhoid  fever,  199 
Soups  in  diabetic  diet,  1003 
Soya  flour  in  diabetes,  1002 
Sparteine  in  atelectasis,  903 

in  peritonitis,  567 
Spasm    in   laryngismus   stridu- 
lus, 861 
inward,  744 
Spasmodic    laryngitis,     severe 

form,  852 
Spasmus  glottidis.     See  Laryn- 
gismus stridulus. 
Specific   fevers   in   etiology  of 
acute  gastric  catarrh,  442 
Spectacles     in    treatment     of 
concomitant   convergent 
strabismus,  1204 
Speech,    afiections    of,   due    to 
peripheral  paralysis,  664 
bad  habits  of,  665 
defects  and  anomalies  of,  658 
from  adenoid  growths,  665 
treatment  of,  665 
in  cretinism,  681 
in  hereditary  ataxia,  818 
in  idiocy,  675 
Sphincter     ani,    paralysis    of, 
with    tumors    of    spinal 
cord,  804 
Spigelia  against  ascarides,  529 

against  seat-worms,  531 
Spina  bifida  in  hydrocephalus, 

627 
Spinal  cord,  tumors  of,  801 
tenderness    in    acute     lepto- 
meningitis, 779 
Spine,     lateral    curvature     of, 
1063.     See  Sclerosis. 
tuberculosis    of,    1064.      See 
Fott's  disease. 


Spirillum    cholereae    Asiaticse, 
232 
bacteriology  of,  232 
modes   of  multiplication 

of,  232 
multiplication  of,  in  cul- 

ture-mediA,  233 
poison  elaborated  by,  235 
Spleen,  chronic  diffuse  tubercu- 
losis of,  282 
enlargement  of,  diagnosis  of, 
14 
in  malarial  cachexia,  314 
in  rachitis,  326 
in  diphtheria,  254 
in  leukaemia,  374 
in  pernicious  malaria,  309 
in  splenic  anaemia,  .368 
in  typhoid  fever,  196,  197,  200 
superior  border  of,  17' 
syphilis  of,  105 
Splenectomy  in  leukaemia,  376 
Splints  for  knee-joint  disease, 

1078 
Sporadic  cerebro-spinal  menin- 
gitis.      See      Meningitis, 
simple   cerebro-spinal. 
cretinism,  684 
Spraying  in  diphtheria,  264 
Sprays  in  hypertrophic  rhinitis, 

832 
Squamous    blepharitis.         See 

Blepharitis. 
Squills  in  broncho-pneumonia, 
883 
in  severe  spasmodic  laryngi- 
tis, 854 
Squint.     See  Strahismus. 
Stacke    operation    in    chronic 
suppurating  middle  ear, 
1172 
Stammering,  664 
Staphylococci  in  croupous  pneu- 
monia, 914 
Staphylococcus   albus  in  acute 
folliculous  tonsillitis,  418 
in  broncho-pneumonia,  904 
in  peritonitis,  564 
pyogenes  aureus  in  acute  fol- 
liculous tonsillitis,  418 
Staphyloma  of  cornea,  1196 

treatment  of,  1196 
Staphylorraphy,  435 

conditions  for  success  In,  436 
Starch,  digestion  of,  45 
diastase  in,  45 
fermentation  of,  22 
Starvation,    partial,    in    treat- 
ment of  taenia,  536 
Statistics  in  appendicitis,  516 
of  operations  for  stone,  1047 
of  tracheotomy,  873 
Status  eclampticus,  744 

epilepticus,  751 
Stenosis,  aortic,  973 
mitral,  973 
of  aorta,  963 
of  conus  arteriosus,  962 
of  pulmonary  artery,  961 
causes  of,  962 
symptoms  of,  962 
Sterilization,  47 
apparatus  for,  26 
at  low  temperature,  48 
method  of,  27 
of  milk,  26 
advantages  of,  48 


Sterilization  of  milk,  disadvan- 
tages of,  48 
Sterilized  milk,  character  of,  27 
Stigmata  degenerationis,  654 
in  cirrhosis  of  liver,  558 
of  epilepsy,  751 
of  hysteria,  732 
Stimulants.     See  Alcohol. 
in  acute  milk  infection,  478 
in  cerebral  meningitis,  604 
in  croupous  pneumonia,  918 
in  dysentery,  493 
in  erysipelas,  229 
in  post-natal  atelectasis,  903 
"Stomach   cough"    in    clironic 

gastric  catarrli,  149 
Stomach-washing  in  acute  milk 

infection,  477 
Stomatitis  aphthosa,  399 
etiology  of,  399 
prognosis  of,  400 
treatment  of,  400 
catarrhal  is,  397 

erythematous  form  of,  397 
etiology  of,  397 
in  pertussis  and  acute  ex- 
anthemata, 398 
in  teething,  412 
prognosis  of,  398 
treatment  of,  398 
crouposa,  407 
diphtheritica,  407 
diagnosis  of,  408 
primary,  in  mouth,  408 
prognosis  of,  408 
treatment  of,  408 
follicular,   in   chronic  intes- 
tinal indigestion,  468 
gangraenosa,  405 
etiology  of,  405 
pathology  of,  405 
prognosis  of,  407 
treatment  of,  407 
in  subacute   milk   infection, 

481 
mycosa,  400 
etiology  of,  401 
in  chronic  gastric  catarrh, 

448 
pathology  of,  401 
prognosis  of,  407 
treatment  of,  402 
syphilitica,  408 

treatment  of,  409 
ulcerosa,  402 
chronic,  404 
etiology  of,  402 
pathology  of,  403 
prognosis  of,  404 
treatment  of,  404 
Stomodaeum,  477 
Stone  in  bladder,  symptoms  of, 

1008 
Stools  in  acute  intestinal  indi- 
gestion, 466 
in  acute  milk  infection,  476 
in  amcebic  dysentery,  491 
in  catarrhal  dysentery,  488 
in  cholera,  237 

in   chronic     intestinal    indi- 
gestion, 468 
in  simple  atrophy,  505 
in   subacute   milk  infection, 
479 
Strabismus,  1102 
after  acute  illness,  1103 
concomitant  convergent,  1102 


1238 


INDEX. 


Strabismus,   concomitant    con- 
vergent, causes  of,  1103 
diagnosis  of,    from  par- 
alytic, 1103 
treatment  of,  1103 
convergent,  1102 
divergent,  1102 
in  cerebral  meningitis,  599 
in  cerebro-spinal  meningitis, 

210 
in  idiocy,  (574 
in       simple      cerebro-spinal 

meningitis,  606 
in    tuberculous     meningitis, 

617 
in  typhoid  fever,  200 
paralytic  convergent,  1102 
upward  or  downward,  1102 
Stramonium  in  asthma,  961 
Strangulation,  internal,  by  ap- 
pendix, 516 
Strapping     in     hydrocephalus, 

629 
Streptococci     associated     with 
bacillus     of    diphtheria, 
252 
in  diphtheria,  266 
in   septic   infection   of  new- 
born, 89 
Streptococcus  erysipelatis,  223 
in  acute  folliculous  tonsillitis, 

418 
infection  by,  in  pustules  of 

variola,  167 
in  peritonitis,  564 
in  pseudo-membrane  of  vari- 
ola, 165 
invasion  of,  in  variola,  167 
lanceolatus  in  pleurisy,  939 
pyogenes  aureus  in  pleurisy, 
939 
in  acute  folliculous  tonsil- 
litis, 418 
in  broncho-pneumonia,  904 
in  croupous  pneumonia,  914 
in  pleurisy,  939 
Stretcher-bed   for    ambulatory 
treatment  of  Pott's   dis- 
ease, 1069 
Stricture  of  anus,  587 

of  rectum,  589 
"  Strippings,"  25 

value  of,  38 
Strontium  lactate    in    chronic 
interstitial         nephritis, 
1026 
Strophanthus     in     atelectasis, 
903 
in   chronic    tubal    nephritis, 

1023 
in  peritonitis,  567 
Strophulus  albidus.     See   Mil- 
inni. 
in  simple  atrophy,  505 
Strumous    keratitis    and    con- 
junctivitis.    See   Kerato- 
conjunctivitis,    phlyctenu- 
lar. 
Strychnine  in  acute  poliomye- 
litis, 795 
in  asphyxia  of  new-born,  80 
in  asthma,  962 
in  broncho-pneumonia,  911 
in  chronic  heart  disease,  985 
in  croupous  pneumonia,  918 
in  diphtheria,  261 
in  diphtheritic  paralysis,  268 


Strychnine  in  incontinence  of 
urine,  997 
in    pulmonary     emphysema, 

954 
in  variola,  170 
Stupes  in  peritonitis,  566 
Stupor  in   invasion  of  variola, 
164 
in    tuberculous     meningitis, 
611,  616 
Stuttering,  664 
Stye.     See  Hordeolum. 
Subcutaneous  nodes  in  chorea, 

755 
Subsultus  tendinum  in  cerebro- 
spinal meningitis,  210 
Succussion  sound  in  pyopneu- 
mothorax, 945 
Sucrose,  46 

Suction,  act  of,  significance  of 
its  diminution,  6 
significance  of    its    re-estab- 
lishment, 6 
Sudamina    in    typhoid    fever, 

199 
Sugar  in  urine  in  simple  atro- 
phy, 506 
proportion   of,  in   milk    and 

cream  mixtures,  59 
tests  for,  in   diabetic  urine, 
1000 
Sugars,  digestion  of,  45 
Suggestion  in  hysteria,  740 
Sulphonal  in  diabetes  mellitus, 
1004 
in  variola,  169 
Sulphur  in  scabies,  1155 

in  pertussis,  193 
Sulphuric  acid  in  cholera,  244 

in  night-sweats,  302 
Sulphur-vapor    after    diphthe- 
ria, 261 
Summer   diarrhrea.      See  Milk 

infection,  subacute. 
Superficial  cervical  fascia,  872 
Suppositories    in    constipation, 
499 
in  prolapse  of  rectum,  591 
Suppuration,  chronic,  in  etiol- 
ogy    of      chronic     tubal 
nephritis,  1018 
fever  of,  in  variola,  165 
in  etiologv  of  amyloid  kid- 
ney, 1024 
in  hydatid  of  liver,  556 
in  typhlitis,  511 
Suppurative  pleurisy,  935 
Supraglottic     laryngitis.       See 
Laryngitis  catarrhalis  sim- 
plex. 
Suprapubic  litliotoniy,  1047 
Surf-bathing     in     etiology    of 
middle     ear     inflamma- 
tion, 1166 
Surgical  treatment  in  infantile 
cerebral  palsies,  657 
of  brain  tumors,  644 
of  epilepsy,  753 
Sweating  in  gangrene  of  lung, 
921 
in    pulmonary    tuberculosis, 
296 
Sweats  in  rlieumatism,  352 
Sylvester's  method  of  artificial 

respiration,  79 
Symblepharon,  1182 
treatment  of,  1182 


Sympathetic  irritation,  1199 

ophthalmitis,  1199 
Syncope,  988 

in  secondary  anaemia,  361 
local,  821 
Synechia,  anterior,  1196 
Synechife,  posterior,  1198 
Synovitis  in  chicken-pox,  159 
Sypliilide,   papular,   of   eyelid, 

1180 
Syphilis,  acquired,  103 
after  vaccination,  175 
as  a  cause  of  ricliets,  323 
haemorrhagica     neonatorum, 

110 
hereditary,  103 
alopecia  in,  112 
blood  in,  110 
bone-lesions  in,  106 

diagnosis       of,       from 
rickets,  113 
from      tubercular, 
113 
conceptional,  103 
coryza  in,  109 
definition  of,  103 
diagnosis  of,  1 12 

from  scrofula,  112 
disturbance     of    nutrition 

in,  110 
glandular  enlargements  in, 

110 
in  etiology  of  splenic  anae- 
mia, 368 
in  infancy,  103 
involvement   of   bones   in, 

111 
lesions  of  heart  in,  106 
of  kidneys  in,  106 
of  liver  in,  106 
of  lungs  in,  105 
of    mucous    membranes 

in,  105,  109 
of  pancreas  in,  106 
of  spleen  in,  106 
of  testicles  in,  106 
maternal  influence  in,  128 
morbid  anatomy  of,  105     ' 
mucous  patches  in,  110 
myositis  in,  111 
nervous    disturbances     in, 

111 
of  nose  and  throat,  842 
paternal  influence  in,  103 
placenta  in,  105 
prognosis  of,  103 
rashes  of,  109 
skin  symptoms  of,  109 
symptoms  of,  108 
teeth  in,  111 
treatment  of,  115 
visceral  lesions  of,  105 
in  etiology  of  acquired  laby- 
rinthine deafness,  1176 
of  amyloid  kidney,  1024 
of  cirrhosis  of  liver,  558 
of  leukaemia,  .370 
of  lymphatic  anaemia,  370 
of  ])aroxysmal   haematuria, 
994 
inherited   nervous   aflTections 

due  to,  645 
late  hereditary,  114 

bone-afTections  in,  114 
genital  organs,  in  115 
interstitial    keratitis   in, 
115 


INDEX. 


1239 


Syphilis,   late  hereditary,   ne- 
phritis in, 115 
periostitis  in,  114 
teeth  in,  114 
of  eyelids,  1180 
of  rectum,  589 
primary  lesions  of,  in  mouth, 

408 
pulmonary,   causative  of  as- 
phyxia, 77 
secondary      lesions      of,      in 

mouth,  408 
skin-lesions  of,  105 
tarda.     See   Byphilis,   late   he- 
reditary. 
Syphilitic  asthma,  954 
headache,  722 
lesions  of  auricle,  1160 
Syphilization,  double,  104 
Syphiloderma,  1143 
diagnosis  of,  1145 
bullous,    from     pemphigus 

neonatorum,  1145 
erythematous,  from    inter- 
trigo, 1145 
etiology  of,  1145 
prognosis  of,  1145 
treatment  of,  1145 
Syringing  in  cerumen    impac- 
tion. 1162 
in  extracting  foreign  bodies 
from  auditory  canal,  1164 
Syringomyelia,  809 
diagnosis  of,  814 
etiology  of,  809 
morbid  anatomy  of,  810 
pathology  of,  SIO 
symptoms  of.  812 
treatment  of,  914 
Systolic  mitral  murmur,  rela- 
tive frequency  of.  982 
murmur  in  aortic  stenosis,  982 
in    defect    of     ventricular 

septum,  9fi9 
in  mitral  regurgitation,  981 

Tabes  mesenterica,  286 
Tache    cerebrale    as   a     differ- 
ential sign  in  tuberculous 
meningitis.  203 
in  cerebral  meningitis,  599 
Tachycardia,  988 
Taenia,  532 

cucumerina.  534 
mediocanellata,  533 
nana,  534 
solium,  533 
Tsenife.  diagnosis  of,  535 
habitat  of,  534 
method  of  infection  by,  534 
ova  of,  534 
treatment  of,  535 
varieties  of,  533 
Talipes  calcaneus,  1083 
equinus,  1083 

in       pseudo  -  hypertrophic 
paralysis,  771 
equino-varus,  1086 

open  incision  for,  1086 
valgus,  1083 
varus,  1083 
Tannin      in     gastro-intestinal 

haemorrhage,  87 
Tapeworm.     See  Teenia. 
Tapotement,  57 

Tar-and-zinc   ointment    in    ec- 
zema of  scalp.  1109 


Tarsitis.  1181 

Tarsorraphy  for  lagophthalmos, 

1182 
Tarsus,  tuberculous  disease  of, 

1079 
Tartar  emetic   in   severe   spas- 
modic laryngitis,  854 
Tattooing  in  leucoderma,  1136 
Taxis  in  intussusception.  -521 
Taylor's    brace   for  Pott's   dis- 
ease, 1070 

long    hip-splint    for   hip-dis- 
ease, 1074,  1075 
Tears,  significance  of,  in  prog- 
nosis, 7 
Teeth,  eruption  of,  in  etiology 
of  eczema,  1103 

in  typhoid  fever,  137 

milk,  appearance  of,  17 

permanent,  17 

order  of  appearance  of,  411 

premature,  411 

time  of  eruption  of,  411 
Teething  as  an  etiological  fac- 
tor. 409 

order  of,  410 

symptoms  of,  412 

treatment  of,  413 
Temperature.  11 

abnormal  depression  of,  12 

during  first  week  of  life,  11 

estimation  of,  11 

in  acute  gastric  catarrh,  443 

in   acute   intestinal   indiges- 
tion, 466 

in  acute  milk  infection,  476 

in  acute  myelitis,  734 

in  acute  poliomyelitis,  790 

in   acute  spinal    meningitis, 
780 

in  acute  tubal  nephritis,  1071 

in  brain  abscess,  631 

in  bronchitis,  923 

in  broncho-pneumonia,  906 

in  catarrhal  dysentery,  488 

in  cerebral  meningitis,  598 

in  cerehro-spinal  meningitis, 
211.  607 

in  chicken-pox,  158 

in  cholera,  238 

in  chronic  intestinal  indiges- 
tion, 468 

in  chronic  peritonitis,  568 

in  cirrhosis  of  liver,  .558 

in  croupous  pneumonia,  914 

in  diphtheria,  256 

in  disease.  12 

in     epidemic    cerebro-spinal 
meningitis.  211 

in  erysipelas,  225 

in  gangrene  of  lung,  921 

in     infectious     pseudo-mem- 
branous tonsillitis,  419 

in  influenza.  216,  217 

in  intussusception,  419 

in  Landry's  paralysis,  799 

in  lithaemia,  97 

in  lymphatic  anpemia,  387 

in  malignant  measles,  123 

in  measles,  119.  121 

in  perinephritic  abscess,  1033 

in  peritonitis,  565 

in  peritonsillar  abscess,  421 

in  pleurisy,  940,  941 

in  post-natal  atelectasis,  900 

in  rachitis.  339 

in  Raynaud's  disease,  822 


Temperature  in  rubella,  154 
in  scarlet  fever,  137 
in  scorbutus,  392 
in  severe  spasmodic  laryngi- 
tis, 583 
in  simple  atrophy,  505 
in  spasmodic  laryngitis,  BoO 
in  stomatitis  catarrhalis,  398 
in  stomatitis  gangrenosa,  406 
in   subacute   milk   infection, 

479 
in  subacute  purpura  hsemor- 

rhagica,  380 
in  syphilitic  inflammation  of 

liver,  5.52 
in     tuberculous    meningitis, 

611.  614 
in  typhlitis,  511 
in  typhoid  fever,  198,  201 
in  vaccinia,  174 
in  variola,  164 

after  eruption,  165 
in  whooping-cough,  185 
maximum  of.  12 
minimum  of,  12 
oscillations  of,  11 

in  disease,  12 
post-mortem   rise  of,  in  ery- 
sipelas. 223 
post-typhoid  elevation  of,  221 
variations  in   typical    range 
of,  12 
Temporal  bone,  necrosis  of,  in 

ear  disease,  1173 
Tenderness  in  intussusception, 
519 
in  peritonitis,  565 
in  typhlitis.  510 
of  surface  in  rachitis,  349 
in  scorbutus,  451 
Tendon-reflexes  in  pseudo-hy- 
pertrophic  paralysis,  771 
Tenesmus,  hysterical,  7.35 
in  intussusception,  520 
Tenotomy  in  club-foot,  1084 
in  infantile  cerebral  palsies, 
657 
Terebene  in  pulmonary  emphy- 
sema. 955 
in  tuberculosis,  302 
Terebinthiue    in    tuberculosis, 

301 
Tertian  intermittent  fever,  310 
chilly  stage  of,  310 
diagnosis  of,  315 
fever  stage  of,  310 
parasite  of,  304 
physical  signs  in.  312 
sweating  stage  of,  311 
temperature  m,  310 
Testicle,  syphilis  of,  106 

tuberculosis  of.  99 
Tetanus  of  new-born,  91 

treatment  of,  91 
Tetany,  794 

diagnosis  of,  766 

from  hysteria,  766 
etiology  of,  764 
in  rachitis,  341 
morbid  anatomy  of,  766 
prognosis  of,  767 
relation    of,   to    laryngismus 

stridulus,  858 
.symptoms  of,  765 
treatment  of,  767 
Theoretical  formula  for  feeding 
with  modified  milk,  55 


1240 


INDEX. 


Thermo-cautery    in   stomatitis 
mycosa,  407  , 

Thirst  in  acute  milk  infection, 
476  ! 

in  cholera,  237 
in  diabetes  insipidus,  977 
in  diabetes  mellitus,  971 
in  measles,  119 
in  rachitis,  339 
in  simple  cerebro-spinal  men- 
ingitis, 607 
in  typhoid  fever,  205,  206 
Thomas's    knee -splint,     1078, 

1079 
Thompson's  mixture  in  rachi- 
tis, 349 
Thomsen's    disease.      See    My- 
otonia. 
Thorax,   deformity  of,    in    ra- 
chitis, 334 
with  adenoid  vegetations, 
432 
rachitic  deformity  of,  341 
Thread-worm.    See  Oxyuris  ver- 

micularis. 
Thrill  in  mitral  stenosis,  982 
Throat,  treatment  of,  in  scarlet 

fever,  146 
Thrombosis   in   infantile   cere- 
bral palsies,  6.56 
of  dural  sinuses  in  dysentery, 
486 
Thrush    in    chronic    intestinal 
indigestion,  486 
in  simple  atrophy,  505 
Thymol  in  tuberculosis,  302 
Thymus  gland,  relations  of,  in 

tracheotomy,  872 
Thyroid  extract  in  cretinism, 
685 
gland,  alteration  in,  in  cretin- 
ism, 683 
connection     of     cretinism 

with,  684 
desiccated,    in     cretinism, 

686 
importance  of,   in   animal 

economy,  683 
transplantation  of,  in  cre- 
tinism, 685 
Tibia,  changes  in,  in  rachitis, 

337 
Tinea  circinata,  1151 
diagnosis  of,  1152 
from  psoriasis,  1152 
from  seborrhcea,  1152 
from  syphilis,  1152 
treatment  of,  1153 
favosa,  1148 

diagnosis  of,  1149 
etiology  of,  1149 
prognosis  of,  1149 
treatment  of,  1150 
tonsurans,  1151 

diagnosis  of,  from  alopecia 
areata,  1152 
from  eczema,  1152 
from  psoriasis,  1152 
from  seborrhcea,  1152 
disseminata,  1152 
treatment  of,  1153 
trichophytina,  1151 
etiology  of,  11.52 
prognosis  of,  1152 
treatment  of,  1153 
Tongue,      appearance     of,     in 
health,  17 


Tongue  in  acute  gastric  catarrh, 
443 

in  catarrhal  dysentery,  488 

in  fever,  17 

in  invasion  of  variola,  164 

in  malignant  measles,  123 

in  measles,  120,  122 

in  peritonitis,  565 

in  post-natal  atelectasis,  899 

in  rheumatism,  3.52 

in  rubella,  1-54 

in  scarlet  fever,  137 

in  simple  atrophy,  505 

in  stomatitis  catarrhalis,  398 

in  stomatitis  syphilitica,  409 

in  typhlitis,  511 

in  typhoid  fever,  197,  199 

paralysis  of,  in  tuberculous 
meningitis,  617 

yellowish  ulceration  of  frae- 
num  of,  in  pertussis,  188 
Tongue-tie,  665 
Tonic  spasms  in  cerebro-spinal 

meningitis,  210 
Tonics  after  parotitis,  180 

after  pericarditis,  976 

in  middle-ear  inflammation, 
1169 
Tonsillitis,    acute     folliculous, 
418 
infectious  nature  of,  418 
treatment  of,  420 

croupous.  See  Tonsillitis,  in- 
fectious pseudo-membran- 
ous. 

infectious      pseudo-membra- 
nous, 418 
diagnosis  of,  419 

from  diphtheria,  419 
etiology  of,  418 

in  rheumatism,  354 

lacunaris,  418 

parenchymatous,  421 

phlegmonous,  421 

simple  folliculous,  419 

suppurative.   See  Peritonsillar 


Tonsillotome,  Mathieu's,  424 
Tonsillotomy,  author's  method 

of,  425 
Tonsils,  hypertrophy  of,  422 
etiology  and  pathology  of, 

422 
hyperplastic  form  of,  422 
symptoms  of,  423 
treatment  of,  423 
Topopliobia,  704 
Torticollis,  1062 
brace  for,  1063 
diagnosis  of,  1062 
difierentiation  from  cervical 
abscess,  1063 
from  Pott's  disease,  1062 
prognosis  of,  1063 
treatment  of,  1063 
with   tumors  of  spinal  cord, 
803 
Toxalbumin  of  diphtheria,  253 
Trachea,   relations  of,   in   tra- 
cheotomy, 873 
Tracheal    dilators  for    trache- 
otomy. 875  ^ 
forceps  for  tracheotomy,  875 
Tracheitis,  924 

Tracheo-bronchial  glands,  sup- 
puration of,  286 
tuberculosis  of,  285 


Tracheo-bronchial    glands,  tu- 
berculosis  of,  symptoms 
of,  2b6 
Tracheotomy,  870 

after-treatment  of,  881 
age  in  prognosis  of,  874 
anaesthetics  in,  877 
cau.ses  of  death  after,  884 
choice  of  operations  for,  876 
complications  after,  885 

during  operation  of,  881 
condition   of   patients  after, 

889 
feeding  after,  884 
immediate  results  of,  881 
indications   for   operation  of, 

873 
in  diphtheritic  or  membran- 
ous laryngitis,  872 
instruments  reijuired  for,  874 
in  treatment  of  foreign  bodies 
in  larynx  and  trachea.  867 
in  very  advanced  cases,  871 
position  of  patient  for,  877 
prognosis  of,  873 
rapid,  889 

removal  of  membrane  in,  880 
statistics  of,  873 
technique  of,  878 
thermo-cautery  in,  889 
time  for  operation  of,  871 
without  tubes,  888 
Tracheotomy-tube,  care  of,  883 
change  of,  883 

difficulties  in  permanent  re- 
moval of.  886 
disinfection  of,  883 
permanent  removal  of,  883 
Tracheotomy-tubes,  875 
Trachoma.     See    Conjunctivitis, 

granular. 
Trachoma-coccus,  1191 
Traction  upon  prepuce  in  stone 

cases,  779 
Tragus-pressure       in     chronic 

tympanic  catarrh,  1175 
Training     in      treatment     of 

speech-defects,  666 
Transitory  frenzy,  699 

psychoses,  698 
Transposition  of  arte  rial 

trunks,  972 
Traumatic  iritis,  1198 
Traumatism      in    etiology    of 
acute  peritonitis,  563 
of   acute   tubal    nephritis, 

1011 
of  hysteria,  729 
of  pleurisy,  938 
Treatment,  general  remarks  on, 

35 
Tremor  in    hereditary  ataxia, 
818 
in  hysteria,  735 
Trephining  in   hydrocephalus, 

629 
Trichiasis,  1182 
Trichocephalus  dispar,  537 
Trichophyton  fungus.  1152 
Tricu-spid  regurgitant  murmur, 
983 
regurgitation,  983 
prognosis  of.  984 
valve,  anomalies  of,  970 
Trigeminal  pulsation,  988 
Trional  in  typhoid  fever,  206 
Trommer's  test  for  sugar,  1001 


INDEX. 


1241 


Trophic  disturbance  in  infan- 
tile cerebral  palsies,  652 
lesions  in  syringomyelia,  813 
with  tumors  of  spinal  cord, 
803 
Tropical  dysentery.     See  Dys- 
entery, amosbic. 
malaria.      See   jEstivo-autum- 
nal  fevers. 
Trousseau  sign  in  tetany,  765 
Trousseau's  diuretic  wine,  1023 
Trypsin  in  diphtheria,  264 
Tubercle  bacilli.    See  Bacillus 
tuberculosis, 
in  air,  274 
in  dust,  274 
in  milk.  286 
diffuse  infiltrated,  278 
in  etiology  of  typhlitis,  510 
of  conjunctiva,  1192 
secondary  inflammatory  pro- 
cesses with,  279 
Tubercular   infection   of    new- 
born, 90 
iritis,  1199 
■     syphiloderm,  1144 

tumors  of  brain  and  menin- 
ges, 635 
Tuberculin,    Hunter's    modifi- 
cation of,  301 
in  lupus  vulgaris,  1033 
in  tuberculosis,  301 
Tuberculocidin     in     treatment 

of  brain  tumors,  643 
Tuberculosis,  270 
acute,  Ehrlich's  reaction  in, 
2B1  „ 

following  operation,  2ii 
miliary,  279 

diagnosis  of,  281 
prognosis  of,  281 
pulmonary  type  of,  280 
typhoid  type  of,  280 
bacillus  of.  271 
chronic  diffuse,  282 
diagnosis  of,  283 

from    gastro-intestinal 

catarrh,  283 
from  rickets,  283 
from  syphilis,  283 
complicating     broncho-pneu- 
monia, 908 
conditions  favoring,  276 
congenital,  273 
experimental,  272 
following  acute  gastro-intes- 
tinal catarrh,  282 
following     infectious     disor- 
ders, 276 
following  measles,  282 
following      whooping-cough, 

282 
general  etiology  and  morbid 

anatomy  of,  270. 
generalized  forms  of,  279 
haemoptysis  in,  277 
hereditary    transmission    of, 

theories  of,  273 
immunity  of,  277 
incidence     of,    statistics     of, 
271 
in   infancy  and  childhood, 
270 
in  dairies,  275 
in  diabetes,  1000 
individual  predisposition  to, 
276 


Tuberculosis    in     etiology    of 
fibroid  phthisis,  964 
inoculation  of,  274 
local  epidemics  of,  274 
localized,  233  _    | 

modes  of  transmission  of,  272 
mortality  of,  271  j 

in  prison,  274  j 

of  abdominal  organs,  287       .  i 
of  ankle,   1079.      See  AnUe- 
joint  disease.  \ 

of    elbow-joint,     1080.       See 

Elboto-joint  disease. 
of  Fallopian  tubes,  299 
of  hip-joint,  1072.    See  Hip- 
joint  disease.  « 
of  intestines,  287,  288 
of  joints,  1071 
of  kidneys,  298 
of  knee-joint,  1076 
of  liver,  23S 
of  lungs,  292 
of  lymph-glands,  283 
of  ovaries,  299 
of  pericardium,  298 
of  pleura,  293 
of  shoulder -joint,  1031 
of   spine,    1064.      See    Potfs 

disease. 
of  testis,  299 
of    wrist-joint,     1030.       See 

Wrist-joint  disease. 
prophylaxis  of,  299 
pulmonary,  294 
course  of.  297 
diajruosis  of,  297 
in  '^etiology   of  bronchitis, 

925 
morbid  anatomy  of  295 
physical  signs  of,  296 
prognosis  of,  297 
symptoms  of,  295 
relation     of      broncho-pneu- 
monia to,  293 
relation  of  scrofula  to,  277 
spontaneous  cure  of,  300 
transmission  of,  by  food,  275 
by  inhalation,  274 
by  meat,  275 
by  milk,  275 
treatment  of,  300 
uro-genital,  298 
Tuberculous  diathesis,  276 
characteristics  of,  15 
inflammation  of  middle-ear, 

1171 
meningitis,    600,    610.       See 
Meningitis,  tnbercnlous. 
in  Pott's  disease,  1067 
ulcer,  description  of,  287 
virus  in  foetus,  273 
Tumor  in  hydatid  of  liver,  556 
in  hydronephrosis,  1030 
in  intussusception,  520 
in  suppurative  hepatitis,  503 
Tumors    about    crura    cerebri, 
641 
at  base  of  brain,  643 
in     causation     of    headache, 

721 
of  brain  and  meninges,  634 
comparative      frequency 
•  of,  634 
differential  diagnosis  of, 

643 
etiology  of,  634 
pathology  of,  634 


Tumors  of  brain  and  meninges, 
prognosis  of,  643 
symptoms  of,  636 
treatment  of,  643 
of  cerebellum,  643 
of  conjunctiva,  1136 
of   cortical    and    subcortical 

regions,  638 
of  evelids,  1180 
of  frontal  lobe,  641 
of  kidney,  1034 
diagnosis  of,  1036 

from  ovarian  cysts,  1036 
from     perityphlitic    ab- 
scess, 1036 
etiologv  and  pathology  of, 

1034" 
prognosis  of,  1036 
symptoms  of,  1035 
treatment  of,  1036 
of  medulla  oblongata,  643 
of  motor  area,  640 
of  occipital  lobe,  640 
of  parietal  lobe,640 
of  pons,  642 

of  quadrigeminal  region,  642 
of  spinal  cord,  801 
diagnosis  of,  806 
from  fracture  of  ver- 
tebra?, 806 
from  hiemorrhage,  806 
from  hysteria.  806 
from  neuritis,  806 
from  pachymeningitis, 

806 
from  spinal  caries,  806 
from    transverse   my- 
elitis, 806 
etiology  of,  SOI 
favorite  sites  of,  804 
morl)id  anatomy  of,  805 
prognosis  of,  807 
surgical  treatment  of,  897 
symptoms  of,  SOI 
type  of,  in   cervical   re- 
gion,  805 
in  dorsal  region,  805 
in  lumbar  region  and 
Cauda,  805 
of  temporo-sphenoidal    lobe, 

641 
of  third  frontal  convolution, 
640 
j  Tuning-fork  tests  in  young  pa- 
I  tients,  1176 

•  Turpentine  as  a  cause  of  hse- 
!  niaturia,  932 

Tympanic   attic,    inflammation 

of.  1169 
Tympanites  in  intussusception, 
519 
in  peritonitis,  565 
Typhlitis,  509 
Tvpho-bacillose,  281 
Typhoid  condition  in  purpura 
hfpmorrhagica,  381 
fever,  194,  207 
bacillus  of,  195 
in  milk,  195 
in  water,  195 
brain  symptoms  in,  200 
Brand's  treatment  of,  206 
convalescence  in,  198 
definition  of,  194 
diagnosis  of,  203 
from    cerebral    pneumo- 
nia, 204 


1242 


INDEX. 


Typhoid    fever,  diagnosis    of, 
from       cerebro-spinal 
iL'Ver,  204 
from    frauk    pneumonia, 

■204 
from     general     tubercu- 
losis, 204 
from  grippe,  204 
from  malaria,  204 
from  tuberculous  menin- 
gitis, 203 
digestive  symptoms  of,  199 
drinking-water  as  a  cause 

of,  195 
duration  of  fever  in,  202 
enlargement  of  spleen    in, 

200 
etiology  of,  194 
family     predisposition   to, 

195 
history  of,  194 
in  children,  194 
influence  of  climate  upon, 
194 
of  sex  on,  194 
intestinal  lesions  in,  196 
mesenteric  glands  in,  196 
morbid  anatomy  of,  196 
nervous  syuii)toms  of,  200 
period  of  incubation  of,  196 
prognosis  of,  205 
prophylaxis  of,  207 
relapse  in,  198 
symptoms  of,  197 
respiratory   svmptoms    in, 

198 
synonyms  of.  194 
treatment  of,  205 
ulcerations  of  intestine  in, 

196 
urine  in,  200 

Widal's   blood-serum    test, 
L'05 
infection  of  new-born,  90 
state  in  jaundice,  543 
symptoms  in  rheumatism,  352 
Typho-tuberculose,  281 
Tyrotoxicon,  473 

Ulcer  of  cornea,  1194  ! 

treatment  of,  1195 
post-variolous,  of  lid,  1179        I 
tuberculous,    description    of,  I 

Ulceration   of  intestine  in   ca-  I 
tarrhal  dysentery,  486       I 
Ulcerations  of   intestine  in  ty-  ' 
l)hoid  fever,  196 
of    laryngeal    cartilages     in 

typhoid  fever,  197  1 

of  rectum,  .589 
of  trachea  after  tracheotomv,  ! 

886  : 

Ulcerous    lesions    of   scrofulo-  ! 

derma,  1141  1 

Ulcers  of  amcebic    dvsentery,  \ 

490 

phlyctenular,  1193 

Ulna,    changes  in,  in   rachitis,  i 

336 
Umbilical      cord.       See      (Jonl,  j 
umhilical.  | 

hfemorrbage,  85  j 

hernia,  86  I 

polyp,  86 
Umbilicus,   warty    tumors    of,  ' 
575 


Unguentum    vaselini    plumbi- 

cum,  1107 
Uraemia  in  acute  tubal  nephri- 
tis, 1011 
Ursemic    convulsions  in    acute 

tubal  nephritis,  1016 
Urea  in  urine  of  chronic  tubal 

nephritis,  1019 
Urethra,   diagnosis  of    hemor- 
rhage from,  981 
dilatation  of,  for  stone,  1052 
in  females.  1046 
in  males,  1045 
Uric  acid  as  a  cause  of  incon- 
tinence of  urine,  998 
of  lithaemia.  95 
in  the  blood,  94 
in  urine  of  new-born,  1006 
Uric-acid  calculus.  lOoc^ 
Uric-acid  sediments  in  urine, 

1006 
Uricacida'mia,  94 
Uricaeniia.  94 
Urinary    organs,    anatomy    of, 

in  children.  1045 
Urination,      diminished      fre- 
quency of,  9 
involuntary,   during  sleep,  9 
painful,  in  litha-mia,  95 
Urine.       See,     also.      Urine    in 
health. 
examination    of,    in    scarlet 

fever,  147 
frequency  of  passage  of,  8 
in  acute  gastric  catarrh,  443 
in  acute  tubal  nephritis,  1011 
in  catarrhal  dysentery,  4ti» 
in  chlorosis,  363 
in  cholera,  238 
in    chronic    tubal  nephritis, 

1019 
in  cirrhosis  of  liver,  558 
incontinence   of.     See  Incon- 
tinence of  nrine. 
in  variola,  164 
in  vesical  calculus,  1042 
with  seat-worms,  530 
in  diabetes  mellitus,  1000 
in  diphtheria,  256 
in  di.sease,  8 
in  erysipelas,  226 
in  health,  8 
characteristics  of,  9 
daily  amount  of,  9 
reaction  of,  9 
specific  gravity  of,  9 
in  jaundice,  543 
in  leuka-mia,  374 
in  lithaemia,  96,  99 
in  measles,  122 
in  perinepbritic  abscess,  1033 
in  peritonitis,  .565 
in  i)yonephrosis,  1032 
in  rachitis,  327 
in  rheumatism,  3.52 
in  scarlatinal  nephritis,  141 
in  sirniile  atro])hy,  .506 
in  tumors  of  kidnev,  1036 
in  typhoid  fever,  197,  200 
in  whooping-cough,  187 
incontinence  of,  in  lithsemia. 
96 
in  tuberculous  meningitis. 
618 
partial     supi)ression     of,    in 
chronic  tubal  nephritis, 
1020 


Urine,   partial   suppression   of, 
in  intussusception,  519 
quantity  of,    in   diabetes   in- 
sipidus, 1005 
in  diabetes  mellitus,  1000 
selection  of  specimen   of,  for 

analysis  for  sugar,  1001 
specific  gravity  of,  in  acute 
tubal  nephritis,  1011 
in      diabetes     insipidus, 

1005 
in  diabetes  mellitus,  1000 
Urostealith,  1038 
Urticaria,  1120 
bullosa,  1120 
diagnosis  of,  1 121 
etiology  of,  1120 
factitia",  1120 
haemorrhagica,  1120 
in  simple  atr()i)hy,  505 
papulosa,  1120 
pigmentosa,  1121 
prognosis  of,  1121 
treatment  of,   1121 
tuberosa.  1120 
vesiculosa,  1120 
with  scarlet  fever,  128 
Uvula,  abscission  of,  417 

elongation  of,  417 
Uvulatome,  417 

V-SHAPED   indenture   of    jaw, 

421 
Vaccination,  171 
after    exposure    to     variola, 

168' 
age    at    which    to    perform, 

ITfi 
arm-to-arm,  175 
by  animal  virus,  176 
comfilications  of,  174 
constitutional   svmptoms  of, 

174 
history  of,  171 
methods  of.  175 
points  for,  176 
protective  power  of,  176 

exceptions  to,  176 
recent  studies  in,  173 
secondary  constitutional 

symptoms  in,  174 
secondary  fever  in.  174 
Vaccine-blepharitis.  1179 
Vaccine-lymi)h.  animal,  1173 
superiority    of,  to   human- 
ized. 174 
from    spontaneous     cow-pox, 

173 
humanized.  173 

transmission  of  svphilis  bv. 
174 
impurities  of,  175 
micro-orga:!isms  in,  173 
selection  of,  174 
varieties  of,  173 
Vaccine-pock,  areola  of,  174 
I      cicatrix  of,  174 
j      desiccation  of,  174 
injury  to.  175 
structure  of.  173 
Vaccine-syphilis.     See    Syphilis 

after  vaccination. 
^'accinia,  171 
auto-inoculation  of,  174 
coccus  of,  173 
erui)tive,  174 
I      etiology  of,  171 


INDEX. 


1243 


Vacciiiia,irregularities  in  course 
of.  174 
Jenner's  theory  of,  172 
lymph  of,  characteristics  of, 

173 
pathological  anatomy  of,  173 
symptoms  of,  174 
theories  of  nature  of,  172 
theory  of  specific  contagium 

of,  172 
traditions  of  dairy -hands  con- 
cerning, 171 
variolation  theory  of,  172 
vesicle  of,  174 
Vagi,    compression    of,   by   en- 
larged glands,  276 
Vaginal  lithotomy,  1052 
Vaginismus  in  hysteria,  735 
Valerian  in  diabetes  insipidus, 

1006 
Valsalva   inflation   in    chronic 

tympanic  catarrh,  1175 
Valve  -  segments,       numerical 

anomalies,  972 
Valvular  disease  of  heart.     See 
Heart  disease,  chronic. 
drains  in  empyema,  948 
Van  Swieten's  liquid,  116 
in  syphiloderma,  1146 
Vapor-baths  in  ascites,  573 
Varicella.     See  Chicken-pox. 
gangrsenosa,  160 
with  pertussis,  188 
Varicella-prurigo,    relation   of, 

to  eczema,  1120 
Variola  and  varioloid,  163 
complications     and    sequelse 

of,  167 
confluent,  166 
course  of,  165 
definition  of,  163 
diagnosis  of,  167 
from  measles,  167 
from  pneumonia,  167 
from  scarlatina,  167 
from  varicella,  167 
discrete,  166 
eruptive  stage  of,  164 
etiology  of,  163 
hsemorrhagic,  166 
incubation  of,  164 

after  inoculation,  164 
influence  of  vaccination,  168 
inoculation  for,  171 
invasion  of,  duration  of,  164 
Jenner's  theory  of,  172 
mortality    of,    without    vac- 
cination, 176 
pathological  anatomy  of,  163 
prognosis  of,  168 
quarantine  of,  170 
second  attacks  of,  163 
secondary  fever  in,  165 
stage  of  invasion  of,  164 
striking  distance  of,  163 
susceptibility  to,  163 
symptoms  of,  164 
transmission  of,  163 
treatment  of,  168 
typhoid  symptoms  in,  165 
vaccination  after  exposure  to, 

168 
varieties  of,  166 
Variola-lymph,  172 
Variolation  of  cow,  172 
Variola-vaccine,  173 
Varioloid,  definition  of,  167 


Varioloid,  types  of,  167 
Vascular  keratitis,  1197 
Vaso-motor  disturbance  in  sy- 
ringomyelia, 813 
involvement  with  tumors  of 
spinal  cord,  804 
Vegetables    in     diabetic     diet, 
1003 
in  lithgemic  diet,  99 
Vegetations  in  endocarditis,  977 

post-tracheotomic,  888 
Vein,  meningeal,  rupture  of,  83 
superficial   anterior   jugular, 
872 
Veins,  jugular,    fulness   of,    in 

rachitis,  339 
Venous  hum  in  chlorosis,  363 
obstruction    in     etiology    of 
ascites,  511 
Ventilation  in   typhoid  fever, 

205 
Ventricular  septum,   defect  of, 

969 
Vernix  caseosa,  1091 
Verruca,  1130 
diagnosis  of,  1130 
etiology  of,  1130 
necrogenica,  98 
treatment  of,  1131 
Vertebrae,  changes   in,  in  rachi- 
tis, 332 
Vertigo  in   acute   tubal  neph- 
ritis, 961 
in  brain  tumors,  637 
in  leukaemia,  374 
Vesical  calculus,  1038 

irritation   in  adherent    pre- 
puce, 1057 
Vesicles  of  chicken-pox,  1057 
diagnosis  of,  from  variola, 
1057 
Vesicular  syphiloderm,  1144 
Villous  growths  in  bladder  a 
cause  of  hsematuria,  982 
Virchow's  theory  of  congenital 
cystic     degeneration    of 
kidney,  1027 
of  cretinism,  683 
Visual  fields,  narrowing  of,  in 

hysteria,  733 
Vocal  cords,  hypersemia  of,  in 
chicken-pox,  157 
resonance  in  pleural  eflusion, 
942 
Voice  in  cholera,  238 

in  simple  catarrhal  laryngi- 
tis, 846 
Volatile  antiseptics  in  diphthe- 
ria, 263 
drugs  in  pertussis,  193 
Volvulus  due  to  ascarides,  528 
Vomit,  lumbricoid  worms  in,  9 
Vomiting,  9 
beef-juice  in,  29 
character  of  ejecta  of,  9 
chronic.     See  Gastric  catarrh, 

chronic. 
in  acute  gastric  catarrh,  443 
in  acute  milk  infection,  476 
in  acute  poliomyelitis,  791 
in  acute   spinal   leptomenin- 
gitis, 779 
in  broncho-pneumonia,  907 
in  cerebral  meningitis,  599 
in  cerebro-spinal  meningitis, 

607 
in  childhood,  9 


Vomiting  in  cholera,  237 

in    chronic    gastric    catarrh, 
448 

in  chronic  intestinal  indiges- 
tion, 469 

in  infancy,  causes  of,  9 

in  intussusception,  519 

in  lithaemia,  96,  97 

in  malarial  fever,  314 

in  measles,  122 

in  migraine,  719 

in   onset   of  croupous   pneu- 
monia, 914 

in  peritonitis,  564 

in  pertussis,  188 

in  scarlet  fever,  136 

in  simple  atrophy,  505 

in    subacute  milk    infection, 
480 

in    tuberculous     meningitis, 
611,  612 

in  typhlitis,  570 

in  typhoid  fever,  197 

in  variola,  164 

in  whooping-cough,  187 

of  blood  in  lithiemia,  97 

ursemic,  in  acute  tubal  neph- 
ritis, 1011 
Vulvo-vagiuitis,  1055 

catarrhal,  1055 

treatment  of,  1056 

from  seat-worms,  530 

gonorrhoeal,  1055 
diagnosis  of,  from  catarrhal, 

1055 
treatment  of,  1056 

symptoms  of,  1053 

treatment  of,  1056 

Walker-Goedon  milk  labora- 
tories, 55 
Wandering  pneumonia,  916 
Warner-Langenbeck       method 
of  staphylorrhaphy,  437 
Warner's     post-nasal     douche, 

836 
Wart,  post-mortem,  274 
Warts  of  anus,  585 
Washburn       spine-brace       for 

Pott's  disease,  1070 
"Washerwoman's    hands"     in 

cholera,  238 
Washing  prohibited  in  eczema, 

1105 
Wasting  in  artificially-fed  chil- 
dren, 503 
in  nursing  infants,  504 
Water  as  a  source  of  typhoid 
fever,  195 
drinking  of,  in  lithsemia,  101 
in  cholera,  246 
in  diet,  20 
in  lithiasis,  1010 
in  scarlatinal  nephritis,  147 
in  treatment  of  vesical  cal- 
culus, 1045 
in  typhoid  fever,  206 
lack    of,  in   etiology  of  con- 
stipation, 497 
Water-bed    in    acute   myelitis, 

787 
Waxy    kidney.       See    Amyloid 

disease  of  kidney. 
Weaning,  date  of,  19 
early,  as  a  cause  of  rachitis, 

344 
gradual,  19 


1244 


INDEX. 


Weaning,  methods  of,  19 

premature,    indications    for, 

20 
sudden,  indications  for,  19 
Weight,  average,    of  new-born 
child,  12 
daily  increase  in,  12 
Werlhof's    disease.      See    Pu,t- 

pura  hsemorrhagica. 
Wet-nurse,  age  of,  20 
feeding  by,  20 

disadvantages  of,  20 
for  syphilitic  infant,  116 
health  of,  20 
qualifications  of,  20 
rules  for  selection  of,  20 
Wharton's     grooved     director, 

874 
Whip-worm.       Sec     Trichoceph- 

alus  dispar. 
White   liquefying  germ,   prod- 
ucts obtained  from,  473 
swelling  of  knee,  1076.     See 
Knee-joint  disease. 
Whooping-cough,  182 
association  of,  with  measles, 

183 
auscultation  in,  187 
catarrhal  stage  of,  185 
complications     and     sequelae 

of,  187 
conditions    of    contagion    in, 

183 
diagnosis  of,  188 
from  bronchitis,  189 


Whooping-cough,  diagnosis  of, 
from      broncho-pneumo- 
nia, 189 
from  pulmonary  tuberculo- 
sis, 1K9 
from  tuberculosis  of  broii 
chial  glands,  189 
during  foetal  life,  183 
etiology  of,  182 
followed  by  tuberculosis,  282 
history  of,  182 
hygienic  treatment  of,  190 
incubation  of,  185 
local  treatment  of,  192 
mortality  of,  189 
paroxysmal  stage  of,  186 
pathology  of,  1H3 
prognosis  of,  189 
prophylaxis  of,  190 
quarantine  in,  190 
second  attacks  of,  182 
symptoms  of,  185 

mechanism  of,  184 
synonyms  of,  182 
terminal  stage  of,  187 
theories  of  nature  of,  184 
treatment  of,  190 
Widal's    blood-serum    test    for 

typhoid  fever,  205 
Winckel's  disease,  92 
Wire  loop  for  foreign  body  in 

auditory  canal,  1165 
Wooden    resistance  in  pleural 

effusion,  942 
Wormwood,  oil  of,  in  reflex  vom- 
iting of  diphtheria,  262 


Wounds  of  cornea,  1198 
of  eyelids,  1183 
of  rectum,  594 
Wright's    adaptation    of    Mac- 
kenzie tonsillotome,  425 
Wrist-joint  disease,  1080 
diagnosis  of,  1080 
prognosis  of,  1080 
symptoms  of,  1080 
treatment  of.  1080 
Wry     neck,    1062.      See     Tor- 
ticollis. 

Xanthic-oxide  calculus,  1038 

Xeroderma  pigmentosum, 

1137.  See  Kaposi's  dis- 
ease. 

Xerophthalmos,  1197 

Xerosis  of  conjunctiva,  1191, 
1197 

Yawning,  significance  of,  10 
Yellow-oxide-of-mercury    oint- 
ment in  eczema  of  lids, 
1110 

ZiNC-AND-TAR  salve,  1107 
Zinc  oxide  in  jaundice,  548 
Zona.     See  Herpes  zoster. 

capillitii,  1116 

facialis,  1116 

frontalis,  1116 

nucha;,  1116 

ophthalmicus,  1116 
Zonular    cataract.       See    Cata- 
ract, congenital. 


Catalogue  £l  Medical  Publications 


OF 


W.  B.  SAUNDERS  6  COMPANY 

PHILADELPHIA        S«  S«  S<  S<  S«  *  LONDON 

925  Walnut  Street        B<  *  *  *      9.  Henrietta  Street.  Covent  Garden 

Arranged  Alphabetically  and  Classified  under  Subjects 

See     page      22     for     a     List     of     Contents      classified      according     to     subjects 


THE  books  advertised  in  this  Catalogue  as  being  sold  by  subscriptio7t  are  usually  to  be  ob- 
tained from  travelling  solicitors,  but  they  will  be  sent  direct  from  the  office  of  publication 
(charges  of  shipment  prepaid)  upon  receipt  of  the  prices  given.     All  the  other  books 
advertised  are  commonly  for  sale  by  booksellers  in  all  parts  of  the  United  States ;  but  books 
viil  be  sent  to  any  address,  carriage  prepaid,  on  receipt  of  the  pubUshed  price. 

Money  may  be  sent  at  the  risk  of  the  publisher  in  either  of  the  following  ways :  A  postal 
money  order,  an  express  money  order,  a  bank  check,  and  in  a  registered  letter.  Money  sent 
in  any  other  way  is  at  the  risk  of  the  sender. 

SPECIAL  To  phj-sicians  of  approved  credit  books  will  be  sent,  post-paid,  on  the  following 
OFFER  terms  :  $5.00  cash  upon  delivery  of  books,  and  monthly  payments  of  ^5.00  there- 
after until  full  amount  is  paid.  Any  one  or  two  volumes  will  be  sent  on  thirty  days'  time  to 
*hose  who  do  not  care  to  make  a  large  purchase. 


An  American  Text-Book  cf  Applied  Therapeutics. 

Edited  by  James  C.  Wilson,  M.  D.,  Professor  of  Practice  of  Medicine 
and  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 
Handsome  imperial  octavo  volume  of  1326  pages.     Illustrated.     Cloth, 

$7.00  net ;  Sheep  or  Plalf  ^Morocco,  S8.00  net. 

An  American  Text-Book  qf  the  Diseases  qf  Children. 

Second  Edition,  Revised. 

Edited  by  Louis  Starr,  M.  D.,  Consulting  Pediatrist  to  the  Ivlatemity 
Hospital,  etc.  :  assisted  by  Thompson  S.  Westcott,  M.  D.,  Attending 
Physician  to  the  Dispensarv^  for  Diseases  of  Children,-  Hospital  of  the 
University  of  Pennsylvania.  Handsome  imperial  octavo  volume  of 
1244  pages,  profusely  illustrated.  Cloth,  S7.00  net;  Sheep  or  Half 
Morocco,  $8.00  net. 

An  American  Text-Book  qf  Diseases  qf  the  Eye,  Ear, 
Nose,  and  Throat. 

Edited  by  G.  E.  de  Schweixitz,  M.  D.,  Professor  of  Ophthalmology^ 
Jefferson  Medical  College,  Philadelphia ;  and  B.  Alexander  Randall, 
M.  D.,  Clinical  Professor  of  Diseases  of  the  Ear,  University  of  Penn- 
sylvania. Imperial  octavo  of  125 1  pages;  766  illustrations,  59  of  them 
in  colors.     Cloth,  57.00  net;  Sheep  or  Half  ^Morocco,  58.00  net. 


MEDICAL  PUBLICATIONS 


An  American  Text-Book  qf  Genito-Urinary  Diseases, 
Syphilis,  and  Skin  Diseases. 

Edited  by  L.  Bolton  Bangs,  M.  D.,  Professor  of  Genito-Urinary  Sur- 
gery, University  and  Bellevue  Hospital  Medical  College,  New  York  ; 
and  W.  A.  Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin  and 
Syphilis,  Washington  University,  St.  Louis.  Imperial  octavo  volume  of 
1229  pages,  with"3oo  engravings  and  20  full-page  colored  plates.  Cloth, 
$7.00  net;  Sheep  or  Half  ;Morocco,  $8.00  net. 

An  American  Text-Book  qf  Gynecology,  Medical  and 

Surgical.       second  Edition,  Revised. 

Edited  by  J.  M.  Baldv,  M.  D.,  Professor  of  Gynecology,  Philadelphia 
Polyclinic,  etc.  Handsome  imperial  octavo  volume  of  718  pages;  341 
illustrations  in  the  text,  and  ^'^  colored  and  half-tone  plates.  Cloth, 
$6.00  net;  Sheep  or  Half  Morocco,  $7. 00  net. 

An  American  Text-Book  cf  Legal  Medicine  and  Toxi- 
cology. 

Edited  by  Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous 
Department,  College  of  Physicians  and  Surgeons,  New  York ;  and 
Walter  S.  Haines,  M.  D.  ,  Professor  of  Chemistry,  Pharmacy,  and 
Toxicology,  Rush  Medical  College,  Chicago.     ///  Preparation. 

An  American   Text-Book  qf   Obstetrics,    second  Edition. 

Thoroughly  Revised  and  Enleu-ged.     In  Two  Volumes. 

Edited  by  Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dick- 
inson, M.  D.  Two  handsome  imperial  octavo  volumes  of  about  600 
pages  each  ;  nearly  500  illustrations  and  a  large  number  of  colored 
plates.  Per  set  :  Cloth,  $0.00  net;  Sheep  or  Half  Morocco,  Jo.  00  net. 
Ready  Soon. 

An  American  Text-Book  qf  Pathology. 

Edited  by  Ludvig  Hektoen,  M.  D.,  Professor  of  Pathology  in  Rush 
Medical  College,  Chicago;  and  David  Riesman,  M.  D.,  Demonstrator 
of  Pathologic  Histology  in  the  University  of  Pennsylvania.  Imperial 
octavo  of  1245  pages,  443  illustrations,  66  in  colors.  Cloth,  ^7..';o 
net;  Sheep  or  Half  Morocco,  S8.50  net.     By  Subscription. 

An  American  Text-Book  qf  Physiology,    second  Edition, 

Revbed,  in  Two  Volumes. 

Edited  by  William  H.  Howell,  Ph.  D.,  M.  D.,  Professor  of  Physi- 
ology, Johns  Hopkins  University,  Baltimore,  Md.  Two  royal  octavo 
volumes  of  about  600  pages  each.  Fully  illustrated.  Per  volume : 
Cloth,  $3.00  net;   Sheep  or  Half  Morocco,  I3.75  net. 

An  American  Text-Book  qf  Surgery.    Third  Edition. 

Edited  by  William  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.);  and 
J.  William  White,  M.  D.  ,  Ph.D.  Handsome  octavo,  1230  pages; 
496  wood-cuts  and  37  colored  and  half-tone  plates.  Thoroughly  revised 
and  enlarged,  with  a  section  devoted  to  "The  Use  of  the  Rontgen 
Rays  in  Surgery."    Cloth,  $7.00  net ;  Sheep  or  Half  Morocco,  $8.00  net. 


OF  W.  B.  SAUNDERS  &-   CO. 


An  American  Text-Book  cf  Theory  and  Practice  of 
Medicine. 

Edited  by  the  late  William  Pepper,  M.  D.,  LL.  D.,  Professor  of  the 
Theory  and  Practice  of  Medicine  and  of  Clinical  Medicine,  University 
of  Pennsylvania.  Two  handsome  imperial  octavos  of  about  looo  pages 
each.  Illustrated.  Per  volume:  Cloth,  $5.00  net;  Sheep  or  Half 
Morocco,  ^6.00  net. 

GET  THE  BEST  THE  NEW  STANDARD 

The  American  Illustrated  Medical  Dictionary. 

Second  E^tion,  Revised. 

For  Practitioners  and  Students.  A  Complete  Dictionary  of  the  Terms 
used  in  Medicine,  Surgery,  Dentistry,  Pharmacy,  Chemistry,  and  the 
kindred  branches,  including  much  collateral  information  of  an  encyclo- 
pedic character,  together  with  new  and  elaborate  tables  of  Arteries, 
Muscles,  Nerves,  Veins,  etc.  ;  of  Bacilli,  Bacteria,  Micrococci,  Strepto- 
cocci ;  Eponymic  Tables  of  Diseases,  Operations,  Signs  and  Symptoms, 
Stains,  Tests,  Methods  of  Treatment,  etc.,  etc.  By  W.  A.  Newman 
DoRLAND,  A.M.,  M.  D.,  Editor  of  the  "American  Pocket  Medical 
Dictionary."  Handsome  large  octavo,  nearly  800  pages,  bound  in 
full  flexible  leather.     Price,  $4.50  net;   with  thumb  index,  I5.00  net. 

Gives  a  Maximum  Amount  of  Matter  in   a   Minimum   Space   and   at  the  Lowest 

Possible  Cost. 
This  Edition  contains  all  the  Latest  Words. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within 
relatively  small  space.  I  find  nothing  to  criticise,  very  much  to  commend,  and  was  interested 
in  finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." — RosWF.LL  PARK, 
Professor  of  Principles  and  Practice  of  Surgery  and  Clinical  Surgery,  University  of  Buffalo. 

"  I  congratulate  you  upon  giving  to  the  profession  a  dictionary  so  compact  in  its  structure, 
and  so  replete  with  information  required  by  the  busy  practitioner  and  student.  It  is  a  necessity 
as  well  as  an  informed  companion  to  every  doctor.  It  should  be  upon  the  desk  of  every  prac- 
titioner and  student  of  medicine." — JOHN  B.  MURPHY,  Professor  of  Surgery  aiid  Clinical 
Surgery,  Northuuesttrn  University  Medical  School,  Chicago. 

The  American  Pocket  Medical  Dictionary.    '^^^  ^^*^°"' 

Revised. 

Edited  by  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to 
the  Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  Amer- 
ican Academy  of  Medicine.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges.     Price  ^i.oo  net;  with  thumb  index,  $1.25  net. 

The  American  Year-Book  qf  Medicine  and  Surgery. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and  investi- 
gators. Arranged  with  critical  editorial  comments,  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  George  M.  Gould,  M.  D. 
Year-Book  of  1902  in  two  volumes — Vol.  I.  including  General  Medicine; 
Vol.  II.,  General  Surgery.  Per  volume :  Cloth,  ^3.00  net;  Half  Mo- 
rocco, $3-75  net.     Sold  by  Subscription. 


MEDICAL  PUB  Lie  A  TLONS 


Abbott  on  Transmissible  Diseases,    second  Edition.  Revised. 

The  Hygiene  of  Transmissible  Diseases :  their  Causation,  Modes  of 
Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351   pages,  with  numerous  illustrations.     Cloth,  $2.50  net. 

Anders*  Practice  qf  Medicine.       Fifth  Revised  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  ]M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo  volume  of  1297  pages,  fully  illustrated.  Cloth,  $5.50  net; 
Sheep  or  Half  Morocco,  $6.50  net. 

Bastin's  Botany. 

Laboratory  Exercises  in  Botany.  By  Edsox  S.  Bastin,  M.  A.,  late 
Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.     Octavo,  536  pages,  with  87  plates.     Cloth,  $2.00  net. 

Beck  on  Fractures. 

Fractures.  By  Carl  Beck,  M.  D.,  Professor  of  Surgery,  New  York 
Post-graduate  Medical  School  and  Hospital.  With  an  appendix  on  the 
Practical  Use  of  the  Rontgen  Rays.  335  pages,  170  illustrations. 
Cloth,  $3.50  net. 

Beck's  Surgical  Asepsis. 

A  ^Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.  D.,  Professor  of 
Surgery,  New  York  Post-graduate  Medical  School  and  Hospital.  306 
pages;   65  text-illustrations  and   12   full-page  plates.      Cloth,  $1.25  net. 

Bergey's  Principles  of  Hygiene. 

The  Principles  of  Hygiene  :  A  Practical  Manual  for  Students,  Physi- 
cians, and  Health  Officers.  By  D.  H.  Bergey,  A.M.,  M.  D.,  First 
Assistant,  Laboratory  of  Hygiene,  University  of  Pennsylvania.  Hand- 
some octavo  volume  of  495  pages,  illustrated.     Cloth,  $3.00  net. 

Boisliniere's    Obstetric   Accidents,   Emergencies,  and 
Operations. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  Bois- 
liniere,  M.  D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis  Medical 
College.      381  pages,  handsomely  illustrated.     Cloth,  $2.00  net. 

Bohm,  Davidoff,   and  Huber*s  Histology. 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic. 
By  Dr.  A.  A.  Bohm  and  Dr.  M.  von  Davidoff,  of  Munich,  and 
G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
Histological  Laboratory,  University  of  Michigan.  Handsome  octavo 
of  503  pages,  with  351  beautiful  original  illustrations.     Cloth,  $3.50  net. 


OF  JJ:  B.  SAUNDERS  d-  CO. 


Brower  and  Bannister's  Manual  of  Insanity. 

A  Practical  Manual  of  Insanity,  ^'or  the  Student  and  General  Practi- 
tioner. By  Daxiel  R.  Brower,  A.  M.,  M.  D.,  LL.D.,  Professor  of 
Nervous  and  2vlental  Diseases  in  Rush  Medical  College,  in  Affiliation 
with  the  University  of  Chicago,  and  in  the  Post-Graduate  Medical 
School,  Chicago;  and  Henry  M.  Baxxister,  A.M.,  M.  D.,  formerly 
Senior  Assistant  Physician,  Illinois  Eastern  Hospital  for  the  Insane. 
Handsome  octavo,  426  pages,  with  13  full-page  inserts.    Cloth,  §3. 00  net. 

Butler's  Materia  Medica,  Therapeutics,  and  Pharma- 
cology.     Fourth  Edition.  Revised  and  Enlarged. 

A  Text-Book  of  :Materia  Medica,  Therapeutics,  and  Pharmacology. 
By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
Octavo,  896  pages,  illustrated.  Cloth^  34.00  net;  Sheep  or  Half  Mo- 
rocco, $5.00  net. 

Chapin  on  Insanity. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.  D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  Honorar}^ 
Member  of  the  ]SIedico-Psychological  Society  of  Great  Britain,  of  the 
Society  of  Mental  ISIedicine  of  Belgium,  etc.  i2mo,  234  pages,  illus- 
trated.     Cloth,  51.25   net. 

Chapman's   Medical    Jurisprudence  and  Toxicology, 

Second  Edition,  Revised. 

Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.  D.,  Professor  of  Institutes  of  ^Medicine  and  Medical  Jurisprudence, 
Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55  illus- 
trations and  3  full-page  plates  in  colors.      Cloth,  Si. 50  net. 

Church  and  Peterson's  Nervous  and  Mental  Diseases. 

Third  Edition.  Revised  and  Enlarged. 

Ner\-ous  and  [Mental  Diseases.  By  Archibald  Church,  rsl.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  ^Medical  School,  •  Chicago ;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York.  Handsome  octavo 
volume  of  875  pages,  profusely  illustrated.  Cloth,  35.00  net;  Sheep  or 
Half  Morocco,  56.00  net. 

Clarkson's  Histology. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  Arthur 
Clarkson,  M.  B.,  cm.  Edin.,  formerly  Demonstrator  of  Physiology 
in  the  Owen's  College,  Manchester;  late  Demonstrator  of  Physiology 
in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages;  22  engravings 
and  174  beautifully  colored  original  illustrations.      Cloth,  S4.00  net. 

Corwin's  Physical  Diagnosis.    Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur  M. 
CoRwiN,  A.  M.,  M.  D.,  late  Instructor  in  Physical  Diagnosis  in  Rush 
iSIedical   College,    Chicago.      219  pages,  illustrated.     Cloth,  31-25  net. 


MEDICAL  PUBLICATIONS 


Crothers*  Morphinism  and  Narcomania. 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral, 
Chloroform,  and  other  Narcotic  Drugs ;  also  the  Etiology,  Treatment, 
and  Medicolegal  Relations.  By  T.  D.  Crothers,  M.  D.,  Superin- 
tendent of  Walnut  Lodge  Hospital,  Hartford,  Conn.  ;  Professor  of 
Mental  and  Nervous  Diseases,  New  York  School  of  Clinical  Medicine, 
etc.     Handsome  i2mo  of  351  pages.     Cloth,  $2.00  net. 

DaC0Sta*S    Surgery.       Third  Edition.  Revised. 

Modern  Surgery,  General  and  Operative.  By  John  Chalmers  Da 
Costa,  M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia  :  Surgeon  to  the  Philadelphia 
Hospital,  etc.  Handsome  octavo  volume  of  11 17  pages,  profusely 
illustrated.     Cloth,  $5.00  net;   Sheep  or  Half  Morocco,  $6.00  net. 

Enlarged  by  over  200  Pages,  with  more  than  100  New  Illustrations. 

Davis's  Obstetric  Nursing. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics,  Jefferson  Medical  College  and  Phila- 
delphia Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia  Hos- 
pital.     i2mo,  400  pages,  illustrated.      Crushed  Buckram,  $1.75  net. 

DeSchweinitz  on  Diseases  qf  the  Eye.      Fourth  Edition. 

Entirely  Reset ;  Thoroughly  Revised  and  Enlarged. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G. 
E.  DE  ScHWEiNiTZ,  M.  D. ,  Professor  of  Ophthalmology,  Jefferson  Medi- 
cal College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  750 
pages ;  300  fine  illustrations  and  6  full-page  chromo-lithographic  plates. 
Cloth,  S5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

Dorland's  Dictionaries. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictiotiary  on  page  3.] 

Dorland'S    Obstetrics.       second  Edition,  Revised  and  Greatly  Enlarged. 

Modern  Obstetrics.  By  W.  A.  New.max  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Associate  in 
Gynecology,  Philadelphia  Polyclinic.  Octavo  volume  of  797  pages, 
with  201  illustrations.     Cloth,  ^4.00  net. 

Eichhorst's  Practice  qf   Medicine. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Hermann  Eich- 
horst.  Professor  of  Special  Pathology  and  Therapeutics  and  Director 
of  the  Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Phila- 
delphia Polyclinic.  Two  octavo  volumes  of  600  pages  each,  over  150 
illustrations.  Prices  per  set :  Cloth,  S6. 00  net ;  Sheep  or  Half  Morocco, 
$7.50  net. 


OF  W.  B.  SAUNDERS  d-  CO. 


Eyre's  Bacteriologic  Technique. 

Bacteriologic  Technique.  A  Laboratory  Guide  for  the  ISIedical,  Dental, 
and  Technical  Student.  By  J.  W.  H.  Eyre,  \l.  D.,  F.  R.  S.,  Edin., 
Lecturer  on  Bacteriology  and  Joint  Lecturer  on  Practical  Public  Health, 
Charing  Cross  Hospital  Medical  School;  Bacteriologist  to  Charing 
Cross  and  to  St.  Mar)''s  Hospital  for  Sick  Children,  Plaistow.  Hand- 
some octavo,  350  pages,  with   150  illustrations.      Cloth,  $0.00  net. 

Friedrich  and  Curtis  on  the  Nose,  Throat,  and  Ear. 

Rhinology,  Laryngology,  and  Otology,  and  Their  Significance  in  Gen- 
eral Medicine.  '  By  Dr.  E.  P.  Friecrich,  of  Leipzig.  Edited  by  H. 
HOLBROOK  Curtis",  M.  D.,  Consulting  Surgeon  to  the  Ne%v  York  Nose 
and  Throat  Hospital.     Octayo,  348  pages.     Cloth,  $2.50  net. 

Frothingham*s  Guide  for  the  Bacteriologist 

Laborator}^  Guide  for  the  Bacteriologist.  By  Langdon  FROxmNGHAM, 
M  D.  v., 'Assistant  in  Bacteriolog}-  and  Veterinary  Science,  Sheffield 
Scientific  School,  Yale  University."    Illustrated.     Cloth,  75  cts.  net. 

Galbraith  on  the  Four  Epochs  qf  Woman's  Life. 

The  Four  Epochs  of  Woman's  Life  :  A  Study  in  Hygiene.  By  Anna 
M.  Galbraith,  M.  D.,  Author  of  "Hygiene  and  Physical  Culture 
for  Women";  Fellow  of  the  Xew  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  John  H.  ^Iusser,  M.  D.,  Professor  of 
Clinical  ^ledicine,  University  of  Pennsylvania.  i2mo  volume  of  200 
pages.     Cloth,  $1.25  net. 

Garrigues*  Diseases  qf  Women.    Third  Edition,  Revised. 

Diseases  of  AVomen.  By  Hexrv  T-  Garrigues,  A.  M.,  M.  D.,  Gyne- 
cologist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  Octavo,  756  pages,  with  367  engravings  and  colored  plates. 
Cloth,  I4.50  net;  Sheep  or  Half  Morocco,  $5.50  net. 

Gorham's  Bacteriology. 

A   Laboratory'    Course   in   Bacteriology.     By   F.    P.   Gorham    M.  A 
Assistant  Professor  in  Biology,   Brown  University.      i2mo  volume   of 
192  pages,  97  illustrations.     Cloth,  $1.25  net. 

Gould  and  Pyle's  Curiosities  qf  Medicine. 

Anomalies  and  Curiosities  of  ^ledicine.  By  George  ZsI.  Gould,  M.  D 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  ot  rare  and 
extraordinary  cases  and  of  the  most  striking  instances  oi  abnormahty  m 
an  branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive 
research  of  medical  literature  from  its  origin  to  the  present  day 
Ibstrlcted  classified,  annotated,  and  indexed.  Handsome  octavo 
yo  ume  of^68^^^^  ^95  engravings  and  12  full-page  plates.  Popular 
SitSn       Cloth,"$3.oonet;  Sheep  or  Half  Morocco,  $4.00  net. 

Gradle  on  the  Nose,  Throat,  ant  Ear. 

Diseases  of  the  Nose,  Throat,  and  Ear.  By  Henry  Gr-^le,  M.  D  , 
Professor  of  Ophthalmology  and  Otology,  Northwestern  Univejity 
Medical  School,  Chicago.  Octavo,  547  P^ges,  illustrated,  including 
2  full-page  colored  plates.     Cloth,  $3-5°  ^^t. 


8  MEDICAL  PUBLICATIONS 


Grafstrom*s  Mechano-Therapy. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hos- 
pital, Blackwell's  Island,  N.  Y.    1 2mo,  139  pages,  illustrated.    $1.00  net. 

Grant's  Surgical  Diseases  of  Face,  Mouth,  and  Jaws. 

For  Dental  Students. 

A  Text-Book  of  Surgical  Pathology  and  Surgical  Diseases  of  the  Face, 
Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace  Grant, 
A.  M.,  M.  D.,  Professor  of  Surgical  Pathology  and  Oral  Surgery,  Louis- 
ville College  of  Dentistry ;  Professor  of  Surgery  and  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  volume  of  215 
pages,  with  60  illustrations.     Cloth,  $0.00  net. 

Griffith    on    the    Baby.       second  Edition.  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.  ,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Pennsylvania;  Phy- 
sician to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages; 
67  illustrations  and  5  plates.     Cloth,  $1.50  net. 

Griffith's  Weight  Chart. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 
25  charts  in  each  pad.     Per  pad,  50  cts.  net. 

Haynes*  Anatomy. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of 
Practical  Anatomy  in  Cornell  University  Medical  College.  680  pages ; 
42  diagrams  and  134  full-page  half-tone  illustrations  from  original  photo- 
graphs of  the  author's  dissections.     Cloth,  $2.50  net. 

Heisler*S    Embryolo^.       second  Edition,  Revbed. 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor 
of  Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volum.e 
of  405  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

Hirst's    Obstetrics.       Third  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  B.arton  Cooke  Hirst,  M.  D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume 
of  873  pages  ;  704  illustrations,  36  of  them  in  colors.  Cloth,  ^5.00  net ; 
Sheep  or  Half  Morocco,  $6.00  net. 

Hyde  and  Montgomery  on  Syphilis  and  the  Venereal 

Diseases.       second  Edition.  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D., 
Professor  of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  and  Frank 
H.  Montgomery,  M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary, 
and  Venereal  Diseases  in  Rush  Medical  College,  Chicago,  111.  Octavo, 
594  pages,  profusely  illustrated.     Cloth,  54.00  net. 


OF  W.  B.    SAUNDERS  c^  CO. 


^e  International  Text-Book  of  Surgery,    in  Two  volumes. 

Second  Edition,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  American  and  British  Authors.  Edited  by  J.  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medi- 
cal School,  Boston ;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer 
on  Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex 
Hospital  Medical  School,  London,  Eng.  Vol.  I.  General  Surgery. — 
Handsome  octavo,  947  pages,  with  458  beautiful  illustrations  and  9 
lithographic  plates.  Vol.  H.  Special  or  Regional  Surgery. — Handsome 
octavo,  1072  pages,  471  text  illustrations,  and  8  lithographic  plates. 
Per  volume:   Cloth,  ^5.00  net;  Sheep  or  Half  Morocco,  ^6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clini- 
cian and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satis- 
faction to  the  editors  as  it  is  a  gratification  to  the   conscientious  reader." — Annals  of  Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has  very 
many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors 
is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor  of  each 
^vriter  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the  technique 
01  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up  to  date  in 
a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional  parts  of  the 
body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which  the  reader 
may  not  learn  something  new." — Medical  Record,  New  York. 

Jackson's  Diseases  (jf  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  i2mo  volume  of  535  pages,  with 
178  illustrations,  mostly  from  drawings  by  the  author.    Cloth,  ^2.50  net. 

Jelliffe  and  Diekman*s  Chemistry. 

A  Text- Book  of  Chemistry.  By  Smith  Ely  JelLiffe,  M.  D.,  Ph.  D., 
Professor  of  Pharmacology,  College  of  Pharmacy,  New  York ;  and 
George  C.  Diekman,  Ph.  G.,  M.  D.,  Professor  of  Theoretical  and 
Applied  Pha-macy,  College  of  Pharmacy,  New  York.  Octavo,  550 
pages,  illustrated.     Ready  Shortly. 

Keatin^'s  Life  Insurance. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating,  M.  D., 
Fellow  of  the  College  of  Physicians  of  Philadelphia ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages.     With  numerous  illustrations.     Cloth,  $2.00  net. 

Keen  on  the  Surgery  qf  Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm. 
W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Phila- 
delphia, etc.    Octavo  volume  of  386  pages,  illustrated.    Cloth,  ^3.00  net. 

Keen's    Operation    Blank.       second  E^ditlon,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc..  Required  in  Vari- 
ous Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S, 
(Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia.  Price  per  pad,  blanks  for  fifty 
operations,  50  cts.  net. 

Kyle  on  the  Nose  and  Throat,    second  Edition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College, 
Philadelphia.  Octavo,  646  pages;  over  150  illustrations  and  6  litho- 
graphic plates.     Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  ^5.00  net. 


MEDICAL  PUBLICATIONS 


Laine's  Temperature  Chart. 

By  D.  T.  Laine,  M.  D.  For  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  etc.  ;  with  the 
Brand  Treatment  of  Typhoid  Fever  on  the  back  of  each  chart.  Pad  of 
25  charts,  50  cts.  net. 

Levy,  Klemperer,  and  Eshner*s  Clinical  Bacteriology. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Pro- 
fessor in  the  University  of  Strasburg,  and  Felix  Klemperer,  Privat- 
docent  in  the  University  of  Strasburg.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadel- 
phia Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  ^2.50  net. 

Lockwood's  Practice  vf  Medicine.         RevfSTa'd^Sjed. 

A  Manual  of  the  Practice  of  Medicine.  By  George  E  oe  Lockwood, 
M.  D.,  Attending  Physician  to  Bellevue  Hospital,  New  York.  Octavo, 
847  pages,  illustrated,  including  22  colored  plates.     Cloth,  ^4.00  net. 

Long's  Syllabus  cf  Gynecology. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

Macdonald's  Surgical  Diagnosis  and  Treatment. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.  D. 
Edin.,  F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical 
Surgery,  Hamline  University.  Handsome  octavo,  800  pages,  fully  illus- 
trated.    Cloth,  ;^5.oo  net;  Sheep  or  Half  Morocco,  $6.00  net. 

Mallory  and  Wright's  Pathological  Technique. 

Second  Edition,  Revised. 

Pathological  Technique.  A  Practical  Manual  for  laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank  B. 
Mallory,  A.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston  ;  and  James  H.  Wright,  A.  M., 
M.  D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.     Octavo,  432  pages,  fully  illustrated.     Cloth,  $3.00  net. 

McClellan's  Anatomy  in  its  Relation  to  Art. 

Anatomy  in  its  Relation  to  Art.  An  Exposition  of  the  Bones  and 
Muscles  of  the  Human  Body,  with  Reference  to  their  Influence  upon 
its  Actions  and  External  Form.  By  George  McClellan,  M.  D., 
Professor  of  Xnatomy,  Pennsylvania  Academy  of  Fine  Arts.  Hand- 
some quarto  volume,  9  by  11^  inches.  Illustrated  with  338  original 
drawings  and  photographs ;  260  pages  of  text.  Dark  Blue  Vellum, 
$10.00  net;  Half  Russia,  $12.00  net. 

McClellan's  Regional  Anatomy.     Fourth  Edition.  Revised. 

Regional  Anatomy  in  its  Relations  to  Medicine  and  Surgery.  By 
George  McClellan,  M.  D.,  Professor  of  Anatomy,  Pennsylvania  Acad- 
emy of  Fine  Arts.  Two  handsome  quarto  volumes,  884  pages  of  text, 
and  97  full-page  chromo-lithographic  plates,  reproducing  the  author's 
original  dissections.      Cloth,  $12.00  net;  Half  Russia,  $15.00  net. 


OF  W.  B.  SAUNDERS  &=   CO.  n 

McFarland's  Pathogenic  Bacteria.    '^S^'^y'^Tr^'^ril" 

Text-Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical 
College  of  Philadelphia,  etc.  Octavo  volume  of  621  pages,  finely 
illustrated.     Cloth,  ^3.25  net. 

Meigs  on  Feeding  in  Infancy. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.  D.  Bound  in 
limp  cloth,  flush  edges,  25  cts.  net. 

Moore's  Orthopedic  Surgery. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.  D.,  Pro- 
fessor of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  Uni- 
versity of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  handsomely  illustrated.     Cloth,  ^2.50  net. 

Morten's  Nurses*  Dictionary. 

Nurses'  Dictionary  of  Medical  Terms  and  Nureing  Treatment.  Con- 
taining Definitions  of  the  Principal  Medical  and  Nursing  Terms  and 
Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treat- 
ments, Operations,  Foods,  Appliances,  etc.  encountered  in  the  ward  or 
in  the  sick-room.  By  Honnor  Morten,  author  of  "How  to  Become 
a  Nurse,"  etc.      i6mo,  140  pages.     Cloth,  ^i.oo  net. 

Nancrede's  Anatomy  and  Dissection.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  Charles 
B.  Nancrede,  M.  D.,  LL.  D.,  Professor  of  Surgery  and  of  Clinical  Sur- 
gery, University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with 
full-page  lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra 
Cloth  (or  Oilcloth  for  dissection -room),  ^2.00  net. 

Nancrede's  Principles  qf  Surgery. 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede,  M.  D., 
LL.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  Univei^ity  of 
Michigan,  Ann  Arbor.   Octavo,  398  pages,  illustrated.    Cloth,  ^2.50  net. 

Norris's  Syllabus  qf  Obstetrics.    Third  Edition,  Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department  of  the 
University  of  Pennsylvania.  By  Richard  C.  Norris,  A.M.,  M.  D., 
Instructor  in  Obstetrics  and  Lecturer  on  Clinical  and  Operative  Obstet- 
rics, University  of  Pennsylvania.  Crown  octavo,  222  pages.  Cloth, 
interleaved  for  notes,  |2.oo  net. 

Ogden  on  the  Urine. 

Clinical  Examination  of  the  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Instructor  in  Chemistry,  Harvard 
Medical  School.  Handsome  octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  I3.00  net. 

Penrose's  Diseases  of  Women.    Fourth  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of  Penn- 
sylvania. Octavo  volume  of  539  pages,  221  illustrations.  Cloth, 
^3-75  i^et. 


MEDICAL  PUBLICATIONS 


Pye's  Banda£(in^. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small 
i2mo,  over  So  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

Pyle*s  Personal  Hygiene. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic 
Basis.  Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the 
Wills  Eye  Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully 
illustrated.      Cloth,  Si -50  net. 

Raymond's  Physiology.     Rewrir:lfd^'Si.^"^Jied. 

A  Text-Book  of  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  in  the  Long  Island  College 
Hospital,  and  Director  of  Physrology  in  Hoagland  Laboratory,  New 
York.     Octavo,  668  pages,  443  illustrations.     Cloth,  S3-5o  net. 

Robson  and  Moynihan*s  Diseases  qf  the  Pancreas. 

Diseases  of  the  Pancreas.  By  A.  W.  Mayo  Robson,  F.  R.  C.  S., 
Leeds,  Senior  Surgeon  to  Leeds  General  Infirmary ;  Emeritus  Pro- 
fessor of  Surgery,  Yorkshire  College  :  and  B.  G.  A.  Moynihan,  M.  B., 
F.  R.  C.  S.,  Assistant  Surgeon  Leeds  Creneral  Infirmary;  Demonstrator 
of  Anatomy,  Yorkshire  College.  Handsome  octavo  of  300  pages, 
illustrated.     Cloth,  So.  00  net. 

Salinger  and  Kalteyer's  Modern  Medicine. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College ;  and  F.  J.  Kaltever, 
M.  D.,  Assistant  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical 
College.     Handsome  octavo,  801  pages,  illustrated.     Cloth,  $4.00  net. 

Saundby's  Renal  and  Urinary  Diseases. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the 
Royal  Medico-Chirurgical  Society ;  Professor  of  Medicine  in  Mason 
College,  Birmingham,  etc.  Octavo,  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  S^-So  net. 

Saunders*  Medical  Hand-Atlases. 

See  Pages   17,  18,  and  19. 

Saunders*  Pocket  Medical  Formulary,  sixth  Edition,  Revised. 

By  William  ]M.  Powell,  M.  D.,  author  of  "Essentials  of  Diseases  of 
Children":  Member  of  Philadelphia  Pathological  Society.  Contain- 
ing 1844  formula  from  the  best-known  authorities.  With  an  Appendix 
containing  Posological  Table,  Formulae  and  Doses  for  Hypodermic 
Medication,  Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis 
and  Fetal  Head,  Obstetrical  Table,  Diet  Lists,  Materials  and  Drugs 
used  in  Antiseptic  Surger}-.  Treatment  of  Asphyxia  from  Drowning,  Sur- 
gical Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc. 
In  flexible  morocco,  with  side  index,  wallet,  and  flap.     S2.00  net. 


OF  IV.  B.  SAUNDERS  6-   CO.  13 

Saunders'  Question-Compends.    see  Page  i6. 

Scudder's   Fractures.       Third  Edition,  Revised. 

The  Treatment  of  Fractures.  By  Chas.  L.  Scudder,  M.  D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard  University  Medical  School, 
Octavo,  460  pages,  with  nearly  600  original  illustrations.  Polished 
Buckram,!  net ;    Half  Morocco,  net. 

Senn's  Genito-Urinary  TubercusIosiSc 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By 
Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush 
Medical  College,  Chicago.  Handsome  octavo  volume  of  320  pages, 
illustrated.      Cloth,  $3.00  net. 

Senn's  Practical  Surgery. 

Practical  Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.  D.,LL.  D.,  Pro- 
fessor of  Surgery,  Rush  Medical  College,  Chicago.  Octavo,  11 33 
pages,  642  illustrations.  Cloth,  $6.00  net;  Sheep  or  Half  Morocco, 
^7.00  net.     By  Subscription. 

Senn's  Syllabus  gf   Surgery. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  con- 
formity with  "An  American  Text-Book  of  Surgery."  By  Nicholas 
Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush  Medical  Col- 
lege, Chicago.     Cloth,  $1.50  net. 

Senn*S    Tumors.       second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas  Senn,  M.  D.  , 
Ph.  D.,  LL.  D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  718  pages,  with  478  illustrations,  including 
12  full-page  plates  in  colors.  Cloth,  ^5.00  net ;  Sheep  or  Half  Morocco, 
^6.00  net. 

Sollmann's  Pharmacology. 

A  Text-Book  of  Pharmacology  :  including  Therapeutics,  Materia  Medica, 
Pharmacy,  Prescription-Writing,  Toxicology,  etc.  By  Torald  Soll- 
mann,  M.  D.,  Assistant  Professor  of  Pharmacology  and  Materia  Medica, 
Western  Reserve  University,  Cleveland,  Ohio.  Handsome  octavo, 
894  pages,  fully  illustrated.     Cloth,  $3.75  net. 

Starr's  Diets  for  Infants  and  Children. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  Louis 
Starr,  M.  D.,  Editor  of  "An  American  Text-Book  of  the  Diseases  of 
Children."  230  blanks  (pocket-book  size),  perforated  and  neatly  bound 
in  flexible  morocco.     ^1.25  net. 

Stelwagon's  Diseases  qf  the  Skin. 

Diseases  of  the  Skin.  By  Henry  W.  Stelwagon,  M.  D.,  CHnical  Pro- 
fessor of  Demiatology,  Jefferson  Medical  College,  Philadelphia.  Royal 
octavo,  over  1000  pages',  with  over  200  text-cuts  and  26  colored  plates. 
Cloth,'$6.oo  net;  Sheep  or  Half  Morocco,  ^7.00  net. 


14  MEDICAL  PUBLICATIONS 


Stengel's    Pathology.       Third  Edition.  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania ;  Visiting  Physician  to 
the  Pennsylvania  Hospital.  Handsome  octavo,  873  pages,  nearly  400 
illustrations,  many  of  them  in  colors.  Cloth,  $5.00  net ;  Sheep  or  Half 
Morocco,  $6.00  net. 

Stengel  and  White  on  the  Blood. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania ;  and  C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical  Medicine, 
University  of  Pennsylvania.      /;;  Press. 

Stevens-  Therapeutics,    ^^^^^i^^tl.,^. 

A  Text-Book  of  Modern  Therapeutics.    By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on    Physical    Diagnosis    in    the    University  of    Pennsvlvania. 
Handsome  octavo  volume  of  about  550  pages.      Cloth,  so. 00  net. 

Stevens'  Practice  qf  Medicine.    Fifth  Edition,  Revbed. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  L^niversity  of  Pennsyl- 
vania. Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.  Post-octavo,  519  pages;  illustrated.  Flexible 
Leather,  $2.00  net. 

Stewart's    Physiolo^.       Fourth  Edition.  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and 
Practitioners.  By  G.  N.  Stewart,  j\L  A.,  M.  D.,  D.  Sc.,  Professor  of 
Physiology  and  Histology,  Western  Reserve  University,  Cleveland, 
Ohio.  Octavo,  894  pages ;  336  illustrations  and  5  colored  plates. 
Cloth,  §3.75  net. 

Stoney's  Materia  Medica  for  Nurses. 

Materia  Medica  for  Nurses.  By  the  late  E.milv  A.  i\L  Stonev,  Superin- 
tendent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Bos- 
ton, Mass.      Handsome  octavo  volume  of  306  pages.      Cloth,  gi.50  net. 

Stoney's    Nursing.       second  Edition.  Revised. 

Practical  Points  in  Nursing.  For  Nurses  in  Private  Practice.  By  the 
late  Emily  A.  ^L  Stonev,  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73 
engravings,  and  8  colored  and  half-tone  plates.      Cloth,  Si.  75  net. 

Stoney's  Surgical  Technic  for  Nurses. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  the  late  Emily  A.  M. 
Stoney,  Superintendent  of  the  Training  School  for  Nurses,  Carney  Hosp., 
South  Boston,  Mass.     i2mo  volume,  fully  illustrated.    Cloth,  31.25  net. 

Thomas's   Diet   Lists.      second  Edition,  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  Jerome  B.  Thom.\s,  I\L  D., 
Visiting  Physician  to  the  Home  for  Friendle:s  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  ^'isiting  Physician  to  the  Kings 
County  Hospital.     Cloth,  $1-25  net.     Send  for  sample  sheet. 


OF  W.  B.  SAUNDERS  &  CO.  15 

Thornton's  Dose-Book  and  Prescription-Writing. 

Second  Edition,  Revised  and  Cnlar|(ed. 

Dose-Book  and  Manual  of  Prescription- Writing.  By  E.  Q.  Thornton, 
M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila. 
Post-octavo,  362  pages,  illustrated.     Flexible  Leather,  ^2.00  net. 

Vecki'S    Sexual    Impotence.        Third  Edition.  Revised  and  Enlarged. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor  G. 
Vecki,  M.  D,  From  the  second  German  edition,  revised  and  enlarged. 
Demi-octavo,  329  pages.     Cloth,  ^2.00  net. 

Vierordt's  Medical  Diagnosis,    rourth  Edition.  Revised. 

Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth 
enlarged  German  edition,  with  the  author's  permission,  by  Francis  H. 
Stuart,  A.M.,  M.  D.  Handsome  octavo  volume,  603  pages;  194 
wood-cuts,  many  of  them  in  colors.  Cloth,  ^4.00  net;  Sheep  or  Half 
Morocco,  $5- 00  net. 

Watson's  Handbook  for  Nurses. 

A  Handbook  for  Nurses.  By  J.  K.  Watson,  M.  D.  Edin.  American 
Edition,  under  supervision  of  A.  A.  Stevens,  A.M.,  M.  D.,  Lecturer 
on  Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages, 
73  illustrations.     Cloth,  ^1.50  net. 

Warren's  Surgical  Pathology,    second  Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard 
Medical  School.  Handsome  octavo,  873  pages;  136  rehef  and  litho- 
graphic illustrations,  ;^;^  in  colors.  With  an  Appendix  on  Scientific 
Aids  to  Surgical  Diagnosis,  and  a  series  of  articles  on  Regional  Bacte- 
riology.    Cloth,  $5.00  net;   Sheep  or  Half  Morocco,  ^6.00  net. 

Warwick  and  Tunstall's  First  Aid  to  the  Injured  and 
Sick. 

First  Aid  to  the  Injured  and  Sick.  By  F.  J.  Warwick,  B.  A.,  M.  B., 
Cantab.,  M.  R.  C.  S.,.  Surgeon-Captain,  Volunteer  Medical  Staff  Corps, 
London  Companies;  and  A.  C.  Tunstall,  M.  D.,  F.  R.  C.  S.  Ed., 
Surgeon-Captain  commanding  East  London  Volunteer  Brigade  Bearer 
Company.     i6mo,  232  pages;  nearly  200  illustrations.    Cloth,  ^i. 00  net. 

Wolfs  Examination  of  Urine. 

A  Handbook  of  Physiologic  Chemistry  and  Urine  Examination.  By 
Chas.  G.  L.  Wolf,  M.  D.,  Instructor  in  Physiologic  Chemistry,  Cornell 
University  Medical  College.  i2mo,  204  pages,  illustrated.  Cloth,  I1.25 
net. 


SAUNDERS' 
QUESTION-COMPEND  SERIES. 

Price.  Cloth,  $1.00  net  per  copy,  except  when  otherwise  noted. 


'  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders  Series, 
in  our  opinion,  bears  off  the  palm  at  present." — Netu  York  Medical  Record. 


1.  Eisentials  of  Physiology.     By  Sidney  Budgett,  M.  D.     A  New  Work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised,  with 

an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles   B.   Nancrede,   M.  D.     Sixth   edition,  thor- 

ouf^hlv  revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.     By  Lawrence  Wolff, 

M.  D.      Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.D.     Fifth   edition,  revised 

and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.     By  F.  J.  Kalteyer,  M  D.     In 

prepaj'ati:n. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing.    By  Heniy 

.Morris,  M.  I).     Fiuh  edition,  revised. 

8.  9.    Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Appendix 

on  Urine  E.xamin..\tion.  By  Lawrence  Wolff,  M.  D.  Third  edition,  enlarged 
by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by  Wm.  M. 
Powell.  M.  D.      i  Double  number,  $1.50  net.) 

10.  Essentials  of  Gynecology.     By  Edwin  B.  Cragin,  M.  D.     Fifth  edition,  revised. 

11.  Essentials  of  Diseases  of  the  Skin.     By  Henry  W.  Stelwagon,  ^L  D.     Fourth 

edition,  revised  and   enlarged. 

12.  EssentizJs  of  Minor  Surgery,  Bandaging,  amd  Venereal   Diseaises.     By  Edward 

.\L\RTIN,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials    of    Legal    Medicine,   Toxicology,    and    Hygiene.     This   volume   is   at 

present  out  of  print. 

14.  Essentials  of  Diseases  of  the  Eye.     By  Edward  Jackson,  M.  D.     Third  edition, 

revised  and  enlarged. 

15.  Essentials  of  Diseases  of  Children.    By  W1LLIA.M  M.  Powell,  M.  D.    Third  edition. 

16.  .Essentials    of    Examination    of    Urine.     By    Lawrence   Wolff,   M.  D.      Colored 

••  Vogel  Scale."     (75  cents  net.) 

17.  Essentials  of  Diagnosu.     By  S.   Solis-Cohen,  M.  D.,  and  A.   A.  Eshner,  NL  D. 

Second  edition,  thoroughly  revised. 

18.  Essentials    of    Practice    of    Pharmacy.     By  Lucius    E.    Sayre.     Second   edition, 

revised  and  enlarged. 

19.  Essentials  of  Diseases  of  the  Nose  and  Throat-     By  E.  B.  Gleason,  ^L  D.     Third 

edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  V.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Insanity.     By  John  C.  Shaw,  ^L  D.     Third 

edition,  revised. 

22.  Essentials  of    Medical    Physics.     By  Fred  J.   Brockway,  >L  D.     Second  edition, 

revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and  Edward 

S.  Lawrance.  M.  D. 

24.  Essentials  of   Dbeases  ot   the  Ear.     By  E.   B.  Gleason,  ^L  D.     Third   edition, 

revi-ed   and  greatly  enlarged. 

25.  Essentizds  of  Histology.     By  Louis- Leroy,  M.  D.     Second  edition,  revised.     With 

S5  original  illustrations. 

Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  appUcadon. 

16 


Saunders*  Medical    Hand-Atlases, 

VOLUMES   NOW   READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With 
182  colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text. 
Cloth,  $3.00  net. 

Atlas  of  Legal  Medicine. 

By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick 
Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of 
Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates  and  193  beautiful  half-tone  illustrations.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P.  Grayson, 
M.  D.  5  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of 
the  University  of  Pennsylvania.  With  107  colored  figures  on  44  plates, 
25  text-illustrations,  and  103  pages  of  text.     Cloth,  ^2.50  net. 

Atlas  and  Epitome  of  Operative  Surgery. 

Second  Edition,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited  by  J.  Chalmers 
DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  of  Clinical  Sur- 
gery, Jefferson  Medical  College,  Phila.  With  40  colored  plates,  278 
text-illustrations,  and  410  pages  of  text.     Cloth,  $3.50  net. 

Atlas   and   Epitome   of    Syphilis    and  the  Venereal 
Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton 
Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  71  colored 
plates,  16  illustrations,  and  122  pages  of  text.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye» 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Phila.  With  76 
colored  figures  on  40  plates;   228  pages  of  text.     Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Skin  Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON,  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical 
College,  Philadelphia.  With  6t,  colored  plates,  39  half-tone  illustra- 
tions, and  200  pages  of  text.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  Special  Pathological  Histology. 

By  Dr.  H.  Durck,  of  Munich.  Edited  by  Ludvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.,  including  Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts, 
120  colored  figures  on  62  plates,  158  pages  of  text.  Part  U.,  including 
Liver,  Urinary  Organs,  Sexual  Organs,  Nervous  System,  Skin,  Muscles, 
and  Bones,  123  colored  figures  on  60  plates,  and  192  pages  of  text. 
Per  part:   Cloth,  $3.00  net. 

17 


Saunders'  Medical  Hand-Atlases. 


VOLUMES  JUST  ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Translated  and  edited,  with 
additions,  by  Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Depart- 
ment of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals, 
New  York.  With  40  colored  plates,  143  text-illustrations,  and  S49 
pages  of  text.     Cloth,  $4.00  net. 

Atlas  and  Epitome  of  Gynecolo^. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  Ger- 
man Edition.  Edited,  with  additions,  by  Richard  C.  Norris,  A.  M., 
M.  D.,  Gynecologist  to  the  Methodist  Episcopal  and  the  Philadelphia 
Hospitals  ;  Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  With 
90  colored  plates,  65  text-illustrations,  and  308  pages  of  text.  Cloth, 
$3.50  net. 

Atlas  and  Epitome  of   the  Nervous  System  and  its 
Diseases. 

By  Prof.  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  Edward  D. 
Eisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University 
and  Bellevue  Hospital  Medical  College,  N.  Y.  With  '&2>  plates ;  copious 
text.      Cloth,  53.50  net. 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  J-  Clifton 
Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell 
University  Medical  School.  With  126  colored  illustrations.  Cloth, 
$2.00  net. 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treat- 
ment. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  J-  Clifton 
Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell 
University  Medical  School.  72  colored  plates,  text-illustrations,  and 
copious  text.     Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal- 
moscopic Diagnosis. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Third  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  G.  E.  de  Schweinitz, 
M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College,  Phila- 
delphia. With  152  colored  figures  and  82  pages  of  text.  Cloth,  $3.00 
net. 

ADDITIONAL  VOLUMES  IN  PREPARATION. 
18 


Saunders'  Medical  Hand-Atlases. 

VOLUMES  JUST   ISSUED.  • 

Atlas  and  Epitome  of  Bacteriology. 

Including  a  Hand-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof.' 
Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  Wiirzburg.  Fj-oin 
the  Second  Enlarged  atid  Revised  German  Edition.  Edited,  with  addi- 
tions, by  G.  H.  Weaver,  M.  D.,  Assistant  Professor  of  Pathology  and 
Bacteriology,  Rush  Medical  College,  Chicago.  In  Two  Parts.  Part  I., 
consisting  of  632  colored  illustrations  on  69  lithographic  plates.  Part  II., 
consisting  of  511  pages  of  text,  illustrated.     Per  part:  Cloth,  ^2.50  net. 

Atlas  and  Epitome  of  Otology. 

By  Dr.  Gustav  Bruhl,  of  Berlin,  with  the  collaboration  of  Prof.  Dr. 
A.  PoLiTZER,  of  Vienna.  Edited,  with  additions,  by  S.  MacCuen 
Smith,  M.  D.,  Clinical  Professor  of  Otology,  Jefferson  Medical  College, 
Philadelphia.  244  colored  figures  on  39  plates,  99  text-cuts,  and  292 
pages  of  text.     Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Abdominal  Hernias. 

By  Privatdocent  Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with 
additions,  by  William  B.  Coley,  Clinical  Lecturer  on  Surgery,  Colum- 
bia University  (College  of  Physicians  and  Surgeons),  New  York ;  Sur- 
geon to  the  General  Memorial  Hospital,  New  York.  With  43  colored 
figures,  on  36  plates,  100  text-cuts,  and  250  pages  of  text.      ///  Press. 

Atlas  and  Epitome  of  Fractures  and  Luxations. 

By  Prof.  Dr.  H.  Helferich,  of  Greifswald.  Edited,  with  additions,  by; 
Joseph  C.  Bloodgood,  Associate  in  Surgery,  Johns  Hopkins  University, 
Baltimore.  With  215  colored  figures  on  72  plates,  144  text-cuts,  42 
skiagraphs,  and  over  300  pages  of  text.     In  Press. 

Atlas  and  Epitome  of  Diseases  of  Mouth,  Throat,  and 

Nose. 

By  Dr.  L.  GriJnwald,  of  Munich.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  James  E.  New- 
comb,'  M.  D.,  Clinical  Instructor  in  Laryngology,  Cornell  University 
Medical  School.  With  42  colored  figures,  39  text-cuts,  and  225  pages 
of  text.     In  Press. 

Atlas  and  Epitome  of  Normal  Histology. 

By  Privatdocent  Dr.  J.  Sobotta,  of  Wiirzburg.  Edited,  with  addi- 
tions, by  G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and 
Director  of  the  Histological  Laboratory,  University  of  Michigan.  With 
80  colored  figures  and  68  text-cuts  from  the  original  of  W.  Freytag,  and 
275  pages  of  text. 

Atlas  and  Epitome  of  Operative  Gynecology. 

By  Dr.  Oskar  Schaeffer,  Privatdocent  at  the  University  of  Heidel- 
berg. With  42  colored  figures  and  2 1  text-cuts  from  the  original  of  A. 
Schmitson,  and  1 25  pages  of  text. 

ADDITIONAL  VOLUMES'  IN  PREPARATION. 
19 


NOTHNAGEL'S   ENCYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 

AMERICAN   EDITION 

Edited    by   ALFRED   STENGEL.  M.  D. 

Professor  of  Ginical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Physician  to  the  Pennsylvania  Hospital 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world   in  Internal 
Medicine  ;  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Speci- 

elle  Pathologie  und  Therapie  "  is  conceded  by  scholars  to  be  without  question 
the  best  System  of  Medicine  in  existence.  So  necessary  is  this  book  in  the  study 
of  Internal  Medicine  that  it  comes  largely  to  this  countn,-  in  the  original  German. 
In  view  of  these  facts,  Messrs.  W.  B.  Saundt-rs  &  Company  have  arranged  with 
the  publishers  to  issue  at  once  an  authorized  American  edition  of  this  great  ency- 
clopedia of  tnedicine. 

For  the  present  a  set  of  ten  volumes,  representing  the  most  practical  part 
of  this  excellent  encyclopedia,  and  selected  with  especial  thought  of  the  needs 
of  the  practiczd  physician,  will  be  published.  These  volumes  will  contain  the 
real  essence  of  the  entire  work,  and  the  purchaser  will  therefore  obtain  at  less 
than  half  the  cost  the  cream  of  the  original.  Later  the  special  and  more  strictly 
scientific  volumes  will  be  offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  the  original,  it  will  represent  the 
very  latest  views  of  the  leading  American  and  English  specialists  in  the  various 
departments  of  Internal  Medicine.  The  whole  System  will  be  under  the  edi- 
torial supervision  of  Dr,  Alfred  Stengel,  who  will  select  the  subjects  for  the 
American  edition,  and  arrange  for  the  editing  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  of  its  publication  by  the  eminent  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number . 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be 
given  the  opportunit\-  of  subscribing  for  the  entire  System  at  one  time  ;  but  any 
single  volume  or  anj-  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  mamy  advemtages  which  will  be  appreciated  by  those 
who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  publishers  are  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 

20 


NOTHNAGEL'S 
ENCYCLOPEDIA   OF  PRACTICAL  MEDICINE. 

AMERICAN    EDITION. 

VOLUMES  JUST  ISSUED  AND  IN  PRESS. 


TYPHOID  AND  TYPHUS  FEVERS.     By  Dr.  H.  Curschmann,  of  Leipsic. 

Editor,  William  Osier,  M.D.,  F.R.C.P.,  Professor  of  the  Principles  and  Practice  of 
Medicine  in  Johns  Hopkins  University,  Baltimore.  Handsome  octavo,  646  pages, 
72  valuable  text  illustrations,  and  two  lithograpliic  plates.  Cloth,  ^5.00  net-  Half' 
Morocco,  ^6.00  net.     Just  Ready.  ' 

VARIOLA  (including  VACCINATION).  By  Dr.  H.  Immermann,  of  Basle.  VARI- 
CELLA.  By  Dr.  Th.  von  Jurgensen,  of  Tiibingen.  CHOLERA  ASIATICA 
and  CHOLERA  NOSTRAS.  By  Dr.  C.  Liebermeister,  of  Tubingen  ERY 
SIPELAS  and  ERYSIPELOID.  By  Dr.  H.  Lenhartz,  of  Hamburg  PER 
TUSSIS  and  HAY-FEVER.  By  Dr.  G.  Sticker,  of  Giessen. 
Editor,  Sir  J.  W.  Moore.  B.A.,  M.D.,  F.R.C.P.I.,  Professor  of  the  Practice  of  Medi- 
cine, Royal  College  of  Surgeons,  Ireland.  Handsome  octavo  of  682  pages,  illustrated. 
Cloth,  ^5.00  net;    Half  Morocco,  ^6.00  net.     Just  Ready. 

DIPHTHERIA,     An  original    article   by  William    P.  Northrup,   M.D.,  of  New  York. 
Measles,  Scarlet  Fever,  Rotheln.      By  Dr.  Th.  von  Jurgensen,  of  Tubingen. 
Editor,  William  P.  Northrup,  M.  D.,   Professor  of  Pediatrics,  University  and  Bellevue 
Medical  College,  N.  Y.      Handsome  octavo,  672  pages,  illustrated,  including  24  full- 
page  plates,  3  in   colors.      Cloth,  ^5x0  net;    Half  Morocco,  ^6.00  net.     Just  Ready. 

DISEASES  OF  THE  BRONCHI.  By  Dr.  F.  A.  Hoffmann,  of  Leipsic.  DIS- 
EASES  OF  THE  PLEURA.  By  Dr.  O.  Rosenbaum,  of  Berlin.  PNEUMONIA 
By  Dr.  E.  Aufrecht,  of  Magdeburg. 

Editor,  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania. Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors.  Cloth,  ^5.00 
net  ;  Half  Morocco,  ^6.00  net.    Just  Ready. 

DISEASES  OF  THE  LIVER.     By  Drs.  H.  Quincke  and  G.  Hoppe-Seyler   of  Kiel 
DISEASES  OF  THE  PANCREAS.     By  Dr.  L.  Oser,  of  Vienna.     DISEASES 

OF  THE  SUPRARENALS.     By  Dr.  E.  Neusser,  of  Vienna. 

Editors,  Frederick  A.  Packard,  M.D.,  Physician  to  the  Penna.  and  the  Children's 
Hospitals,  Phila.  ;  and  Reginald  H.  Fitz,  A.  M,.  M.  D..  Hersey  Prof,  of  the  Theory 
and  Practice  of  Physic,  Harvard  Univ.  Handsome  octavo  of  750  pages,  illustrated. 
Cloth,  ^5.00  net;   Half  Morocco,  ^6.00  net.     Just  Ready. 

INFLUENZA  AND  DENGUE.  By  Dr.  O.  Leichtenstern,  of  Cologne  MALA- 
RIAL  DISEASES.     By  Dr.  J.   Mannaberg,  of  Vienna. 

Editor,  Ronald  Ross.  F.R.C.S.,  Eng.,  D.P.H.,  F.R.S.,  Major,  Indian  Medical 
Service,  retired;  Walter  Myers,  Lecturer,  Liverpool  School  of  Tropical  Medicine, 
Liverpool.      Handsome  octavo,  700   pages,  7  full-page  lithographs  in  colors. 

ANEMIA,  LEUKEMIA.  PSEUDOLEUKEMIA.  HEMOGLOBINEMIA.     By  Dr.  P. 

Ehrlich,  of  Frankfort-on-the-Main,  Dr.  A.  Lazarus,  of  Charlottenburg,  and  Dr. 
Felix  Pinkus,  of  Berlin.  CHLOROSIS.  Bv  Dr.  K.  von  Noorden,  of  Frank- 
fort-on-the-Main. 

Editor,  Alfred  Stengel.  M.D..  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania.     Handsome  octavo,  750  pages,  5  full-page  lithographs  in  colors. 

TUBERCULOSIS  AND  ACUTE  GENERAL  MILIARY  TUBERCULOSIS.  By 

Dr.  G.  Cornet,  of  Berlin. 

Editor  to  be  announced  later.      Handsome  octavo,  700  pages. 

DISEASES  OF  THE  STOMACH.     By  Dr.  F.  Riegel,  of  Giessen. 

Editor,  Charles  G.  Stockton.  M.D..  Professor  of  Medicine,  University  of  Buffalo. 
Handsonie  octavo,  800  pages,  with  29  text-cuts  and  6  full-page  plates. 

DISEASES   OF  THE   INTESTINES  AND   PERITONEUM.     By  Dr.  Hermann 

Nothnagel,  of  Vienna. 

Editor,  Humphry  D.  Rolleston,  M.D..  F.R.C.P..  Physician  to  and  Lecturer  on  Pathol- 
ogy at  St.  George's  Hospital,  London.    Handsome  octavo,  800  pages,  finely  illustrated. 

21 


i^^i^sifei 


